The Villa at the Park
For profit - Corporation
114 Beds
VILLA HEALTHCARE
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
1/100
#348 of 422 in MI
Last Inspection: August 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Villa at the Park has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #348 out of 422 facilities in Michigan, they are in the bottom half of state options, and they are #58 out of 63 in Wayne County, meaning there are very few local alternatives that perform better. While the facility's trend is improving, having reduced issues from 18 in 2024 to just 1 in 2025, they still face serious concerns such as a concerning $64,623 in fines, which is higher than 76% of other Michigan facilities, indicating repeated compliance problems. Staffing is a relative strength with a turnover rate of 30%, lower than the state average, but the facility has less RN coverage than 95% of Michigan facilities, which may impact care quality. Specific incidents have raised alarms, including a resident with cognitive impairment who eloped from the facility unnoticed and a serious incident where a resident was choked by staff, highlighting significant safety and care issues that families should consider.
- Trust Score
- F
- In Michigan
- #348/422
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ✓ Good
- 30% annual turnover. Excellent stability, 18 points below Michigan's 48% average. Staff who stay learn residents' needs.
- Penalties ○ Average
- $64,623 in fines. Higher than 55% of Michigan facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 13 minutes of Registered Nurse (RN) attention daily — below average for Michigan. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 55 deficiencies on record. Higher than average. Multiple issues found across inspections.
1/100
Bottom 18%
Review needed
18 → 1 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★★
5.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 18 issues
2025: 1 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (30%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (30%)
18 points below Michigan average of 48%
Facility shows strength in quality measures, staff retention, fire safety.
The Bad
2-Star Overall Rating
Below Michigan average (3.1)
Below average - review inspection findings carefully
Federal Fines: $64,623
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: VILLA HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 55 deficiencies on record
1 life-threatening 3 actual harm
Sept 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
This citation pertains to complaint 1310450 Based on observation, interview, and record review, the facility failed to ensure two confidential residents were treated with dignity and respect from a to...
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This citation pertains to complaint 1310450 Based on observation, interview, and record review, the facility failed to ensure two confidential residents were treated with dignity and respect from a total census of 106. Findings include:A review of the intake 1310450 revealed that several residents had concerns about the Activity Director (AD) and their interaction with the residents. One concern stated that the AD is rude, mean, disrespectful and uses profanity towards residents, anytime the residents ask for anything, the AD gets mad and cuts off the television as punishment. On 9/15/25 at 10:00 AM, an activity was observed occurring on the second floor. The activity staff was observed setting up resident for games and preparing music for an exercise activity. On 9/15/25 at 11:05 am, a confidential meeting of residents was held in the second-floor dining room. During the meeting, nine residents spoke of dissatisfaction with the AD saying . they don't know what they are doing . they talk to us mean . talk to us inappropriate .we don't have activities for our age. We need better games . the activities can be better, and we can have more fun. During the meeting, residents also stated they have notified the administrator, and nothing has been done. On 9/17/25 while touring the facility, a resident who wished to remain confidential stated they had a problem with the AD. The resident stated, I don't like the AD, their attitude is bold, and they talk to us crazy when we go out and smoke, and they have discussed other residents' business with other residents. On 9/17/25 at 12:50 PM, an interview was held with a certified nursing assistant (CNA) who wished to remain confidential, said they had witnessed the AD to withhold cigarettes or not provide activities on both floors and speak rudely to residents. On 9/17/25 at 2:00 PM an interview was held with the AD to discuss concerns. The AD revealed they were new to the position at the building and had been working there since March. Their experience included having worked as an activity assistant at several other buildings. The AD stated the building and some of the residents are challenging, and they (the residents) were used to the prior director and now they are adjusting to changes. On 09/17/25 at 2:25 PM, the Director of Nursing (DON) was queried about the resident's concerns with the AD and indicated they were not aware of any pertinent concerns, but the Regional Director was. On 09/17/25 at 3:00 PM, the Regional Director was queried about the resident's concerns with the AD and stated that changes were coming. A review of the facility policy titled Dignity revealed the following: It is the policy of this facility to assure residents are treated in a manner that preserves the resident's dignity and promotes a quality life experience. PROCEDURE: 1. All residents will be treated with respect. 2. Resident's preferences will be taken into consideration for all aspects of care and honored to the extent practicable.
Nov 2024
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation relates to Intake #MI00147451.
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 relates to Intake #MI00147451.
Based on observation, interview, and record review, the facility failed to provide adequate pest control with the potential to affect all 102 facility residents. Findings include:
Observations of random rooms adjacent to room [ROOM NUMBER] revealed the following: (In pest glue traps):
115: Two adult cockroaches and several nymphs. (2:22 p.m.)
111: Three adult cockroaches and one nymph. (2:23 p.m.)
On 11/06/24 at 2:00 p.m., Licensed Practical Nurse (LPN) B, was asked about the cockroaches in the room. LPN B acknowledged the concern and said they had told facility administration.
On 11/06/24 at 2:10 p.m., Housekeeping Staff C was observed cleaning on the 100 hall East unit. Staff C was asked about the cockroaches on the unit and in room [ROOM NUMBER] and responded they had seen dead cockroaches when they cleaned but had not seen any live cockroaches.
On 11/06/24 at 2:29 p.m., anoymous resident in room [ROOM NUMBER] was asked if they had any bugs in their room and responded, I have seen five bugs this week.
On 11/06/24 at approximately 2:35 p.m., the Nursing Home Administrator NHA), the Director of Nursing (DON), the the Maintenance Director, Staff D, were asked about the cockroaches observed on the 100 hall on the East side of the building. All acknowledged the cockroaches in the building, and the NHA and Staff D reported the pest control company had increased their visits to every two weeks in the past month. The NHA and Staff D were shown the concerns in R113's room, and on the unit, and reported they understood the concerns with the cockroaches, food and clothing/clutter.
On 11/06/24 at 3:38 p.m., Observation of the outer doors to the building was completed with the Maintenance Director, Staff D. The [NAME] South door revealed a crack about the size of a half dollar on the right side of the lower door, where the outdoors could be visualized. Staff D reported one of the [NAME] doors had been replaced, and they had received approval for this door to be replaced this week and recognized the concern.
On 11/06/24 at 3:45 p.m., Staff D was asked about the cause of the cockroaches found on the 100 hall. Staff D reported the cockroaches were worse on the East side of the building. Staff D explained they believed the cause was residents' personal food (snacks) and some hoarding behaviors (of food/clutter).
Review of the facility pest control invoice, dated 10/17/24, obtained from Staff D, reviewed with Staff D and the NHA, revealed an extensive cockroach infestation in the facility in the past month. The logs revealed there were at least 18 resident rooms with cockroaches found in the pest bait traps (zone monitors), primarily on the second floor. The NHA confirmed these rooms were resident occupied.
Review of the 10/17/24 pest control invoice revealed room [ROOM NUMBER] had 15 cockroaches, mostly adults, room [ROOM NUMBER] had heavy cockroach activity, and room [ROOM NUMBER] had moderate cockroach activity. The rooms were treated and the zone monitors were replaced. Further review of the invoice revealed several rooms on the second floor were found with many cockroaches.
On 11/06/24 at approximately 4:30 p.m., the Regional Environmental Director, Manager E, and Regional Housekeeping Supervisor, Manager G, with the NHA and Staff D present, were asked during a phone interview about the cockroach infestation. Manager E and Manager G shared they would continue their efforts related to increased pest control visits and treatment, increased deep cleaning, onsite visits, weekly audits, and other prevention measures. Manager D reported they understood cockroaches were attracted to food and would address any concerns along with Manager E and the facility staff. Environmental audits were requested and not received by survey exit.
On 11/06/24, beginning at approximately 5:50 p.m., observations were completed of three random second floor rooms with heavy or medium pests found, with the NHA. rooms [ROOM NUMBERS] showed the pest glue traps were full of cockroaches, with two live cockroaches on the heat vent in room [ROOM NUMBER].
On 11/06/24 at 6:00 p.m., the residents in both rooms were asked about the cockroaches saying, They [the pesticide company] have been spraying. I do see a roach once in a while. I see the bugs on the wall. I'm afraid to wear my clothes as they lay eggs on them, and pointed to clothing on their dresser.
Review of the (Provider) Pest Control Contract, labeled, General Pest Control Proposal, dated 5/29/20, unsigned, revealed, [Vendor] agrees to provide professional pest control service for the control of covered pests listed in Services section below .We will correct pest concerns as quickly and efficiently as possible and implement a successful preventative maintenance program. Essential to the success of your overall program is your cooperation with repair and sanitation recommendations we may make you aware of .Crawling Insects .Interior services [to be provided] twice per month. 24 [times] per year .
Review of the policy, Infection Prevention and Control .Pest Control, dated 2017, revealed, .1. Ongoing measures are taken to prevent, contain, and eradicate common household pests, such as roaches .3. Monitor for breaks in screens and doors on a routine basis .5. All food items kept in residents' rooms [will be] stored in covered containers .7. A contract with a pest control company may be elected to assure regular inspection and application of pesticides .12. Environmental services .will maintain records of pest control services and applicable contracts with pest control services.
Aug 2024
15 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R40
On 8/27/24 at 2:33 PM, during an interview R40 described an incident with Licensed Practical Nurse (LPN) C and Certified Nur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R40
On 8/27/24 at 2:33 PM, during an interview R40 described an incident with Licensed Practical Nurse (LPN) C and Certified Nurse Assistant (CNA) F. R40 stated LPN C choked them. R40 stated CNA E took a picture of R40's neck after the incident and reported the incident to the Director of Nursing (DON). R40 stated LPN C still worked at the facility and CNA F is on a leave.
A review of R40's medical record revealed they were admitted to the facility on [DATE] with the following diagnoses: Chronic obstructive pulmonary disease, senile degeneration of brain, and muscle weakness. A review of R40's Minimum Data Set revealed a brief interview for mental status score of 10 indicating cognitive impairment.
On 8/28/24 at 1:20 PM, during an interview, LPN C was asked about the incident involving R40. LPN C explained there was an altercation with another staff member in front of the nursing station and said R40 and the other staff member were getting closer to each other and were both agitated. LPN C explained they tried to diffuse the situation but R40 Got up out of (their) wheelchair and tried to jump at LPN C and the other staff member pushed (R40) back into their chair. LPN C confirmed the incident was reported to Registered Nurse (RN) D and CNA F no longer worked at the facility.
On 8/28/24 at 1:49 PM, during an interview, the nursing home administrator (NHA) was asked if they recalled an incident involving R40. The NHA stated CNA 'F' is not here anymore. Yeah (they) probably did get into it with R40. The NHA was asked to provide the incident report. The NHA explained they would have to find it.
On 8/28/24 at 3:16 PM a voicemail was left for RN D with a request for a return call. A call was not returned by the completion of the survey.
On 8/28/24 at 3:36 PM, during an interview, CNA E was asked if they recalled an incident involving R40. CNA E explained R40 told them CNA F and LPN C choked them. CNA E confirmed (R40's) neck did look red. CNA E explained they took a picture of R40's neck and reported it to RN D.
On 8/29/24 at 9:06 AM, LPN C was observed to be working on the unit in which R40 resides. R40 was asked if they felt safe with LPN C working on their unit. R40 stated, I don't know why (they) still work here.
On 8/29/24 at 8:19 AM, during an interview, the Assistant Director of Nursing (ADON) was asked to describe what should happen if there is an altercation between two residents or between a resident and a staff member. The ADON stated If it's only a verbal altercation involving residents we separate or redirect, same with staff but we would also reassign the staff member. If its physical, then an incident report is filled out and we notify the administrator, and an investigation is started. The staff member is suspended until the investigation is completed.
The ADON was informed of the allegations made by R40 and was asked to provide the documentation of the alleged incident. The ADON was observed looking through R40's medical record and explained they could not find a record of the incident or investigation.
On 8/29/24 at 9:31 AM, a review of CNA F's employee file revealed a discipline form that stated: Description of policy, procedure, rules or requirements violated: Verbal altercation with resident. Factual basis for the discipline, including prior counseling: Employees are not allowed to engage into any altercation with a resident this violates company policy. Level of discipline: indefinite suspension pending investigation.
A review of the facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property stated the following: The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal requirements immediately .C. PREVENTION ABUSE POLICY REQUIREMENTS: It is the policy of this facility to prevent abuse by providing residents, families and staff information and education on how and to whom to report concerns, incidents and grievances without the fear of reprisal or retribution. The facility will provide feedback regarding complaints and concerns. The facility leadership will assess the needs of the residents in the facility to be able to identify concerns in order to prevent potential abuse .
This citation pertains to Intake MI00146593.
Based on observation, interview, and record review, the facility failed to prevent resident to resident and staff to resident abuse for two residents (R24 and R40) of three reviewed for abuse, resulting in a broken leg and verbal abuse. Findings include:
R24
On 8/28/24 at 3:20 PM, during an interview with an anonymous resident they reported they didn't understand why R38 was allowed back to the facility after they assaulted another resident. The anonymous resident explained R24 was pulled out of their wheelchair to the ground a couple of days ago by R38, R38 then was on top of R24 which broke their leg. The anonymous resident stated R24 is a small person and was sent out to the hospital.
On 8/28/24 at 8:46 AM, Registered Nurse (RN M) was asked the reason R24 was in the hospital. RN M explained R24 reported pain in their leg that weekend, an x-ray was ordered with the findings of an acute proximal left tibula/fibula fracture. RN M stated, Resident [R38] tripped and fell on [R24]. RN M stated, R38 was being aggressive towards staff when this happened and later R38 was petitioned out to the hospital for a psychological intervention.
A review of R24's Minimum Data Set (MDS) assessment noted, Quarterly dated 8/6/24, impaired cognition, Functional Limitation in Range of Motion: Upper extremity (shoulder, elbow, wrist, hand) 0. no impairment. Lower extremity (hip, knee, ankle, foot) No impairment.
A review of R24's progress notes revealed, 8/23/2024 13:41 (1:41 PM) Health Status Note: Resident received in back day room. Resident told writer that [R24] is experiencing pain in [their] leg and around [their] ankle. Medications administered as ordered. Supervisor notified about pain in leg. X-rays ordered .
Further review of R24's progress notes revealed:
8/23/2024 14:41 (2:41 PM) Health Status Note Late Entry: Resident MD (medical doctor) ordered an X-Ray to left leg.
8/24/2024 01:14 (AM) Health Status Note: [R24] in bed with HOB (head of bed) elevated . no s/s (signs symptoms) of distress some discomfort awaiting for leg x-ray .
8/24/2024 15:17 (3:17 PM) Health Status Note: Resident received alert and verbally responsive. Able to make needs known. Noted resident left leg swelling and resident c/o pain to left leg. Pain meds given as ordered. X-ray done. Awaiting for result .
8/25/2024 07:21 (AM) Health Status Note: Received X-ray results displaced Fx (fracture) Rt. (right) Tibia. [physician] called. Transfer to Hospital.
8/25/2024 07:55 (AM) Health Status Note: Transfer complete to (local) hospital.
8/25/2024 07:41 (AM) Transfer to Hospital or other Facility .Reason for Transfer: Displaced Fracture of the Proximity Rt. Tibia .
On 8/28/24 at approximately 9:30 AM, RN M provided an incident and accident report noting, Date: 8/24/24 14:33 (2:33 PM) Incident Description: This writer was informed by [R24] that another resident fell on [their] leg when the resident was being aggressive towards the staff. Was this incident witnessed: Resident [R24] c/o (complained of) pain to left leg this writer asked was it a new onset resident stated another resident fell on [R24] leg when [R38] was trying to throw [R38's] walker. Immediate Action taken. Description: Resident MD (medical doctor) notified that the resident c/o pain to [R24's] left leg a order was given to administered Tylenol 325mg (milligrams) two tabs times one now and PRN (as needed) for pain and a X-ray ordered. Statements: No Statements found .
On 8/28/24 at 10:37 AM, the Assistant Director of Nursing (ADON) was asked to review and provide the date the incident and accident report was completed. A review of the ADON's computer revealed the incident and accident report was not signed/completed and had been revised on 8/28/24 at 9:33 AM. The document did not have the statement section completed. The ADON was asked the procedure for completing the incident and accident report and explained the report is to be fully complete with statements and signatures.
The ADON was asked for a policy regarding incident and accident report documentation. The policy was not provided by the end of the survey.
A review of R24's hospital record documentation revealed, History and Physical: Date of service: 8/25/24. Chief Complaint: Arrive date/time 8/25/24 13:27:00 Nursing Home. Ambulance EMS. Service: trauma: Trauma Code Level: Trauma Evaluation. Chief Complaint: Fall. Site of Injury: residential. History of Present Illness. [R24] . with a hx (history) of a stroke who presented to (local hospital) from nursing home after a fall from a wheelchair. Patient reports that she was at her nursing home when one of the fellow nursing home residents pushed her out the wheelchair . Left tib/fib (tibla/fibula) xray showed acute proximal left tib/fib fracture .
A review of R24's hospital Physical Therapy (PT) eval revealed, PT Initial Evaluation Acute Care Entered On: 8/27/24 . General Info. Reason for Referral to Physical Therapy: Decreased mobility . Past Medical & Surgical History: pt (patient) admit s/p (status post) being pushed out of w/c (wheelchair) at NH (nursing home) by another resident Left tib/fib fx now s/p ORIF (Open reduction and internal fixation (ORIF) is a type of surgery used to stabilize and heal a broken bone). PMHx: BLE (bilateral lower extermies) weakness .
On 8/29/24 at 11:23 AM, R24 was observed lying in bed and was asked about their leg. R24 stated, [R38] knocked me out of my wheelchair. [R38] has to come downstairs because [R38] starts trouble. R24 stated, [R38] pulled me out of the wheelchair. I can't do anything to fight back, I don't know why [R38] is back (at the facility).
R38
On 8/27/24 at 9:35 AM, R38 was observed lying in bed wearing green disposable scrubs. R38 had recently been readmitted from the hospital.
A review of R38's medical record noted, R38 was admitted on [DATE] with diagnosis of Dementia. A review of R38's annual MDS dated [DATE] revealed, moderate cognitive impairment and mobility devices walker. A review of R38's care plan did not reveal a care plan to address abusive behavior.
A review of R38's progress notes reveled, a pattern of aggressive behavior.
6/1/2024 16:34 (4:34 PM) Behavior Narrative Text: Resident rode the elevator by [R38's self] without assistance. Resident became agitated and verbally aggressive with staff. Redirection unsuccessful .
6/12/2024 20:22 (8:22 PM) Behavior Narrative Note: Resident verbally aggressive and combative with staff unprovoked .
6/13/2024 22:46 (8:46 PM) Behavior Narrative Note: Res (resident) continues with aggressive behavior towards staff. Res lashed out at undersign when trying to redirect res away from female bathroom. Res yelled out obscenities to undersign and was redirected back to [R38's] room by other staff members .
6/14/2024 22:22 (8:22 PM) Behavior Narrative Note: Res continues with aggressive behavior towards staff .
7/17/2024 20:33 (8:33 PM) Behavior Narrative Note: Resident verbally and physically aggressive with other residents unprovoked. Refused afternoon shower. Redirected several times unsuccessfully .
7/27/2024 17:56 (5:56 PM) Health Status Note: Periods of verbal/physical aggression with staff and other residents. Refuses meds and lab draws. No changes in baseline.
8/14/2024 10:17 (AM) Behavior Narrative Note: [R38] is in a bad mood he refused breakfast and was verbally and physically aggressive towards staff and residents .
8/21/2024 15:29 (3:29 PM) Behavior Narrative Note: Resident being disruptive to other residents during activity time. Verbally and physically aggressive unprovoked. Attempts to use [R38's] walker as a defensive tool. Redirected x2.
8/23/2024 11:42 (AM) Transfer to Hospital or other Facility Note: .Key clinical Information: Violent towards staff and other residents, sister notified .doctor informed .
8/23/2024 12:02 (AM) Health Status Note: Resident was picked up by [local] police to go to crises center officer will call back with location of center.
On 8/29/24 at 3:37 PM, the Nursing Home Administrator (NHA) was asked about the incident. The NHA administrator explained R38 is shaky on their walker and they bumped R24's wheelchair and R38 fell on top of R24. The NHA could not explain if R38 bummped into R24's wheelchair or if R38 pulled or pushed R24 from the wheelchair.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0658
(Tag F0658)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to obtain and assess the blood pressure (B/P) and administer blood pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to obtain and assess the blood pressure (B/P) and administer blood pressure medication based on that assessment for one sampled resident (R104) of one reviewed for monitoring, resulting in a significant low blood pressure and hospitalization. Findings include:
A review of R104's closed record revealed they were admitted to the facility on [DATE] with a diagnosis of Hidradenitis suppurativa (chronic skin condition featuring lumps in armpits and groin) and hypertension (high blood pressure). A review of R104's Minimum Data Set assessment revealed R104 had a death within the facility.
A review of R104's orders revealed the following orders:
-Carvedilol (a medication that lowers B/P) oral tablet 3.125 MG (milligrams) Give 1 tablet by mouth two times a day for hypertension.
-Spironolactone (a medication for fluid retention which can also lower the B/P)) oral tablet 25 MG give 1 tablet by mouth one time a day for diuretics. Vital signs every shift.
On [DATE] at 1:39 PM, on admission into the facility R104's blood pressure was documented as 112/76 (normal blood pressure 120/80).
A review of R104's Medication Administration Record (MAR) revealed on [DATE] at 5:00PM, Carvedilol was administered without the blood pressure being documented as being obtained prior to medication administration.
The next blood pressure that was documented was on [DATE] at 6:15 AM which noted B/P - 87/56.
A review of the MAR revealed on [DATE] at 9:00AM, Spironolactone was administered by Licensed Practical Nurse (LPN) C. Carvedilol was not administered at this time with a notation stating, Vitals outside of parameters for administration. There was no blood pressure documented at that time.
The medical record did not reveal a progress note that indicated the physician was contacted.
Further record review revealed a physician progress note dated [DATE] at 8:47 PM, Restart B/P meds with hold parameters (a pre-determined parameter to guide the nursing staff when to give and when to hold the medication).
MAR revealed on [DATE] at 9:00 AM, Spironolactone and Carvedilol were both administered by LPN C. R104's blood pressure at that time was documented as 89/56 on the MAR. There were no hold parameters noted on the MAR.
The medical did not reveal a progress note that indicated the physician was notified of the low blood pressure.
R104's MAR revealed on [DATE] at 5:00 PM, Carvedilol was administered, no B/P was documented.
Further record review revealed a progress note dated [DATE] at 11:08 PM, R104 was transferred to the hospital for a Change in condition; B/P reading 55/34.
On [DATE] at 11:25 AM, during an interview, the Assistant Director Of Nursing (ADON) was asked about the status of R104 and if they expired in the facility or if they were transferred to the hospital. The ADON requested an update from the admissions coordinator.
On [DATE] at 12:57 PM the ADON provided a list of discharged residents and explained R104 was transferred to the hospital on [DATE] and is now deceased . The ADON explained the MDS is correct in listing R104 as a death within the facility due to the resident expiring within 24 hours of transfer to the hospital.
On [DATE] at 11:55 AM during an interview with Licensed Practical Nurse (LPN) B was asked if orders for blood pressure medications include holding parameters. LPN B explained the majority of the orders for B/P meds do include hold parameters that usually say to hold if the systolic (top number) B/P is less than 130 or if the diastolic (bottom number) B/P is less than 60 but some orders do not. LPN B stated if there were no parameters, I'd use my nursing judgement. If someone's B/P is 100/60 I'm not gonna give them a pill to drop it lower. I would also call the doctor.
On [DATE] at 2:45 PM, during an interview LPN C was asked if orders for blood pressure medications include holding parameters and stated Some do, some don't have hold parameters but if the blood pressure is too low, I would hold it and put in a note why it was held. Most of the blood pressure medications ask you for a blood pressure on the Medication Administration Record (MAR). LPN C was asked to review the blood pressure and medication administration record for R104 on [DATE]. LPN C verified their initials on the MAR for the Spironolactone and Carvedilol indicating they administered the medications. LPN C stated I don't remember. It should not have been given.
On [DATE] at 3:04 PM, during an interview the ADON was asked to review R104's record. The ADON confirmed that R104 had a low B/P documented on [DATE] at 9:00 AM and the medications (Spironolactone and Carvedilol) were administered. The ADON was asked to review the administration of blood pressure medications on [DATE] at 5:00PM and confirmed no B/P results were present. The ADON was asked if it was concerning that R104's blood pressure meds were given with a low blood pressure and without it being reevaluated. The ADON stated Yes. They should not have been given and (name of LPN C) should have called the physician.
A medication administration policy was requested and not returned by the conclusion of the survey.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
This citation pertains to Intake MI00146498.
Based on observation, interview, and record review, the facility failed to provide an appropriate sized bed for one (R255) of five residents reviewed for a...
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This citation pertains to Intake MI00146498.
