SKLD Livonia
For profit - Limited Liability company
110 Beds
SKLD
Data: November 2025
Trust Grade
45/100
#231 of 422 in MI
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
SKLD Livonia has a Trust Grade of D, which means it is below average and has some concerning issues. Ranking #231 out of 422 facilities in Michigan places it in the bottom half of nursing homes in the state, and #37 out of 63 in Wayne County indicates that only a few local options are better. The facility is worsening, with the number of reported issues increasing from 4 in 2024 to 8 in 2025. Staffing is relatively stable with a turnover rate of 38%, which is below the state average, though the overall staffing rating is just average. However, the facility has faced significant issues, including a serious incident where a resident died after a change in condition was not properly monitored, and another resident fell from bed during incontinence care, resulting in a head injury. Additionally, there are concerns about sanitation in the kitchen, which could pose risks for foodborne illnesses among residents.
- Trust Score
- D
- In Michigan
- #231/422
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 38% turnover. Near Michigan's 48% average. Typical for the industry.
- Penalties ✓ Good
- $45,429 in fines. Lower than most Michigan facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 38 minutes of Registered Nurse (RN) attention daily — about average for Michigan. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 34 deficiencies on record. Higher than average. Multiple issues found across inspections.
45/100
Bottom 46%
Needs review
4 → 8 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 4 issues
2025: 8 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (38%)
10 points below Michigan average of 48%
Facility shows strength in fire safety.
The Bad
3-Star Overall Rating
Near Michigan average (3.1)
Meets federal standards, typical of most facilities
Staff Turnover: 38%
Near Michigan avg (46%)
Typical for the industry
Federal Fines: $45,429
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: SKLD
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 34 deficiencies on record
2 actual harm
Jan 2025
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain the call light within resident reach for one (R22) of six residents reviewed for call light access. Findings include...
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Based on observation, interview, and record review, the facility failed to maintain the call light within resident reach for one (R22) of six residents reviewed for call light access. Findings include:
Review of the facility record for R22 revealed an admission date of 08/23/22 with diagnoses including Anorexia, Cirrhosis of the Liver, and Diabetes Mellitus. The record further indicated R22 was receiving hospice services.
On 01/14/25 at 10:25 AM and12:09 PM, R22 was observed laying in bed. They were not responsive to verbal greetings. The resident's call light was observed laying on the floor under the head of the bed out of reach.
On 01/14/25 at 02:28 PM and 3:18 PM, R22 was observed laying in bed and the call light remained on the floor under the head of the bed after staff had been observed in the room assisting the resident.
On 01/15/25 at 08:50 AM, R22 was observed laying in bed trying to call out for help. They were interviewed at bedside and asked for help stating that their hip was hurting. The call light was observed laying on the floor under the head of the bed out of reach as it was the previous day. R22 was asked if they know how to use the call light to request assistance and they stated yeah I can use it but I don't have it.
On 01/15/25 at 10:50 AM, the facility's Director of Nursing (DON) was was made aware of the concern regarding R22's call light not being accessible during multiple observations. The DON reported the expectation is resident's call lights should be kept within reach at all times.
Review of the facility policy Call Lights dated 07/11/18 revealed the policy statement It is the policy of this facility to provide the resident a means of communication with nursing staff. The Procedure portion of the policy includes the entry 7. Be sure call lights are placed within reach of residents who are able to use it at all times.
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 complete wound care per the physician order for one res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to complete wound care per the physician order for one resident (R84) of one reviewed for wound care. Findings include:
On 01/13/25 at 10:24 AM, R84 was observed to be dressed and seated in a wheelchair at the left side of the bed. R84 reported the cream for their buttocks wound was not applied as often as it was supposed to be. A review of the record documented a physician order dated 01/07/25 which revealed, R (right) buttock: Cleanse with NS (normal saline), apply triad, cover with border gauze. BID (two times a day) /PRN (as needed); every day and night shift for treatment.
On 01/14/25 at 11:33 AM, a skin and wound observation of R84's right buttock was conducted with the wound care nurse. A dressing was not observed to be in place. A quarter size open area was observed. The wound nurse applied a dressing to the wound area. The dressing was dated for 01/14/25 and had the initals of the wound care nurse. A review of the January 14, 2025 Treatment Administration Record (TAR) revealed the dressing change had been documented as done by the night shift nurse.
On 01/15/25 at 9:11 AM, the right buttocks area and dressing for R84 were observed with Registered Nurse (RN) H. The dressing was observed to be the dressing placed by the wound nurse on 01/14/25. A review of the January 15, 2025 Treatment Administration Record (TAR) revealed the dressing change had been documented as done by the night shift nurse.
Review of the December 2024 TAR revealed missing documentation for completion of the right buttocks treatment.
On 01/15/25 at 12:06 PM, the Director of Nursing (DON) reported the order should not have been written as two times a day and the facility had made attempts to ensure orders were not written that way unless specifically requested by the physician. The DON further noted audits of documentation were being completed. A review of the audits indicated they were checking for missing documentation. R84's wound care was documented as done but not completed and would not have been caught with only a chart review.
A review of the facility record for R84 revealed R84 was admitted into the facility 10/23/24. Diagnoses included Age Related Physical Debility and Myasthenia Gravis. The MDS dated [DATE] documented intact cognition, impaired range of motion of both upper extremities and the need for partial/moderated assistance of one person for personal hygiene, to roll left and right and to go from sitting to lying. The care plan revised 01/06/25 documented, Resident has an ADL self care performance deficit .
A review of the facility policy titled, Dressings, Non-Sterile adopted 07/11/2018 revealed, It is the policy of this facility to perform treatments and dressing changes per physician orders.
A review of the facility policy titled, Charting and Documentation Adopted 07/11/2018, revealed, All services provided to the resident, progress toward the care plan goals, or any changes in the
resident's medical, physical, functional or psychosocial condition, shall be documented in the
resident's medical record. The medical record should facilitate communication between the
interdisciplinary team regarding the resident's condition and response to care . Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment; f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure application of palm protector devices for one ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure application of palm protector devices for one resident (R76) of two residents reviewed for restorative services, resulting in unprotected palm of hand from contracted fingers. Findings include:
On 1/13/25 at 10:05 AM, R76 was in their room in their wheelchair. An observation of the left hand revealed a contracture (shortening of mucles causing joints to stiffen) of second, third, fourth, and fifth finger. A device to protect the palm or prevent the worsening of the contracture was not observed in use, and a splint was observed on the dresser.
On 1/13/25 at 10:54 AM, an interview was conducted with R76's family member and durable power of attorney. They said they were concerned about R76's left hand contracture and the potential for their fingernails to cause a wound in the palm. They said the staff were supposed to use a splint and or some device in the hand to prevent the worsening of the contracture or the development of a wound.
On 1/13/25 at 11:20 AM, 12:36 PM, 4:42 PM, and 1/14/25 at 7:53 AM, R76 was observed with no splint or device in their palm.
On 1/13/24 at 3:28 PM, R76 was observed in their room seated in their wheelchair. A splint or device to protect the palm was not present. With R76's Durable Power of Attorney's permission and R76's permission, an observation of their palm was conducted. R76 was able to slightly open and unclench their fingers from their palm and a reddened, small open area where the index finger nail met the palm was observed. R76's fingernails were discolored with debris under the nail bed, extended approximately a quarter of an inch beyond the nail bed, and were filed in a square fashion that gave them sharp edges. A foul odor was noted when R76's hand was opened. R76 was asked if they had any pain and made a grunting noise and nodded their head yes.
On 1/14/25 at 9:59 AM, R76's fingernails remained long, discolored, with debris under the nail bed and filed with sharp edges. They were asked if their palm still hurt and nodded saying, still hurts.
A review of R76's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: rectal cancer, drug induced subacute dyskinesia (uncontrollable involuntary movements), profound intellectual disabilities, autistic disorder and moderate intellectual disabilities. R76's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed they had severely impaired cognition. R76's physician orders were reviewed and an order dated 5/21/24 read, Apply foam roll in between left hand during daytime, remove at night. A review of R76's most recent Occupational Therapy Discharge Summary for service dates of 5/21/24 thru 8/1/24 was conducted and read, Patient Goals .L. digit contraction of digit 3,4,5 .continued hand splinting a must daytime foam roll and night time resting hand splint .
On 1/14/25 at 10:10 AM, an observation of R76's hand was conducted with Wound Care Nurse 'I'. Nurse 'I' observed R76's fingernails and palm and confirmed the presence of odor and a new wound to the palm.
A progress note entered into the record on 1/14/25 at 4:07 PM, by Wound Care Nurse 'I' was reviewed and read, .Writer completed skin observation to (L) (left) hand(contracture) with nails causing tear. Odor noted. Writer cleansed applied Bacitracin/4x4 gauze hand roll. Writer to follow with wound care.
On 1/14/25 at 12:15 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding R76's left hand contracture, splint, palm protector, fingernails, and development of a wound. The DON confirmed R76 was to have a splint at night and a foam roll or other device to protect the palm during the day. When made aware R76 had not been observed with any devices in place on 1/14/25 they had no explanation. They were then asked about the square nails with sharp edges and said family manicured them that way. They were asked if the family had been educated on the hazards of the nail shape and replied they should have been. They were next asked about the length of the nails and the odor in the palm and said staff should have noticed the condition of the hand and nails and addressed it.
A review of a facility provided document, Subject: Restorative Care was conducted and read, It is the policy of this facility to ensure that: Restorative care will be provided to each resident according to his/her individual needs and desires as determined by assessment and interdisciplinary care planning. The resident will receive services to attain and maintain the highest possible mental/physical functional status and psychosocial well-being defined by the comprehensive assessment and plan of care .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain the resident's water cup within reach for one resident (R22) of five residents reviewed for access to water. Finding...
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Based on observation, interview, and record review, the facility failed to maintain the resident's water cup within reach for one resident (R22) of five residents reviewed for access to water. Findings include:
Review of the facility record for R22 revealed an admission date of 08/23/22 with diagnoses including Anorexia, Cirrhosis of Liver, and Diabetes Mellitus. The record further indicated R22 was receiving hospice care services.