Based on observation, interview, and record review, the facility failed to provide an appropriate sized bed for one (R255) of five residents reviewed for accommodation of needs. Findings include:
On 08/27/24 at 10:21 AM, R255 was observed laying in bed. Their left heel was resting on top of the footboard of the bed and the right leg was bent at the knee and resting over the left leg.
Review of the facility record for R255 revealed an admission date of 08/22/24 with diagnoses that included Parkinson's Disease and Dementia. The resident's height was documented to be six feet, four inches.
On 08/28/24 at 10:23 AM, R255 was observed laying in bed. Their head was near the top of the mattress and their feet were resting on top of the footboard of the bed. R255 was asked if their feet resting on the footboard was uncomfortable and they stated yes. When asked if they would prefer a bed that accommodates their height R255 stated That would be nice. R255 expressed they were only able to fit on the matress by bending their legs.
On 08/28/24 at 02:19 PM, R255 was observed laying in bed. The head of the bed was raised to approximately 70 degrees and the resident had slid down far enough in the bed that their legs were hanging over the end of the bed from the knees down. R255 was asked about their positioning and they stated I need some help. It was observed the bed adjustments were manual and did not have a remote control. R255 was not able to adjust themselves up in the bed independently.
On 08/29/24 at 09:24 AM, R255 was observed laying in bed. The resident was positioned with their head near the head of the bed and their feet were resting on the footboard.
On 08/29/24 at 10:26 AM, the facility Assistant Director of Nursing (ADON) reported their expectation is that residents should have a bed that fits their body and residents feet/legs should not be resting on the footboard. The ADON reported a bed extension can be added or a larger bed can be ordered and direct care staff would have identified that the bed was too small and addressed the issue.
Review of the facility policy Accommodation of Needs and Preferences and Homelike Environment Guideline dated 11/28/17 included the following entries: Purpose: It is the practice of this facility to identify and provide reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. The objective of the accommodation of resident needs and preferences is to create an individualized, home-like environment to maintain and/or achieve independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preference. Reasonable accommodation of resident needs and preferences means the facility's efforts to individualize the resident's physical environment.
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 MI00146593.
Based on Interview and record review the facility failed to investigate a physical ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00146593.
Based on Interview and record review the facility failed to investigate a physical altercation between staff to resident and between resident to resident for two residents (R24 and R40) out of three residents reviewed for abuse. Findings include:
R24
On 8/28/24 at 3:20 PM, during an interview with an anonymous resident they reported they didn't understand why R38 was allowed back to the facility after they assaulted another resident. The anonymous resident explained R24 was pulled out of their wheelchair to the ground a couple of days ago by R38, R38 then was on top of R24 which broke their leg. The anonymous resident stated R24 is a small person and was sent out to the hospital.
On 8/28/24 at 8:46 AM, Registered Nurse (RN M) was asked the reason R24 was in the hospital. RN M explained R24 reported pain in their leg that weekend, an x-ray was ordered with the findings of an acute proximal left tibula/fibula fracture. RN M stated, Resident [R38] tripped and fell on [R24]. RN M stated, R38 was being aggressive towards staff when this happened and later R38 was petitioned out to the hospital for a psychological intervention.
A review of R24's Minimum Data Set (MDS) assessment noted, Quarterly dated 8/6/24, impaired cognition, Functional Limitation in Range of Motion: Lower extremity (hip, knee, ankle, foot) No impairment.
On 8/28/24 at approximately 9:30 AM, RN M provided an incident and accident report noting, Date: 8/24/24 14:33 (2:33 PM) Incident Description: This writer was informed by [R24] that another resident fell on [their] leg when the resident was being aggressive towards the staff. Was this incident witnessed: Resident [R24] c/o (complained of) pain to left leg this writer asked was it a new onset resident stated another resident fell on [R24] leg when [R38] was trying to throw [R38's] walker. Immediate Action taken. Description: Resident MD (medical doctor) notified that the resident c/o pain to [R24's] left leg a order was given to administered Tylenol 325mg (milligrams) two tabs times one now and PRN (as needed) for pain and a X-ray ordered. Statements: No Statements found .
A review of R24's hospital record documentation revealed, History and Physical: Date of service: 8/25/24. Chief Complaint: Arrive date/time 8/25/24 13:27:00 Nursing Home. Ambulance EMS. Service: trauma: Trauma Code Level: Trauma Evaluation. Chief Complaint: Fall. Site of Injury: residential. History of Present Illness. [R24] . with a hx (history) of a stroke who presented to (local hospital) from nursing home after a fall from a wheelchair. Patient reports that she was at her nursing home when one of the fellow nursing home residents pushed her out the wheelchair . Left tib/fib (tibla/fibula) xray showed acute proximal left tib/fib fracture .
R38
A review of R38's medical record noted, R38 was admitted on [DATE] with diagnosis of Dementia. A review of R38's annual MDS dated [DATE] revealed, moderate cognitive impairment and mobility devices walker.
8/21/2024 15:29 (3:29 PM) Behavior Narrative Note: Resident being disruptive to other residents during activity time. Verbally and physically aggressive unprovoked. Attempts to use [R38's] walker as a defensive tool. Redirected x2.
8/23/2024 11:42 (AM) Transfer to Hospital or other Facility Note: .Key clinical Information: Violent towards staff and other residents, sister notified .doctor informed .
8/23/2024 12:02 (AM) Health Status Note: Resident was picked up by [local] police to go to crises center officer will call back with location of center.
On 8/29/24 at 3:37 PM, the Nursing Home Administrator (NHA) was asked about the incident. The NHA administrator explained R38 is shaky on their walker and they bumped R24's wheelchair and R38 fell on top of R24. The NHA could not explain if R38 bumped into R24's wheelchair or if R38 pulled or pushed R24 from the wheelchair because an investigation was not done.
R40
On 8/27/24 at 2:33 PM, during an interview R40 described an incident with Licensed Practical Nurse (LPN) C and Certified Nurse Assistant (CNA) F. R40 stated LPN C choked them. R40 stated CNA E took a picture of R40's neck after the incident and reported the incident to the Director of Nursing (DON). R40 stated LPN C still worked at the facility and CNA F is on a leave.
A review of R40's medical record revealed they were admitted to the facility on [DATE] with the following diagnoses: Chronic obstructive pulmonary disease, senile degeneration of brain, and muscle weakness. A review of R40's Minimum Data Set revealed a brief interview for mental status score of 10 indicating cognitive impairment.
On 8/28/24 at 1:20 PM, during an interview, LPN C was asked about the incident involving R40. LPN C explained there was an altercation with another staff member in front of the nursing station and said R40 and the other staff member were getting closer to each other and were both agitated. LPN C explained they tried to diffuse the situation but R40 Got up out of (their) wheelchair and tried to jump at LPN C and the other staff member pushed (R40) back into their chair. LPN C confirmed the incident was reported to Registered Nurse (RN) D and CNA F no longer worked at the facility.
On 8/28/24 at 1:49 PM, during an interview, the nursing home administrator (NHA) was asked if they recalled an incident involving R40. The NHA stated CNA 'F' is not here anymore. Yeah (they) probably did get into it with R40.
On 8/28/24 at 3:36 PM, during an interview, CNA E was asked if they recalled an incident involving R40. CNA E explained R40 told them CNA F and LPN C choked them. CNA E confirmed (R40's) neck did look red. CNA E explained they took a picture of R40's neck and reported it to RN D.
On 8/29/24 at 9:31 AM, a review of CNA F's employee file revealed a discipline form that stated: Description of policy, procedure, rules or requirements violated: Verbal altercation with resident. Factual basis for the discipline, including prior counseling: Employees are not allowed to engage into any altercation with a resident this violates company policy. Level of discipline: indefinite suspension pending investigation.
On 8/29/24 at 10:02 AM, during an interview with the Nursing Home Administrator (NHA) they stated I have been looking for the incident report and I can't find anything. The NHA was asked to provide the reference number for the facility reported incident. The NHA stated We didn't call it in. I've been looking for the investigation and can't find it. The CNA was suspended. The NHA was asked if CNA F was suspended in response to the incident. The NHA stated yes. The NHA was asked if the incident should be documented in R40s medical record. The AD responded, Yeah, there should be something. They usually put it in the chart. The NHA was asked if they reported the incidents to the State of Michigan and complete a 5-day investigative follow-up. The NHA stated, I didn't think we had to.
A review of the facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property stated the following: The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal requirements immediately . E. INVESTIGATION ABUSE POLICY REQUIREMENTS: It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. PROCEDURE: The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration. a. Investigation of abuse: When an incident or suspected incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include:i. Who was involved ii. Residents' statements a. For non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview resident first. If unable, observe resident, complete an evaluation of resident behavior, affect and response to interaction, and document findings. iii. Resident's roommate statements (if applicable) iv. Involved staff and witness statements of events v. A description of the resident's behavior and environment at the time of the incident vi. Injuries present including a resident assessment vii. Observation of resident and staff behaviors during the investigation
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop a comprehensive care plan to address aggressiv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop a comprehensive care plan to address aggressive behaviors, for one sampled resident (R38) of a total sample of 21 residents reviewed for care plans. Findings include:
On 8/29/24 at 11:23 AM, R24 was observed lying in bed and was asked about their leg. R24 stated, [R38] knocked me out of my wheelchair. [R38] has to come downstairs because [R38] starts trouble. R24 was asked how did R38 knock them out of their wheelchair. R24 was observed to motion with their arms in a pulling motion. R24 stated, [R38] pulled me out of the wheelchair. I can't do anything to fight back, I don't know why he's back.
A review of R38's progress notes revealed, the following patterns of aggressive behavior.
6/1/2024 16:34 (4:34 PM) Behavior Narrative Text: Resident rode the elevator by [R38's self] without assistance. Reorientated resident of facility policy and safety concerns. Resident became agitated and verbally aggressive with staff. Redirection unsuccessful. Safety maintained.
6/12/2024 20:22 (8:22 PM) Behavior Narrative Note: Resident verbally aggressive and combative with staff unprovoked. Repeatedly gives roommate drinks despite being asked not to r/t (related to) roommates fluid restriction. Requires constant redirection. Safety maintained.
6/13/2024 22:46 (8:46 PM) Behavior Narrative Note: Res (resident) continues with aggressive behavior towards staff. Res lashed out at undersign when trying to redirect res away from female bathroom. Res yelled out obscenities to undersign and was redirected back to [R38's] room by other staff members. Will monitor.
6/14/2024 22:22 (8:22 PM) Behavior Narrative Note: Res continues with aggressive behavior towards staff. Res also continues to give [R38's] roommate items after staff has told [R38] on several occasions not to do this. Res yells obscenities when staff reminds him. Will continue to monitor behaviors.
7/17/2024 20:33 (8:33 PM) Behavior Narrative Note: Resident verbally and physically aggressive with other residents unprovoked. Refused afternoon shower. Redirected several times unsuccessfully. Removed from area. Safety maintained.
7/27/2024 17:56 (5:56 PM) Health Status Note: MONTHLY SUMMARY Resident remains alert. Able to make needs known . Remains a safe smoker with staff supervision. Periods of verbal/physical aggression with staff and other residents. Refuses meds and lab draws. No changes in baseline.
8/14/2024 10:17 (AM) Behavior Narrative Note: [R38] is in a bad mood he refused breakfast and was verbally and physically aggressive towards staff and residents. Redirected several times with success.
8/21/2024 15:29 (3:29 PM) Behavior Narrative Note: Resident being disruptive to other residents during activity time. Verbally and physically aggressive unprovoked. Attempts to use [R38's] walker as a defensive tool. Redirected x2. Safety maintained.
8/23/2024 11:42 (AM) Transfer to Hospital or other Facility Note Text: Most Recent admission: [DATE] 11:48. Key clinical Information: VIOLENT TOWARDS STAFF AND OTHER RESIDENTS SISTER NOTIFIED . Dr . informed. Reason for Transfer: VIOLENT TOWARDS RESIDENTS AND STAFF .
8/23/2024 12:02 (AM) Health Status Note: Resident was picked up by [local] Police to go to crises center officer will call back with location of center.
A review of R38's medical record noted, R38 was admitted on [DATE] with diagnosis of Dementia. A review of R38's annual Minimum Data Set Assessment (MDS) dated [DATE] revealed, moderate cognitive impairment and mobility devices walker. A review of R38's care plan did not reveal resident does not have a care plan regarding abusive behavior.
On 8/29/24 at 3:26 PM, the Assistant Director of Nursing (ADON) was asked about R38's care plan for interventions regarding R38's aggressive behavior. The ADON was observed to look at the medical chart and explained that R38 should have one because R38 has a history of aggressive behavior but was unable to locate a care plan that addressed R38's aggressive behavior.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide proper oral care for one (R83) out of five re...
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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 proper oral care for one (R83) out of five residents reviewed for actvities of daily living (ADLs). Findings include:
On 8/27/24 at 9:01 AM and 11:19 AM, R83 was observed lying in bed. R83's mouth was observed to be dry and R83's teeth were observed to be coated with a noticeable layer of white residue, particularly accumulating between the teeth and around the gum line.
On 8/27/24 at 2:31 PM, R83 was observed in their room sitting in their gerichair (medical recliner). R83's mouth appears unchanged from the previous observations.
On 8/28/24 at 9:56 AM, R83 was observed lying in bed. R83's mouth remained unchanged from the previous observations. R83 was asked if the staff helps them brush their teeth. R83 explained they needed help to brush their teeth and sometimes the aide helps them. R83 was asked how long it had been since they brushed their teeth. R83 stated About 4 or 5 days. A toothbrush and tooth paste were observed to be covered with other belongings and papers in the night stand drawer.
On 8/28/24 at 12:24 PM, R83 was observed sleeping in bed with their mouth open. The white substance was still observed in R83's mouth and on their teeth.
On 8/28/24 at 1:34 PM, R83 was observed sitting in their chair. R83's mouth appeared unchanged from previous observations. R83 was asked if anyone helped them brush their teeth or clean their mouth yet. R83 stated No. They haven't.
On 8/29/24 at 8:57 AM, R83 was observed lying in bed. R83's mouth was observed to be unchanged from previous observations.
A review of R83's record revealed they were admitted to the facility on [DATE] with the following diagnoses: bacterial meningitis and aphasia (difficulty swallowing). A review of R83's Minimum Data Set (MDS) revealed a brief interview for mental status score of 8 indicating cognitive impairment. Further review of R83's MDS revealed the Functional Abilities Assessment stated the following: Dependent with dressing and hygiene including oral care.
A review of R83's care plan revealed the following: (R83) has actual/potential for an ADL self-care performance deficit r/t (related to) disease process.
On 8/28/24 at 12:33 PM, during an interview, Licensed Practical Nurse (LPN) N was asked if R83 was able to perform any of their own oral hygiene care. LPN N confirmed R83 needs assistance and encouragement with oral care.
On 8/29/24 at 9:13 AM, during an interview, Certified Nurse Assistant (CNA) O explained R83 requires help with hygiene and oral care. CNA O stated R83 receives oral care every day when I (am assigned to them), otherwise, I'm not sure. CNA O stated Yes. I brush my teeth every day so the residents should too.
On 8/29/24 at 11:34 AM, during an interview, the Assistant Director Of Nursing (ADON) explained the CNA is responsible for the residents ADLS (activities of daily living) but the nurse is responsible to ensure it was performed. The ADON stated, If a resident is dependent, they should receive it every day. The ADON stated If R83 refuses, it should be documented. It is expected for them to receive oral hygiene every day.
A facility policy on ADL care was requested and was not provided by the completion of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat a wound for one resdent (R3) of one reviewed fo...
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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 treat a wound for one resdent (R3) of one reviewed for skin conditions. Findings include:
On 8/27/24 at 9:29 AM, R3 was observed lying in bed. A wound was noted on the third toe of their right foot with a bandage partially stuck to the wound and partially hanging off. R3 was asked how long the bandage had been there. R3 stated too long.
On 8/27/24 at 10:41 AM, R3 was observed in the hallway reclined in a gerichair (medical recliner) wearing a sock on their left foot. Their right foot was bare, and the same bandage was observed to be unchanged from the previous observation.
On 8/27/24 at 11:16 AM, R3 was observed still in the gerichair in the hallway. An unnamed Certified Nurse Assistant (CNA) was observed putting a sock on R3's right foot over the wound and the bandage was unchanged from the previous observations.
On 8/28/24 at 3:54, PM R3 was observed lying in bed with socks on both feet. The sock was removed from R3's right foot and the wound on the third toe was observed to still have the same bandage stuck to it.
On 8/29/24 at 9:13 AM, R3 was observed lying in bed. The same bandage was observed to still be partially stuck to the wound and partially hanging off R3's toe as previously observed.
A review of R3's medical record revealed, that they were admitted to the facility on [DATE] with a diagnosis of epilepsy, unspecified. A review of R3's Minimum Data Set assessment revealed a brief interview for mental status score of 5 indicating cognitive impairment.
Further review of R3's record revealed the following orders: Paint digits of bilat (both) feet with Betadine (iodine solution), no drsg (dressing). every day shift for -Skin Irritation; Soak Right foot for 20 minutes then apply triple Antibiotic with dry dressing to right toes digit 3 and 4 two times a day every other day for Wound.
On 8/28/24 at 4:00 PM, during an interview, wound care nurse Licensed Practical Nurse (LPN) C was asked if R3 had any wounds. LPN C stated No. R3 does not have any wounds right now but sometimes (they) have issues with their feet so I watch them every day.
On 8/29/24 at 9:14 AM, during an interview, LPN C was asked why R3 had a bandage on their toe to which they replied, That's the area that keeps breaking down. LPN C stated, The treatment is supposed to be every day but I only do it as needed. LPN C stated, We can soak them in the whirlpool. During the survey an observation was made of the whirlpool tub to be unusable and filled with bags of linen and other belongings.
On 8/29/24 at 11:40 AM, during an interview, the Assistant Director Of Nursing (ADON) was asked to review R3's wound care orders and was asked if the orders should be implemented. The ADON stated, Yes if it was ordered by the physician the order should be carried out.
A wound care policy was requested and not returned by the conclusion of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to document or offer the influenza or pneumonia vaccine for two resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to document or offer the influenza or pneumonia vaccine for two residents (R23 and R305) out of five reviewed for vaccinations. Findings include:
On 8/28/24 at approximately 11:00 AM, during an interview, the Assistant Director Of Nursing (ADON) was asked to review the vaccination status of R23 and R305.
During the review, R23's medical record revealed R23 was admitted to the facility on [DATE]. A review of R23's record revealed a brief interview for mental status score of 15 indicating intact cognition. Review of R23's vaccination status revealed there were no vaccine consents, and no vaccines were offered or provided. The ADON explained they're not sure how that got missed.
A review of R305's medical record revealed a consent signed by R305's guardian for the influenza and the pneumonia vaccine. The vaccinations were documented as resident refused. A progress note indicated the resident was educated on the vaccines. No note indicating the guardian was notified the resident refused the vaccines.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview, and record review, the facility failed to offer and document the Covid vaccine for one residents (R23) out o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview, and record review, the facility failed to offer and document the Covid vaccine for one residents (R23) out of five reviewed for Covid vaccinations. Findings include:
On 8/28/24 at approximately 11:00 AM during an interview the ADON was asked to review R23's Covid vaccination status.
During the review, R23's medical record revealed R23 was admitted to the facility on [DATE]. A review of R23's record revealed a brief interview for mental status score of 15 indicating intact cognition. A review of R23's vaccination status revealed there were no Covid vaccine consents, and no vaccines were offered or provided. The ADON explained that they are not sure how that got missed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 8/27/24 at approximately 9:00 AM, a hand sanitizer dispenser mounted in the hallway on the 2nd floor west wing was noted to b...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 8/27/24 at approximately 9:00 AM, a hand sanitizer dispenser mounted in the hallway on the 2nd floor west wing was noted to be empty. The other hand sanitizer dispensers on the 2nd floor west wing were all tested and were all found to be empty.
On 8/27/24 at 10:46 AM, an unidentified staff member #1 was observed to enter room [ROOM NUMBER] and to pick up dirty laundry from the floor next to the bed. The staff member carried the laundry without bagging it, across the hall into the soiled utility room. The staff member immediately walked out of the soiled utility room and into another resident's room without performing hand hygiene.
On 8/27/24 at 10:44 AM, an unidentified staff member #2 was observed performing a blood draw on a resident in room [ROOM NUMBER]. On 8/27/24 at 10:48 AM, the staff member finished the blood draw and removed their gloves, threw them away and walked out of room [ROOM NUMBER] while placing the specimens into the bag hanging over their shoulder. The staff member then walked directly into another residents room without performing hand hygiene. The staff member then applied gloves and performed a lab draw without performing hand hygiene. On 8/27/24 at 10:53 AM, the staff member then removed their gloves and left the room carrying the specimen without performing hand hygiene.
On 8/27/24 at 10:55 AM, an unidentified staff member #3 was observed removing the linen from room [ROOM NUMBER] bed, linens was observed to have a brown substance on it. The staff member was observed to not be wearing gloves and carried the bed linens without being bagged across the hall to the soiled utility room and immediately left the soiled utility room and walked down the hall past the nurse's station without washing their hands.
On 8/27/24 at 11:16 AM, Certified Nurse Assistant (CNA) O was observed putting a sock on a residents foot that had an uncovered wound on it. CNA O was observed to not perform hand hygiene before or after putting the sock on.
On 8/28/24 at approximately 11:00 AM during an interview the Assistant Director of Nursing (ADON) was asked to describe the facility's hand hygiene practices. The ADON explained they use hand sanitizer which is maintained by housekeeping and does hand washing audits and education. The ADON provided hand hygiene education and a check off skills hand wash observation form instead of audits. The skills check off provided were not completed and lacked signatures. The ADON explained the hand sanitizer in the hallways is sometimes removed because the residents will eat it. The ADON explained there should be sanitizer at the nurse's station and all staff should use the sanitizer before and after coming out of resident rooms or providing care to the residents.
A facility policy on hand hygiene and copies of the hand hygiene education was requested but not returned by the completion of the survey.
Based on observation, interview, and record review, the facility failed to date and store oxygen tubing for one (R64) of five residents reviewed and failed to complete proper hand hygiene for four of four staff members (Staff member's #1, #2, #3, and CNA O) . Findings include:
Review of the facility record for R64 revealed an admission date of 08/03/22 with diagnoses that included Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure. R64's record included active physician orders for supplemental oxygen use.
On 08/27/24 at 11:00 AM, R64 was using oxygen that was connected to the room condenser and the tubing was not dated. Extra oxygen tubing was laying on the floor and was not in a bag or dated. The oxygen tubing connected to R64's portable condenser on the wheelchair was not dated or bagged. Two flies were observed on and around R64 during the interview.
On 08/28/24 at 10:30 AM, R64's oxygen tubing attached to the large condenser was not dated or bagged. Additional tubing was laying on the bed and was not dated or bagged and the tubing on the portable condenser the resident was using at the time was not dated.
On 08/29/24 at 09:33 AM, R64's oxygen tubing being used from the room condenser was not dated. The tubing connected to the portable condenser was not dated or bagged.
On 08/29/24 at 10:20 AM, the facility Assistant Director of Nursing (ADON) reported the expectation is oxygen tubing should be dated. The ADON reported that oxygen tubing not in use should be stored in a bag and should not be on the floor.
A facility policy addressing maintenance of oxygen tubing was requested however the policy provided only addressed storage and safety as it related to oxygen cylinders or tanks.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 104 residents, resulting in the increased likelihood for c...
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Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 104 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination.
Findings include:
On 08/27/24 at 08:53 A.M., An initial tour of the food service was conducted with Dietary Manager H and Dietary Support G. The following items were noted:
The Randell 2-door reach-in cooler door gaskets and upper door ledge were observed soiled with accumulated and encrusted food residue.
12 of 12 overhead plastic light lens covers were observed soiled with accumulated and encrusted dust, dirt, and food residue. Dietary Manager H indicated she would have staff thoroughly clean and sanitize the door gaskets and light lens covers as soon as possible.
The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.
The Randell 2-door reach-in cooler door gaskets were observed worn and torn. The damaged gasket surfaces measured approximately 12-inches-long and 8-inches-long respectively. Dietary Manager H indicated she would have maintenance replace the worn and torn door gaskets as soon as possible.
The 2017 FDA Model Food Code section 4-501.11 states: (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. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened.
On 08/29/24 at 01:50 P.M., Record review of the Policy/Procedure entitled: Kitchen Equipment dated 9-1-21 revealed under Standard: All food service equipment will be clean, sanitary, and in proper working order. Record review of the Policy/Procedure entitled: Kitchen Equipment dated 9-1-21 further revealed under Guidelines: (1) All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the outdoor waste and cardboard recycling receptacles effecting 104 residents, resulting in...
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Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the outdoor waste and cardboard recycling receptacles effecting 104 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and pest attraction/harborage.
Findings include:
On 08/28/24 at 09:00 A.M., An environmental tour of the outdoor waste receptacle cement pad area was conducted with Regional Director of Dietary Services I. The following items were noted:
The cardboard waste receptacle was observed missing 1 of 2 plastic lids. The metal mounting rod was also observed bent and convoluted. The drain plug was further observed missing from the cardboard waste receptacle port.
The solid waste receptacle was observed with offset plastic lids. The metal mounting rod was also observed bent and convoluted. The rear metal brace bars were further observed bent, unattached, and convoluted. Regional Director of Dietary Services I indicated she would contact the waste removal contractual service for necessary repairs as soon as possible.
The cement pad surface was observed heavily soiled with accumulated and encrusted dirt and debris. One large plastic container with wheel castors was also observed full of water. Two wooden containers were further observed resting on the cement pad near the rear fence line. The waste grease container was additionally observed with rancid and malodorous used grease product. One large wooden skid was further observed resting against the waste grease container.
On 08/29/24 at 02:00 P.M., Record review of the Policy/Procedure entitled: Dispose of Garbage and Refuse dated 09/01/2021 revealed under Standard: All garbage and refuse will be collected and disposed of in a safe and efficient manner. Record review of the Policy/Procedure entitled: Dispose of Garbage and Refuse dated 09/01/2021 further revealed under Guideline: (1) The Dining Services Director coordinates with the Director of Maintenance to ensure that the area surrounding the exterior dumpster area is maintained in a manner free of rubbish or other debris. (3) Appropriate lids are provided for all containers.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 104 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality.
Findings include:
On 08/27/24 at 10:05 A.M., A common area environmental tour was conducted by this surveyor. The following items were noted:
Staff Break Room (Basement): The microwave oven was observed (etched, scored, particulate, corroded).
The building rear exterior entrance metal door sweep was observed corroded and broken, allowing a significant air gap between the door slab and metal threshold plate. The significant air gap created an increased likelihood for pest entrance into the building.
1st Floor Back Dining Room: The wall mounted Friedrich air conditioner filters and intake grills were observed heavily soiled with accumulated and encrusted dust/dirt deposits. The two window tracks were also observed soiled with accumulated dust and dirt deposits. The window curtains were additionally observed worn, threadbare, and torn.
1st Floor Front Dining Room: The American Standard air conditioning unit intake grills were observed heavily soiled with dust and dirt deposits. The activity storage room was also observed in complete disarray. Holiday decorations and activity items were observed stacked on top of each other, within the storage room. The flooring surface was observed heavily soiled with accumulated and encrusted dirt/grime, and black from accumulated and encrusted dirt/grime deposits.
1st Floor West
Soiled Utility Room: The liquid waste hopper interior was observed heavily soiled with accumulated and encrusted soil residue. The return-air-exhaust ventilation was observed non-functional. The ambient air was further observed extremely malodorous.
Men's Restroom: Four of four commode base stalls were observed partially or completely plugged with human waste. One of four commode base stalls were also observed with human waste resting directly upon the flooring surface. One of four hand sink faucet assemblies were additionally observed missing both the hot and cold-water control handles. The four-hand sink basin countertop surface was further observed warped and sunken. The countertop front lip was also observed separated from the laminate surface, exposing the porous particle board subsurface.
Storage Room: Four of four wooden shelving units were observed (etched, scored, particulate), exposing the porous particle board subsurface.
Nurses Station: The restroom hand sink faucet assembly was observed loose-to-mount. The wall mounted radiator cover was also observed loose-to-mount, within the nurse station cubicle. The cubicle flooring surface was further observed soiled with accumulated and encrusted dirt/grime. The nurse station desk laminate surface was also observed (etched, scored, particulate, missing). The wall/floor junctures were further observed heavily soiled with accumulated and encrusted dirt/grime.
Two bedside tables were observed (etched, scored, particulate), adjacent to the Nurses Station.
Occupational/Physical Therapy: The rolling stool seat cushion was observed (etched, scored, particulate), exposing the inner Styrofoam padding. The Sharp Carousel microwave oven interior was observed (etched, scored, particulate). The black refrigerator exterior and interior was also observed soiled with accumulated and encrusted food residue.
Oxygen Storage Room: The flooring surface was observed soiled with accumulated dust and dirt deposits. Paper tags were also observed resting upon the flooring surface.
Bathing Room: The body wash and skin protectant dispenser exteriors were observed soiled with accumulated dust and dirt deposits.
1st Floor East
Shower Room: Three anti-skid strips were observed (etched, peeling, missing), within the shower stall. The atmospheric vacuum breaker was also observed missing on the shower wand assembly. The shower wand assembly control head chrome plated surface was further observed etched and peeling.
Women's Restroom: The commode base grab bar was observed loose-to-mount.
Mop Closet: The mop sink basin was observed soiled with accumulated and encrusted dirt/grime. The flooring surface was also observed with two wire hangers, two plastic milk crates, and a severely soiled mop bucket.
Staff Restroom: The return-air-exhaust ventilation grill was observed heavily soiled with dust and dirt deposits. The hand sink basin was also observed loose-to-mount.
Nurses Station: The laminate countertop surface was observed (etched, scored, particulate, missing). The damaged laminate surface edge measured approximately 2-feet-long and 6-feet-long respectively. The upper laminate countertop surface corner edge was also observed completely missing. The damaged upper laminate countertop surface edge measured approximately 18-inches-long.
2nd Floor East
The Sanyo wall mounted air-conditioning unit filters (4) were observed heavily soiled with accumulated dust and dirt deposits.
Restroom: 1 of 4 hand sink basin faucet assemblies were observed missing the handle extensions. 2 of 2 overhead light plastic lens covers were also observed soiled with accumulated dust, dirt, and insect carcasses. The overhead light switch cover was further observed soiled with accumulated soil residue.
Nurses Station: The desktop laminate surface was observed (etched, scored, missing), creating a non-cleanable and non-sanitizable surface. The medication refrigerator was also observed unsecured. One Healthy Choice Pineapple Chicken meal and a bottle of drinking water was further observed stored within the medication refrigerator. The medication refrigerator ambient temperature was also observed to read 55.8 degrees Fahrenheit. The medication refrigerator was further observed with accumulated ice [NAME] resting upon the refrigeration coil plate. The restroom hand sink basin faucet assembly was additionally observed leaking water, was loose-to-mount and separated from the wall surface. The return-air-exhaust ventilation grill was also observed heavily soiled with accumulated dust and dirt deposits.
2nd Floor Back Dining Room: The Emerson Electronic Air Cleaner intake grill was observed heavily soiled with accumulated dust and dirt deposits. The Blueridge wall mounted air-conditioning unit was also observed soiled with accumulated dust and dirt deposits. Previous moisture discoloration was further observed on the wall surface, adjacent to the Blueridge air-conditioning unit.
2nd Floor Front Dining Room: 8 of 8 return-air-exhaust ventilation grills were observed heavily soiled with accumulated and encrusted dust/dirt deposits. The Activity Storage Room was also observed in disarray. Activity items were further observed stacked upon each other. The drywall surface was also observed unfinished on the central column pillar. The unfinished drywall surface measured approximately 5-feet-wide by 6-feet-long times two. The wall/floor vinyl coving strip was further observed missing around the column pillar perimeter.
2nd Floor West
Bathing Room: The return-air-exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits. The commode base grab bar was also observed loose-to-mount. The oxygen storage room was further observed in disarray. Two wire hangers and paper tags were also observed resting upon the flooring surface.
Nurses Station: The oscillating desk fan was observed heavily soiled with accumulated dust and dirt deposits. The desktop laminate surface was observed loose-to-mount in various locations. One small cockroach nymph was observed moving across the upper desktop laminate surface. One adult cockroach was also observed above the restroom entrance door.
On 08/28/24 at 10:50 A.M., An environmental tour of the facility Laundry Service was conducted with Director of Housekeeping and Laundry Services K. The following items were noted:
Clean Laundry Room: The large floor fan (36-inches-wide) was observed soiled with accumulated dust and dirt deposits. The wall surface, adjacent to the waste receptacle, was also observed soiled with dust, dirt, and debris. The flooring surface was further observed soiled with accumulated dust and dirt deposits, directly behind the three commercial driers.
Soiled Laundry Room: The flooring surface was observed soiled with accumulated dust and dirt deposits. The corners and wall/floor junctures were also observed soiled with accumulated and encrusted dust/dirt deposits. The return-air-exhaust ventilation grill plate and interior plenum were additionally observed soiled with accumulated and encrusted dust/dirt deposits. The mop sink basin interior and backsplash faucet countertop were further observed heavily soiled with accumulated and encrusted soil residue.
Washing Machine Room: The flooring surface, located between and directly behind the two commercial washers, was observed heavily soiled with accumulated and encrusted dust/dirt deposits.
On 08/28/24 at 11:05 A.M., An interview was conducted with Regional Director of Maintenance L regarding the facility maintenance work order system. Regional Director of Maintenance L stated: We have the TELS system.
On 08/29/24 at 09:20 A.M., An environmental tour of sampled resident rooms was conducted with Director of Maintenance J and Director of Housekeeping and Laundry Services K. The following items were noted:
102: The window tracks were observed soiled with accumulated and encrusted dust/dirt deposits. One pest control monitoring glue board was also observed with numerous dead adult cockroaches, adjacent to the room entrance door.
104: The hand sink basin was observed loose-to-mount. One pest control monitoring glue board was also observed with numerous dead adult and nymph cockroaches resting upon the surface. The glue board was additionally observed resting on the flooring surface, directly behind the wooden wardrobe. The window tracks were further observed soiled with accumulated and encrusted dust/dirt deposits. The wall/floor vinyl coving strip was also observed missing throughout the entire room perimeter.
106: The window tracks were observed soiled with accumulated and encrusted dust/dirt deposits. The radiator metal cover upper ledge was also observed soiled with accumulated and encrusted dust/dirt deposits.
108: The hand sink faucet assembly was observed loose-to-mount. The wall/floor vinyl coving strip was also observed missing throughout the entire room perimeter.
110: The wall/floor vinyl coving strip was observed missing throughout the entire room perimeter. The radiator metal cover was also observed loose-to-mount, adjacent to the corner surface. The window tracks were additionally observed soiled with accumulated and encrusted dust/dirt deposits.
111: The wall/floor vinyl coving strip was observed missing throughout the entire room perimeter. The window tracks were also observed with accumulated and encrusted dust/dirt deposits. The flooring surface wall/floor edge was additionally observed heavily soiled with accumulated and encrusted dust/dirt deposits.
113: The wall/floor vinyl coving strip was observed missing throughout the entire room perimeter. The window tracks were also observed soiled with accumulated and encrusted dust/dirt deposits.
115: The wall/floor vinyl coving strip was observed missing throughout the entire room perimeter. The radiator metal cover upper ledge was also observed soiled with accumulated dust, dirt, and debris. The window tracks were additionally observed soiled with accumulated and encrusted dust/dirt deposits. The window shade was further observed soiled with dust, dirt, and food residue.
202: The electrical cover plate was observed loose-to-mount, adjacent to the wooden wardrobe next to the room entrance door.
203: The oscillating wall fan was observed heavily soiled with accumulated and encrusted dust/dirt deposits.
207: The window tracks were observed soiled with accumulated and encrusted dust/dirt deposits. The radiator metal cover plate upper ledge was also observed soiled with accumulated and encrusted dust/dirt deposits.
208: The window tracks were observed soiled with accumulated and encrusted dust/dirt deposits. The flooring surface wall/floor vinyl coving strip was also observed missing throughout the entire room perimeter.
210: The hand sink basin was observed loose-to-mount. The window tracks were also observed soiled with accumulated and encrusted dust/dirt deposits.
211: The wall/floor vinyl coving strip was observed missing throughout the entire room perimeter. The radiator metal cover plate upper ledge was also observed soiled with accumulated and encrusted dust/dirt deposits. The window tracks were additionally observed soiled with accumulated and encrusted dust/dirt deposits.
212: The window tracks were observed soiled with accumulated and encrusted dust/dirt deposits. The wall/floor vinyl coving strip was also observed missing throughout the entire room perimeter.
215: The box fan was observed heavily soiled with accumulated and encrusted dust/dirt deposits. The flooring surface wall/floor edge was also observed heavily soiled with accumulated and encrusted dust/dirt deposits. The window tracks were additionally observed soiled with accumulated and encrusted dust/dirt deposits.
218: The window tracks were observed soiled with accumulated and encrusted dust/dirt deposits.
On 08/29/24 at 02:15 P.M., Record review of the Policy/Procedure entitled: Daily Cleaning Procedures dated (no date) revealed under Procedures: (4) High Dust. Work your way clockwise around the room (starting at the door and finishing at the door) and dust all high surfaces. This includes, but is not limited to: pictures/prints, televisions, over-the-bed lights, blinds, vents, and all corners. (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 siderails, bed frame, footboard and headboard, bedside tables, closet handles, windowsills, chairs, heating unit, and any flat surfaces. If the resident has a fan in his/her room, check and clean routinely to avoid buildup of dust. (7) Clean Restroom. Complete the following steps in the restroom: (a) Restock all supplies - paper towel, toilet paper, soap, etc. (b) Empty trash (follow step 2 above). (c) High dust - lights, vents. (d) Disinfect sink area. (e) Disinfect toilet area - including handrails, call lights, and tub/shower.
On 08/29/24 at 02:25 P.M., Record review of the Policy/Procedure entitled: Preventative Maintenance (TELS) and Inspections dated (no date) revealed under I. Policy Guidelines: It is the policy of (facility name) that in order to provide a safe environment for residents, employees, and visitors, a preventative maintenance program (TELS) has been implemented to promote the maintenance of equipment in a state of good repair and condition. Record review of the Policy/Procedure entitled: Preventative Maintenance (TELS) and Inspections dated (no date) further revealed under III Procedural Components: (D) Work Orders and Service Requests: (1) A system for electronic work orders is established in TELS among all staff, and maintenance personnel that provides rapid communication regarding equipment problems. (2) The system includes documentation of: (a) The problem, (b) Date the problem was identified, (c) Who was assigned, and (d) Location of the problem.
On 08/29/24 at 02:35 P.M., Record review of the Direct Supply TELS Work Orders for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns.
CONCERN
(F)
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 observations, interviews, and record reviews, the facility failed to effectively provide pest control services effecting 104 residents, resulting in the increased likelihood for pest attracti...
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Based on observations, interviews, and record reviews, the facility failed to effectively provide pest control services effecting 104 residents, resulting in the increased likelihood for pest attraction and harborage.
Findings include:
On 08/27/24 at 10:05 A.M., The rear building exterior entrance door sweep was observed (corroded, loose, broken), creating a significant air gap between the door slab and metal threshold plate. The significant air gap created an increased likelihood for pest entrance into the building.
On 08/27/24 at 10:20 A.M., One lone cockroach was observed on the flooring surface, near the 1st floor Back Dining Room entrance door.
On 08/27/24 at 11:15 A.M., One small cockroach nymph was observed moving across the upper desktop laminate surface of the 2nd Floor [NAME] Nurses Station. One adult cockroach was also observed above the 2nd Floor [NAME] Nurses Station restroom entrance door.
On 08/28/24 at 10:17 A.M., The facility Pest Control Program was reviewed with Director of Maintenance J and Regional Director of Maintenance L.
On 08/28/24 at 10:30 A.M., Record review of the facility Pest Control Contract revealed the following treatment categories and frequencies:
Crawling Insects & Mice - Interior serviced twice per month. (24/year)
Exterior Treatment - May thru October treat for crawling insects and spiders. (6/year)
Fall Invader Treatment - Fall time treat exterior for fall invaders. (1/year)
ILT (Insect Light Traps) Service - Install 2 units service April thru October. (8/year)
Rodent Control - 10 exterior bait stations serviced and cleaned monthly. (12/year)
Supplemental Fly Control - Fly control large and small April thru November. (8/year)
On 08/28/24 at 10:35 A.M., Record review of the Pest Control Technician Treatment Invoices for the last 12 months revealed no specific treatment for targeted pests only general treatment for pests.
On 08/28/24 at 04:10 P.M., One housefly was observed flying throughout the facility Administrator's Office, during our day 2 team meeting.
On 08/29/24 at 09:20 A.M., An environmental tour of sampled resident rooms was conducted with Director of Maintenance J and Director of Housekeeping and Laundry Services K. The following items were noted:
102: One pest control monitoring glue board was observed with numerous dead adult cockroaches resting upon the surface. The glue board was also observed resting on the flooring surface, adjacent to the room entrance door.
104: One pest control monitoring glue board was observed with numerous dead adult and small nymph cockroaches resting upon the surface. The glue board was also observed resting on the flooring surface, directly behind the wooden wardrobe.
On 08/29/24 at 09:40 A.M., An interview was conducted with Resident #51 regarding cockroach activity. Resident #51 was asked: Have you seen any cockroaches in your room? Resident #51 stated: Yes. I have seen them around.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected most or all residents
Based on observations, interviews, and record reviews, the facility failed to provide 80 square feet of living space per bed within multiple resident rooms in 21 (#'s 102, 103, 104, 105, 106, 107, 108...
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Based on observations, interviews, and record reviews, the facility failed to provide 80 square feet of living space per bed within multiple resident rooms in 21 (#'s 102, 103, 104, 105, 106, 107, 108, 112, 115, 119, 201, 202, 203, 204, 207, 209, 211, 212, 214, 218, 219) of 36 rooms, resulting in the increased likelihood for resident dissatisfaction and psychosocial impairment.
Findings include:
On 08/28/24 at 01:20 P.M., An environmental tour of resident room minimum square footage requirements (80 square feet per bed) was conducted by this surveyor. The following resident rooms were noted:
102: 3 bed ward (216 square feet)
103: 2 bed ward (155 square feet)
104: 2 bed ward (149 square feet)
105: 4 bed ward (291 square feet)
106: 4 bed ward (289 square feet)
107: 4 bed ward (291 square feet)
108: 4 bed ward (288 square feet)
112: 4 bed ward (282 square feet)
115: 4 bed ward (283 square feet)
119: 4 bed ward (288 square feet)
201: 3 bed ward (220 square feet)
202: 3 bed ward (219 square feet)
203: 2 bed ward (155 square feet)
204: 2 bed ward (152 square feet)
207: 4 bed ward (291 square feet)
209: 4 bed ward (291 square feet)
211: 4 bed ward (288 square feet)
212: 4 bed ward (294 square feet)
214: 4 bed ward (289 square feet)
218: 4 bed ward (272 square feet)
219: 4 bed ward (287 square feet)
Note: Queries were made of residents available for interview in the affected rooms. The residents verbalized they were not affected by the current room size.
On 08/29/24 at 02:40 P.M., Record review of the Policy/Procedure entitled: Resident Rights dated 11/28/17 revealed under Purpose: It is the practice of this facility to provide for an environment in which residents may exercise their rights, each day. Our residents have certain rights and protections under federal law. Our facility meets and provides these rights through care and related services at all times . Safe Environment: The right to a safe, clean, comfortable, and homelike environment that allows independence as possible.
Feb 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00142814.
Based on observation, interview, and record review, the facility failed to ensure a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00142814.
Based on observation, interview, and record review, the facility failed to ensure a level two assessment was completed prior to admission or exemption criteria was documented for one resident (R700) out of one reviewed for Preadmission Screening/Annual Resident Review (PASARR) (Mental Illness/Intellectual Disability/Related Conditions Identification). Findings Include:
On 2/28/2024 at 9:41 AM, R700 was observed going into their room. R700 was noted to be mumbling to themselves. R700 was asked how their day was going and they stated that it was going okay and continued to talk to themselves.
A review of the medical record revealed that R700 admitted into the facility on [DATE] with the following diagnoses, Schizoaffective Disorder, Brief Psychotic Disorder, and anxiety disorder. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 12/15 indicating an impaired cognition.
A review of R700's hospital paperwork revealed that R700 admitted into the facility from an inpatient psychiatric facility. No Level I screening or Level II evaluation from the hospital was noted in the medical record.
On 2/28/2024 at 9:59 AM, a request was made for R700's Level II.
On 2/28/2024, R700's level one PASARR form 3877 was received and reviewed. The Level I PASARR 3877 was dated 10/26/2023 and revealed Yes was checked for the first four items in section two. The section Explain any Yes revealed, The person screened shall be determined to require a comprehensive Level II OBRA (Omnibus Budget Reconciliation Act) evaluation if any of the above are Yes unless a physician or physicians assistant certifies on form DCH-3878 that the person meets at least one of the exemption criteria.
On 2/28/2024 at 11:51 AM, an interview was conducted with Social Worker (SW) B. SW B stated that they did not know why R700 was admitted into the facility from an inpatient psychiatric facility without a Level II evaluation being completed. SW B stated that they completed the Level I 3877 in house. SW B stated that R700 had a dementia exemption. SW B was queried as to why R700 had a dementia exemption, even though they were admitted from inpatient psychiatric, as well as having Schizoaffective as their admitting diagnosis. SW B stated that they just put what the physician told them to put on the form.
On 2/28/2024 at 12:16 PM, an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated that they are unsure why R700 was admitted without an PASARR screening, as well as a Level II evaluation. The NHA stated that centralized admissions in in charge of that.
On 2/28/2024, a review of a facility policy titled, PASARR Guideline noted the following, The PASARR process consists of the completion of a Level I screen per State and Federal requirements as well as the review and implementation of the Level II recommendations upon admission into the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
This citation pertains to Intake MI00142814.
Based on observation, interview, and record review, the facility failed to properly monitor the use of an antipsychotic for one resident (R700) out of one ...
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This citation pertains to Intake MI00142814.
Based on observation, interview, and record review, the facility failed to properly monitor the use of an antipsychotic for one resident (R700) out of one reviewed for antipsychotic use, resulting in adverse side effects. Findings Include:
On 2/28/2024 at 9:41 AM, R700 was observed going into their room. R700 was noted to be mumbling to themselves. R700 was asked how their day was going and they stated that it was going okay and continued to talk to themselves.
A review of the medical record revealed that R700 admitted into the facility from an inpatient psychiatric facility on 10/6/2023 with the following diagnoses, Schizoaffective Disorder, Brief Psychotic Disorder, and anxiety disorder. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 12/15 indicating an impaired cognition.
A review of the physician orders revealed that R700 was on the following medications, Ativan 1 MG (Milligram) (Antianxiety medication), Rexulti (Antipsychotic), and Benztropine (Anti-Tardive Dyskinesia). R700 was also on Haldol from 10/6-10/25.
A review of a progress note dated 10/25/2024 revealed the following, Pt (Patient) appears to have had a dystonic reaction to Haldol .
On 2/28/2024 at 9:59 AM, a request was made for psychiatry notes and the most recent Abnormal Involuntary Movement (AIMS) test.
On 2/28/2024 at 11:36 AM, an email was received stating that R700 was not being followed by psychiatry.
On 2/28/2024 at 11:51 AM, an interview was conducted with Social Worker (SW) B. SW B stated that R700 does not display any behavior and that is why they were not being followed by psychiatry. SW B was queried as to who manages R700's antipsychotic gradual dose reduction since they are not being followed by psychiatry. SW B stated that R700 should not be on the antipsychotic anymore and they would check into it. SW B was asked if R700 had any AIMS testing completed since admission. SW B stated that the nurses or psychiatry completes the AIMS testing, but they did not see any in the medical record.
A review of a facility policy titled, Use if Anti-Psychotic Medications noted the following, did not address monitoring of Anti-Psychotic Medications.
Nov 2023
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes MI00140574 and MI00140631.
This citation has two deficient practice statements.
Deficient prac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes MI00140574 and MI00140631.
This citation has two deficient practice statements.
Deficient practice statement #1.
Based on interview and record review, the facility failed to provide adequate monitoring and supervision to prevent an elopement for one resident (R901) from a total sample of two who were reviewed for elopement, when resident R901, who had a severe cognitive impairment and was assessed, and care planned as an elopement risk. R901 also had a recent history of exit seeking behavior. R901 eloped from the facility during a smoke break on 10/15/2023 at approximately 11:00 AM, without the staff being aware of R901's whereabouts. The facility was notified by R901's guardian at approximately 12:30 PM that they were picking R901 up from a hospital associated building in a city ([NAME] Arbor) that was located 39 miles away from the facility.
This resulted in an Immediate Jeopardy (IJ) to the safety and health to the residents in the facility and the likelihood for serious harm, injury, or death.
The Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy on 11/6/2023 at 3:56 p.m. and was asked for a plan to remove the immediacy.
The IJ was removed on 11/6/2023 based on the facility's implementation of the removal plan as verified onsite on 11/7/2023.
Findings Include:
A review of Intake MI00140574 documented the following, .[R901] left the facility and was found in [NAME] Arbor. The guardian called the [facility] and had no knowledge that [R901] was gone. They made multiple excuses as to how [R901] left. They first reported that [R901] left walking after smoking a cigarette and then they reported that [R901] called someone for a ride and left. [R901] is elderly with dementia, and [R901] has no family or support. [R901] only knows their guardian and [they] don't know their guardian's phone number due to the dementia. APS (Adult Protective Services) is concerned that [R901] was not being monitored properly at this facility.
A review of Intake MI00140631 documented the following, [R901] escaped and they didn't follow proper protocol. They created a fake AMA (Against Medical Advice).