On 01/14/25 at 10:25 AM, R22 was observed laying in bed. They were not responsive to verbal greetings. A water cup was observed on the nightstand out of the resident's reach. There was a fall mat on the floor between the bed and the nightstand.
On 01/14/25 at 12:09 PM, R22 was interviewed as they were laying in bed. It was observed R22's water cup was on the nightstand out of reach. R22 was asked if they would like to be able to reach their water cup without assistance and they stated yes.
On 01/14/25 at 02:28 PM, R22 was observed laying in bed. The water cup was on an over-bed table at the foot of the bed out of the resident's reach after staff were observed in the room assisting the resident with their lunch.
Further review of R22's record revealed the 12/03/24 care plan Focus area statement The resident has dehydration or potential fluid deficit related to Hepatitis, Diabetes Mellitus, history of Adult Failure to Thrive. This focus area included the Goal statement Resident will be free of symptoms of dehydration and maintain moist mucous membranes. The Interventions portion of the focus area included the entry Encourage the resident to drink fluids of choice. R22's record revealed no indication the resident should not have access to their water cup.
On 01/14/25 at 03:18 PM, R22's water cup remained on the over-bed table out of reach near the foot of the bed.
On 01/15/25 at 08:50 AM, R22 was observed laying in bed. R22's water cup was observed on the over-bed table at the foot of the bed, out of reach. There was a fall mat on the floor to the right of the bed and there was approximately 20 inches of space between the left side of the bed and the wall that would accommodate the over-bed table in order to have the water within the resident's reach. R22 was asked if they would like to have access to their water cup and they stated yes.
On 01/15/25 at 10:55 AM, the facility Director of Nursing (DON) was informed of the concern regarding R22's water not being accessible while having a care plan item specific to dehydration risk and asked if they were aware of any reason that the water was not being kept within the resident's reach. The DON acknowledged that they were not aware of a care-planned or clinical reason for the water to not be accessible but indicated staff may be placing it out of reach due to a history of the resident spilling water.
Review of the facility policy Hydration dated 07/11/18 revealed the policy statement It is the policy of this facility to encourage fluid intake to maintain resident's hydration in compliance with physician orders. The Procedure portion of the policy includes the entry 2. Every resident will be provided fresh ice water every shift. and 3. Fluids will offered at a minimum of every two hours for the dependent resident, unless contraindicated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure a medication error rate less than five percent when two errors were made, from 27 opportunities resulting in a medicat...
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Based on observation, interview, and record review, the facility failed to ensure a medication error rate less than five percent when two errors were made, from 27 opportunities resulting in a medication error rate of 7.41% for one resident, (R39) of four residents reviewed for medication administration. Findings include:
On 1/14/25 at 8:20 AM, Nurse 'A' was observed preparing medications for administration to R39. Nurse 'A' prepared multiple medications including an oral folic acid supplement 400 mcg (micrograms). After preparing the medications Nurse 'A' proceeded to the room and administered the medications to R39. After R39 took the medications Nurse 'A' exited the room and signed the medications as given on the eMAR (electronic medication administration record). They were asked to confirm all medications due at that time had been administered and confirmed they were.
On 1/14/25 at 8:52 AM, R39's medications observed administered were reconciled (compared) with their physician's orders. It was discovered R39's order for folic acid was for 1 mg (milligram). It was further discovered R39 had an order for cyanocobalamin (Vitamin B12) 1000 mcg due at the 9 AM medication pass, however; it was not observed the medication had been prepared and administered to R39 at that time.
A review of a facility provided policy for medication administration updated 12/2019 was reviewed and read, .It is the policy of this facility that medications shall be administered as prescribed by the attending physician .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure treatment and services were provided in a dignified manner for eight residents, (R#'s 20, 70, 10, 76, 17, 13, 5, and 40...
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Based on observation, interview, and record review the facility failed to ensure treatment and services were provided in a dignified manner for eight residents, (R#'s 20, 70, 10, 76, 17, 13, 5, and 405) of eight residents reviewed for dignity. Findings include:
R20
On 1/13/25 at 1:19 PM, R20 was observed in the Rainbow dining room in their geri-chair (reclining lounge chair). R20 was being fed their lunch meal by CNA (Certified Nurse Aide) 'B'. At the conclusion of the meal, CNA 'B' was observed to transport R20 down the hall in their geri-chair by pulling the chair in a forward motion with the chair and R20 facing rearward.
On 1/13/25 at 1:22 PM, CNA 'B' was asked about pulling R20 backward in the geri-chair and said sometimes the wheels on the chair drift from side to side. They were asked if they were instructed to pull the chair with the resident facing rearward and they said no, the resident should face forward and the chair should be pushed from behind.
On 1/14/25 at 4:10 PM, an interview was conducted with the Director of Nursing (DON) regarding the proper way to transport a resident in a wheelchair or geri-chair and they said the resident should be facing forward and pushed in a forward motion.
R70, R10, R17, R13, R5, R405, R76
On 1/13/25 from 12:50 PM to 1:31 PM, an observation of the Rainbow dining room was conducted and eight residents were seated at six tables in the room. Certified Nurse Aide 'D' was overheard requesting bibs (clothing protectors) be brought to the dining room to be placed on residents prior to the lunch meal being served. Further observations included:
At 12:59 PM, R70 was sleeping in their wheelchair at the table with their lunch meal in front of them. R10 was seated across from R70 but did not have a meal tray.
At 1:05 PM, one-to-one feeding assistance was being provided to R76. R17 was seated across from R76 but was not served a meal. CNA 'E' was observed providing one-to-one feeding assistance to R13, but was observed to leave R13 in the middle of the meal to set up R5's meal tray.
At 1:23 PM, R70 remained asleep in their wheelchair with their meal in front of them, R10 was seated across the table and was provided a meal tray more than twenty minutes after R70.
At 1:28 PM CNA 'E' attempted to provide one-to-one assistance to R70 a half an hour after their meal had been served but R70 refused.
On 1/14/25 from 12:35 PM until 1:03 PM, a second dining observation was conducted in the Rainbow dining room. Nine residents were observed seated at six tables and two CNA's were present passing the trays, setting up the meals and providing one-to-one feeding assistance.
At 12:46 PM, R70 was provided a meal tray and R405 seated across the table. They had fallen asleep in their wheelchair and was not provided their meal until 12:55 PM. R70 was fidgeting with their meal ticket making no attempts to feed themselves. R17 had also been served a meal tray but was making no attempts at feeding themselves.
At 12:50 PM, CNA 'F' was providing one-to-one feeding assistance to R76 and CNA 'G' was providing one-to-one assistance to R20. R70 had a meal tray in front of them but was making no attempts at feeding themselves and two residents. R405 and R5 were not provided a meal tray while the rest of the diners either received assistance or fed themselves.
At 12:55 PM, CNA 'F' was observed to leave R76 in the middle of the meal to serve and set up R405's tray before returning to R76.
At 12:56 PM, R5 was the only resident in the dining room who had not received a meal tray. It was overheard the meal had been delivered to the hallway and CNA 'G' left the dining room to retrieve the tray. R70 remains with a tray in front of them fidgeting with their meal ticket and staff were not observed to be available to cue them or provide one-to-one assistance.
At 12:59 PM, CNA 'G' began providing one-to-one feeding assistance to R17, more than ten minutes after their meal had been served.
At 1:06 PM, CNA 'F' was observed to transport R76 from the dining room. It was observed their meal tray contained an unopened ice cream and an unopened yogurt. At 1:13 PM, CNA 'F' was asked why they did not offer those meal items to R76 and said they should have. They were then asked if they had enough help in the dining room to provide the one-to-one feeding assistance and cueing and said, they did not and that was why they were, all over the place in the dining room
On 1/14/24 at 4:10 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding the observations in the dining room. The DON acknowledged the concerns and indicated the dining process for individuals requiring more assistance and cueing was an ongoing process.
A review of a facility provided document regarding Resident rights, dignity, and respect was conducted and read, It is the policy of this facility that all residents be treated with kindness, dignity, and respect .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure bathing and hair care was completed and facial ...
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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 bathing and hair care was completed and facial hair removed timely for six residents (R34, R57, R63, R84, R99) of six residents reviewed for activities of daily living (ADL) care. Findings include:
R57
A review of the facility records for R57 revealed R57 was admitted into the facility on [DATE]. Diagnoses included Need for assistance with Personal Care, Above the knee leg amputations, and Diabetes. The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition and the need for partial/moderate assistance of one person for personal hygiene, substantial/maximal assistance to roll left and right and dependent to go from sitting to lying.
The shower/bath self was documented as not attempted due to medical condition or safety concerns.
The care plan revised 01/02/25 documented, Resident has an ADL self care performance deficit .
A review of the shower task in the electronic medical record on 01/14/25 documented three showers attempted in 30 days: 01/01/25 was a bed bath; 12/25/24 was a bed bath; and 12/21/24 was documented as refused. Paper shower sheets documented bathing on 01/11/25, 01/08/25 and 12/14/24. Six of eight possible showers were documented or attempted. The task documented showers were to be given Wednesdays and Saturdays in the evenings.
R63
On 01/13/25 through 01/15/25, R63 was not observed out of bed.
A review of the facility record for R63 revealed R63 was admitted into the facility 10/23/24. Diagnoses included Stroke, and Bone and Muscle Disorders. The MDS dated [DATE] documented impaired cognition and the need for partial/moderate assistance of one person for personal hygiene, substantial/maximal assistance to roll left and right and dependent to go from sitting to lying.
The shower/bathe self was documented as not attempted due to medical condition or safety concerns.
The care plan revised 11/08/24 documented, Resident has an ADL self care performance deficit .
A review of the facility records and tasks on 01/14/25 revealed five of eight showers were documented or attempted in thirty days: 12/18/24 was refused, a bed bath 12/25/24; 01/01/25 was documented not applicable; a bed bath on 01/4/25, and a bed bath on 01/09/25. Shower sheets were provided for 10/30/24, 11/27/24, 11/30/24, 12/07/24, 12/11/24 and 12/14/24. No additional shower sheets were provided to substantiate showers were given. The task documented showers were to be given Wednesdays and Saturdays in the evenings.