A review of the medical record revealed that R901 admitted into the facility on [DATE] with the following diagnoses, Schizophrenia, Heart Failure, Chronic Kidney Disease, and Psychoactive Substance Abuse. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental score of 7/15 indicating severe cognitive impairment. R901 also required supervision set up for bed mobility and transfers.
Further review of R901's care plan revealed the following, Focus: The resident is an elopement risk/wanderer) r/t (related to) speaks often of going back to [NAME] Arbor and staring at the exit signs on the unit. Date initiated: 10/6/2023.
A review of the progress notes revealed the following:
Date:10/9/2023 14:18 (2:18 PM). Note Text: Resident received awoke walking the hall with coat on .Resident continued to seek an exit. Resident moved upstairs to [room number] to prevent elopement and maintain safety. Notified guardian through voicemail.
Date:10/15/2023 12:56 PM. Note Text: Resident went out on smoke break this am, staff unable to locate resident when smoke break was over. Building alert sounded (Code White). Staff went out looking for resident, police called, along with police report, guardian/DON (Director of Nursing) notified.
Date: 10/15/2023 15:49 (3:49 PM) Note Text: Facility wide search, all locked doors opened by security noted in resident beauty shop. Resident assisted to unit, stating I'm leaving, unable to contact guardian writer continuing to tell resident that attempts were being made to contact Guardian, resident becoming combative with staff stating I'm getting the hell out of here. Resident stated [they] had called a ride, attempted to obtain ride information, refused, finally resident agreed to sign AMA paper, resident walked out of building and got into car before staff was able to get license plate number. Still unable to contact Guardian.
On 11/6/2023 at 9:46 AM, an interview was conducted with Licensed Practical Nurse (LPN) A. LPN A stated that they were the assigned nurse for R901 on 10/15/2023. LPN A stated that R901 went downstairs to smoke at 10:00 AM and that they were told that R901 put a chair up to the back fence and hopped over it. LPN A stated that the Certified Nursing Assistant (CNA) noticed that R901 was not back on the unit, around 11:00 AM and that is when they called the code, and the weekend supervisor called the police. LPN A stated that R901 was not found prior to them leaving the facility for the day at approximately 4:00 PM.
On 11/6/2023 at 11:00 AM, an interview was conducted with Guardian I. Guardian I stated that they had called the facility around 10:00 AM to speak with R901 and was put on hold for approximately 30 minutes until they were told that by the facility that they would contact them back as they could not locate R901. Guardian I stated that they were called by the hospital related facility in [NAME] Arbor at approximately 11:00 AM stating that R901 was at their location. Guardian I stated that they contacted the facility at approximately 12:00 PM and informed them that R901 was in [NAME] Arbor, and that they would be bringing them back to the facility. Guardian I stated that they do not believe the facility realized that R901 was gone until they called and told them. Guardian I stated that R901 told them that they jumped over a fence located around the perimeter of the facility, and walked to the bus stop.
On 11/6/2023 at 11:10 AM, an interview was conducted with APS Worker (AW) J. AW J stated that they had been working with R901 for about ten months prior to R901 being admitted into the facility, so they were very familiar with them. AW J stated that the guardian called them and informed them that R901 had ran away from the facility and that the facility did not know where R901 was located. AW J stated that they called the facility and were told multiple stories from the facility. AW J stated that they were first told that R901 walked away from the facility during smoke break. Then AW J stated they were told that R901 walked away, and then finally R901 allegedly called a ride. AW J stated that R901 had Dementia, as well as mental health issues. AW J confirmed that R901 could not call anyone for a ride because they did not have any support in Michigan to call besides their guardian and R901 did not know their number.
On 11/6/2023 at 12:42 PM, an interview was conducted with Licensed Practical Nurse (LPN) B. LPN B stated that they worked a double shift the day of the elopement on the first floor. LPN B stated that from their understanding when the residents went outside to smoke, R901 ended up getting outside the gate. LPN B stated that one of the CNA's stated that R901 was missing, and they began to do a count. LPN B stated that they did not see R901 again in the facility and they heard that R901 had got away and was found in [NAME] Arbor.
On 11/6/2023 at 1:24 PM, an interview was conducted with the Director of Nursing (DON) regarding the incident. The DON stated that they were called by the facility nurses indicating that R901 had gotten out of the facility. The DON stated that when they arrived to the facility, staff were still looking for them, but no one had checked the basement. The DON stated that they went down to the basement and noticed that the beauty shop door was closed. The DON stated that they had maintenance open the door and R901 was found in the beauty shop, sitting behind the door, with the lights off. The DON was queried as to if this should have been checked prior to them arriving to the facility to which they replied, Yes, it should have. The DON stated that R901 was very belligerent and agitated, stating how they were getting out of the facility. The DON stated that they were still able to get R901 up to the second-floor unit. The DON stated that when they made it to the unit, R901 was calm and sat at the dining room table. The DON was queried on how R901 was able to get to the basement as the elevator and stairwells require codes to enter and and exit, and she stated You know these residents know the codes.
The DON was asked if they told anyone that R901 was found, including their assigned nurse or CNA. The DON stated that they think they told the CNA's that they (R901) was back and then they proceeded to walk downstairs. The DON stated that when they made it back down to the first floor, R901 was on the first floor as well. The DON stated that R901 stated that they were leaving the facility and that they had called a ride. The DON stated that R901 was yelling and cursing and refused to calm down, so they had R901 sign an AMA form. The DON was asked why the facility would allow a resident who was mentally ill, severely cognitively impaired, a known elopement risk, had a guardian and exhibiting a mental health crisis leave the facility AMA. The DON explain that they are unsure how they got out the locked front door, and that they also were unable to get the vehicle information that R901 left in.
On 11/6/2023 a tour of the beauty shop was completed with the Nursing Home Administrator. Upon going down to the beauty shop, two different codes had to be entered to get in the corridor for the steps, as well as to get in the basement. It was noted that a code is also needed to use the elevator (a total of 3 different codes). In the basement the beauty shop was unlocked and there was a camera noted right above the door. The NHA was queried if the video could be seen of R901 going into the beauty shop. The NHA stated that they did not have any video of that. The NHA stated that maintenance mostly uses the beauty shop for storage.
On 11/6/2023 at 2:08 PM, an interview was conducted with Certified Nursing Assistant (CNA) F. CNA F stated that they were working with the other CNA on the floor taking care of all the residents so there really wasn't an assignment. CNA F stated that they saw R901 that morning before they went to smoke. CNA F stated that a CNA that was working on the first floor came and told them that they believed they saw R901 at a bus stop but needed to see a picture because R901 was a newer resident. After seeing the picture of R901 they confirmed it was R901 and then they went and got in a car to look for them, but R901 was long gone by then. CNA F stated that they did not see R901 in the facility after that and had not heard anything about R901 being found in the basement.
On 11/6/2023 at 2:10 PM, an interview was conducted with CNA G. CNA G stated that they were on their way to break from working on the first floor and saw R901 at the bus stop located about two miles away from the facility. CNA G stated that they were unsure, so they didn't want to approach R901 until, they were sure. CNA G stated that they then went back to the facility and told R901's CNA's and Nurse and confirmed that R901 was missing and then everyone went out looking for R901. CNA G stated that it was about 11:00 AM when they confirmed that R901 was not in the facility. CNA G stated that R901 was not back in the facility prior to them leaving for their shift. CNA G stated that they never heard about R901 being found in the basement.
A review of a facility policy titled, Wandering and Elopement Guideline revealed the following, .Missing Resident .The person in charge will assign each staff member an area to search to include: All residents rooms, Offices ,Storage Rooms, Beauty Shop, Bathrooms, Therapy Rooms, Linen Rooms, Basement, Closets, Kitchen, Dining Rooms, Breakroom, Bathing Rooms, Freezers, Housekeeping and Maintenance Storage, and Ancillary .Notify the search team that the resident has been located( e.g., police, hospitals, friends, staff, etc).
Facility Abatement Plan
The facility is providing the following information to demonstrate that the immediacy of the cited deficiencies has been removed.
RESIDENT AT RISK
Resident #901 no longer resides in the facility
IDENTIFYING OTHER RESIDENTS AT RISK
Residents who are assessed as an elopement risk and smoke have the potential to be affected.
Residents deemed at risk for elopement had a care-plan review to ensure appropriate interventions were in place.
Residents who smoke care-plans are being reviewed to ensure appropriate interventions were in place.
PROCESSES IMPLEMENTED TO PREVENT FURTHER OCCURRENCE
On 11.6.2023 the facility measures to implement and endure a second employee to supervise outdoor smoking sessions. An employee will assist residents in and out of the facility, while another employee will remain in the smoking corridor at all times.
On 11.6.2023, in-servicing for all staff was initiated by the DON/Designee on the required supervision during smoking sessions and on immediately notifying someone in management if a resident is seen off the premises. At this point, 90% of required staff have been in-serviced.
Smoking times will be posted at the main entrance and nursing stations to enhance awareness of when residents are out of the facility.
Head counts of residents going out to smoke will be performed upon exiting the facility and re-entering the facility.
Elopement Guidelines was reviewed with staff during in-servicing.
The facility alleges the immediacy of these discrepancies have been removed on 11.6.2023.
Deficient practice #2.
Based on observation, interview, and record review, the facility failed to safely store medications for one resident (R902) out of one reviewed for medication storage, resulting in the potential for mistakes in medication administration. Findings Include:
On 11/6/2023 at 9:40 AM, a medication cart on the second floor was observed with the computer screen (revealing resident information) and cart unlocked, and six pills in a medication cup sitting on top of the cart. No staff were visible in the hallway and the assigned nurse was observed in another resident's room. Residents were observed walking around in the hallway where the medicaiton cart was located.
On 11/6/2023 at 9:43 AM, an interview was conducted with Licensed Practical Nurse (LPN) L. LPN L stated that they were the assigned nurse for the medication cart. LPN L was queried as to if the pills should have been left on the cart, and the computer screen and cart unlocked. LPN L stated that everything should have been secured and locked.
On 11/7/2023 at 12:31 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that they have completed in-services with LPN L. The DON stated that their expectation is that the computer screen and cart is to be locked when not in use, and pills are not placed into cup until the time of administration.
A review of a facility policy titled, Medication Storage in the Facility noted the following,
Policy: Medications and biologicals are stored safely, securely and properly, following manufacture's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.
Sept 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected 1 resident
This citation pertains to Intake M100138331.
Based on observation, interview and record review, the facility failed to prevent flies and gnats on and around one (R701) of three residents reviewed for ...
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This citation pertains to Intake M100138331.
Based on observation, interview and record review, the facility failed to prevent flies and gnats on and around one (R701) of three residents reviewed for pest control concerns, resulting in resident dissatisfaction with the living environment and unsanitary conditions.
On 09/25/23 at 12:20 PM, R701 was initially observed in their room laying in bed. During this initial interview two flies were observed on R701's body.
On 09/25/23 at 12:30 PM, two flies continued to be observed on and flying around R701's upper body.
On 09/25/23 at 1:37 PM, R701 was observed laying in bed and continued to have multiple flies around and on their body. R701 was asked about the flies and they shook their head no.
On 09/25/23 at 3:23 PM, R701 was observed laying in bed. Flies were observed flying around the resident and the bed. Upon exiting the room, multiple flies were observed in the hallway outside of R701's room.
On 09/25/23 at 4:14 PM, R701 was observed laying in bed and multiple gnats were observed around the bed and on the residents left-side curtain.
On 09/26/23 at 1:18 PM, R701 was observed up in the wheelchair in the activity area. R701's room was observed to have flies and gnats present around their bed and curtain area.
On 09/26/23 at 3:12 PM, R701 was observed laying in bed and two flies were present, one on the resident and one on the table adjacent to the bed. The unit pest control log was reviewed and no recent entry notes were present identifying an issue with pests in R701's room.
On 09/26/23 at 3:16 PM, the facility Administrator (NHA) reported that the expectation is that any noted or observed pests be addressed immediately and that residents not be exposed to pests in any sustained manner as observed.
The facility-provided and undated Pest Control Policy included the following entry: Ongoing measures are taken to prevent, contain and eradicate common household pests such as roaches, ants, mosquitoes, flies, mice and rats.
Jul 2023
14 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00135866.
Based on observation, interview, and record review, the facility failed to perform ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00135866.
Based on observation, interview, and record review, the facility failed to perform adequate and timely assessment for two of two residents (R42 and R71), resulting in a delay in treatment and evaluation of a fractured arm (R42) and delay in diagnostic evaluation of a resident who complained of abdominal pain (R71). Findings include:
R42
A review of multiple Intakes submitted to the State Agency revealed allegations surrounding R42 sustaining a broken arm at the facility.
A review of R42's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on 2/3/15 with medical diagnoses of Cardiovascular Disease, Dementia, Anxiety, Depression, Psychotic Disorder, and Malnutrition. Further review revealed that the resident was severely cognitively impaired and required limited to extensive assistance from staff for activities of daily living (ADLs).
On 7/17/23 at 9:41 AM, R42 was observed sitting at a table in the dining room. R42 was unable to accurately answer interview questions and was pleasantly confused. R42 was observed to be wearing plain white socks and had no shoes on. R42 had a yellow Fall Risk band on their wrist. R42 was observed to not be using their right arm.
A review of R42's progress notes revealed the following:
-6/5/2023 19:02 (7:02 PM) Skin Observation Note Text: Resident has NO NEW skin issue(s) observed .
-6/15/2023 19:14 (7:14 PM) Received resident awake and alert in bed. Unable to move .right arm and observed to be bruised. Resident unable to describe what happened due to confusion. (Doctor) was notified and ordered STAT (right away) X-Ray of right arm and requested. Written by Registered Nurse (RN) I (who works the 3 PM to 11 PM afternoon shift).
No progress notes were found entered into the record between the above dated 6/5/23 through 6/15/23. Additionally, a review of R42's Evaluations revealed no entries (skin assessments, nursing assessments, etc.) from 6/6/23 through 6/15/23.
Subsequent progress notes included the following:
-6/15/2023 21:07 (9:07 PM) .Waiting for x-ray.
-6/15/2023 22:57 (10:57 PM) .(Staff) from x-ray called at 11:00 pm stated x-ray machine was not working but will do x-ray in AM.
-6/16/2023 10:24 (AM) .X-ray completed, waiting on results.
-6/16/2023 16:22 (4:22 PM) .Writer talked to resident and asked (them) did (they) fall .shook (their) head yes, MD (physician) notified and said to send resident out, resident is now (on the way to the hospital) .
-6/17/2023 11:52 (AM) .Resident return (sic) from hospital alert and orientated to self. Has sling on right arm. Has taken sling off .needs to be seen by orthopedic evaulateing (sic) .
-6/17/2023 13:17 (1:17 PM) .Late Entry: .Resident has NEW skin issue(s) observed .Right shoulder (rear) - Bruising .
-6/17/2023 19:29 (7:29 PM) .Received resident in bed awake and verbally responsive. Has a displaced fracture of right humerus (bone between shoulder and elbow). Refused to wear a sling provided .will require orthopedic consult and need to bring the papers from (hospital) .Right arm remained bruised .
A review of R42's radiology results for the x-ray performed in the facility revealed: Reported Date: 06/16/2023 09:56 .PROCEDURE: Shoulder, Complete, 2+ Views .IMPRESSION: Proximal right humeral fracture as discussed above .
A review of R42's June 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that pain medication was not ordered for R42 until the resident re-entered the facility from the hospital on 6/17/23. No administrations of any pain medication prior to 6/17/23 were found. The MAR/TAR indicated that on day shift on 6/16/23, R42's pain was rated as a 5/10 (moderate pain).
Continued review of R42's June 2023 MAR/TAR revealed the following: Weekly Skin Check on first Bath/Shower Day of each week every evening shift every Tuesday for Routine Skin Monitoring -Start Date- 09/05/2017. Documentation for the skin check scheduled on 6/13/23 was not present in the record. No documentation was found elsewhere in the record to indicate it was completed.
On 7/18/23 at 8:49 AM, Certified Nursing Assistant (CNA) C was interviewed. CNA C revealed that she had been the aide caring for R42 when the resident sustained their broken arm. CNA C explained that on the day of the injury, she had been working midnight shift, but was unable to recall the exact date. CNA C stated that it had been early in the morning and she was helping R42 get up out of bed for the day. CNA C claimed that there was a puddle of urine on the floor and that she told the resident to wait while she grabbed something to clean it up with. CNA C explained that R42 got up and she grabbed the resident's arm as the resident slipped and fell. CNA C claimed she reported it to the nurse on duty, Licensed Practical Nurse (LPN) J. CNA C stated she was suspended partially due to the fact that the resident was unable to say how their injury occurred. CNA C stated that LPN J assessed the resident, however, review of R42's record did not reveal documentation to support that claim.
On 7/18/23 at 9:09 AM, R42 was observed sitting at a table in the dining room. R42 was observed to be using their left arm, but not their right arm. R42 remained confused and unable to be interviewed. R42 was observed to now have on yellow non-slip socks.
On 7/18/23 at 1:09 PM, LPN B was interviewed. LPN B indicated she had cared for R42 on 6/16/23 and initiated the resident's transfer to the hospital. When queried regarding how the injury occurred, LPN B indicated that she was not directly involved at the time of the injury and as far as she knew, R42 had fallen the previous day while a staff member was getting them up out of bed at 4-5 AM. LPN B confirmed that CNA C had been suspended and the situation had been investigated because initially, they could not determine exactly what happened. LPN B claimed the resident indicated to her that they fell when she asked. LPN B was unable to speak to the lack of documentation from when the resident was reported to have fallen at 4-5 AM (on midnight shift) to when RN I entered an assessment at 7:14 PM (afternoon shift).
On 7/19/23 at 8:46 AM, R42 was observed sitting at a table in the dining room. R42 was observed to not be using their right arm.
On 7/19/23 at 8:50 AM, RN I was called for an interview and a voicemail was left for call-back. No return call was received prior to survey exit.
On 7/19/23 at 9:57 AM, LPN J was called for an interview and a voicemail was left for call-back. No return call was received prior to survey exit.
On 7/19/23 at 12:31 PM, the Director of Nursing (DON) was interviewed. The DON confirmed that CNA C had been suspended after R42 sustained their broken arm. The DON indicated that the facility wanted to ensure that the CNA had not been too rough during the incident. The DON added that CNA C should have been calling out for someone to help her. When queried if CNA C reported the incident and possible injury to the nurse on duty, the DON stated, My understanding is she did, however, the DON also confirmed there was no documentation in the record to support that claim. While discussing lack of documentation to support that skin assessments have been completed, the DON indicated that is an area that needs improvement.
On 7/19/23 at 2:11 PM, the Nursing Home Administrator (NHA) was interviewed. When queried regarding the circumstances surrounding R42's fractured humerus, the NHA indicated that the situation was brought to her attention to rule out any abuse concerns. The NHA also acknowledged the lack of documentation in R42's record related to the fall and injury. The NHA indicated she would have expected the nurse to have documented an assessment after being made aware of the incident involving R42.
R71
A review of R71's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was most recently re-admitted into the facility on 6/4/22 with medical diagnoses of Dementia, Arthritis, and Malnutrition. Further review revealed that the resident is moderately cognitively impaired and requires limited assistance from staff for activities of daily living (ADLs).
On 7/17/23 at 9:27 AM, R71 was observed sitting in the dining room. R71 was noted to have a healing bruise around their eye (black eye). When queried, R71 indicated they do not know how it happened.
On 7/17/23 at 9:33 AM, LPN K was interviewed regarding R71. LPN K indicated that she did not know how R71 obtained a black eye but would check the resident's record. LPN K stated that the resident has dementia and is confused.
A review of R71's progress notes revealed the following:
-7/11/2023 07:25 (AM) .resident was calling out around 0100 (AM) on 7/11/2023, CNA went into the room saw resident and (resident) seemed to have had a incident was back in .bed. Noticed a small mark on face not really looking like a bruise until 0630 (AM) then the right eye was totally red and bruise and (resident) was c/o (complaining of) right side pain in the abdomen and notice a bruise (black eye) present at that time also. Contacted MD (physician)/family/caregiver assessed vitals and ordered labs. Will continue to monitor for pain and communicate any additional findings to MD.
No additional progress notes were entered into R71's record prior to survey exit on 7/19/23.
A review of R71's orders revealed the following:
-X-Ray of the right side and abdomen for c/o (complaints of) abdominal pain .7/15/23.
-X-Ray of the right side and abdomen for c/o (complaints of) abdominal pain .Ordered 7/11/23 .Revised 7/17/23.
No radiology results were found in R71's record and no documented reason for the delay in obtaining the x-ray per order was found during further review.
On 7/19/23 at 12:31 PM, the Director of Nursing (DON) was interviewed. When queried regarding the status of R71's abdominal x-ray, the DON confirmed that the test had been ordered multiple times due to an alleged fall. The DON was unable to say why the order had not yet been carried out and was unable to provide results of the x-ray when asked.
A review of the facility's policy/procedure titled, Fall Evaluation Safety Guideline, dated 11/28/17, revealed, .Post Fall Action: .Determine causal factors of fall, evaluate resident and re-evaluate risk, evaluate effectiveness of interventions .
A review of the facility's policy/procedure titled, Laboratory, Radiology, and Other Diagnostic Services Guideline, dated 6/1/2020, revealed, Purpose: To ensure laboratory, radiology and other diagnostic services meet the needs of residents, that results are reported promptly to the ordering provider to address potential concerns and for disease prevention, provide for resident assessment, diagnosis and treatment .Our facility is responsible for the quality and timeliness of the services .
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 F0559
(Tag F0559)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00137913.
Based on interview and record review, the facility failed to provide a written noti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00137913.
Based on interview and record review, the facility failed to provide a written notice, including the reason, for a room change, affecting one (R91) of one resident reviewed for room changes, resulting in the lack of opportunity to see their new room, ask questions, as well as the resident feeling a loss of control. Findings include:
A review of R91's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on 3/25/23 with medical diagnoses of Cardiovascular Disease, Stroke, and Depression. Further review revealed that the resident is cognitively intact and requires supervision to limited assistance from staff for activities of daily living (ADLs).
A review of R91's progress notes revealed the following:
-6/22/2023 13:25 (1:25 PM) Health Status Note: Resident room changed [to room on 1st floor]. Resident awear (sic) of change.
-6/22/2023 21:34 (9:34 PM) Health Status Note: Resident was transferred to room [first floor room] from [second floor room] per SW (social worker) .All personal belongings taken with .Friendly with new roommates. No behavior problem observed .
On 7/19/23 at 10:49 AM, the facility's social worker (SW) was interviewed regarding R91's room change on 6/22/23. When queried, the SW was unable to provide information as to why the resident's room was changed. The SW indicated that he would find out.
At 11:01 AM, the SW stated that R91 was moved to the 1st floor per the Director of Nursing (DON). The SW was asked if the resident requested a room change. The SW replied that he did not know because he was not the one who moved the resident.
At 11:15 AM, R91 was interviewed regarding moving from the 2nd floor to the 1st floor. R91 stated, They pretty much told me, 'Pack up, you're moving.' I didn't request to, and they told me I had to. R91 stated that they were moved out of their room when they did not want to be moved.
At 12:31 PM, the DON was interviewed. The DON was asked if R91 had requested a room change. The DON stated that the resident did not request to have their room changed and indicated that she decided to move R91 to the 1st floor. The DON added that R91 is, More alert, than other residents on the 2nd floor. When asked if written notice was provided to the resident prior to the room change and reason for it, the DON indicated that written notice had not been provided. The DON added that R91's guardian had been contacted by phone about the change but did not sign any paperwork approving it.
At 2:11 PM, the Nursing Home Administrator (NHA) was interviewed regarding R91's room change. The NHA stated that the facility decided the best thing for R91 was to move them from the 2nd floor to the 1st floor. The NHA claimed that R91 had many complaints about the 2nd floor, so it was decided to bring them down to the 1st floor. Prior to survey exit, the facility did not provide documentation to support that R91 nor their guardian was given written notice and reason for a room change prior to R91's move.
A review of the facility's policy/procedure titled, Notification of Changes Guideline, revised 5/11/18, revealed, .In addition to a change in the resident's condition, the resident and/or representative(s) shall be notified promptly if there is: .A change [in] the resident's room or roommate assignment .explain the reason for the change to the residents and/or representative .Document the notification and the resident's response in the resident's medical record .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to develop a baseline care plan for a tether (electronic monitoring device to monitor and supervise a defendant in the community...
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Based on observation, interview, and record review, the facility failed to develop a baseline care plan for a tether (electronic monitoring device to monitor and supervise a defendant in the community) for one of one sampled resident (R263) who is under the supervision of the State Department of Corrections (MDOC) who was reviewed for baseline care plans, resulting in no established goals and interventions related to their parole status and tether monitoring. Findings include:
On 7/17/23 at 9:30 AM, R263 was observed sitting in bed and asked about their stay in the facility. R263 was observed to have a tether located on their right ankle.