R84
On 01/13/25 at 10:24 AM, R84 was observed to be dressed and seated in a wheelchair at the left side of the bed. R84 reported they had not always received fresh water and the cream for their buttocks wound was not applied as often as it was supposed to be.
A review of the facility record for R84 revealed R84 was admitted into the facility 12/16/24. Diagnoses included Age Related Physical Debility and Myasthenia Gravis. The MDS dated [DATE] documented intact cognition, impaired range of motion of both upper extremities and the need for partial/moderate assistance of one person for personal hygiene, to roll left and right and to go from sitting to lying.
The shower/bathe self was documented as not attempted due to medical condition or safety concerns.
The care plan revised 01/06/25 documented, Resident has an ADL self care performance deficit .
A review of the facility records and tasks on 01/14/25 indicated five of eight showers were documented in the last thirty days: 12/18/24 was a shower, 12/21/24 was refused; 12/25/24 was a bed bath; 01/01/25 was documented refused; 01/11/25 was a shower. Shower sheets were provided for 12/18/24, 12/21/25, and 12/25/24. The task documented showers were to be given Wednesdays and Saturdays in the evenings.
R99
On 01/14/24 at 12:36 PM, a visitor for R99 reported concerns with R99 left in the same socks for three days; R99's feet were dependent all day which caused a dusky purple appearance.
A review of the facility record for R99 revealed R99 was admitted into the facility 12/06/24. Diagnoses included Stroke with affected right dominant side and Cerebral Palsy. The MDS dated [DATE] documented impaired cognition and the need for partial/moderate assistance of one person for personal hygiene, substantial/maximal assistance to roll left and right and to go from sitting to lying.
The shower/bath self section was documented as substantial/maximal assistance.
The care plan initiated 01/07/25 documented, Resident has an ADL self care performance deficit .
A review of the electronic shower documentation on 01/14/24 for the last thirty days revealed: showers were documented 12/16/24, 12/19/24, 12/23/24, and 12/26/24. 12/30/24, 01/06/25, 01/09/25 were documented as not applicable. Mondays and Thursdays were the indicated shower days which indicated ten opportunities since Friday 12/06/24. Four showers were documented as
attempted or completed.
On 01/15/25 at 12:11 PM, the Director of Nursing (DON) acknowledged a resident scheduled for a bath two times a week should be provided a bath two times a week and the completion or attempt documented.
R34
On 1/13/25 at 10:28 AM, R34 was observed in their room sitting on their bed with a one-to-one sitter. R34's long, gray hair was not combed and had a greasy appearance. They were further observed to have long, thick, facial hairs covering their chin. They were asked if they would like the hair removed and said they wanted to get rid of them but nobody would help.
On 1/14/25 at approximately 9:30 AM and 1:40 PM, R34 was observed in their room. Their hair remained uncombed, greasy in appearance and their face remained with thick, long facial hair on their chin.
On 1/14/25 at 9:16 AM, a review of R34's clinical record revealed they admitted to the facility on [DATE] and most recently re-admitted on [DATE]. R34's diagnoses included: toxic encephalopathy, cirrhosis, dementia, and anxiety disorder. The most recently completed Minimum Data Set (MDS) assessment dated [DATE] indicated R34 had severely impaired cognition, exhibited no hallucinations, delusions, behaviors, or rejection of care, and required mostly moderate assistance from staff for ADL's.
A review of R34's Certified Nurse Aide (CNA) task for showers for a 30-day look-back revealed they were scheduled for showers on Tuesdays and Fridays but had only received one bed bath for the 30-day look-back period. The documentation reviewed did not indicate R34 had their hair shampooed or was assisted with the removal of facial hair.
A review of R34's CNA task for behaviors for a 30-day look-back period was also conducted and did not document any behaviors. Further review of the record included progress notes, however; no progress notes dating back to November 2024 revealed any documentation to indicate R34 had been offered and refused any ADL care.
On 1/14/24 at 12:15 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding R34's ADL care. The DON indicated R34 frequently refused the care offered and would fight with the staff. They were asked about the lack of documentation to demonstrate the ADL care had been offered, attempted, and refused by R34 and said staff would have to do better documenting attempts at care, rejection of care, and behaviors.
A review of the facility policy titled, Charting and Documentation Adopted 07/11/2018, revealed, All services provided to the resident, progress toward the care plan goals, or any changes in the
resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the
interdisciplinary team regarding the resident's condition and response to care .Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care;
c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment; f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting .
A review of the policy title, Shaving adopted 07/11/2018 revealed, It is the policy of this facility to improve the resident's appearance. In accordance with the resident's preference.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene during care for four residents (R82, R70, R76, and R5) of four residents reviewed for hand hygiene...
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Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene during care for four residents (R82, R70, R76, and R5) of four residents reviewed for hand hygiene and infection control, resulting in the potential for the spread of infection. Findings include:
R82
On 1/13/25 at 9:03 AM, Nurse 'C' was observed preparing medications at the medication cart in the hallway for R82. They were not observed to perform hand hygiene prior to beginning to prepare the medications. Nurse 'C' prepared multiple medications including an ordered 81 milligram aspirin tab. Two aspirin tabs were deposited from the bottle into the cap for transfer to the medication cup. Nurse 'C' was observed to remove the second tab from the bottle cap with their bare hands and placed it back in the aspirin bottle. When the medication preparation at the medication cart was complete, Nurse 'C' entered R82's room, and was not observed to perform hand hygiene upon entry. They administered the medications, and at that time, R82 requested a medication for pain. Nurse 'C' exited the room and returned to the medication cart to prepare the pain medication. They were not observed to perform hand hygiene upon exiting the room prior to preparing the pain medication. Nurse 'C' deposited two of the pain medication pills from the bottle into the lid of the bottle for transfer into the medication cup. R82 was only to receive one pill and Nurse 'C' was observed to grab the second pill from the bottle cap with their bare hands and place it back into the bottle. Nurse 'C' returned to R82's room to administer the medication and again was not observed to perform hand hygiene prior to administering the medication.
On 1/13/25 from 12:50 PM until 1:31 PM, an observation of the Rainbow dining room was conducted and the following was observed:
Certified Nurse Aide (CNA) 'D' was observed to place clothing protectors on R70, R76, and R5. They were not observed to perform hand hygiene in between contact with the different residents. They were further observed to straighten R70's hair then sit down to provide one-to-one feeding assistance to R76 without performing hand hygiene.
CNA 'D' finished assisting R76 and moved to assist R17, they were not observed to perform hand hygiene after touching R76's utensils, plate, and napkins prior to assisting R17.
The dining room was observed without a hand washing sink or dispenser for hand sanitizing gel/foam.
On 1/14/25 at 4:10 PM, the infection control observations were discussed with the Director of Nursing. They indicated hand hygiene should be conducted in between resident contacts and pills should not be touched with bare hands.
A review of a facility provided document, Subject: Hand Hygiene was reviewed and read, Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a resident . Proper hand hygiene should be performed between all services to residents . After touching a resident or the resident's immediate environment .
Nov 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00147709.
Based on observation and interview, the facility failed to ensure resident wound ca...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00147709.
Based on observation and interview, the facility failed to ensure resident wound care treatments were documented and skin maintained intact for one resident (R901) of three whose skin management was reviewed. Findings include:
A review of the record for R901 revealed:
R901 was admitted into the facility on [DATE] and discharged on 10/22/24. Diagnoses included Pain, Anxiety, Kidney Disease and Heart Disease. A review of the Minimum Data Set (MDS) assessment dated [DATE] documented R901 had severely impaired cognition with a 2/15 Brief Interview for Mental Status score and the need for dependance of one or two persons for toileting hygiene, bathing, lower body dressing, rolling left or right in bed, and going from sitting to lying and back again. The MDS further documented R901 had Moisture Associated Skin Damage (MASD).
A physician order updated 09/26/24 documented MASD/Buttocks: Cleanse with soap and water. Pat dry. Apply barrier cream/AD. Cover with border guaze (two times a day/as needed) BID/PRN. Every day and night shift for treatment.
A review of the Treatment Administration Record (TAR) for August 2024 revealed treatment for a MASD buttocks wound began 08/29/24.
A review of the Treatment Administration Record (TAR) for September 2024 revealed six missed or undocumented treatments on the day shift and eight missed or undocumented treatments on the night shift for the MASD buttocks wound.
A review of the Treatment Administration Record (TAR) for October 2024 revealed two missed or undocumented treatments on the day shift and four missed or undocumented treatments on the night shift for the MASD buttocks wound.
On 11/21/24 at 1:00 PM, the missing treatments and desciption of the buttocks wound were reviewed with the wound care nurse staff A. The wound care nurse acknowledged some of the treatments may have been completed but not documented by them. The wound nurse supplied a wound assessment for September which documented the MASD to the buttocks and when asked, reported the area to the buttocks as excoriation or as something from a skinned knee. The wound nurse confirmed R901 was incontinent of urine and stool and this as the likely cause of the MASD.
On 11/21/24 at 4:27 PM, the missing documentation concern for R901 was reviewed with the Director of Nursing (DON). The DON reported R901 had a decline in condition and the buttocks wounds were recurring. Documentation of the the missing treatment was requested.
On 11/21/24 at 5:08 PM, Certified Nursing Assistant (CNA) B was asked about the care provided to R901 on 10/22/24 and reported there was a wound to the buttock that did not have dressing on it and needed they to clean it and have the nurse put a dressing on it. The CNA was asked to describe the wound and reported it to be around the size of a quarter and was red in the middle.
On 11/21/24 at 5:40 PM, the DON was asked about the missing documentation. The DON acknowledged the missing documentation and noted the treatment as an order with a dressing and confirmed an order with a dressing required documentation. No furtner documentation of the buttocks wound treatment was provided prior to survey exit.
A review of the facility policy titled, Skin Monitoring and Management: Pressure Ulcer adopted 07/11/18, revealed, .Once a wound has been identified, assessed and documented, nursing shall administer treatment to each affected area as per the Physician's order. All wound or skin treatments should be documented in the resident's clinical record at the time they are administered.