A review of R263's medical record revealed that they were admitted into the facility on 7/7/23 with diagnoses that include Hypertension, Crohn's Disease, Kidney Failure and Colostomy Status. Further review of the medical record revealed a Minimum Data Set assessment dated for 7/8/23 indicating that R263 had an intact cognition, and required extensive assistance for bed mobility, transfers and dressing.
Further review of R263's medical record revealed baseline care plans however, it did not address the resident's parolee status and tether monitoring.
On 7/19/23 at 12:55 PM, the Director of Nursing (DON) was asked about R263's parole status and tether monitoring not being included in their baseline care plan. The DON verbally explained the steps the facility would take in order to address issues related to the resident, but did admit that they hadn't thought about care planning the resident's tether.
A review of the facility's Care Plan Standard Guideline revealed the following, It is the practice of this facility to develop and implement a baseline care plan for each resident that include the instructions needed to provide effective and person centered care of the resident hat meet professional standards of quality of care .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to include a resident's primary language in the comprehe...
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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 include a resident's primary language in the comprehensive plan of care for one resident (R86) of one reviewed for language/communication, resulting in the potential for unmet care needs or preferences. Findings include:
On 7/17/23 at 10:02 AM, during the initial tour, an interview was attempted with R86. R86 indicated that their primary language is Arabic and attempted to speak to this surveyor through broken English. R86 was unable to adequately answer interview questions. R86 repeated the words, Money, and Bank card. R86 pulled a tablet device out of a drawer, however, seemed to indicate that it did not work. R86 did not turn on the tablet device. No alternate means of communication were noted in the resident's room such as a translator telephone or a communication/language board. R86's roommate (R15), came into the room and stated they they try to communicate with R86 but is mostly unable to. R15 was asked how staff communicates with R86. R15 stated, They mostly don't .[R86] needs a translator! R15 did add that R86 can do a lot of things independently (like activities of daily living).
On 7/18/23 at 8:44 AM, Certified Nursing Assistant (CNA) L was interviewed regarding R86's language barrier. CNA L indicated that R86 can speak a few English words and will usually let staff know if they need something. When asked if the facility provides translator services, CNA L stated she was not aware of any. CNA L was then asked if R86 had some type of communication aide. CNA L stated not that she had seen. R86 was observed sitting in the common dining area amongst many other staff and residents not interacting with anyone.
A review of R86's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on 1/29/22 with medical diagnoses of Hypertension, Diabetes, and Schizophrenia. Further review revealed that the resident moderately cognitively impaired and requires supervision to limited assistance from staff for activities of daily living (ADLs). A review of R15's MDS assessment dated [DATE] revealed that the resident is cognitively intact.
On 7/18/23 at 9:04 AM, while attempting another interview with R86, the resident continued to bring up the words, Money, and Telephone, and Bank. R86's nails were observed to be extremely overgrown on both hands. When queried regarding their nails, R86 said the word, Clippers, and shrugged.
A review of R86's progress notes revealed the following:
-2/27/2023 14:12 (2:13 PM) Activities Participation Note: Resident .has a language barrier and communicates some of needs and wants via the communication board .
A review of R86's comprehensive care plan revealed no information regarding the resident's preferred language, ability to communicate through Arabic, nor interventions promoting optimal communication with and understanding of the resident. Further review of R86's record did not reveal a full language assessment. R86's admission assessment dated [DATE] revealed that the resident could not read English.
On 7/19/23 at 10:40 AM, the Activities Director (AD) was queried regarding a communication aide for R86. The AD stated there is usually a communication aide/board in the resident's room. A communication aide was not found in R86's room at this time. The AD brought two pieces of paper from her office and indicated that she would give them to R86, who sometimes folds them up and puts them in their pockets. The pieces of paper had photos and English words on them but did not include any Arabic. Licensed Practical Nurse (LPN) E was also interviewed at this time regarding R86's primary language. LPN E claimed that the resident will come tell the staff what they need by using English words. When queried about R86's primary language being included in their care plan, LPN E indicated she was unsure and would have to check. LPN E was unaware of the status of R86's nails.
At 12:31 PM, the Director of Nursing (DON) was interviewed. The DON was queried regarding R86's language barrier. The DON claimed that R86 could understand and speak some English, and that staff usually repeats themselves when speaking to the resident (in English). The DON was asked if the resident had ever been provided the opportunity to be fully assessed with an Arabic translator present or the use of translating service (phone, etc.). The DON indicated that no, a full conversation in Arabic had never been attempted with R86. The DON was queried regarding the lack of presence of R86's language needs in the comprehensive care plan and stated the facility, Should probably have it covered in the care plan.
A review of the facility's policy/procedure titled, Translation and/or Interpretation of Facility Services, revised March 2012, revealed, This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility .It is understood that providing meaningful access to services provided by this facility requires also that the LEP resident's needs and questions are accurately communicated to staff .translation and/or interpretation must be provided in a way that is culturally relevant and appropriate to the LEP individual .
A review of the facility's Care Plan Standard Guideline revealed the following, It is the practice of this facility to develop and implement a baseline care plan for each resident that include the instructions needed to provide effective and person centered care of the resident hat meet professional standards of quality 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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R67
On 7/17/23 at 8:37 AM, R67 was observed sitting on the side of their bed after finishing their breakfast. R67 was observed t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R67
On 7/17/23 at 8:37 AM, R67 was observed sitting on the side of their bed after finishing their breakfast. R67 was observed to have facial hair located on her chin and sides of their cheeks that resembled a beard.
A review of R67's medical record revealed that they were admitted into the facility on with diagnoses that included Cerebral Infarction, Schizoaffective Disorder, and Muscle Weakness. A review of the Minimum Data Set assessment dated for 5/15/23 revealed a Brief Interview for Mental Status score of 5/15 indicating a severely impaired cognition, and required one person physical assistance for personal hygiene and bathing.
Further review of R67's medical record revealed that within a 30 day period, R67 had one documented shower which occurred on 7/17/23 (same day as observation).
A review of R67's care plan documented the following, (R67) has actual ADL (activites of daily living) self-care performance deficit and remains at risk for changes in adl r/t (related to) requiring assistance with (their) adls, confusion and impaired balance .Interventions: Bathing: Physical Assist Date Initiated: 05/13/2020 . Dressing: Physical Assist Date Initiated: 05/13/2020 .
A facility policy titled Activities of Daily Living (ADLs) Effective Date: 05/07/2020 documented, Purpose: Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, our facility provides necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate such diminution was unavoidable. Guideline: In accordance with the comprehensive assessment, together with respect for individual resident needs and choices our facility provides care and services for the following activities: Hygiene: Bathing .
This citation pertains to Intakes MI00135821 and MI00135866.
Based on observation, interview, and record review the facility failed to offer, provide, and document showers and bed baths for two residents (R33 and R67) of five residents reviewed for activities of daily living (ADL) care, resulting in feelings of dissatisfaction with care and unmet care needs. Findings include:
R33
On 7/17/23 at 9:35 AM, during an initial tour of the facility R33 was interviewed in their room and asked about the care and services that they received at the facility. R33 indicated that they did not receive enough bed baths. R33 was asked about the frequency of showers they received at the facility and stated, I like bed baths.
On 7/18/23 at 4:13 PM, a follow-up interview was conducted with R33 regarding the frequency of bed baths being offered and provided to them. R33 stated, It makes me upset when I don't get bed baths.
At 4:20 PM, a review of R33's shower/bed bath schedule located in a binder on R33's unit revealed that R33's shower/bed bath days were Mondays and Fridays.
At 4:22 PM, Certified Nursing Assistant (CNA) A was interviewed about bed baths and showers being offered to R33. CNA A indicated that (R33) was offered a bed bath Every day. CNA A then referenced a binder located behind the second floor nurses station and indicated that R33's shower/bed bath documentation was located in the binder.
On 7/19/23 at 10:30 AM, CNA C was interviewed regarding bed baths and showers being offered and provided to residents and stated, Showers/bed baths are documented in the resident's electronic medical record (EMR). CNA C was further interviewed and asked about the binder located behind the nurses station containing resident shower and bed bath documentation and stated, That's the shower/bed bath assignments. CNA C again indicated that all showers and bed baths should be documented in the EMR.
At 10:43 AM, a review of R33's shower/bed bath documentation in their EMR from June 18, 2023 through July 18, 2023 revealed that R33 had been offered and provided showers on July 17, 2023 and July 18, 2023. No other documentation regarding R33's showers/bed baths was noted in their EMR.
Further review of R33's EMR revealed that R33 was most recently admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) (Lung disease) and Epilepsy (Neurological disorder). R33's most recent minimum data set assessment (MDS) dated [DATE] revealed that R33 had a moderately impaired cognition and required one person total dependence for bathing.
At 11:01 AM, the Director of Nursing (DON) was interviewed regarding their expectations for staff regarding showers and bed baths being offered, provided, and documented for the residents. The DON indicated that showers and bed baths should be documented in the EMR. The DON indicated that they would attempt to locate shower/bed bath documentation for R33 and provide it to the surveyor.
At 11:25 AM, the DON provided the surveyor with a paper sheet titled, ADL-Bathing-how resident takes bath/shower . dated July 2023. This documentation did not reveal specific dates when R33 was offered/received showers and/or bed baths.
At 12:13 PM, CNA C was further interviewed regarding residents shower/bed bath documentation and shown the sheet provided by the DON regarding R33's showers/bed baths for July 2023. CNA C stated, I've never seen this.
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
Based on observation, interview and record review, the facility failed to accurately complete and document weekly skin assessments, and complete ordered skin treatments for one sampled resident (R7) o...
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Based on observation, interview and record review, the facility failed to accurately complete and document weekly skin assessments, and complete ordered skin treatments for one sampled resident (R7) of two residents reviewed for pressure ulcers resulting in, unidentified skin conditions, and the potential for the development and/or worsening of exisiting pressure ulcers. Findings include:
On 7/17/23 at 8:35 AM, R7 was observed in bed eating breakfast, and asked about the care in the facility. On the foot of R7's bed was an empty rack that typically holds the pump of an low air loss mattress (pressure relieving mattress used to prevent and treat pressure ulcers).
A review of R7's medical record revealed that they were admitted into the facility on 8/29/06 with diagnoses that included Dementia, Chronic Obstructive Pulmonary Disease, Diabetes, and Muscle Weakness. Further review of R7's medical record revealed a Minimum Data Set assessment (MDS)dated for 4/22/23 indicating that R7 was severely cognitively impaired and required extensive assistance with toilet use, personal hygiene and dressing.
Further review of R7's medical record revealed that the resident had a Stage II pressure ulcer (partial thickness loss of skin) to their sacrum (buttocks) identified on 7/17/23 after it initially resolved on 6/14/23. Following the resolution of the wound, a physician's order was put into place as an intervention and revealed the following, Clean with soap and water and apply calmoseptine (ointment used to protect and heal the skin). Every shift for wound. This order was dated for 6/19/23.
On 7/17/23 at 2:29 PM, weekly skin assessments for R7 for the months of May, June and July (2023) were requested and not received by the end of the survey.
On 7/18/23 at 10:00 AM, the Director of Nursing (DON) was asked where residents' weekly skin assessments are documented, and indicated that she would get back with the surveyor.
At 10:54 AM, the DON explained that she was unable to locate skin assessments. At that time, a nurse working on the floor was nearby (Licensed Practical Nurse -LPN E), and she was asked where she documented skin assessments, in which she explained that they were located on the Medication Administration Record (MAR).
A review of R7's medical record did not reveal skin assessments on the MAR however, the June MAR did reveal that a number of skin treatments that were ordered on 6/19/23 were missed on the following dates and shifts: Afternoon shift, 6/24, 6/25, and 6/30. Night shift, 6/19, 6/20, 6/22, 6/23, 6/24, 6/27, and 6/20. The July MAR revealed the following missed treatments: Day shift, 7/4, 7/9, 7/12, 7/14. Afternoon Shift, 7/8, 7/9 and 7/14. Midnight shift, 7/2, 7/3, 7/4, 7/5, 7/6, 7/7, 7/10, and 7/11.
On 7/19/23 at 11:03 AM, an interview was completed with Wound Care Nurse F (WCN F) regarding R7. WCN F explained that she had just returned from vacation and learned that R7's wound had opened back up as of 7/18/23. WCN F was asked about weekly skin assessments and explained that in her role, she completes wound rounds once a week were she will measure and take pictures of the wounds. She reports that the nurses on the floor are responsible for also completing weekly skin assessments as well, and are also supposed to complete the ordered wound treatments. WCN F explained that residents may have had two skin assessments in one week in the electronic medical record.
At this time, a review of the skin assessments were made with WCN F. The last skin assessment reviewed was completed by WCN F on 7/18/23. There were no other skin assessments located for the month of July, and the last skin assessment that was completed by WCN was on 6/14/23.
At 12:53 PM, the DON was asked about expectations for skin assessment and explained that interventions should be implemented, and that she is in the process of training staff on completing and accurately documenting skin issues.
A review of the facility's Skin Protection Guideline outlined the following, Purpose: To ensure residents that admi and reside at our facility are evaluated and provided individualized interventions to prevent, reduce and treat skin breakdown .Interventions .Inspection of skin daily with cares and weekly by a licensed nurses Monitoring of Skin Integrity .weekly skin observation by a licensed nurse .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
This citation pertains to Intake MI00135821.
Based on observation, interview and record review, the facility failed to complete smoking evaluations per policy for one sampled resident (R73) of one rev...
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This citation pertains to Intake MI00135821.
Based on observation, interview and record review, the facility failed to complete smoking evaluations per policy for one sampled resident (R73) of one reviewed for smoking resulting in, missing smoking evaluations, and the potential for hazards of an unsafe smoker. Findings include:
On 7/17/23 at 8:57 AM, R73 was observed lying in bed with uncontrollable movements of their arms and legs.
At 10:33 AM, R73 was observed in the courtyard during the facility's smoking time smoking a cigarette. R73 was observed to have a helmet connected to their wheelchair, and was observed standing up with an unsteady gait. Staff had consistently redirect R73 to sit back down into their wheelchair while the resident was observed with a cigarette in their hand.
A review of R73's medical record revealed that they were admitted into the facility on 9/15/21 with diagnoses that included, Huntington's Disease, Borderline Personality Disorder, Ataxic Gait, and Schizoaffective Disorder. Further review of the medical record revealed a Minimum Data Set (MDS) assessment dated for 5/15/23 indicating the resident had an intact cognition, and required supervision to limited assistance with Activities of Daily Living.
A review of R73's medical record revealed that they had a smoking risk evaluation upon admission into the facility (9/15/21), and another evaluation 3 months later (12/2021). There wasn't a completed annual smoking evaluation for the year of 2022, or when the resident experienced a significant change in 2022 when they were enrolled into a Hospice program.
On 7/19/23 at 1:00 PM, the Director of Nursing (DON) was asked about R73's missing smoking risk evaluations, and explained that the evaluations should be completed yearly and if the resident is not abiding by the facility smoking policy. The DON also explained that the evaluations are kept in the electronic medical record.
A review of the facility's Smoking Guideline policy revealed the following, Purpose: Residents who want to smoke are evaluated and assessed for smoking safely .Procedure: 2. The evaluation is to be used at the time of admission, annually, with quarterly review and with changes in condition.
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 F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a social service evaluation for a resident on psychotropic me...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a social service evaluation for a resident on psychotropic medication was completed for one resident (R78) of five whose medication were reviewed resulting in the potential for decreased monitoring, efficacy of interventions and unmet care needs. Findings include:
A review of the facility record for R78 revealed R78 was admitted into the facility on [DATE] with diagnoses which included Depression and Dementia moderate with other behavioral disturbance and cognitive communication deficit. The Minimum Data Set (MDS) assessment dated [DATE] indicated R78 had intact cognition and the need for limited assist or supervision for Activities of Daily Living.
The current physician's orders documented;
-Fluphenazine (Prolixin-antipsychotic medication) HCl Oral Tablet 2.5 (milligram) MG, Give 1 tablet by mouth at bedtime for Antipsychotic and
-Fluoxetine (Prozac-) HCl Oral Capsule 20 MG, Give 1 capsule by mouth at bedtime for Antidepressant. There was no documented diagnoses for the use of the antipsychotic or antidepressant.
On 07/19/23 at 1:43 PM, the Social Worker was asked about the Social Services admission evaluation, antipsychotic and antidepressant care plans for R78 and reported they would have to check for it and further noted it may not have transferred in the computer system changeover.
The social service admission evaluation was requested but not found in R78's EMR.
At 1:49 PM, the missing care plans and social service evaluation were reviewed with the Director of Nursing (DON). The DON was not able to locate the current care plan in the current electronic medical record (EMR).
The DON and a corporate support person said that the floor nurse and certified nurse assistants would not be able to view the care plan or [NAME] (guide to individualize a residents care) when that information was not in the EMR.
Review of a care plan in the EMR titled: Resident has nutritional problem or potential nutritional problem related to nutrition risk secondary to : schizophrenia date 06/12/23 did not address R78's medication or potential behavioral needs.
A review of the policy titled, Care plan Standard Guideline dated 11/28/17, indicated , All resident/client will be evaluated for individual risk factors which may increase the risk of hospitalization .The resident care plan will incorporate risk factors identified in preadmission assessment, hospital records and admission evaluations .Interventions should be specific to reflect the specific goal. The intervention should be individualized to the resident .The care plans will be reviewed and revised at the care conference .
Review of Center's for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) 3.0 Manual, The admission assessment is a comprehensive assessment for a new resident .review medical record documentation during the 7 day look back period to determine the resident's baseline, fluctuations in behavior, and behaviors that might have occurred .Interview staff, family members and others in a position to observe the resident's behavior during 7 day look back period .subsequent assessments and documentation can be compared with a baseline to identify changes in the resident's behavior, including response to interventions This allows care plans to be individualized.
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 interview and record review the facility failed to ensure a pharmacy recommendation was followed up timely for one (R78...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a pharmacy recommendation was followed up timely for one (R78) of three resident records reviewed, resulting in the potential for decreased efficacy of the medication. Findings include:
A review of the facility record for R78 revealed R78 was admitted into the facility on [DATE]. Diagnoses included: Cancer, Depression and Dementia. The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition and the need for limited assist or supervision for Activities of Daily Living.
Review of a current physician order documented, Alendronate Sodium (for bone health) 70 (milligrams) Give one tablet by mouth one time of day every Wednesday for endocrine and metabolic agents.
Review of a pharmacy note and corresponding pharmacy report dated 7/7/23 documented, In order to follow the manufacturer's specifications, please amend the order to include the following: Please give at least 30 minutes before the first meal, beverage (except water) or other medications and should sit upright for at least 30 minutes once given. The indication for use should also be changed to Osteoporosis.
Review of the care plans documented no diagnosis for the use of Alendronate.
On 07/19/23 at 1:49 PM, R78's pharmacy report and current orders were reviewed with the Director of Nursing (DON) and corporate personal. The DON was queriered regarding the delay in implementing the pharmacist recoomendations to which she responded, the recommendation is normally provided to the physician for review and then implemented according to their decision. The nurse would enter the recommendation into the orders once accepted by the physician. The DON was not able to confirm this had been done.
Review of the facility Resident Rights policy dated 11/28/17 revealed Purpose: It is the practice of this facility to provide for an environment in which residents may exercise their rights, each day. Our residents have certain rights and protections under Federal law. Our facility meets and provides these rights through care and related services at all times. Planning and Implementing Care .The right to receive the services and /or items included in the plan of care .
Review of the policy titled, Care plan Standard Guideline dated 11/28/17, indicated , All resident/client will be evaluated for individual risk factors which may increase the risk of hospitalization .The resident care plan will incorporate risk factors identified in preadmission assessment, hospital records and admission evaluations .Interventions should be specific to reflect the specific goal. The intervention should be individualized to the resident .
CONCERN
(D)
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 educate and offer the COVID-19 vaccination to one sampled resident (R28) of five residents reviewed for immunizations, resulting in the pot...
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Based on interview and record review, the facility failed to educate and offer the COVID-19 vaccination to one sampled resident (R28) of five residents reviewed for immunizations, resulting in the potential for miscommunication and misunderstanding of resident immunization preferences, and the potential for the development of severe disease if infected with COVID-19 (highly contagious respiratory virus). Findings include:
A review of R28's medical record revealed that they were admitted into the facility on 4/21/23 with diagnoses that included Diabetes and Hypertension. Further review of R28's medical record did not reveal whether or not R28 had received the COVID-19 vaccine.
On 7/18/23 at 2:29 PM, a request was made to the facility for the declination and/or consents for the COVID-19 vaccine for R28. They were not received by the end of the survey.
On 7/19/23 at 1:02 PM, the Director of Nursing (DON) was asked about the process for obtaining consents for vaccines, and she explained that vaccines should be offered, and consents completed yearly.
The facility's Infection Prevention and Control policy was reviewed but did not address the offering of the COVID-19 vaccine.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document and provide evidence of the administration of the flu vacc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document and provide evidence of the administration of the flu vaccine, provide consents and/or declinations, and education for flu and pneumococcal immunizations for four sampled residents (R33, R73, R76, R77) reviewed for immunizations resulting in, the potential for increased risk of acquiring and transmitting influenza and pneumonia, and the potential for miscommunication and misunderstanding of residents' immunization preferences. Findings include:
On 7/18/23 at 2:29 PM, a request was made to the facility for declinations and/or consents for the Flu (2022-2023 flu season) and Pneumococcal vaccines for the following residents: R33, R73, R76, and R77.
A review of R33's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Diabetes and Epilepsy. One flu consent was located in their medical record when R33 was initially admitted into the facility. In addition, the last flu shot was documented as being provided on 1/7/22, and no other consents or declinations were provided by the end of survey.
A review of R73's medical record revealed that they were admitted into the facility on 9/15/21 with diagnoses that included Huntington's Disease, Muscle Weakness, and Borderline Personality Disorder. R73's flu consent for the 2022-2023 flu season was provided however, the last flu shot that was documented as administered was on 11/2/21.
A review of R76's medical record revealed that they were admitted into the facility on 5/7/21 with diagnoses that included Schizophrenia, COPD and Depression. A Flu consent was provided by the facility which was dated for 11/9/22 however, upon further review of R76's medical record in the immunizations section, it indicated that the residents declined both the flu and pneumococcal immunizations.
A review of R77's medical record revealed that they were admitted into the facility on 5/23/23 with diagnoses of Mood Disorder, Depression and Pneumonia. A declination or consent for R77 was not received for the pneumococcal vaccine by the end of survey.
On 7/19/23 at 9:39 AM, the Infection Control Preventionist (ICP G) was asked the date that residents received the flu vaccine for the 2022-2023 flu season. ICP G explained that flu shots were offered in September, October and November, but did not provide a specific date for when they were administered to residents.
On 7/19/23 at 1:02 PM, the Director of Nursing (DON) was asked if when the flu shots were provided to the residents for the 2022-2023 flu season and was unable to recall. The DON was asked the process for obtaining consents for vaccines, and she explained that pneumococcal and flu vaccines should be offered, and consents completed yearly.
A review of the facility's Influenza Immunization Guideline outlined the following, Purpose: It is the practice of this facility that annually residents are offered immunization against influenza 3. All new admission will be screen and given the influenza vaccine unless specifically ordered otherwise .6. A record of vaccination will be placed in the resident's medical records and their vaccination record .Before offering the influenza vaccine, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the vaccine .Documentation in the resident's medical record will include a. That the resident or the resident's representative was provided education regarding the benefits and potential side effects of the influenza vaccine and b. The resident received the influenza vaccine. i. Temperature and symptoms ii. Date and time of administration .c. The resident did not receive the influenza vaccine and the reason .
A review of the facility's Guideline for Administering the Pneumococcal Vaccination outlined the following, It is the practice of this facility to offer residents pneumococcal vaccinations as required during their stay with us. Residents will be provided a vaccination information (VIS) which gives details about the vaccine and then provides the opportunity to decline vaccination .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes MI00135821 and MI00135866.
Based on observation, interview and record review the facility fail...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes MI00135821 and MI00135866.
Based on observation, interview and record review the facility failed to ensure the repair of damaged door frames, peeling or missing wall paper, and loose toilet mounts, resulting in the potential for an unsafe and unhomelike environment. Findings include:
On 07/17/23 at 9:48 AM, during the initial tour and on 07/18/23 and on 07/19/23 the following was observed: The right lower portion of the metal entry door frame was missing three to five inches up from the floor and exposed crumbling cinder block. The left lower portion of the metal entry door frame to room [ROOM NUMBER] was missing and ran in a jagged diagonal pattern from the floor up about three inches which exposed the concrete cinder block behind; The toilet in the last stall of the community style women's bathroom was loose. The mount on the right side was broken, missing or loose and allowed the toilet to rock and or rotate; The second stall had do not enter sign for needed repairs; The right lower portion of the metal entry door frame to room [ROOM NUMBER] was missing about three inches up from floor which exposed the cinder block behind; A 12 to 18 inch section of missing wallpaper between a vent and the bathing room on the men's side of the first floor; A corner of the wallpaper was peeled away at right side of room [ROOM NUMBER]; The iron work on the outside of the building facing the street appeared rusty and in need of repair. Residents were observed to move independently in the resident halls of the facility during the survey.
On 07/19/23 at 8:53 AM, the identified concerns were reviewed with the Corporate Maintenance Person M and Maintenance Staff N. The maintenance reporting Work Orders log for June and July of 2023 was reviewed. Five items were noted and all as closed: A toilet in the east multipurpose restroom; A sink in room [ROOM NUMBER] was off the wall; multiple broken kitchen floor tiles; Ceiling tile penetrations; and Gnats in the 2 [NAME] bathroom with a wet rusty towel under the sink. The maintenance staff were unaware of the identified concerns or if they had been addressed or if a work order had been placed. It was noted that a computer system change in the last month may have interrupted reporting. When asked if there was a paper based system for maintenance concerns the maintenance staff reported there was not and the facility was working on the external link: and using verbal work orders. The door frame to kitchen was viewed and the Dietary Manager was asked if they were aware if any query had been made about repair of the damaged door frame and they said no. The Maintenance Supervisor was on vacation and not available for comment. The pest control logs were reviewed and noted bimonthly visits for pest control. It was noted an inch long roach had been seen in the first floor dining area entry to the women's rooms.
On 07/19/23 at 2:14 PM, the Administrator was asked about the pest control for the month of November and reported that the regular pest control did not come in because specialty contractor came in to treat for bed bugs. It was noted to the Administrator that the pest control visits did not specifically address bed bugs or correlate with the sightings documented in the pest control logs at the nurse stations and sightings were documented since the November treatment.
A review of the undated facility policy titled, Preventative Maintenance (TELS) and Inspections revealed, It is the policy of (the facility) that in order to provide a safe environment for residents, employees and visitors a preventative maintenance program (TELS) has been implemented to promote the maintenance of equipment in a state of good repair and condition .Maintenance includes monitoring, tests, measurements, adjustments, and parts replacement that maintenance personnel perform .
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to ensure food items in the kitchen area were labled and stored properly and serving utensils stored clean resulting in the poten...
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Based on observation, interview, and record review the facility failed to ensure food items in the kitchen area were labled and stored properly and serving utensils stored clean resulting in the potential for food borne illness. This deficient practice has the potential to affect all 102 residents that reside in the facility. Findings include:
On 07/17/23 at 8:42 AM, a tour of the kitchen revealed the following:
-three plastic bags of meat were observed at the bottom of the far right hand refrigerator located in the dry storage room. There was no date on the bags nor on the bin to indicate the age or length of thaw time in the refrigerator. The meat had pooled drippings in the bin. At this time, the Dietary Manager (DM) indicated the meat had been placed there the day before.
-a carton of eggs stored on the bottom of the refrigerator was observed to have one broken egg with the yolk visible.
-three tubes of ground meat in a gray tub also at the bottom of the refrigerator. Two tubes of ground meat were dated for 07/13 and one was dated for 07/06. The DM indicated the dates were when the meat was removed from the freezer. The DM said the meat dated 07/06 should have been used.
-A selection of food scoops were observed on top of a food prep area. A green handled food scoop had a tan colored, dried piece of food on the inside that could not be removed.
On 07/18/23 at 11:18 AM, the quaternary sanitizer from the wall mounted tap was tested. The DM filled a small bucket with the sanitizer water and was noted to be in the 400-500 parts per million range. The DM said the recommendation was for the sanitizer to be in the 250 parts per million range.
A review of the facility policy titled, Food Safety Requirements Guideline dated 11/28/17, documented, It is the practice of this facility to provide safe and sanitary storage, handling and consumption of all foods .certain foods are considered more hazardous than others .ground beef,,,unpasteurized eggs .foods that have a high level of water encourage bacterial growth .
The undated Storage of Perishable Food policy documented, The Dining Service Department will store perishable food in a clean and sanitary manner in the refrigerator .5. Perishable/refrigerated items are labeled and dated upon receiving. 6. If opened note the date opened and to be discarded . 14. Replace thawing pans daily or more frequently as necessary .
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide 80 square feet of living space per bed within 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 provide 80 square feet of living space per bed within multiple resident rooms in 21 of 36 rooms (#'s 102, 103, 104, 105, 106, 107, 108, 112, 115, 119, 201, 202, 203, 204, 207, 209, 211, 212, 214, 218, 219), resulting in the potential for resident dissatisfaction with living space and conditions. Findings include:
On 07/17/23, 07/18/23 and 07/19/23, data for the square footage of the rooms was reviewed and the following resident rooms were monitored for minimum living space square footage requirements:
Room # SqFt #Beds
102
217
3
103
152
2
104
152
2
105
287
4
106
287
4
107
287
4
108
287
4
112
287
4
115
287
4
119
287
4
201
217
3
202
217
3
203
152
2
204
152
2
207
287
4
209
287
4
211
287
4
212
287
4
214
287
4
218
287
4
219
287 4
On 07/19/23 at 10:03 AM, RM [ROOM NUMBER] was observed to have a storage/wardrobe cabinet intruding partially into the entrance of the room's doorway due to space limitations as the cabinet was positioned as far as possible to the right of the doorway up against the head of the first bed to the right. Queries were made of residents available for interview in the affected rooms and the residents verbalized they were not affected by the current room size.
A review of the policy titled Resident Rights dated 11/28/17 revealed, Purpose: It is the practice of this facility to provide for an environment in which residents may exercise their rights, each day. Our residents have certain rights and protections under Federal law. Our facility meets and provides these rights through care and related services at all times .Safe Environment: The right to a safe, clean, comfortable and home-like environment that allows independence as possible.
Apr 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00132417.
Based on interview and record review, the facility failed to ensure care conference...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00132417.
Based on interview and record review, the facility failed to ensure care conferences were completed and/or documented for one resident (R901) out of one reviewed for care conferences (meeting to discuss resident's plans of care), resulting in the resident and resident representative not being informed or included in their plan of care. Findings Include:
A review of complaint called into the State Agency noted the following, .There has not been a care conference either.
A review of the medical record revealed that R901 admitted into the facility on 8/18/2022 with the following diagnoses, Generalized Anxiety and Hypertension. A review of the Minimum Data Set, dated [DATE] revealed a Brief of Interview for Mental Status score of 3/15 indicating an impaired cognition. R901 also required extensive one person assistance with bed mobility and limited two-person assistance with transfers.
Further review of the medical record did not reveal a documented care conference.
On 4/17/2023 at 12:32 PM, an interview was conducted with Social Worker (SW) A regarding care conferences. SW A stated that they try to complete care conferences within the first 48 hours or the first 7 days. SW A stated that care conferences are documented in the progress notes. SW A was asked if R901 had a care conference while they were in the facility. SW A stated that they would have to look into it.
No further information was provided by the end of survey.
A review of the facility policy titled, Care Management Guidelines noted the following, .1. Meetings are scheduled in 20 minute increments at established times in the facility. The established times allow completion of the meeting within 48 hours 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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00132170.
Based on interview and record review, the facility failed to prevent the developmen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00132170.
Based on interview and record review, the facility failed to prevent the development of pressure ulcers for one resident (R901) out of one reviewed for skin management, resulting in a facility acquired pressure ulcer and the potential for pain and wound complications. Findings include:
A review of complaint called into the State Agency noted the following, Complainant states while in care the resident developed an ulcer on their coccyx and right heel.
A review of the medical record revealed that R902 admitted into the facility on 6/23/2022 with the following diagnoses Psychotic Disturbances and Anxiety. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental (BIMS) Status score of 9/15 indicating an impaired cognition. R902 also required extensive one person assist with bed mobility and transfers. R902 was noted as limited one person assistance with walking.
A review of the progress notes revealed the following, Date: 10/12/2022 at 17:55 (5:55 PM). Note Text: During skin assessment writer noted open area to right buttock, pink/yellowish in color, approximately, 2.5 cm (centimeters-Length) and 0.5-1.0 cm (Width). MD (Medical Doctor) notified, wound care consult and TX (Treatment) for Medihoney to open area daily and PRN (as needed) and implemented. DON (Director of Nursing) notified and made aware. Turning and repositioning Q2H (Every two hours).
On 4/17/2023 at 2:42 PM, an interview was conducted with wound care nurse (WCN) B. WCN B stated that R902's wound was facility acquired. WCN B stated that R902 did walk independently, so they believe R902 developed the wound because they were eating less. WCN B stated that R902's skin was intact when they came into the facility.
A review of a facility policy titled, Skin Protection Guideline revealed the following, Purpose: To provide evidenced based practice standards for the care and treatment of skin. To ensure residents that admit and reside at our facility are evaluated and provided individualized interventions to present, reduce and treat skin breakdown.
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** This citation pertains to Intake MI00132170.
Based on interview and record review, the facility failed to include a 14-day stop ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00132170.
Based on interview and record review, the facility failed to include a 14-day stop date on an order for as needed (PRN) psychotropic medication for one resident (R902) out of one reviewed for unnecessary medications, resulting in prolonged use of a PRN psychotropic medication, and the potential for adverse reactions and serious medication side effects. Finding include:
A review of the medical record revealed that R902 admitted into the facility on 6/23/2022 with the following diagnoses Psychotic Disturbances and Anxiety. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 9/15 indicating an impaired cognition. R902 also required extensive one person assist with bed mobility and transfers. R902 was noted as limited one person assistance with walking.
A review of the progress notes revealed that R902 was started on Valium (antianxiety) by the primary physician due to increased anxiety and agitation.
A review of the physician orders revealed the following, Valium Oral Tablet 5 MG (Milligram). Directions: Give 5 MG by mouth every 12 hours as needed for Behaviors (Anxiety). Start Date: 8/24/2022.
No stop date was noted on the order.
On 4/17/2023 at 12:32 PM, an interview was completed with Social Worker (SW) A stated that R902 did not have many behaviors and did not need to be started on Valium. SW A stated that R902 was not followed by psychiatric services.
On 4/18/2023 at 2:29 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that expect for PRN psychotropic's to have a 14 day stop date and be re-evaluated.
A request for the facility policy on psychotropic's was requested, but not received by end of survey.
May 2022
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to serve meals at tables simultaneously for two residents...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to serve meals at tables simultaneously for two residents (Resident #21 and Resident #42) of two residents reviewed for dining. Resulting in frustration and feelings of hunger, using the reasonable person concept. Findings include:
Resident #21
On 05/10/2022 at 01:04 PM-01:25 PM, Resident #21 was observed dressed, sitting in a chair at a table. There were five other residents at the table eating meals. Resident #21 was staring intently at other residents eating and simulating by using their hands as if they were using utensils and eating, too. Resident #21 was confused and did not initiate conversation. At 01:25 PM, Resident #21 was served their lunch tray.
On 05/11/2022 at 09:05 AM, Resident #21 was observed dressed, sitting up at table waiting for breakfast. There were four other residents at the table that had food in front of them that were almost done eating. Resident #21 was sitting at the head of the table, watching the other residents eat.
On 05/11/2022 at 09:15 AM, Resident #21 was observed with no food yet. Certified Nursing Assistant (CNA) A was asked when Resident #21 was going to be served their breakfast tray. CNA A went to the Resident and asked if they had eaten yet. The Resident said they had not eaten. CNA A stated they would get the Resident a tray.
On 05/11/2022 at 09:22 AM, Resident #21 was served breakfast. The other residents at the table had finished eating.
On 05/11/2022 at 12:41 PM, Resident #21 was observed to be sitting in the dining area, with no food in front of them. There were five other residents at the table. Half the table had been served their lunch and were already eating.
On 05/11/2022 at 12:57 PM, Resident #21 was served their lunch tray. The Resident immediately starting eating their food hastily.
A review of the medical record revealed that Resident #21 was admitted to the facility on [DATE]. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident had diagnoses of Dementia with Behavior Disturbance, Schizoaffective Disorder and Unspecified Psychosis. Resident #21 had a Brief Interview for Mental Status (BIMS) score of 05, indicating an impaired cognition and needed limited assistance with eating.
On 05/12/2022 at 12:35 PM, the Director of Nursing (DON) was interviewed in regard to Resident #21 not receiving their meals the same time as the rest of the table and stated, We usually have a feeding table (a table set up with residents that need assistance with meals only), and those residents are served later. (Resident #21) should be sitting at a different table. The DON was notified of the Resident simulating eating while other residents were eating. The DON stated that the Resident simulates other acts as well (smoking), all the time.
Resident #42
On 05/10/2022 at 09:11 AM, Resident #42 was observed dressed and groomed sitting in the dining area. There were two other residents at the table who were eating their meals. At 09:41 AM, the Resident had asked a staff member if there was a breakfast tray for them, at that time, an unknown staff member called for a breakfast tray. The Resident received their meal at 09:44 AM.
On 05/11/2022 at 12:53 PM, Resident #42 was observed to be dressed and groomed sitting at the table looking around. There was one other resident at the table who was already eating. The Resident was approached and asked if they had eaten lunch yet and stated, No! This same thing happened to me yesterday! I don't know what is going on!
On 05/11/2022 at 01:12 PM, Resident #42 was still at the table waiting for their meal. There were staff members around, feeding other residents. At this time, an unknown staff member was asked by this surveyor if Resident #42 had eaten lunch. The staff member went to the Resident and asked if they had eaten yet. Resident #42 stated, No. The staff member left the area and came back with a lunch tray for the Resident at 01:18 PM.
On 05/12/2022 at 09:13 AM, Resident #42 was observed dressed and groomed sitting at their usual spot in the dining area. There were two residents eating at the table. Resident #42 was asked if they had eaten their breakfast yet, and stated, No, I can't catch a break here! An unknown staff member was queried about the missing meal tray for Resident #42 and retrieved a tray for the Resident at 09:19 AM.
A review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #42 was admitted to the facility on [DATE] with a BIMS score of 03, indicating an impaired cognition. Resident #42 was independent with eating.
On 05/12/2022 at 12:35 PM, the DON was interviewed in regard to Resident #42 sitting and waiting to be served meals while others at the table had been served already. The DON explained that the Resident was originally going to be discharged (the previous Monday) and believed the kitchen may have thought the Resident was discharged .
On 05/12/2022 at 01:15 PM, the Nursing Home Administrator (NHA) was interviewed in regard to the dining process, particularly serving the meals at the same time per table. The NHA stated, They are usually served at the same time. [Activities Staff] at activities got together and that's what they do. Sometimes we get new residents or people don't get along and then people have to be moved in the dining room with their tray to a table that may not have their trays. We put that through QAPI (quality assurance process improvement) in February and have been working on it.
A review of the facility policy titled THE DINING EXPERIENCE, dated 2017, revealed the following:
POLICY: Meals served will respect the clients ' dignity as an individual .Meals are served at approximately the same time to all the clients sitting at a table .
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 complete an (annual) Preadmission Screening Annual Resident Review ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete an (annual) Preadmission Screening Annual Resident Review (PASARR) assessment for two residents (Resident #21 and #45) of four reviewed for PASARR assessments, resulting in the potential for inadequate mental health services. Findings include:
Resident #21
On 05/10/2022 at 01:04 PM-01:25 PM, Resident #21 was observed dressed, sitting in a chair at a table. There were five other residents at the table eating meals. Resident #21 was staring intently at other residents eating and simulating by using their hands as if they were using utensils and eating, too. Resident #21 was confused and did not initiate conversation.
On 05/11/2022 at 09:05 AM, Resident #21 was observed dressed, sitting up at the table waiting for breakfast. The Resident was talking to themselves, but appeared calm.
On 05/11/2022 at 12:41 PM, Resident #21 was observed to be sitting in the dining area. The Resident was calm, and would occasionally mumble words.
A review of the medical record revealed that Resident #21 was admitted to the facility on [DATE]. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #21 had diagnoses of Dementia with Behavior Disturbance, Schizoaffective Disorder and Unspecified Psychosis. Resident #21 had a Brief Interview for Mental Status (BIMS) score of 05, indicating an impaired cognition.
A review of the PASARR located in electronic medical record for Resident #21 revealed the assessment as dated for 2019.
Resident #45
On 05/10/2022 at 11:42 AM, Resident #45 was observed sitting in their wheelchair in the corner of the common area looking out the window. The resident had a towel over their head and had their head resting in their hand. At that time, an unknown staff member was near. The staff member was asked if Resident #45 was interviewable. The staff member explained that the Resident was not interviewable and was often verbally agitated.
On 05/11/2022 at 09:39 AM, Resident #45 was observed sitting at the table in the common area eating. The Resident was not initiating conversation, but appeared calm.
A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #45 was admitted to the facility on [DATE] with a diagnosis of Schizophrenia. Resident #45 had a BIMS score of 09, indicating an impaired cognition.
A review of the PASARR located in the electronic medical record for Resident #45 revealed a date of 2020.
On 05/12/2022 at 11:38 AM, Social Worker (SW) F was interviewed in regard to the PASARR completion for residents. SW F verbalized that the process had changed and that the PASARRs were submitted online and he was unable to pull them up and did not have them available. SW F was unable to explain when the assessment would be available. SW F stated, I can't pull it up, I submit the information but I can't pull it up. So I wait til either someone comes here to deliver them or mail them to the facility.
On 05/12/2022 at 12:35 PM, the Director of Nursing (DON) was interviewed in regard to the process of getting the PASARR assessments. The DON stated, When a resident is admitted , we get the initial assessment from the hospital. Then we are supposed to follow up but, the process has changed. My Social Worker has been complaining that he doesn't know what to do.
On 05/12/2022 at 01:15 PM, the Nursing Home Administrator (NHA) was interviewed in regard to the PASARR assessments being completed and explained that they are done electronic now. The NHA stated With the electronic system we aren't able to pull it off and put it in [electronic medical record] .We have never had a problem with them being completed.
A request for the policy for the completion of PASARR assessments was requested on 05/12/2022 at 01:43 PM, but not received by the end of the survey process.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to 1) Update fall care plan interventions following resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to 1) Update fall care plan interventions following resident falls for two sampled Residents (R28 and R62) of three sampled residents reviewed for falls, and 2) Ensure an activity care plan was initiated and implemented for two sampled Residents (R28, R82) of five whose care plans were reviewed, resulting in unsuccessful fall care plan interventions, continued falls, the potential for boredom, isolation and depression. Findings include:
Resident #62 (R62)
On 5/10/22 at 9:14 AM, during the initial tour of the facility, R62 was interviewed about their level of satisfaction with their care and reported that they had a recent fall at the facility. Upon further interview of R62, they indicated that they had fallen multiple times at the facility.
On 5/12/22 at 10:55 AM, R62's progress note section was reviewed in their electronic medical record (EMR) and revealed the following:
11/3/2021 16:05 (4:05 PM) *Health Status Note (nurses note) Note Text: Resident received alert and verbally responsive. Able to make needs known. All due AM meds accepted tolerated well. Resident told writer that they fell yesterday after dinner 11/2/21. ROM performed. Resident is able to move all upper or lower extremities with no (complaint of) c/o pain. No changes within residents baseline. Dr notified. Resident is self responsible party. (Vital Signs Stable) VSS. Safety precautions maintained (will continue to monitor) WCTM. (Physical Therapy) PT notified for evaluation.
3/26/2022 13:44 (1:44 PM) *Fall Risk Evaluation Late Entry: Note Text: This evaluation is being completed on a quarterly or annual schedule. Fall Risk Score is: 17
Fall risk scored above 5, resident is at a high risk for falls.
4/6/2022 11:04: *Incident Note: Note Text: The assigned (certified nursing assistant) CNA informed writer at 8:30 AM that resident fell on the floor in their room near their bed. Resident stated 'I was trying to get out the bed and (hit) my left knee (and) my head on the floor.' Resident was assessed by writer, no visible signs of injury, able to move arms and legs with no problems, no complaints of pain voiced. (Blood pressure) BP 148/92 (Heart Rate) HR 96, (Respirations) R 20, (temperature) Temp 97.7, (oxygen saturation) O2 99% on room air, resident was advised to call for help when [they need] assistance. (Medical Doctor) MD was notified with order to order (immediately) STAT x-ray of skull and both knees. Resident is their own responsible party.
On 5/12/22 at 11:10 AM, R62's fall care plan was reviewed and indicated the following, Focus: [R62] is at risk for falls .Date Initiated: 08/16/2021. Goal: The resident will be free of minor injury through the next review period. Date Initiated: 09/24/2020 Target Date: 07/12/2022. Interventions: Bed in low position when in bed. Date Initiated: 03/26/2021. Anticipate and meet the resident's needs. Date Initiated: 03/17/2020. Ensure the resident's call light is within reach .encourage the resident to use it. Date Initiated: 03/26/2021. Follow the facility fall protocol. Date Initiated: 03/26/2021. PT (Physical Therapy) to evaluate and treat as ordered .Date Initiated: 03/26/2021. Focus: The resident has had an actual fall with no injury. Date Initiated: 04/06/2022. Goal: The resident will resume usual activities without further incident through the review date. Date Initiated: 04/06/2022 Target Date: 07/12/2022. Interventions: Date and description of other interventions put in place after fall (specify). Date Initiated: 04/06/2022.
On 5/12/22 at 11:15 AM, a thorough review of R62's fall care plan revealed that there were no specific fall interventions indicated on the resident's care plan following their falls on 11/2/21 and 4/6/22.
On 5/12/22 at 11:22 AM, a further review of R62's EMR revealed that R62 was admitted to the facility on [DATE] with diagnoses that included Cerebral infarction (stroke) affecting left non-dominant side and Hypertension. R62's most recent minimum data set assessment (MDS) dated [DATE] revealed that R62 had a moderately impaired cognition and required supervision-limited assistance of one person for all activities of daily living (ADLs).
On 5/12/22 at 11:53 AM, the Director of Nursing (DON) was interviewed and asked about their expectations regarding interventions being placed on care plans following a resident fall. The DON indicated that a fall intervention should be placed on the resident's care plan following a fall.
On 5/12/22 at 10:52 AM, a fall intervention facility policy was requested from the facility and was never received prior to exit from the facility.
On 5/12/22 at 1:00 PM, a facility policy titled .Care Planning Guidelines Revised 3/2/2018 was reviewed and did not address the deficient practice in this citation.
Resident #28 (R28)
On 05/10/22 at 3:50 PM, R28 was observed seated in a wheelchair in the day room. R28 was dressed and wore a ball cap style hat. The TV was on. The volume was high and a child's movie was playing on the TV. No other activity was observed.
On 05/11/22 at 8:39 AM, R28 was observed seated in a wheelchair in the day room, R28 leaned toward the right while seated in the wheelchair. R28 was dressed. The TV was on.
On 05/11/22 at 1:38 PM, R28 was observed in the day room with the TV on. R28 reported they kept busy as desired. Staff brought R28 outside, but R28 was not particularly engaged.
A review of the record for R28 revealed R28 was admitted into the facility 01/08/22 with an original admission date of 11/03/21. Diagnoses included Dementia, Diabetes and Heart Disease. Planned activities documented for the last 30 days were arts and crafts on 04/15/22, activity cart on 04/18/22 and exercise on 05/11/22. On 05/02/22 R28 was documented as Active. Daily Activity for the last thirty days was documented as watching TV. The admission Minimum Data Set (MDS) assessment dated [DATE] Interview for Activity Preferences indicated it was somewhat important to do do things with a group of people and very important to get fresh air when the weather is good. A review of the nursing care plan with date initiated of 01/08/22 revealed no care plan had been initiated for activity interests/leisure preferences.
Resident #82 (R82)
On 05/10/22 at 10:31 AM, R82 was observed to be seated on their bed with their feet up on the seat of a wheelchair. R82 leaned against the wall with their legs across the bed. R82's bed was parallel to and against the wall. R82 reported they had entered the facility around Thanksgiving and reported the desire to return home. R82 reported they hoped they would be home by June.
On 05/11/22 at 12:41 PM, R82 was observed on their bed as before. R82 was asked if they went out of their room and indicated they had not. R82 indicated they liked being in their room. R82 had the TV on.
On 05/12/22 at 11:17 AM, R82 was observed to be seated in a similar position as before, with their back leaned against the wall, legs across the bed and feet up on the seat of a wheelchair. R82 had also pulled the bed covers over their head. Certified Nurse Assistant O was asked if R82 had come out of their room and reported they had not seen R82 out of their room. R82 was not observed to be out of their room during the days of the survey.
A review of the record for R82 revealed R82 was admitted into the facility on [DATE]. Diagnoses included Dementia, Muscle Weakness and Protein Calorie Malnutrition. Planned activities documented for the last 30 days were arts and crafts on 04/15/22, active on 04/18/22 and 05/11/22. On 05/02/22 R28 was documented as Cooking. Daily Activity for the last thirty days was documented as watching TV. The admission Minimum Data Set (MDS) assessment dated [DATE] Interview for Activity Preferences indicated it was somewhat important to do things with a group of people and very important to get fresh air when the weather is good. A review of the nursing care plan with date initiated of 01/03/22 revealed no care plan had been initiated for activity interests/leisure preferences.