Oct 2024
2 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: MI00147554
Based on interview and record review, the facility failed to provide ongoing monito...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00147554
Based on interview and record review, the facility failed to provide ongoing monitoring and treatment for a change in condition for one resident (R901) of four residents reviewed for change of condition resulting in the initiation of Cardiopulmonary Resuscitation (CPR). Findings include:
A review of Intake: MI00147554 revealed the following, Complainant states the resident was exhibiting an altered mental status and the nurse on duty called EMS (emergency medical services) to have the resident sent to the hospital. The complainant states EMS arrived at the residents bedside and the administrator made them leave and told the Nurse Practitioner to treat the resident in house. The complainant states the resident was found dead the next day. The complainant states they don't know the residents cause of death but appeared fine prior to showing signs of altered mental status.
A review of R901's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, Diabetes, and Heart Failure. Further review revealed the resident was cognitively intact, oxygen dependent, and required 1-2-person assistance for transfers, toileting and dressing.
Further review of R901's medical record revealed the following progress note:
[DATE] 17:35 (5:35pm). General Progress Note
Patients left, and right hand noticeably shaking, unable to grasp things without it falling. MD (medical doctor) notified via Doctors book. Will continue to monitor patient duration of this shift.
[DATE] 17:19 (5:19pm) Change of Condition Note Text:
pt (patient) hypotensive (low blood pressure) in am (morning), bs (blood sugar) wnl (within normal limits), general weakness, lethargy difficulty speaking, [insurance company] NP (nurse practitioner) present, straight cath (catheter) for possible u/a, (urinalysis) STAT CXR ( immediate xray) ordered, lasix (diuretic) on hold, parameters added,02 (oxygen) tank replaced .continue to monitor and notify oncoming shift.
On [DATE] at 12:33 PM, an interview was completed with Licensed Practical Nurse (LPN) A regarding R901 on [DATE], and they explained they were inside the resident's room when staff were attempting to get the resident up in the sit to stand lift (used to help transfer patients from a seated to a standing position) however, the resident was exhibiting decreased strength with the inability to grasp the bars to the sit to stand, as each time they attempted to hold on to the bar, they would become too weak and let go. LPN A explained R901 kept stating they didn't feel good. LPN A explained the following morning, [DATE], they observed the resident with an altered mental status, with the inability to feed themselves due to their decreased strength with attempting to hold their spoon. LPN A confirmed R901's assigned nurse attempted to send the resident out via EMS on [DATE] however, it they were directed the resident could be treated in the facility.
On [DATE] at 12:40 PM, Registered Nurse (RN) B was asked about the incidents leading up to [DATE] when CPR was initiated on R901. RN B explained the resident's assigned nurse called 911 on [DATE] due to R901 exhibiting a change of condition however, there was a directive for EMS to leave without the resident as they could be treated at the bedside. RN B explained they observed R901, and they looked like they needed to be sent out, as their mental status had declined. They explained R901 normally was alert and oriented to person, place and things with the ability to express their needs, however, R901 was observed as alert, but lethargic and not able to get out of bed. RN B explained the resident's assigned Nurse Practitioner (NP E) who is familiar with the resident was not in the building during this time, and the Nurse Practitioner covering for her (NP J) was not familiar with the resident. RN B confirmed the covering Nurse Practitioner ordered labs, a chest x-ray, and a urinalysis. RN B further explained on [DATE] between 9:45-10:00am a code blue (need for immediate medical intervention) was called for R901 who later died.
On [DATE] at 12:51 PM, Certified Nursing Assistant (CNA C) who was assigned to R901 on [DATE] and [DATE] was asked about the resident's baseline on those dates. CNA C explained the resident was shaky and in pain for those two days, explaining they had to assist the resident with eating the morning of [DATE] due to their inability to hold their spoon, and consumed, a little (name of gelatin). CNA C explained on [DATE], R901's assigned nurse called EMS for the resident due to a change of condition however, they left without R901.
On [DATE] at 2:30 PM, the Director of Nursing (DON) was interviewed regarding R901's change of condition, and she explained she was not in the building however, in interviewing facility staff, she learned R901 showed a decline and attempts to send the resident to a higher level of care was unsuccessful. The DON explained she relies on her nurses to assess the residents, and they did what was expected of them. The DON explained she would have liked for the resident's physician to have been contacted regarding the resident so they could assess the timing of when their results (labs, Xray, urinalysis) would have been received. The DON explained there was also discussion among facility staff regarding the Nursing Home Administrator (NHA) becoming involved in the decision for the resident to be treated at beside and EMS's directive to leave, and indicated that if this was the case, she (the Administrator) should have stayed in her lane.
A review of R901's progress notes revealed the following:
[DATE] 02:39 (2:39am) General Progress Note. Note Text: chest Xray result was faxed in and result shows Heaviness in the lower chest, with blunting of the costophrenic angle (pleural effusion), and Loculated pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest) on the L (left) Side appears to be present. I tried calling the Dr (doctor) but no response, so I sent a text message to him and notified the morning shift nurse for follow up.
On [DATE] at 3:09 PM, Physician D was interviewed regarding R901 and their change of condition, and acknowledged the resident experienced a change of condition, and that the nurse texted them at 2:00am, which he didn't receive until 9:00am, and upon review attempted to reach someone at the facility for the resident to be sent out. At that time, Physician D was informed that CPR had already been initiated on the resident. Physician D acknowledged the resident should have been sent out to the hospital upon their change of condition as they were hypoxic, had chronic kidney disease, high potassium levels, and the hospital is approximately 1 mile away.
On [DATE] at 3:30 PM, Nurse Practitioner (NP) E was interviewed via phone regarding R901's change of condition. NP E explained she saw R901 regularly with the last time being [DATE], as there were other Nurse Practitioners assigned to the building while she was off. NP E explained that upon returning to the building on [DATE], and going to see R901, she located the resident with blueish lips, and called a code blue. NP E explained she was informed that leading up to [DATE], R901 showed a change of condition resulting in EMS arriving to the building and although appearing ill looking and sick, EMS was directed to leave as the resident would be treated at the bedside. NP E explained the staff at the nursing facility know her very well, and explained that if she would have seen the resident, she would have sent them out (to the hospital). NP E explained if treatment would have occurred at bedside, she would have expected for IV (intravenous) fluids to have been provided if the resident was arousable however, continued monitoring would also have been appropriate. NP E further explained, an altered mental status and lethargy in R901 warranted them sending the resident out.
On [DATE] at 4:07 PM, an interview was completed the with the Nursing Home Administrator (NHA) regarding R901's change of condition, and she explained the ambulance arrived, and the nurse practitioners from R901's health plan indicated they could treat the resident at the bedside, and would contact the physician.
On [DATE] at 9:19 AM, an interview was completed with LPN F, assigned nurse to R901 on [DATE]. LPN F was asked about R901's change of condition, and they explained the resident was not their normal self. They explained the resident is usually talkative, but was sparingly using their words and was in and out of it and was also weak and lethargic. LPN F explained he checked the resident's vitals in which at that time the resident's blood pressure was 80/50. He explained he left the room to allow the resident to rest, and returned approximately a half hour later hoping the resident's blood pressure would have improved but upon assessing the resident, there was no improvement, so he called EMS to take the resident to the hospital. LPN F further explained they had everything ready for the resident to be transferred and was providing EMS with everything needed for the transfer when the NHA, Unit Manager, and Nurse Practitioner approached the room. LPN F confirmed the Nurse Practitioner advised they would take over, asked him to retrieve supplies to obtain urine for a urinalysis, and a suppository. LPN F explained EMS left, and he continued to monitor the resident for the duration of their shift which when until 7:00pm, noting no improvement in R901's mental status or condition.
On [DATE] at 11:10 AM, an interview was completed with LPN G regarding the change of condition of R901, and explained the morning of [DATE], she was approached by CNA C who asked she assess R901 as their assigned nurse had taken a break and she had concerns about the resident. LPN G explained she assessed R901 and observed them to be unable sit up, appeared in and out of consciousness to the point they had to be held up to obtain their vitals. LPN G explained in R901's state of unconsciousness, they said, Please help me. LPN G explained she informed the resident's assigned nurse upon their return from break, and reports approximately 10 minutes later, EMS arrived and later left without R901. LPN G explained the Nurse Practitioner asked them if she had a suppository in her medication cart because they wanted to clean [R901] out.
On [DATE] at 11:45 AM, an interview was completed with Central Supply Staff H (CS H) regarding observations of R901 on [DATE], and she explained on that date she entered R901's room regarding supplies for their oxygen, and while in the room, she observed R901 crying and stating, Help me. CS H explained upon exiting the room, she witnessed the CNA talking to the assigned nurse about R901, and later witnesses EMS enter the building for R901. CS H further explained later that day, after EMS exited the facility, she continued to witness R901 crying, which was unlike R901, as they were an active resident who was usually up daily participating in activities.
On [DATE] at 2:48 PM, Nurse Practitioner (NP J), the covering NP on [DATE] for R901 was interviewed via phone. NP J explained upon assessing R901, she observed them lethargic appearing weak and was asking for their oxygen as their concentrator was malfunctioning. NP J explained this was her first time seeing the resident, and orders were placed for the resident following her assessment, and any continued monitoring would be done by nursing staff. NP J was asked if she contacted R901's physician, in which she explained she did not. NP J was asked what treatments were provided to R901and why the condition didn't warrant a transfer to the hospital, NP J stated, My progress note speaks for itself.
A review of R901's progress note written by NP J revealed the following:
[DATE] 13:00 (1:00pm) Late Entry: Note Text .New Patient Encounter
([DATE]) .History of Present Illness
Resident seen today for acute change in condition or left and right hand tremors reported by NH (nursing home) staff yesterday evening. Upon arrival to the resident's room, EMS was present due to NH staff's concerns regarding the resident's lethargy, and weakness, which the nurse observed while administering medications that morning. It was noted that the resident's oxygen concentrator was malfunctioning, with an unclear duration of time without oxygen, SPO2 85%. The resident is oxygen-dependent at baseline, requiring 2L (liters) continuous NC (nasal cannula). Resident was transitioned to a portable oxygen tank set at 4L NC and administered a DuoNeb breathing treatment while EMS assessed the resident at the bedside. The resident responded well to the breathing treatment, with SPO2 improving to 96%. It was agreed upon by the writer and paramedics that the resident's condition was likely r/t (related to) hypoxia and it was appropriate to treat in place in which resident consented to .Upon further exam, the resident appeared lethargic but conversational and orientedx4. Afebrile . resident requested oral fluids and expressed a desire for lunch. Able to make her needs known .