On 05/12/22 at 1:09 PM, the Director of Nursing (DON) was interviewed and queried if an activity care plan should be included in the nursing care plan and reported it should.
A review of the facility Resident Rights policy dated 11/28/17 revealed Purpose: It is the practice of this facility to provide for an environment in which residents may exercise their rights, each day. Our residents have certain rights and protections under Federal law. Our facility meets and provides these rights through care and related services at all times. Planning and Implementing Care. Residents and/or resident representatives have the right to be fully informed of the medical condition in a language you they can understand, and to participate in your person-centered care planning and treatment, including the type of caregiver who provides services .The right to be informed, in advance of changes to the plan of care. The right to receive the services and /or items included in the plan of care. The right to see the care plan including the right to sign after significant changes to the plan of care.
CONCERN
(D)
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 interview and record review the facility failed to ensure care conferences were held quarterly for two sampled Resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure care conferences were held quarterly for two sampled Residents (R82 and R90) of three reviewed for care conference needs, resulting in the resident's decreased knowledge of care plan changes and not routinely updated on the complete plan of care. Findings include:
On 05/10/22 at 10:31 AM, R82 and R90 were interviewed and asked about their care at the facility and if they had any care conferences with the facility staff. Each resident stated they had not and would like to. R82 wondered about their discharge plan and R90 asked about their therapy needs and about a brace for their foot. Neither resident recalled if a care plan was reviewed with them nor a responsible party.
Resident #82 (R82)
A review of the record for R82 revealed R82 was admitted into the facility on [DATE]. Diagnoses included Dementia, Protein Calorie Malnutrition and High Blood Pressure. The Minimum Data Set assessment dated [DATE] indicated moderately impaired cognition and the need for supervision and set up for all activities of daily living. The progress notes documented an initial Ongoing or Discharge Care Management Meeting was held on 01/19/22 and a follow up note written on 01/26/22. Additional meetings were not documented. Additional care conference notes were not received. A review of the nursing care plan initiated 04/08/22 revealed, Discharge Potential: Resident require(s) 24 hour care and supervision at all times .Resident will remain in facility at the highest level of care and daily functioning .
On 05/12/22 at 1:37 PM, the Social Worker reported R82 could function outside of a nursing home.
Resident #90 (R90)
A review of the record for R90 revealed R90 was admitted into the facility on [DATE] and re-admitted [DATE] after hospitalization. Diagnoses included Multiple Sclerosis, Muscle Wasting and Depression. The MDS dated [DATE] indicated intact cognition and the need for supervision for bed mobility and transfer, limited assist for dressing and extensive assist for toilet needs and personal hygiene. Care conference documentation was requested. Documents for care conferences on 04/20/21 and 07/28/21 were received. No additional care conference meeting documentation was received prior to survey exit.
On 05/12/22 at 1:09 PM, the Director of Nursing reported care conferences should be held on a regular basis.
A review of the undated Care Management Guideline revealed, Guideline: Care Management is implemented when a qualifying change in condition occurs which requires skilled services, interdisciplinary (IDT) collaboration, and timely proactive communication beyond the standard practices of communication established in the facility. Care Management is conducted upon admission or readmission from an acute setting. The purpose of the Initial Care Management Meeting is to communicate to the patient and patient representative, within 48 hours of admission, the baseline plan of care, barriers to the discharge plan and care and services to be provided. The Initial Care Management Meeting is an important part of establishing a partnership with the patient and patient representative, which contributes to meeting transitional care goals. Ongoing Care Management Meetings allows the IDT to communicate regarding the patient's progress and adjust the plan of care should the patient's clinical status and/or stated discharge plans change. The patient and patient representative are informed of any changes to the plan of care established at the Initial Care Management Meeting.
A review of the facility Resident Rights policy dated 11/28/17 revealed Purpose: It is the practice of this facility to provide for an environment in which residents may exercise their rights, each day. Our residents have certain rights and protections under Federal law. Our facility meets and provides these rights through care and related services at all times. Planning and Implementing Care. Residents and/or resident representatives have the right to be fully informed of the medical condition in a language you they can understand, and to participate in your person-centered care planning and treatment, including the type of caregiver who provides services .The right to be informed, in advance of changes to the plan of care. The right to receive the services and /or items included in the plan of care. The right to see the care plan including the right to sign after significant changes to the plan of care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide restorative services to maintain and/or improv...
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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 restorative services to maintain and/or improve activities of daily living for one sampled Resident (R8) of one resident reviewed for restorative services, resulting in the likelihood for a decrease in mobility, comfort, and independence with activities of daily living. Findings include:
On 5/10/2022 at 12:15 PM, R8 was observed lying in bed in their nightgown. R8 was asked how they were doing, and stated, Ok but did not provide any additional information. R8's left hand was observed as contracted, with no splint device noted.
A review of R8's medical record revealed that they were admitted into the facility on 5/18/17 with diagnoses that included Dementia, Anxiety and Muscle Weakness. A review of R8's Minimum Data Set assessment dated [DATE] revealed that the resident had a significantly impaired cognition and required extensive assistance with Activities of Daily Living (ADLs).
Further review of R8's medical record revealed that they were discharged from physical therapy on 7/29/2021 with the following recommendations outlined on their Physical Therapy Discharge Summary, Discharge Recommendations and Status Restorative Program Established/Trained = Restorative Range of Motion Program (ROM), Restorative Splint and Brace Program. Range of Motion Program Established /Trained: Patient is currently able to raise arms above head, and raise arms straight out from shoulders, and is functional and with Restorative Nursing Program, patient will be able to raise arms straight out from shoulders by performing the following Restorative Nursing interventions: encourage resident to assist with the ROM .
Further review of R8's medical record did not reveal any restorative therapy progress notes post physical therapy discharge on [DATE]. A request was made to the facility to provide R8's restorative notes and was provided with two progress notes dated from 2020.
On 5/12/2022 at 9:11 AM, R8 was observed in bed awake. R8's left hand was observed as it had been during the entire duration of the survey, contracted and not splinted.
On 5/12/2022 at 9:43 AM, an interview was completed with Physical Therapist Q about R8's left hand, and he provided a document titled,Therapy to Restorative Nursing Communication-Resident Status Update which revealed the following, Device: Left Hand Splint .Comments: Left U/E (upper extremity) carrot or hand towel roll to prevent further limitations with nail care with daily ADLs 4 hrs (hours) on 4 hrs off .Range of Motion. Type: Passive and Active Assist .Recommended Exercises: PROM (passive range of motion/AAROM (active assist range of motion) WFL (within functional limit) 10 reps (repetitions) to maintain ROM WFL while in bed or geri-chair level. Physical Therapist Q was asked if therapy follows up with the resident regarding restorative services, and explained that nursing staff is responsible for bringing concerns to therapy if they have concerns, or need to be re-evaluated.
On 5/12/2022 at 1:52 PM, the Director of Nursing (DON) was asked about R8's lack of restorative services, and she explained that everyone is supposed to complete restorative and that it hasn't been completed. She further stated, As we gain staff, there will be a structured restorative program.
A review of the facility's Restorative Nursing Guideline revealed the following, Purpose: To ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical, condition demonstrates they a reduction in range of motion is unavoidable; and a resident with limited range of motion receives appropriate treatment and services to include range of motion and/or to prevent further decrease in range of motion .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains in part to MI00127663.
Based on observation, interview and record review the facility failed to ensure a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains in part to MI00127663.
Based on observation, interview and record review the facility failed to ensure a fall was investigated, the Physical Rehabilitation Team was notified, appropriate post fall interventions were care planned and/or care planned timely and the resident transported timely to the hospital for one sampled Resident (R90) of two reviewed for falls, resulting in the potential for additional falls with injury. Findings include:
Resident #90 (R90)
On 05/10/22 at 4:29 PM, R90 was observed to be dressed and seated in their wheelchair. R90 did not have any footrests and propelled the wheelchair with their arms and feet. The right foot was turned in and contracted. R90 reported this was due to the (Multiple Sclerosis) MS. R90 was asked about their fall on 04/06/22. R90 reported they were outside wheeling themselves up the ramp and their feet got caught and R90 went forward face first onto the concrete. R90 reported a swollen lip and knee pain. The roommate for R90 reported R90 was sent out to the hospital for a busted lip and hurt knee and stayed the night.
A review of the record for R90 revealed R90 was admitted into the facility on [DATE] and re-admitted [DATE] after hospitalization. Diagnoses included Multiple Sclerosis, Muscle Wasting and Depression. The Minimum Data Set (MDS) dated [DATE] indicated intact cognition and the need for supervision for bed mobility and transfer, limited assist for dressing and extensive assist for toilet needs and personal hygiene. A review of the care plan Resident has had a fall with (minor injury) laceration to lip date initiated 04/06/22 revealed no new interventions were initiated until 04/23/22. The resident is at risk for falls care plan with date initiated 08/15/19 did not have any new interventions post the fall on 04/06/22. The most recent intervention was dated 08/15/19. The goal was updated last on 04/24/19. A goal dated 08/15/19 documented, The resident will be free of minor injury through the review date. The goal target date was documented as 05/27/22.
A review of the progress note by Nurse S revealed, 04/06/2022 at 9:49 PM Incident Note: Staff reported to this writer that the resident fell outside during a smoke break. Assessment completed. Deep laceration on lip noted. Drainage noted. Vital signs stable. No changes with (level of consciousness) LOC. Dr. notified, ordered to send resident to hospital. Awaiting EMS. (Director of Nursing) DON aware of situation. A progress note by Nurse B dated 04/07/2022 at 7:01 PM revealed, Health Status Note (nurses note): Resident returned from hospital on a stretcher via Ambulance accompanied by 2 attendants. Resident is alert, verbally responsive and is aware of self, place and time. There is swelling to the mid top lip area without bleeding or open areas noted. The resident refused to allow this writer to fully examine the lip area by opening it to examine the inner lip area and the teeth. Resident stated that it is very sore. This writer noted two abrasion areas with scabs, mild redness and swelling to the right knee Diagnoses per (hospital): Fall, initial encounter; Acute pain of both knees; Human bite, initial encounter. Instructions per (hospital): You were seen in the (emergency department) ED for a fall. You had a laceration in your upper lip which likely was from impact from the ground and your tooth. We are treating this as a human bite, and you will need to take an antibiotic, Augmentin, twice a day for a total of 7 days. You were given a (tetanus) Tdap vaccine in the ED as well for this. We feel the laceration will heal on its own, and did not need any sutures. There was a concern for injury to your knees since you fell on it, but we did X-rays of both knees and there were no fractures.
A review of the Occupational Therapy (OT) evaluation and treatment note signed 04/27/22 revealed, Fall Risk Assessment: History of Fall: Has the patient fallen in the last year? No . A nursing care plan for OT services was not initiated.
A review of the Physical Therapy (PT) evaluation and treatment note signed 04/30/22 revealed, Fall Risk Assessment: History of Fall: Has the patient fallen in the last year? No . A nursing care plan for PT services was not initiated.
On 05/11/22 at 3:13 PM, R90's fall was reviewed with Nurse S. Nurse S reported they did not witness the fall and only saw R90 in their room after the fall. Nurse S reported R90 went out via non -emergency ambulance and did not get picked up until after they had left for the night. An anonymous complaint indicated R90 was picked up around one AM.
On 05/12/22 at 11:46 AM, Activities Staff N was observed assisting residents onto the elevator upon return from having been outside. Activities Staff N was asked about R90's fall and reported they were not at the facility during that time. Staff N reported that R90 takes themselves out when going on a smoke break or outside and does not require staff assistance.
On 05/12/22 at 10:22 AM, the Director of Nursing (DON) was asked about witnesses to R90's fall and reported there was only one. This was reported by the security guard as this happened later in the evening. A phone number for the security guard or phone call from the security guard was requested but not received prior to survey exit. No additional witnesses were identified. An incident and investigation report were requested. At 1:09 PM, the incident report and investigation were requested a second time from the DON. The DON printed out an incident report. The incident nor investigation were provided prior to survey exit.
A review of the undated Care Management Guideline revealed, Guideline: Care Management is implemented when a qualifying change in condition occurs which requires skilled services, interdisciplinary (IDT) collaboration, and timely proactive communication beyond the standard practices of communication established in the facility. Care Management is conducted upon admission or readmission from an acute setting. The purpose of the Initial Care Management Meeting is to communicate to the patient and patient representative, within 48 hours of admission, the baseline plan of care, barriers to the discharge plan and care and services to be provided. The Initial Care Management Meeting is an important part of establishing a partnership with the patient and patient representative, which contributes to meeting transitional care goals. Ongoing Care Management Meetings allows the IDT to communicate regarding the patient's progress and adjust the plan of care should the patient's clinical status and/or stated discharge plans change. The patient and patient representative are informed of any changes to the plan of care established at the Initial Care Management Meeting.
A review of the facility Resident Rights policy dated 11/28/17 revealed Purpose: It is the practice of this facility to provide for an environment in which residents may exercise their rights, each day. Our residents have certain rights and protections under Federal law. Our facility meets and provides these rights through care and related services at all times. Planning and Implementing Care. Residents and/or resident representatives have the right to be fully informed of the medical condition in a language you they can understand, and to participate in your person-centered care planning and treatment, including the type of caregiver who provides services .The right to be informed, in advance of changes to the plan of care. The right to receive the services and /or items included in the plan of care. The right to see the careplan including the right to sign after significant changes to the plan of care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0710
(Tag F0710)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the physician service maintained accuracy in the medical reco...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the physician service maintained accuracy in the medical record and documented follow up of medication changes for one sampled Resident (R64) of three whose medications were reviewed, resulting in inaccurate progress notes, the potential for confusion by nursing staff, unknown medication changes and lack of documented follow up after medication changes. Findings include:
A review of the medical record for R64 revealed R64 was re-admitted into the facility on [DATE] post a transfer to the hospital and hospital stay. Diagnoses included: Heart Disease, Pacemaker, Coronary Artery Bypass Grafts and Atrial Fibrillation (irregular heart beat).
A review of R64's current electronic medical record medication orders revealed, Eliquis (blood thinner generic name is Apixaban) five milligrams (mg) two times a day replaced Xarelto (blood thinner, generic name is Rivaroxaban) 15 mg once a day on 01/18/22.
A review of notes by R64's primary Physician L with visit dates of 01/26/22 and 02/28/22 revealed the Current Medications to include the Xarelto 15 mg, Rivaoxaban 15 mg and Warfarin 2.5 mg (a blood thinner), neither of which was active in the medical record. A record of the Warfarin use was not found. The Eliquis/Apixaban was not included in the current medications for R64. A more current note was requested but not received prior to survey exit.
A review of notes by a Physician Assistant M from the Cardiac Care Team with visit dates of 04/01/22 and 02/02/22 indicated R64's Current Medications included Xarelto tablet 15 mg (Rivaroxaban) give one tablet by mouth one time a day .patient is currently on xarelto . The note did not include the Eliquis/Apixaban in the current medications. The notes appeared similar to a previous notes dated 10/04/21, 11/03/21, 12/01/21 and 01/02/22.
On 05/12/22 at 10:02 AM and 1:09 PM, the Director of Nursing (DON) was asked about the inaccurate physician and physician assistant notes with regard to the blood thinners. The DON appeared surprised by the discrepancies and confirmed the notes should accurately reflect the condition of the resident. A more recent physician note for R64 was requested for R64 but not received prior to survey exit.
A review of the facility policy titled Resident Rights dated 11/28/17 revealed, Purpose: It is the practice of this facility to provide for an environment in which residents may exercise their rights, each day. Our residents have certain rights and protections under Federal law. Our facility meets and provides these rights through care and related services at all times . All residents have the right to equal access to quality care regardless of a diagnosis, severity of a condition, or payment source.
A review of the facility policy titled, Physician Services Guideline dated 11/28/2017 revealed, Purpose: To provide guidance on the practice guidelines for the physician, physician assistant, nurse practitioner or clinical nurse specialist within the skilled post-acute care environment. Responsible Party: Clinical. Guideline: Physician Services upon Admission.
A physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident' immediate care and needs. Physician Supervision: The facility must ensure that: 1-The Medical care of each resident is supervised by a physician; and 2-Another physician supervised the medical care of residents when their attending physician is unavailable. Physician Visits: The physician must: 1-Review the resident's total program of care, including medications and treatments, at each visit; 2-Write, sign and date progress notes at each visit;
3-Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician approved facility policy after an assessment for contraindications .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure accuracy in the medical record was maintained for one sampled...
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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 accuracy in the medical record was maintained for one sampled Resident (R64) of three whose medications were reviewed, resulting in an inaccurate record and the potential for confusion. Findings include:
A review of the medical record for R64 revealed R64 was re-admitted into the facility on [DATE] post a transfer to the hospital and hospital stay. Diagnoses included: Heart Disease, Pacemaker, Coronary Artery Bypass Grafts and Atrial Fibrillation (irregular heart beat).
A review of R64's current electronic medical record medication orders revealed, Eliquis (blood thinner generic name is Apixaban) five milligrams (mg) two times a day replaced Xarelto (blood thinner, generic name is Rivaroxaban) 15 mg once a day on 01/18/22.
A review of notes by R64's primary Physician L with visit dates of 01/26/22 and 02/28/22 revealed the Current Medications to include the Xarelto 15 mg, Rivaoxaban 15 mg and Warfarin 2.5 mg (a blood thinner), neither of which was active in the medical record. A record of the Warfarin use was not found. The Eliquis/Apixaban was not included in the current medications for R64. A more current note was requested but not received prior to survey exit.
A review of notes by a Physician Assistant M from the Cardiac Care Team with visit dates of 04/01/22 and 02/02/22 indicated R64's Current Medications included Xarelto tablet 15 mg (Rivaroxaban) give one tablet by mouth one time a day .patient is currently on xarelto . The note did not include the Eliquis/Apixaban in the current medications. The notes appeared similar to a previous note date 01/02/22.
On 05/12/22 at 10:02 AM and 1:09 PM, the Director of Nursing (DON) was asked about the inaccurate physician and physician assistant notes with regard to the blood thinners. The DON appeared surprised by the discrepancies and confirmed the notes should accurately reflect the condition of the resident. A more recent physician note for R64 was requested for R64 but was not received prior to survey exit.
A review of the facility policy titled Resident Right dated 11/28/17 revealed, Purpose: It is the practice of this facility to provide for an environment in which residents may exercise their rights, each day. Our residents have certain rights and protections under Federal law. Our facility meets and provides these rights through care and related services at all times . All residents have the right to equal access to quality care regardless of a diagnosis, severity of a condition, or payment source.
A review of the facility policy titled, Physician Services Guideline dated 11/28/2017 revealed, Purpose: To provide guidance on the practice guidelines for the physician, physician assistant, nurse practitioner or clinical nurse specialist within the skilled post-acute care environment. Responsible Party: Clinical. Guideline: Physician Services upon Admission.
A physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident' immediate care and needs. Physician Supervision: The facility must ensure that: 1-The Medical care of each resident is supervised by a physician; and 2-Another physician supervised the medical care of residents when their attending physician is unavailable. Physician Visits: The physician must: 1-Review the resident's total program of care, including medications and treatments, at each visit; 2-Write, sign and date progress notes at each visit;
3-Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician approved facility policy after an assessment for contraindications .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to operationalize policies and procedures and ensure completion of routine COVID-19 testing of staff who were not fully vaccinated, in 1 of 9 ...
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Based on interview and record review, the facility failed to operationalize policies and procedures and ensure completion of routine COVID-19 testing of staff who were not fully vaccinated, in 1 of 9 staff members reviewed for COVID-19 testing, resulting in inaccurate/incomplete documentation, and the potential for delayed identification of COVID-19 infections. Findings include:
On 5/11/22 at 1:04 PM, the surveyor met with the Infection Control Preventionist (ICP) to review infection control documentation. The ICP was asked for the number of COVID-19 vaccine exempted staff, and explained that there were 11 staff members, all which were religious exemptions. The ICP was asked about the testing requirements for the unvaccinated staff and explained that they were required to get tested twice weekly. Further review of the testing logs provided by the ICP identified two religious exempted staff members who were not identified on the testing logs. It was explained that one of the staff members were no longer an employee of the company, and the other staff member worked infrequently, and had been off work for personal reasons. At this time, an updated vaccination matrix for staff was requested.
A review of the updated vaccination matrix for staff was reviewed and identified 9 religious exempted staff members however, the testing logs noted that all the religious exempted staff members were not listed on the testing logs. Registered Nurse (RN T) was not listed, was cross-referenced as an active employee on the employee list, and there was no documented reason as to why they had not been tested. In addition, the testing logs provided to the surveyor started with the week of 2/20-2/26 and ended the week of 5/1 to 5/7. No other testing logs were provided for testing completed prior to February.
A review of the facility's COVID-19 Vaccine Mandate for Staff revealed the following, Additional precautions and Contingency Plans for Unvaccinated Staff. Staff who receive an exemption to the COVID-19 vaccine will be required to adhere to additional precautions which will include: COVID-19 testing weekly, unless otherwise specified for transmission-based testing .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0912
(Tag F0912)
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 80 square feet of living space per bed within 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 provide 80 square feet of living space per bed within multiple resident rooms in 22 of 36 rooms (#'s 102, 103, 104, 105, 106, 107, 108, 112, 115, 119, 201, 202, 203, 204, 207, 209, 210, 211, 212, 214, 218, 219), resulting in the potential for resident dissatisfaction with living space and conditions. Findings include:
On 05/10/22, 05/11/22 and 05/12/22, data for the square footage of the rooms was reviewed and the following resident rooms were monitored for minimum living space square footage requirements:
Room # SqFt
#Beds
102
217
3
103
152
2
104
152
2
105
287
4
106
287
4
107
287
4
108
287
4
112
287
4
115
287
4
119
287
4
201
217
3
202
217
3
203
152
2
204
152
2
207
287
4
209
287
4
210
287
4
211
287
4
212
287
4
214
287
4
218
287
4
219
287 4
On 05/12/22 at 11:21 AM, R82 was observed to be seated on their bed which was parallel to and against the wall. Their back was against the wall and Resident (R82) had their feet up on their wheelchair seat. R82 was asked about the room size and reported that at times they feel they could use more space as their neighbors items such as the tray table was sometimes moved into their space. R82 had a bed, tray table and night stand in their area. The foot of R82's bed was separated from the neighbors bed by a curtain which hung from the ceiling at the foot of R82's bed and a second curtain for the neighbors area. The neighbors bed was arranged perpendicular to R82's bed with the neighbor's tray table lengthwise along the side of the bed. The curtains were along the edge of the tray table. R82 further noted the recent bed bug out break and wanting to return home. In room [ROOM NUMBER] the foot of bed two was within a foot of the side of bed three. This space was filled by the curtain for bed two. room [ROOM NUMBER] had three occupied beds. room [ROOM NUMBER] had three occupied beds. Additional queries were made of residents and room size and the residents verbalized they were not affected by the current room size.
A review of the policy titled Resident Rights dated 11/28/17 revealed, Purpose: It is the practice of this facility to provide for an environment in which residents may exercise their rights, each day. Our residents have certain rights and protections under Federal law. Our facility meets and provides these rights through care and related services at all times .Safe Environment: The right to a safe, clean, comfortable and home-like environment that allows independence as possible.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure and maintain intact privacy curtains for the 26...
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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 and maintain intact privacy curtains for the 26 Residents (including R35, R82, R90) of the one west unit, resulting in and the potential for a lack of privacy during incontinence care and other Activities of Daily living and embarrassment. Findings include:
On 05/10/22 at 9:24 AM, it was observed that rooms on the one west unit did not have privacy curtains hanging around the resident beds.
On 05/10/22 at 10:51 AM, R35 was asked how long the privacy curtains had been down and reported along with a roommate, that the curtains had been taken down due to a bed bug problem in the facility and had been down around a month. R35 reported that they are someone who receives care in their bed and room and the curtains provide some visual privacy. R35 commented the curtains prevent other resident from seeing them during care.
On 05/10/22 at 11:07 AM, Housekeeper C was observed to be hanging privacy curtains in room [ROOM NUMBER]. Housekeeper C reported they had been called in on an off day to hang the curtains. Housekeeper C reported the privacy drapes had been down about a week. The resident in bed C reported the curtains had been down two or three weeks.
On 05/10/22 at 11:15 AM, Nurse O reported that the facility had stripped all the rooms and sprayed for bed bugs and that the privacy curtains had been down about a week and a half or two.
On 05/10/22 at 12:43 PM, Laundry staff P was asked about the privacy drapes and reported they had a special cycle for the drapes. Staff P reported they had drapes in the laundry for a week off and on and the curtains would be washed in between all the linen and personals that needed to be done.
On 05/10/22 at 12:55 PM, the room of R35 and room [ROOM NUMBER] remained without drapes.
On 05/10/22 at 3:44 PM, Nurse B was, asked about bed bugs and the privacy curtains and said they had all the drapes and clothes bagged and in the hall way but were not sure how long the drapes had been down but that they are up now.