On [DATE] at 12:55 PM, an interview was completed with the resident's representative, Family Member I regarding R901. Family member I explained they visited R901 on [DATE] between 2:00pm-5:30pm. Family Member I was unaware EMS had arrived earlier and was advised to leave the facility after being called by LPN F. They explained that upon arriving to the facility, they had no idea the resident hadn't been feeling well all day, and upon observing R901 in bed, explained they did not seem like themselves as they were lethargic, not speaking clearly, stated they felt dizzy and tired. Family Member I said R901 seemed out of it as they would say something and then float off. Family Member I said they stopped by the office where the Nurse Practitioner (NP J) was located after visiting with R901, and explained to them they wanted her to check out R901 again because they seemed out of it, and NP J confirmed they would. Family Member I explained there was no way that she thought her family would have died the following morning, as they hadn't been ill, hadn't been hospitalized , and was going to outside appointments regularly.
Further review of R901's medical record revealed that following, NP J's initial assessment of the resident, there was no further documentation of any treatment and/or monitoring provided to the resident after a noted change of condition.
A review of the facility's Change in a Resident's Condition or Status policy did not address ongoing monitoring and/or treatment related to a resident showing a change of 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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
This citation pertains to Intake: MI00147554.
Based on interview and record review, the facility failed to notify the resident representative of a change of condition for one resident (R901) of three ...
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This citation pertains to Intake: MI00147554.
Based on interview and record review, the facility failed to notify the resident representative of a change of condition for one resident (R901) of three residents reviewed for notification. Findings include:
A review of R901's medical record revealed they were admitted into the facility on 7/13/23 with diagnoses that included Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, Diabetes, and Heart Failure. Further review revealed that the resident was cognitively intact, oxygen dependent, and required 1-2-person assistance for transfers, toileting and dressing.
Further review of R901's medical record revealed the following progress note:
10/6/2024 17:35 (5:35pm). General Progress Note
Patients left, and right hand noticeably shaking, unable to grasp things without it falling. MD (medical doctor) notified via Doctors book. Will continue to monitor patient duration of this shift.
10/7/2024 17:19 (5:19pm) Change of Condition Note Text:
pt (patient) hypotensive in am (morning), bs (blood sugar) wnl (within normal limits), general weakness, lethargy difficulty speaking, [insurance company] NP (nurse practitioner) present, straight cath (catheter) for possible u/a, (urinalysis) STAT CXR ( immediate xray) ordered, lasix (diuretic) on hold, parameters added,02 (oxygen) tank replaced .continue to monitor and notify oncoming shift.
On 10/23/24 at 9:19 AM, an interview was completed with LPN F, assigned nurse to R901 on the morning shift on 10/7/24. LPN F was asked about R901's change of condition, and they explained that the resident was not their normal self. They explained that the resident is usually talkative, but was sparingly using their words and was in and out of it. They explained that the resident was also weak and lethargic. LPN F explained that he checked the resident's vitals in which at that time the resident's blood pressure was 80/50. He explained that he left the room to allow the resident to rest, and returned approximately a half hour later hoping that the resident's blood pressure would have improved but upon assessing the resident, there was no improvement, so he called EMS to take the resident to the hospital. LPN F further explained that they had everything ready for the resident to be transferred and was providing EMS with everything needed for the transfer when the NHA (Nursing Home Administrator), Unit Manager, and Nurse Practitioner approached the room. LPN F explained that the Nurse Practitioner advised that they would take over, asked him to retrieve supplies to obtain urine for a urinalysis, and a suppository. LPN F explained that EMS left, and he continued to monitor the resident for the duration of their shift which was until 7:00pm, noting no improvement in R901's mental status or condition.
On 10/23/24 at 12:55 PM, an interview was completed with the resident's representative, Family Member I regarding R901. Family member I explained they visited R901 on 10/7/24 between 2:00pm-5:30pm and someone mentioned to them upon arrival to the facility that R901 wasn't feeling well that day, as R901 could usually be located in the activity room. Family Member I explained when they arrived to R901's room, they found the Nurse Practitioner in the room who explained they would be conducting a urinalysis of R901. Family Member I explained they were unaware R901 had been assessed by their assigned nurse who determined the resident needed to be trasnferred to a higher level of care, and that EMS had been called, and left withthout R901. Family Member I explained they observed R901 in bed, and they did not seem like themselves as they were lethargic, not speaking clearly, stated that they felt dizzy and tired. Family Member I explained R901 seemed out of it as they would say something and then float off. Family Member I explained they stopped by the office where the Nurse Practitioner was located after visiting with R901, and explained to them she wanted them to check out R901 again because they seemed out of it, and the nurse practitioner confirmed that they would.
A review of the facility's Change in a Resident's Condition or Status policy revealed the following, The facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status .
Sept 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #1 (R1):
Review of the medical record reflected R1 admitted to the facility on [DATE], with diagnoses that included loc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #1 (R1):
Review of the medical record reflected R1 admitted to the facility on [DATE], with diagnoses that included local infection of the skin and subcutaneous tissue. The admission/5-day Medicare Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/7/24, reflected R1 was coded for infection of the foot, open lesion(s) on the foot and application of dressings to the feet. R1 discharged from the facility on 8/16/24 and did not reside in the facility at the time of the survey.
A Progress Note for 8/4/24 reflected R1 admitted to the facility with ulcers (wounds) on both great (big) toes and the second toe of the right foot.
A Physician visit note for 8/7/24 reflected R1 had the following wounds:
-An abrasion to the left great toe, measuring 3 centimeters (cm) in length by (x) 0.8 cm in width.
-An abrasion to the right great toe, measuring 3 cm in length x 1.5 cm in width
-An abrasion to the second toe of the right foot, measuring 0.5 cm in length x 0.5 cm in width
-A right calf avulsion (skin torn away) trauma wound, measuring 2 cm in length x 2 cm in width x 0.3 cm in depth
-A right anterior (front) shin trauma wound, measuring 1.8 cm in length x 1.3 cm in width x 0.3 cm in depth
The same Physician visit note reflected wound care orders for the left great toe, right great toe and second toe of the right foot, which included cleansing with normal saline, application of triple antibiotic ointment and application of an ABD pad and kling wrap/kerlix to secure the dressing. The dressings were to be changed daily and as needed.
Additionally, the Physician visit note reflected recommendations for the right calf and right anterior shin wounds, which included cleansing with normal saline and the application of Xeroform (type of wound dressing), an ABD pad and kling wrap/kerlix to secure the dressing. The dressings were to be changed daily and as needed.
R1's Treatment Administration Record (TAR) for 8/2024 reflected an order to cleanse the left and right great toes with betadine and apply triple antibiotic ointment. The dressing was to be wrapped with kerlix and changed every Monday, Wednesday and Friday on day shift. The treatments began on 8/7/24, which was three days after R1 admitted to the facility.
No further wound treatment orders were noted in R1's medical record.
In an interview on 9/19/24 at 2:30 PM, Licensed Practical Nurse (LPN) P reported being the Wound Nurse for the facility. After reviewing R1's medical record, LPN P acknowledged she did not see treatment orders for R1's second toe on the right foot, right shin or right calf and could not explain why.
This citation pertains to Intakes MI00146343, MI00146953, and MI00146881.
Based on interview and record review, the facility failed to provide treatments, medications, and blood sugar monitoring as ordered for two (Resident #2 and Resident #1) of four reviewed.
Findings include:
Resident #2 (R2)
Review of the medical record revealed R2 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included multiple sclerosis, type 2 diabetes, and dysphagia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/14/24 revealed R2 scored 4 out of 5 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R2 was hospitalized from [DATE] until 8/31/24 at which point they were readmitted to the facility with a new PEG (Percutaneous endoscopic gastrostomy/feeding tube). R2 transferred back to the hospital on 9/5/24 and did not return to the facility.
Review of the Physician's Order dated 8/31/24 revealed an order for insulin lispro (Humalog/fast acting insulin), inject 6 units before meals. Review of the Medication Administration Record (MAR) revealed lispro was administered on 9/1/24 at 7:00 AM and 11:30 AM. The order was discontinued on 9/1/24.
Review of a Physician's Order dated 9/1/24 at 1:35 PM and entered by the pharmacy, revealed insulin lispro was changed to Lyumjev (fast acting insulin) 6 units before meals. The order was scheduled to begin on 9/2/24 at 7:00 AM, therefore, R2 did not receive any fast acting insulin on 9/1/24 at 5:00 PM as scheduled. The pharmacy did not add supplementary documentation of blood sugar checks with the insulin administration order. There was no documentation of blood sugar checks on 9/2/24 at 7:00 AM, 11:30 AM, 5:00 PM or 9/3/24 at 7:00 AM and 11:30 AM. The Lyumjev order was discontinued on 9/2/24 at 1:36 PM.
Review of the Medical Practitioner Progress note dated 9/1/24 at 9:20 PM revealed Glucose labile. Start sliding scale insulin.
Review of a Physician's Order dated 9/2/24 at 1:36 PM and entered by Unit Manager (UM) C revealed an order for Lyumjev 6 units before meals in addition to a sliding scale. The order was scheduled to start on 9/2/24 at 5:00 PM. The order was discontinued on 9/2/24 at 3:18 PM due to a therapeutic interchange.
Review of the Physician's Order dated 9/2/24 at 3:20 PM and entered by pharmacy, revealed an order for Fiasp (fast acting insulin) sliding scale. The pharmacy did not include the 6 units before each meal with the order. The supply directions indicated both 6 units before meals in addition to the sliding scale, however the 6 units before meals did not transcribe to the MAR. The order was scheduled to start on 9/3/24 at 5:00 PM; therefore, R2 did not receive any fast acting insulin on 9/2/24 at 5:00 PM, 9/3/24 at 7:00 AM, and 9/3/24 at 11:30 AM. R2 also did not receive 6 units of Fiasp before meals from 9/3/24 to 9/5/24
Review of the MAR revealed Fiasp sliding scale was not administered on 9/4/24 at 7:00 AM for a blood sugar of 370 milligrams/deciliter (mg/dL). R2 should have received 10 units sliding scale. The progress notes revealed the Fiasp was not administered because it was on order and pharmacy was notified. On 9/5/24 at 5:00 PM, R2's blood sugar was 389 mg/dL, but R2 did not receive the 10 units per sliding scale as ordered. The progress notes did not state why R2 did not receive sliding scale insulin at that time.