On 05/10/22 at 4:00 PM, R82 and R90 were asked about care concerns when the privacy curtains were down and commented the curtains were taken down because of the bed bugs and felt they did not miss having them up.
On 05/12/22 at 9:40 AM, the Administrator was interviewed and asked about the privacy curtains and reported the bed bug problem was addressed over a 12 week period and all the rooms were cleaned out and treated. Each unit was treated by pest control once a week for three weeks and one west was the last to be treated.
On 05/12/22 at 9:47 AM, the Housekeeping Manager was asked about the laundering of the privacy curtains and reported normally when they take the curtains down it takes a day or two to get them back up, but because all the curtains had to come down it took longer to get them back up.
On 05/12/22 at 1:15 PM, the Administrator was asked about the importance of privacy curtains and reported, A lot of people are depressed and they want to cover themselves or not look at their roommates. We had to take some down for the spraying and wash them. Sometimes they are without them a week because we are washing and spraying, its all a process. It can take a couple of days. It can be four to five days before they can get their clothes back. I know it can take a little while.
A review of the Resident Rights policy dated 11/28/17: Purpose: It is the practice of this facility to provide for an environment in which residents may exercise their rights, each day. Our residents have certain rights and protections under Federal law. Our facility meets and provides these rights through care and related services at all times . Our facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility protects and promotes the (rights) of the residents.
A review of the undated Daily Cleaning Procedures indicated, .Inspect all privacy curtains. If dirty notify your supervisor which curtains need to be changed . The policy did not address how long privacy curtains could be down.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #36 (R36)
On 5/11/2022 at 9:45 AM, Resident #36 was observed sitting at the table in the common area eating. The reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #36 (R36)
On 5/11/2022 at 9:45 AM, Resident #36 was observed sitting at the table in the common area eating. The resident was not initiating conversation but appeared calm.
A review of R36's medical record revealed that they were admitted into the facility on 2/18/2022 with diagnoses of Dementia, Heart Failure and BI-Polar Disorder. A review of R36's Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 3/15 indicating a severely impaired cognition, and required limited assistance for Activities of Daily Living (ADLs)
Further review of R36's medical record revealed the following physician order dated for 2/18/2022, Quetiapine Fumarate (Seroquel) Tablet 25 MG (milligrams) Give 3 tablet by mouth at bedtime for Antipsychotics/Antimanic Agents.
Further review of R36's Medication Administration Records for February 2022, March 2022, April 2022, and May 2022 revealed that the resident was administered the Seroquel medication daily as prescribed.
Further review of R36's medical record revealed that they were not being followed by any behavioral health agency, nor were there documented behaviors or indicators for the use of an anti-psychotic.
A review of R36's Consent to Receive Psychotropic Medication was reviewed and revealed the resident name written at the top of the form. The date and resident's physician were blank. The medication Risperdal was checked off, along with the attestation, I am aware and agree with the use of psychotropic medications. On the signature line for the Resident/ Guardian/Responsible Party to sign, was the statement, Verbal Consent and a date of 2/18/22. The form was signed by the facility's social worker and was undated by him.
On 5/12/2022 at 12:50 PM, Social Worker F was asked about the psychotropic consent for R36, and who provided verbal consent. Social Worker F stated, [R36's son]. Social Worker F was asked if R36's son had guardianship of the resident, as R36 signed all their admission paperwork on 2/18/2022. Social Worker F explained that R36's son did not have guardianship but was very involved.
On 5/12/2022 at 1:15 PM, the Nursing Home Administrator (NHA) was interviewed in regard to the process of obtaining consents for psychotropic medication, the NHA explained that they complete the consents in the Electronic Medical Record (EMR) on admission, and believed the consents were in the admission packet.
On 5/12/2022 at 1:52 PM, the Director of Nursing (DON) was asked about R36's indications for use of the psychotropic medication, lack of documented behaviors and follow-up by behavioral services. The DON reviewed R36's progress notes and admitted that the documentation was lacking, and that Staff are so used to residents acting out, that they don't think it's a problem. The DON explained that they are working on improving the documentation, as R36 does have behaviors.
A review of the facility policy titled Psychotropic Medication Management dated 11/28/2017 revealed the following:
Purpose: It is the practice of this facility that a resident will not receive unnecessary
medications including psychoactive medications, unless non-pharmacological interventions
have failed to sufficiently modify a resident's target behavioral, mood, or sleep disturbance.
Each psychoactive medication will be given to treat clearly defined targeted conditions and to
promote or maintain highest practicable physical, functional, and psychosocial well-being.
Residents prescribed psychoactive medications will receive adequate monitoring and will have
gradual dose reductions attempted, unless clinically contraindicated .10. If medication is ordered, an appropriate diagnosis will be obtained .11. Risks and benefits will be explained and a copy provided to resident and/or responsible party .12. Informed consent including effects and potential side effects will be obtained from resident and/or resident representative for each psychoactive medication.
13. If verbal consent by resident representative is provided document on informed consent and place copy in chart until signature is obtained .16. Appropriate monitoring for mood/behavior/sleep, along with monitoring for side effects and medication efficacy, will be reviewed and/or initiated. (Refer
to Target Mood/Behavior/Sleep Monitoring Guideline) dry mouth (cholinergic effects) etc .
Resident #28 (R28)
On 5/12/22 at 2:33 PM, R28's electronic medical record (EMR) was reviewed and indicated the following medication orders for R28, Citalopram 20mg (Milligrams) 1x day for depression. Start date: 1/9/22. Aripiprazole 10mg 1x day for behaviors. Start date: 1/9/22.
WebMD 2022 online medication reference reflected the following, .Citalopram Selective Serotonin Reuptake Inhibitor (SSR) it can treat depression. Aripiprazole, .Antipsychotic, it can treat schizophrenia, bipolar disorder, depression .
On 5/12/22 at 2:38 PM, further review of R28's EMR revealed that the resident had no documented psychiatric diagnosis, no psychiatric evaluation (PE), and/or no documented progress notes or documents that indicated that R28 was being monitored by psychiatric services.
On 5/12/22 at 2:42 PM, R28's EMR further indicated that R28 was admitted to the facility on [DATE] with diagnoses that included Kidney failure and Dementia. R28's most recent minimum data set assessment (MDS) dated [DATE] revealed that R28 had a severely impaired cognition and required extensive assistance of one person for all activities of daily living (ADLs) other than eating and bed mobility.
On 5/12/22 at 2:53 PM, R28 was interviewed regarding being prescribed psychotropic medication. R28 was unable to respond logically to any questions asked to them.
On 5/12/22 at 3:13 PM the Director of nursing (DON) was interviewed regarding her expectations regarding residents prescribed psychotropic medications and involvement with psychiatric services. The DON indicated that any resident prescribed psychotropic medication should have a psychiatric diagnosis and be followed regularly by psychiatric services. The DON was asked why R28 was being prescribed psychotropic medications and had no psychiatric diagnoses and no documented indication that they were being followed/monitored by psychiatric services. The DON had no answer to this question and agreed that there was no documented psychiatric diagnosis for R28 and no psychiatric services documentation in R28's EMR.
Based on observation, interview and record review, the facility failed to identify indicators for use, and/or complete consents for use of psychotropic medication for five Residents (Resident #28, #36, #42, #45, #59) of nine residents reviewed for unnecessary medications, resulting in the potential for adverse reactions and prolonged use of unnecessary medications. Findings include:
Resident #42 (R42)
On 05/10/2022 at 09:11 AM, Resident #42 was observed dressed and groomed sitting in the dining area. The Resident was calm and pleasant.
On 05/11/2022 at 01:12 PM, Resident #42 was sitting at the table, dressed and groomed. Resident #42 was interviewed and explained that they were going home with their son soon and was excited.
On 05/12/2022 at 09:13 AM, Resident #42 was observed dressed and groomed sitting at their usual spot in the dining area. The Resident did not talk to other residents, but appeared calm.
A review of the Progress Notes for Resident #42 revealed the following:
05/3/2022 at 13:32 (01:32 PM) Social Service Note .Resident remains alert and verbally responsive with periods of confusion. No current psych diagnoses but receiving psych meds. Team psychiatrist will further evaluate .There are no plans for discharge at this time, will continue to monitor.
A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #42 was most recently admitted to the facility on [DATE] with a diagnosis of Hypertension.
A review of the physician orders revealed the following for Resident #42:
Trazodone (an antidepressant) daily.
A review of the medical record did not reveal a diagnosis listed in the medical record for the medication.
Resident #45 (R45)
On 05/10/2022 at 11:42 AM, Resident #45 was observed sitting in their wheelchair in the corner of the common area looking out the window. The resident had a towel over their head and had their head resting in their hand. At that time, an unknown staff member was near. The staff member was asked if Resident #45 was interviewable. The staff member explained that the Resident was not interviewable and was often verbally agitated.
On 05/11/2022 at 09:39 AM, Resident #45 was observed sitting at the table in the common area eating. The Resident was not initiating conversation, but appeared calm.
A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #45 was admitted to the facility on [DATE] with the diagnosis of Schizophrenia. Resident #45 had a BIMS (Brief Interview for Mental Status) score of 09, indicating an impaired cognition.
A review of the physician orders for Resident #45 revealed the following psychotropic medications ordered:
Seroquel (antipsychotic medication), Trazodone, and Zyprexa (antipsychotic). These medications were given daily.
A review for the consents of the psychotropic medications revealed there were none completed for Resident #45.
Resident #59 (R59)
On 05/10/22 10:09 AM, Resident #59 was observed sitting at the dining room table with their head down on the table.
On 05/11/2022 at 09:33 AM, 12:46 PM and 01:28 PM, Resident #59 was observed resting in bed with their eyes closed.
On 05/12/2022 at 09:55 AM, Resident #59 was observed sitting at the table in the dining area. The Resident was calm, and watching TV.
A review of the physician orders for Resident #59 revealed the following:
Risperdal (an antipsychotic) was administered daily.
A record review of the MDS dated [DATE] revealed that Resident #59 was admitted on [DATE] with the diagnosis of Schizoaffective Disorder, and had a BIMS score of 10, indicating a moderately impaired cognition.
A record review for the consent of the psychotropic medication for Resident #59 revealed no signed informed consent in the medical record.
On 05/12/2022 at 12:19 PM, Social Worker (SW) F was interviewed in regard to the missing consent for Resident #59's psychotropic medication. SW F explained that depending on who orders the medications (psych or nursing), they are to complete the consent for the medication. SW F also stated that when he does the chart audits, if he notices consents missing, he gets them in place. SW F did not have an explanation for the missing consent for Resident #59.
On 05/12/2022 at 12:35 PM, the Director of Nursing (DON) was interviewed in regard to the missing consent for Resident #59. The DON explained that when residents come in with psychotropic medications, they get an order and notify the Guardian of the medication. The DON further explained that they had a high homeless population. The DON stated, When they come in, we get an order, we notify the guardian. A lot (of residents) have no family or guardians, so we have to find guardians for them because the family wants nothing to do with them, then we can get the consents.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0564
(Tag F0564)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to allow visitation per Centers for Medicaid and Medicare Services (CMS) regulations for all residents residing in the facility reviewed for v...
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Based on interview and record review, the facility failed to allow visitation per Centers for Medicaid and Medicare Services (CMS) regulations for all residents residing in the facility reviewed for visitation, resulting in restricted visitations, loss of resident and resident representative rights, and the potential for self-isolation and depressed feelings. Findings include:
On 12/01/2021 a review of a CMS memo revealed the following regarding guidance on visitation in Long Term Care Facilities:
Subject: Nursing Home Visitation-COVID-19 (Revised)
Revised: 11/12/2021
Visitation is now allowed for all residents at all times.
On 5/12/2022 at 1:15 PM, the Nursing Home Administrator (NHA) was interviewed and asked about visitors not being allowed throughout the building. The NHA explained the visitation process that visitors call and schedule an appointment, and when they come into the facility, they have to take a Covid test. They then go to the day room. The visits only last a half an hour or 45 minutes. There can only be one visit with two people at a time, and visits start at 11am and then break for lunch and start back at 1 PM until 3 PM.
On 5/12/2022 at 4:40 PM, during the exit conference when preliminary concerns for visitation were addressed with the NHA, she adamantly stated, It's not going to happen.
A review of the requested facility visitation policy, was a letter dated for June 22, 2021 and ended by the name of the NHA outlined the following, Hello Villa Families, We are excited to announce that we are starting outdoor visitation. Visits will be in accordance with the Michigan Department of Health and Human Services guideline. Visits will be scheduled only on designated days and times to maintain the safety of our residents. Please be aware of the following guidelines: Please Note Indoor Visitation will be allowed for the following residents: End of life, Hospice patients.
-Call the receptionist to schedule your visit. Call Monday-Friday between 11am-5pm to schedule a visit. Please leave a message as needed and we will return your call to schedule your visit.
-Current visits are limited to 30 minutes at a time, 2 visitors per resident.
-Visits may be supervised to a designated area outside the facility.
-No hugging, kissing or physical contact will be allowed.
-No smoking, food or fluids by resident or visitor during the visit.
-Visitors will require a health screening prior to entry.
-Resident and visitors must hand sanitize before and after the visit.
-Masks will need to be worn by both visitors and resident regardless of vaccination status.
-Visitors will be required to have a rapid swab completed by the facility staff, complete a sign in attestation and must follow all rules.
-Visitors cannot enter the facility for any other reason unless approved by administration,
-Visitors that do not follow guidelines will be asked to leave.
-Please make sure you are on time for your visit. If you are late, the facility may have you reschedule your visit for another day
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the facility failed to ensure food was handled under sanitary conditions, potentially affecting all 101 residents, resulting in the potential for food...
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Based on observation, interview and record review the facility failed to ensure food was handled under sanitary conditions, potentially affecting all 101 residents, resulting in the potential for food contamination and related illness. Findings include:
On 05/10/22 at 8:38 AM, during an initial tour of the kitchen, the area around the dishwasher and food preparation area was observed to have visible black build up on the terracotta colored tiles. The Dietary Manager commented that they did not currently have a porter who comes in to mop the floor regularly. [NAME] H was observed to have a gold bracelet worn on the left wrist during the preparation and serving of food. Milk and juice filled cups were observed in the refrigerator without lids or a cover.
On 05/10/22 at 11:35 AM, Dietary Staff K was observed in the kitchen with a braid of hair which hung down loose outside their hairnet. Dietary Staff I was observed to have fingernails which were painted green and extended past the tip of their fingers. Dietary Staff I was observed to scoop ice from the ice machine without the use of gloves. Dietary Staff J was observed to have their fingernails painted white. Dietary staff J was observed to pour juice and milk into cups and prep meal trays without gloves. An observation of the food prep utensils hanging above the wash sink revealed: A long handled metal strainer with broken and missing mesh which appeared rusty; Two spatulas had pieces broken off the tapered ends. During the plating of the food a wall mounted fan was blowing onto the steam table area.
Later the same day at 11:48 AM, the Dietary Manager was asked about the length of fingernails and the use of nail polish and reported they would have to check the policy. At 12:35 PM, the concern related to the nail polish was reviewed with the Senior Dietitian.
On 05/11/22 at 8:25 AM and on 05/12/22 at 10:53 AM, [NAME] H was observed to prep food wearing the gold bracelet.
A review of the facility policy titled, Employment Practices with copyright date of 2017 revealed, Employees must use hair restraints such as hair nets and beard restraints as needed. Fingernails should be clean and trimmed. Unless wearing intact gloves in good repair, no fingernail polish or artificial nails are allowed. While preparing food employees shall not wear jewelry on arm and hands except a plain ring or medical information band.
The 2017 Food and Drug Administration (FDA) Food Code revealed, Fingernails: 2-302.11 Maintenance. A) Food employees shall keep their fingernails trimmed, filed, and maintained so the edges and surfaces are cleanable and not rough. (B) Unless wearing intact gloves in good repair, a food employee may not wear fingernail polish or artificial fingernails when working with exposed food. Jewelry 2-303.11 Prohibition: Except for a plain ring such as a wedding band, while preparing
food, food employees may not wear jewelry including medical information jewelry on their arms and hands .Hair Restraints: 2-402.11 Effectiveness. (A) Except as provided in ¶ (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to operationalize policies and procedures to accurately track and document the COVID-19 vaccination status of contract staff, and vendors worki...
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Based on interview and record review the facility failed to operationalize policies and procedures to accurately track and document the COVID-19 vaccination status of contract staff, and vendors working within the facility resulting in, an inaccurate vaccination matrix, and the potential for transmission of COVID-19. Findings include:
On 5/11/22 at 1:04 PM, the vaccination matrix of staff was reviewed with the Infection Control Preventionist (ICP) and asked about the missing contract/vendor staff on the matrix. The ICP explained that they do not include contract staff on the vaccination matrix, and that anyone coming into the facility has a COVID-19 test completed.
On 5/12/22 at 1:15 PM, the Nursing Home Administrator (NHA) was asked for her expectations regarding tracking the vaccination status of contract staff and stated the following, When they come into the building, we make them take a test whether they are vaccinated or not. They show us their card upon entry. We haven't been tracking that because they see us before they can enter the building. They have to have their cards (vaccination), otherwise they are denied.
On 5/12/22 at 1:52 PM, the Director of Nursing (DON) was asked about the vaccination matrix of staff not including contract staff and vendors and stated, They have to be vaccinated .a lot of them have the cards on their phone .if they've been coming here for a while, we just know.
A review of the facility's COVID-19 Vaccine Mandate for Staff policy revealed the following, Definitions: Staff refers to individuals who provide care, treatment, or other services for the facility and/or its residents, including employees, licensed practitioners, adult students, trainees, and volunteers; and individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangements including Hospice and dialysis staff, physical therapists, occupational therapists, mental health professionals, licensed practitioners, or adult students, trainees, or volunteers .Documenting COVID-19 Vaccine for Staff. The facility will maintain documentation for staff on COVID-19 vaccination, including primary series, boosters, and additional doses on a tracking tool that will include: The staff person was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. The name of the vaccine administered and any additional doses or boosters. Date of vaccination. If vaccine was not administered, reason for and documentation of medical or religious exemption.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain mattresses in a sanitary condition and furnitu...
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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 mattresses in a sanitary condition and furniture items in good repair for two rooms (106 and 108) observed, resulting in the potential for lingering odors, leakage of incontinence into the mattress and disrepair. Findings include
On 05/10/22 at 9:28 AM, the unmade bed for room [ROOM NUMBER] bed C was observed. The top side of the mattress was faded to a cloudy white color with areas of orange as compared to the sides which were a dark blue. The center area of the mattress was sunk in and had cracks in the cover and had a musty odor. This mattress remained in the room for bed C on 05/11/22 and 05/12/22. The three drawer night stand for 106 C was missing the top drawer. The tray table for 106 D was missing the edge trim so that the particle board could be seen.
On 05/10/22 at 9:56 AM, the headboard for bed 108 A was tilted down toward the left side and was not secure to the bed frame. The covering on the mattress for 108 B was cloudy white in color and had orange coloring along the top of the mattress as compared to the dark green color on the sides. The mattress was sunken in the center area. The aide entered the room and was asked about the mattress. It was reported that the mattress needed to be plugged in. The aide checked the power to the mattress; The mattress did not appear to inflate further.
On 05/12/22 at 10:29 AM, the Maintenance Director was asked if they were made aware of any mattress in need of replacement and specifically 106 C and reported they were not. The Maintenance Director reported they replace mattresses when reported and rely on the staff to tell them when needed.
A review of the policy titled Resident Rights dated 11/28/17 revealed, Purpose: It is the practice of this facility to provide for an environment in which residents may exercise their rights, each day. Our residents have certain rights and protections under Federal law. Our facility meets and provides these rights through care and related services at all times .Safe Environment: The right to a safe, clean, comfortable and home-like environment that allows independence as possible .Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains in part to MI00127102 .
Based on observation, interview, and record review, the facility failed to effect...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains in part to MI00127102 .
Based on observation, interview, and record review, the facility failed to effectively eliminate the insects in the facility living and care areas potentially affecting the 101 residents that reside in the facility, resulting in insect sightings and the potential for the spread of bacteria and contamination of surfaces in the facility. Findings include:
On 05/10/22 at 10:31 AM, Resident (R82) reported they felt they were getting bit by bed bugs. At 4:23 PM, R82 was observed to have a squashed bed beg in a napkin. The bug appeared in an area of blood colored smear on a white napkin. Nurse aide D had entered the room and took the napkin from R82 and left the room. This room was occupied by four residents.
On 05/10/22 at 10:47 AM, an insect which appeared to be a bed bug was observed on the window sill in room [ROOM NUMBER]. The room was occupied by four residents. A review of an entry in the pest control log at the nurse station indicated the room had tons of bed bugs and roaches in March. Ongoing sightings were documented into April.
On 05/11/22 at 5:18 AM, during a medication pass observation on the second floor, a roach was observed to scamper across the floor inside the entrance to room [ROOM NUMBER]. This room was occupied by two residents. room [ROOM NUMBER] had also been documented as treated for bed bugs on 04/07/22.
On 05/11/22 at 12:41 PM, R82 was observed to have killed another bed bug in a napkin. R82 was asked where this one was found and pointed to the surface of the bed.
On 05/11/22 at 3:44 PM, Nurse B reported that pest control had come in and treated the whole building for bed bugs and staff had pulled all clothing and curtains out of the rooms and bagged it. Nurse B also noted that one west was the last wing to be done and pest control was just in late last week.
On 05/12/22 at 10:53 AM, a roach (around one inch long) was observed to crawl across the floor in front of the basement elevator and under some carts in the hallway. At 11:02 AM, three roaches were observed, the smallest around a quarter of an inch long and the larger around one inch long.
On 05/12/22 at 11:17 AM, Certified Nurse Assistant G was asked about the treatment for the bed bugs. CNA G was also asked if there were any new admissions into the room of R82 since pest control had come in and sprayed and reported there were not.
On 05/12/22 at 10:29 AM, the facility bed bug outbreak was reviewed with the Maintenance Director. The Maintenance Director reported the pest control company had come in every week for the past twelve weeks and each of the four wings were treated once a week for three weeks. One west was the last to be treated. The Maintenance Director reported the bed bugs may pass through the walls between floors. The Maintenance Director further commented that they had not had much of a bed bug problem until the last couple of years. The facility pest control visit sheets were reviewed and indicated bed bug activity back to March of 2021 and ongoing until the problem worsened in February of 2022 and has been a focus of treatments along with roaches through May of 2022. The visits included sightings and treatments in the room of R82. The whole building had sightings of roaches, bed bugs or suspected mouse activity.
On 05/12/22 at 1:15 PM, the Administrator was asked, What does an effective pest control Program mean to you? and replied, That we don't ever have them again. The Administrator was also asked about what does observation of bed bugs and roaches mean to you? and reported, We get a lot of patients from (the hospital, home and dialysis, and they keep getting brought in. Also the area we are in. We just got through doing the whole building. Three weeks on each floor. The problem is not as bad as it was. We have seen some and we are going to do it again. We have the dogs come in and everything. We are trying to watch the donating of clothes and the residents belongings. We can throw away people's things but they want their things. We put people's things in the dryer for 20-40 minutes and are just being vigilant. We bought some clothes from (outlet department store) and their outfits were full of bed bugs.
A review of the facility policy titled Pest Control revised May 2008, revealed, Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 30% annual turnover. Excellent stability, 18 points below Michigan's 48% average. Staff who stay learn residents' needs.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 life-threatening violation(s), 3 harm violation(s), $64,623 in fines, Payment denial on record. Review inspection reports carefully.
- • 55 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $64,623 in fines. Extremely high, among the most fined facilities in Michigan. Major compliance failures.
- • Grade F (1/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is The Villa At The Park's CMS Rating?
CMS assigns The Villa at the Park 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 Villa At The Park Staffed?
CMS rates The Villa at the Park's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 30%, compared to the Michigan average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at The Villa At The Park?
State health inspectors documented 55 deficiencies at The Villa at the Park during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, 49 with potential for harm, and 2 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates The Villa At The Park?
The Villa at the Park 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 VILLA HEALTHCARE, a chain that manages multiple nursing homes. With 114 certified beds and approximately 103 residents (about 90% occupancy), it is a mid-sized facility located in Highland Park, Michigan.
How Does The Villa At The Park Compare to Other Michigan Nursing Homes?
Compared to the 100 nursing homes in Michigan, The Villa at the Park's overall rating (2 stars) is below the state average of 3.1, staff turnover (30%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting The Villa At The Park?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.
Is The Villa At The Park Safe?
Based on CMS inspection data, The Villa at the Park has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Michigan. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at The Villa At The Park Stick Around?
Staff at The Villa at the Park tend to stick around. With a turnover rate of 30%, the facility is 16 percentage points below the Michigan average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly.
Was The Villa At The Park Ever Fined?
The Villa at the Park has been fined $64,623 across 2 penalty actions. This is above the Michigan average of $33,725. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is The Villa At The Park on Any Federal Watch List?
The Villa at the Park 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.