In a telephone interview on 9/19/24 at 9:14 AM, Pharmacy Technician (PT) E reported Fiasp and Lyumjev were interchangeable. PT E reported four pens, containing 100 units each, of Lyumjev were delivered to the facility on 8/31/24. PT E reported they did not have note that the facility contacted them on 9/4/24.
In a telephone interview on 9/19/24 at 12:39 PM, Pharmacy [NAME] President of Quality Assurance (VPQA) D reported Lyumjev and Fiasp were part of the pharmacy's therapeutic interchange program; therefore either could be used.
Review of the Therapeutic Interchange (TI) Formulary provided by Pharmacy VPQA D revealed insulin lispro (humalog), Lyumjev, and Fiasp were all interchangeable unit to unit and same frequency. The document also revealed Following any insulin product interchange, close blood glucose monitoring is recommended, with possible insulin dosage titration based on follow-up blood glucose values.
In a telephone interview on 9/19/24 at 12:13 PM, Physician M reported they could not recall the specifics of R2's insulin orders. Physician M reported R2 should have had their blood sugar checked three to four times a day. Physician M reported they were not made aware that R2 did not receive insulin and that Fiasp was not available. Physician M reported they would expect to be notified and that there were alternative insulins available for use.
In an interview on 9/19/24 at 1:06 PM, UM C reported the facility had an arrangement with the pharmacy for therapeutic interchanges and that each physician was required to review and sign the interchange. UM C reported that occasionally, pharmacy entered orders and that nursing would confirm the orders. UM C agreed R2 did not receive any fast-acting insulin and blood sugars checked as ordered. UM C agreed when the order was changed from Lyumjev to Fiasp, the 6 units before meals was dropped off the order and therefore the order was transcribed as only a sliding scale.
In an interview on 9/19/24 at 2:52 PM, Director of Nursing (DON) B reported the physicians signed a pharmacy therapeutic interchange which allowed the pharmacy to make changes. DON B reported pharmacy could write the order in the electronic medical record and that the pharmacy would contact the physician if they had any questions or concerns. DON B agreed the pharmacy's Therapeutic Interchange (TI) Formulary listed Lyumjev, Fiasp, and lispro/Humalog as being interchangeable. DON B reported R2's blood sugar would normally be monitored three times a day and reported they were not sure why R2 missed doses of fast acting insulin.
Nov 2023
9 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure safety measures were followed per the plan of c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure safety measures were followed per the plan of care and prevent a fall from bed during incontinence care for two sampled residents (R41 and R64) from a sample of three residents reviewed for accidents, resulting in fall with head injury and a transfer to the hospital. Findings include:
R41
On 10/30/23 at 10:12 AM, R41 was observed sitting in their wheelchair eating breakfast. R41 was observed to have a healed scar to the left side of their forehead. They were asked about their stay in the facility, and they reported that they were hospitalized a few months prior as a result of a fall from their bed while being provided care. R41 reports that they were lying on their side while their assigned Certified Nursing Assistant (CNA D) was providing incontinence care. R41 explained that they were facing away from the CNA when they started to roll out bed. R41 explained that they ultimately fell onto the floor, hitting their head, and requiring a transfer to the hospital where they obtained stitches to their forehead.
A review of R41's medical record revealed that they were admitted into the facility on 3/29/16 with diagnoses that included Chronic Kidney Disease, Hypertension, BI-Polar Disorder, and Epilepsy. Further review of R41's medical record revealed a quarterly Minimum Data Set assessment dated [DATE] indicating that R41 had a Brief Interview for Mental Status score of 13/15 indicating an intact cognition, and required extensive assistance of two people for bed mobility, transfers and toilet use.
A review of R41's progress notes revealed the following:
10/4/2023 06:52 (6:52am)
General Progress Note
Note Text: Aide notified writer that resident had rolled out of bed as she was cleaning [them] up, on going to resident's room resident observed laying on the floor besides [their] bed on [their] left hand side bleeding from [their] head, resident was noted to still be conscious, able to identify [themselves] and situation at hand transferred back to [their] bed, bleeding noted to be coming from the top of [their] left eye open area noted, pressure dressing applied to stop the bleeding . guardian notified [contact information] about incident and that resident was being sent out to hospital to rule out a concussion .c/o (complain of) pain 8/10 -headache.
10/4/2023 11:39 (11:39am) General Progress Note
Note Text: Patient returned from ER (emergency room) via stretcher at approximately 11:18 am. Resident is alert. Writer noted 5 stitches on left forehead laceration. new order for cyclobenzaprine (muscle relaxant) 5 mg (milligrams) 3 times daily PRN (as needed). Provider notified of Resident Return and new Med .
10/4/2023 14:59 (2:59pm)
Medical Practitioner Progress Note .New Patient Encounter. Reason: Fall on 10/04/2023. History of Present Illness (HPI) (10/04/2023). The patient`s recent experience or cause of the new problem: Per staff member had fall from bed during repositioning. [R41] was transferred to [local] hospital ED [emergency department] visit only treated for laceration to lateral forehead. Member was examined today upright in bed. Noted to have five intact sutures to left lateral temporal forehead area no, negative signs and symptoms of infection.
Post Fall Evaluation
(10/04/2023)
1.Date of fall: 2023-10-04
2.Time of fall: 4:01 am - 8:00 am
3.Witnessed fall?: Yes
4.Location of fall: Patient Room
5.Injuries of fall: Major (fracture, head injury)
6.Is the resident on a Toileting Program? Yes
7.Please list any other factors that impacted this fall: CNA repositioning on bed.
8.Disposition: Emergency Department Only .
Plan Facial laceration, initial encounter
1. [R41] is seen upright on bed, baseline cognition and non-illness appearing. Monitor changes neurological status and notify MD (medical doctor)/Telehealth; Keep suture site clean and dry every shift and monitor s/s (signs and symptoms) infection;
2. Continue Tylenol Tablet 325 MG , Ibuprofen Tablet 400 MG; consider antibiotic ointment ->Neosporin or bacitracin as indicated; Sutures removal 5-7 days if wound edges well approximate .
10/5/2023 08:49 (8:49am) General Progress Note
Note Text: Resident indicated to writer that [their] left knee was in pain and signs of swelling. These symptoms are related to a fall the resident said [they] had. Writer asses the clients left knee; swelling visual to eye. Writer administered PRN Acetaminophen for pain. Left Knee X-ray Ordered. Physician notified. Neuro checks in place. Writer will continue to monitor resident for pain, discomfort or alt (alteration) in neuro for duration of shift.
Further review of R41's medical record revealed a physician progress note dated for 10/5/23 revealing the following, .seen in follow-up regarding a fall for which [they were] sent to the hospital for head laceration and knee pain .Patient also complains of left knee pain .[R41] indicates that so much attention was paid to the laceration in the emergency department, that no imaging was conducted of the left knee. We will order an x-ray. [R41] does have pain and swelling .
On 11/1/23 at 11:41 AM, an interview was completed with CNA D via phone, and asked about R41's fall during care. CNA D explained that they were attempting to get R41's brief from underneath them when they rolled over onto the floor. CNA D explained that R41 was turned toward her but as she turned R41 a little bit they rolled over and fell. CNA D was asked if R41 required one or two people for repositioning, and she explained that R41 is usually a one person, but that they try to utilize two. She reports that on this date, there was no one available to assist her.
A review if R41's care plan revealed the following:
Focus: [R41] is at risk for falls due to potential medication side effects, weakness, impaired balance, use of psych (psychotropic) meds, DX (diagnosis) of Vertigo, and a HX (history) falls. [R41] is
mobile via wheelchair. [R41] also requires assistance with bed mobility, transfers, and toileting needs 2 persons assist with positioning PRN Date Initiated: 12/25/2018. Created on: 05/26/2017 .
R64
On 10/30/23 at 11:07 AM, R64 was observed lying in bed. Due to their cognition, they were unable to respond to surveyor's questions.
A review of R64's medical record revealed that they were admitted into the facility on 3/17/22 with diagnoses that include Cerebral Edema. Aphasia, Depression, and Gastrostomy Status. Further review revealed a quarterly Minimum Data Set assessment dated [DATE] indicating that R64 was severely cognitively impaired, and was Total Dependent on two staff for Activities of Daily Living, including toileting, bed mobility and transfers.
Further review of the R64's medical record revealed the following progress note:
9/18/2023 19:46 (7:46pm) General Progress Note
Note Text: Writer was called about resident falling off from the bed during care. Caregiver stated [R64] fell on [their] back and butt and did not hit [their] head
On 10/31/23 at 11:08 AM, an interview was completed with Nurse E regarding R64's fall, and she reported that the CNA was providing care by themselves, and the resident fell to the floor. Nurse E was asked if the resident was supposed to have one or two people providing care at that time, and explained, [R64] required two people.
On 10/31/23 at 2:12 PM, CNA F was interviewed via phone and asked about R64's fall. CNA F explained that he was providing care by himself when he attempted to view what was underneath R64. CNA F explained that he pushed the resident away from him and thought that the perimeter mattress would prevent the resident from falling however, it gave away and the resident started to roll. CNA F explained that he attempted to grab the resident but was unable to do so. CNA F denied that the resident was injured or hit their head.
On 11/1/23 at 12:23 PM, the Director of Nursing (DON) was interviewed regarding R41's fall, and did not provide an explanation, rather interventions implemented following the fall. Regarding R64's fall, she did indicate that CNA F was provided with education on ensuring that the plan of care is checked, and ensuring that you're turning residents toward you, and not away when providing care.
A review of CNA F's education was provided and dated for 9/18/23. It revealed the following, Always turn the resident toward you, not away from you. Check the [NAME] care plan, ask your nurse or fellow aides for assistance as needed.
On 11/1/23 at 2:02 PM, the Nursing Home Administrator (NHA) was asked if falls have been addressed in Quality Assurance, and she explained that falls have been identified as a concern, and that the root cause was staff needing additional education and needing to check the plan of care. She further explained that they have implemented audits as a result.
A review of the facility's Fall Prevention policy revealed the following, POLICY:
It is the policy of this facility that the Fall Prevention Program is designed to ensure a safe environment for all residents. Each resident will be evaluated upon admission, quarterly and as needed by an RN/LPN (registered nurse/licensed practical nurse) to assess his/her individual level of risk. The Interdisciplinary Team will review the Fall Risk Assessment completed by the nursing department and if appropriate, a fall prevention protocol will be initiated. PURPOSE:
1. To identify residents at risk in a timely manner.
2. To gather accurate, objective and consistent data for the purpose of implementing an individualized Plan of Care designated to meet the resident's needs.
3. To ensure consistency in the implementation of preventive measures to assist with the reduction of falls.
4. To evaluate outcomes .
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 maintain the dignity of one (R30) of five residents 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 maintain the dignity of one (R30) of five residents reviewed for dignity by limiting their clothing to a hospital-style gown with the resident's incontinence brief consistently exposed, resulting in an undignified appearance for a resident who is unable to express clothing choices or preferences. Findings include:
Review of the facility record for R30 revealed an admission date of 07/08/20 with diagnoses that included Cerebral Palsy, Chronic Respiratory Failure and Dysphagia/Aphasia. The Minimum Data Set (MDS) assessment dated [DATE] indicated R30 required total assistance for all care including dressing. R30 did not demonstrate the ability to actively participate in a BIMS assessment.
On 10/30/23 at 11:32 AM, R30 was observed laying in bed and was verbally unresponsive. R30 was wearing a gown and their brief was exposed.
On 10/30/23 at 1:31 PM, R30 was observed laying in bed in their gown with the lower half of their brief exposed.
On 10/30/23 at 4:10 PM, R30 was observed laying in bed wearing a gown.
On 10/31/23 at 9:17 AM, R30 was observed laying in bed and wearing a gown with the lower half of their brief exposed.
On 10/31/23 at 11:35 AM, R30 was observed laying in bed wearing a gown with their brief exposed.
On 10/31/23 at 3:55 PM, R30 was observed laying in bed wearing a gown with their brief exposed.
On 11/01/23 at 9:21 AM, R30 was observed laying in bed wearing a gown with the lower half of their brief exposed.
On 11/01/23 at 10:09 AM, R30 was observed laying in bed wearing a gown with their brief exposed.
On 11/01/23 at 10:17 AM, Certified Nurse Assistant (CNA) C reported that they were assigned to R30 for the current shift and that they had experience working with R30. CNA C reported that R30 does have facility-provided clothing available other than gowns.
On 11/01/23 at 11:44 AM, the facility Director of Nursing (DON) was interviewed and made aware that R30 was observed wearing only a gown and remaining in bed for the entirety of the surveyor's observations since facility entry. When asked their expectation regarding the resident being dressed in clothing other than gowns, the DON reported that they would expect the social worker to contact the guardian to request that clothing be provided. The DON was informed that R30's direct care staff had indicated that the resident did have clothing available. The DON reiterated that they felt the issue involved difficulty in obtaining clothing/financial resources from the resident's guardian service. The DON reported that the resident is always dressed when they are up in a chair and that the facility goal is to have R30 up in a chair two to three times per week. The DON reported that they did not know why the resident had not been up/dressed during the time of the survey.
The facility policy titled Dignity and Respect dated 07/11/18 includes the Policy statement: It is the policy of this facility that all residents be treated with kindness, dignity and respect. The Procedure portion of the policy includes the entry:
3. Residents will be appropriately dressed in clean clothes arranged comfortably on their persons, and be well groomed as per their preference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to update a care plan following a fall for one resident (R398) of three residents reviewed for falls, resulting in a lack of assessed and imple...
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Based on interview and record review the facility failed to update a care plan following a fall for one resident (R398) of three residents reviewed for falls, resulting in a lack of assessed and implemented fall interventions to prevent further falls. Findings include:
10/30/23 at 1:46 PM, R398 was observed sitting in their room eating breakfast. Due to their cognition, the resident was unable to respond to surveyor's questions.
A review of R398's medical record revealed that they were admitted into the facility on 4/17/23 with diagnoses which included Dementia, Acute Kidney Disease, and Anemia. Further review of the medical record revealed that the resident was severely cognitively impaired, and required extensive assistance for transfers, toilet use, and dressing.
A review of R398's care plan revealed the following:
Focus: Resident had actual fall r/t (related to) unsteady balance. Fall with minor injury 7/4/23, small laceration to head. 8/16/23- Observed on Floor. 10/17/23- Observed on Floor, Abrasion to head
Date Initiated: 07/05/2023
Created on: 07/05/2023
Interventions: Encourage resident to ask for assistance with transfers prn
Date Initiated: 07/05/2023
Created on: 07/05/2023
o Offer toileting on a schedule, before and after meals and as part of AM/PM cares
Date Initiated: 07/05/2023
Created on: 07/05/2023
o Staff will encourage resident to ask for assistance with ADLs and when she does
ask, offer her praise.
When staff does assist resident with ADLs, they will encourage and allow resident to
do what she can do, assisting as needed
Date Initiated: 07/24/2023
Created on: 07/24/2023
o Wound care nurse to follow
Date Initiated: 10/18/2023
Created on: 10/18/2023
o Monitor, document and report for 72h to MD any s/sx: pain, bruises, change in
mental status, new onset confusion, sleepiness, inability to maintain posture,
agitation. Adjust plan of care as directed.
Date Initiated: 07/05/2023
Created on: 07/05/2023
o Skilled Rehabilitation Therapy evaluation and treat as ordered.
Date Initiated: 07/05/2023
Created on: 07/05/2023
o Continue interventions on the at-risk plan.
Date Initiated: 07/05/2023
Created on: 07/05/2023
Further review of R398's medical record revealed that R398 was transferred to the hospital for falls that occurred on 8/16/23 and 10/17/23 however, their care plan was not updated to reflect a revision until 10/18/23, and the intervention did not address how to prevent further falls of the resident.
On 11/1/23 at 12:34 PM, the Director of Nursing (DON) was asked about R398's falls and revision of their care planning following the falls. The DON explained that her expectation is that care plans be updated however, she further explained that there probably won't be too many interventions that they can implement because everything has been unsuccessful and the resident is very impulsive.
A review of the facility's Care Planning policy revealed the following, 8. The Care Plan will be reviewed and revised by the IDT (Interdisciplinary Team) after each assessment and as the resident's care needs change.
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 remove a splint in a timely manner in accordance with ...
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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 remove a splint in a timely manner in accordance with the physician order for one (R30) of one resident reviewed for splints, resulting in the potential for skin breakdown and increased pain. Findings include:
Review of the facility record for R30 revealed an admission date of 07/08/20 with diagnoses that included Cerebral Palsy, Chronic Respiratory Failure and Dysphagia/Aphasia. The Minimum Data Set (MDS) assessment dated [DATE] indicated R30 required total assistance for all care including dressing. R30 did not demonstrate the ability to actively participate in a BIMS assessment.
On 10/30/23 at 11:32 AM, R30 was observed laying bed and primarily unable to respond verbally. A splint was present on their right wrist/hand in an incorrect position appearing to have slipped partially off the hand. The hand/fingers were unsupported and the palm curvature of the splint was resting improperly against the anterior aspect of the wrist joint.
On 10/30/23 at 1:31 PM, R30 was observed laying in bed in the same position as during the 11:32 AM observation with the right hand splint incorrectly placed.
Review of R30's physician orders revealed the following order dated 10/24/23 with active status: Ensure aide applies right hand splint at 2000 (8 PM), remove at 0400 (4 AM).
Review of R30's Care Plan dated 10/13/23 revealed the Focus statement Resident is at risk for contractures related to diagnosis of Cerebral Palsy. This Focus included the following Interventions:
- Place splint on right hand as ordered
- PROM to right hand prior to placing hand splint and after splint is removed
On 10/30/23 at 4:10 PM, R30 was observed laying in bed with the right hand splint remaining
incorrectly placed. When R30 was asked about the splint or any related discomfort they were unable to clearly respond.
Review of R30's [NAME] Task checklists revealed the following task statement: SPECIAL NEEDS: NIGHTS Remove right hand splint at 0400 (4 AM) Provide gentle ROM (range of motion) after removal. Check skin integrity and notify nurse with any concerns. The completion checkbox for this task for 10/30/23 was not present as the list skipped from 10/29/23 to 10/31/23.
On 11/01/23 at 1:25 PM, the facility Director of Nursing (DON) was made aware of the observation that R30's right hand splint had remained on in an incorrect position on 10/30/23 for at least 12 hours beyond the physician-ordered removal time. The DON reported that the expectation for follow through with R30's right hand splint placement and removal is that the order be followed for approximately 8 PM placement and approximately 4 AM removal daily.
Review of the facility policy Physician Orders dated 04/09/21 revealed the Policy statement It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders. The facility shall ensure to follow physician orders as input into the medical chart.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow-up on hearing loss recommendations for one sam...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow-up on hearing loss recommendations for one sampled resident (R41) of one reviewed for ancillary services resulting in unmet care needs, and the potential for the worsening of their hearing without treatment. Findings include:
On 10/30/23 at 10:12 AM, R41 was observed sitting in their wheelchair eating breakfast. R41 was asked about their stay in the facility, and they reported that they have been asking about being seen for a hearing test, as they have been having a hard time hearing and believes that they may need hearing aids. R41 explained that this issue has been ongoing for several years, and explained that they don't want to have to continue to ask people to repeat themselves.
A review of R41's medical record revealed that they were admitted into the facility on 3/29/16 with diagnoses that included Chronic Kidney Disease, Hypertension, BI-Polar Disorder, and Epilepsy. Further review of R41's medical record revealed a quarterly Minimum Data Set assessment dated [DATE] indicating that R41 had a Brief Interview for Mental Status score of 13/15 indicating an intact cognition, and required extensive assistance of two people for bed mobility, transfers and toilet use.
Further review of R41's medical record revealed that the resident was seen on 10/4/22, 6/27/23, and 10/30/23 by Nurse Practitioner from a mobile hearing ancillary service revealing the following:
10/4/22 ear visit note revealed the following, Resident reports history of ear wax issues. Hearing difficulty per patient-R>L (right greater than left). Resident is interested in audiology services Patient Plan: .May benefit from Hearing Test from Audiologist for Hearing Loss based upon additional information from the Facility, Resident and approval from Primary Care Physician. Follow-Up: Established patient eval (evaluation) in 6-9 months. Refer to Audiologist.
6/27/23 ear visit note revealed the following, resident reports hearing of ear wax issues. Hearing difficulty per patient. Resident is interested in audiology services .Patient Plan: .May benefit from Hearing Test from Audiologist for Hearing Loss based upon additional information from the Facility, Resident and approval from Primary Care Physician. Follow-Up: Established patient eval (evaluation) in 6-9 months. Refer to Audiologist.
10/30/23 ear visit noted revealed the following, Resident reports history of ear wax issues. Hearing difficulty per patient - R>L. Resident is interested in audiology services .Patient Plan: .May benefit from Hearing Test from Audiologist for Hearing Loss based upon additional information from the Facility, Resident and approval from Primary Care Physician. Follow-Up: Established patient eval (evaluation) in 6-9 months. Refer to Audiologist.
On 11/1/23 at 12:13 PM, the Director of Nursing (DON) was asked who within the facility is responsible for ensuring that recommendations are being carried through following ancillary services. The DON indicated that she would check with Social Worker J who explained that recommendations are usually discussed in team meetings however, she would look further into it.
On 11/1/23 at 12:19 PM, the DON relayed that R41 was just scheduled for an audiology appointment on December 12th, 2023.
A review of the facility's Referral to Outside Agencies revealed the following, POLICY:
It is the policy of this facility to establish guidelines for making referrals to outside agencies that will meet the psychosocial and/or concrete needs of a resident, and at the same time, safeguarding a resident's protected health information. Information: Referrals can be made by the Social Service Director, licensed nurse, or a member of the IDT based on a resident's individualized, specific needs identified through interviews, evaluations, and assessments .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure consistent repositioning for one resident with a...
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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 consistent repositioning for one resident with an active sacral wound of two residents reviewed for pressure ulcer care, resulting in the potential for decreased wound healing, increased wound healing time and or worsening of a pressure ulcer. Findings include:
On 10/30/23 at 9:56 AM, R33 was observed to be in bed dressed in a hospital style gown. The head of the bed was up around 30-45 degrees. R33 was on their back in bed with the lower legs elevated on a pillow and both heels with gauze wraps. A low air loss mattress was in place and active. A wedge nor pillow nor a device to offload pressure from the sacral area were observed to be in place at the sides/torso of R33.
On 10/30/23 at 10:05 AM, R33 appeared as before.
On 10/30/23 at 12:49 PM. R33 continued their on back in bed, dressed in a gown, with a sheet over the lower legs and the head of the bed was up around 30-45 degrees. The TV was on and a sandwich and drink items were on the over bed table.
On 10/30/23 at 1:05 PM, a review of a physician progress note for R33 dated 10/28/23 documented, .Assessment and Plan: 1) Impaired mobility: Will continue with (physical therapy) PT to improve bed mobility, transfers, and ambulation; partial assist with transfers and bed mobility; no ambulation 2) Impaired (activities of daily living) ADLs: will continue with (occupational therapy) OT to improve transfers and ADLs; max assist with transfers and ADLs, 3) sacral and heel ulcers: float at nighttime and when in bed 4) Pain management: controlled on Norco (as needed) prn and gabapentin .
On 10/30/23 at 4:11 PM, R33 continued to be observed on their back in bed, without a device to shift the resident from pressure on the sacral area. The head of the bed was around 30-45 degrees, a sheet was over their feet, the lower legs and heels were up on a pillow and the low air loss mattress was in place. R33 was asked about their wounds and their buttocks and sacral area and reported, Right now it is starting to hurt. I think I need to order a pain pill.
On 10/31/23 at 8:14 AM, R33 was observed dressed in a hospital style gown and on their back in bed without a device to the sides of the torso. The gown was off the left shoulder. The heels and lower legs were elevated on a pillow. The head of the bed up 30-45 degrees.
On 10/31/23 at 10:08 AM and 10:37 AM, R33 was observed to be in bed as before.
On 10/31/23 at 12:53 PM, two visitors were in with R33 and R33 continued on their back in bed as before with their feet up and partially covered with a sheet.
On 10/31/23 at 1:58 PM, a visitor was present and R33 declined wound care. R33 was observed to be on their back in bed as before.
On 10/31/23 at 3:26 PM, R33 was observed to be in bed as before.
On 10/31/23 at 3:47 PM, the Therapy Director was asked about the care of R33 and reported R33 had shown a decline and had been on and off therapy since their admission. Also noted were issues with pain, eating, and gout. Restricted range of motion (ROM) for both shoulders, elbows and legs, poor trunk control while sitting, and an inability to reposition themselves was also reported.
On 10/31/23 at 4:25 PM, R33 was observed on their back in bed with pillows under both arms. R33 expressed that they were sore on their backside.
On 11/01/23 at 8:06 AM, R33 was observed to be on their back in bed, with their feet uncovered, a sheet reached to the ankles. The feet were wrapped in gauze dressings bilaterally and up on a pillow. The head of bed was up around 20-30 degrees and R33 had a white foam drinking cup in their hands. The cup rested on the abdomen.
On 11/01/23 at 9:00 AM, R33 was on their back in bed, the head of the bed down more, and the cup was no longer in R33's hands. No devices were observed at the sides of the torso.
On 11/01/23 at 9:12 AM, R33 was on their back in bed with the head of the bed up around 30-45 degrees. R33 was feeding themselves breakfast.
On 11/01/23 at 9:18 AM, Licensed Practical Nurse (LPN) I reported R33 did not refuse care and had not personally cared for R33's wounds.
On 11/01/23 at 9:21 AM, Registered Nurse (RN) E reported R33 was alert and oriented, did not take pain medication very often, had no refusals of care and does lay on (their) back a lot.
On 11/01/23 at 9:32 AM, Certified Nursing Assistant (CNA) K reported R33: was a two to three person assist, was really tight and sensitive to movement, often did not like to be touched, had frequent pain, liked to be independent and they were aware of the wound on the backside. CNA K also noted R33 was difficult to turn as R33 had a fear that they were going to fall out of bed and refusals of care are documented and reported to the nurse.
On 11/01/23 at 10:30 AM, R33 continued on their back in bed as before and appeared asleep. The head of the bed was up around 30-45 degrees. A device at the side of the torso was not observed,
On 11/01/23 at 11:33 AM, R33 appeared as before.
A review of the record R33 revealed R33 was admitted into the facility on [DATE]. Diagnoses included Pressure Ulcer of the Sacral Region, Foot Drop, Diabetes and Heart Disease. The Minimum Data Set (MDS) assessment dated [DATE] indicated: intact cognition with a 15/15 Brief interview for Mental Status score, documented limited ROM of the upper extremities but not the lower extremities, and R33 was dependant to roll left and right. The care plan titled, Stage four coccyx wound revised 10/04/23 indicated Treatments as ordered. Air mattress in place. no additonal interventions were documented. A wound consult noted dated 11/01/23 noted the sacral wound to be 4.4 centimeters (cm) by 4.1 cm by 1.2 cm deep with a small amount of drainage. Preventative measure included turn and repositon every two hours.
On 11/01/23 at 12:42 PM, the repositioning concern for R33 was reviewed with the Director of Nursing (DON) and the Assistant Director of Nursing. The DON reported that R33 had some shoulder pain and had not been feeling well. The DON reported they would have to review the care plan and wound orders if R33 had been refusing care to see what was going on. It was noted residents should be positioned off the sacral area to relieve pressure as tolerated.
A review of the policy titled, Best Practice Wound Management updated 05/31/22 did not specifically address repositioning of residents with sacral wounds.
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 F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure a resident identifier and an opened were on the medication container in three of five medication carts resulting in the ...
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Based on observation, interview and record review the facility failed to ensure a resident identifier and an opened were on the medication container in three of five medication carts resulting in the potential for loss and or use for a secondary resident. Findings include:
On 10/31/23 at 8:36 AM, the South B medication cart was reviewed with Licensed Practical Nurse (LPN) G. A Lantus insulin vial did not have an opened date; A Humulin R insulin had not date and no resident identifier; Three Alphagan eye droppers for three differnt residents were without a date opened - one did not have a resient identifier; A container of glucometer test strips were not dated when opened and a Fluticasone and Salametrol inhaler did not had a date opened nor a redient identifier on the actual inhaler.
On 10/31/23 at 9:39 AM, the North medication cart was reviewed with Nurse H. A timolol eye dropper was not labled with a resident identifier; A Dorzolomide eye dropper was not labled with a resident identifier, Five Artificial tears eye dropper were note labled with a resident identifier; An Alphagan/brimonidine eye dropper was without a name on the vial; A budesonide/formoterol inhaler was not labled with a resident identifier on the inhaler and two Fluticasone and salmeterol inhalers were without a resident identifier on the inhaler.
On 10/31/23 at 10:05 AM, the North C 2 medication cart was reviewed with LPN I An Incruse inhaler and and Advair inhaler were not dated when opened on the inhaler. A labeled and dated Advair inhaler was observed out of the box and on the bottom of the drawere in the cart.
On 11/01/23 at 12:42 PM, the label and dating of medications was reviewed with the Director of nursing and Assistant Director of Nursing. It was reported that they are checks by the pharmacy, corporate and nursing to identify concerns and that the expectationis that the medications will be dated when opened and labled with resident identifier on the actual container.
A review of the facility policy titled Labeling of Medications and Biologicals with date adopted of 07/11/2018 documented, It is the policy of this facility that medications and biologicals are labeled in accordance with facility requirements, state and federal laws. Only the provider pharmacy modifies or changes prescription labels.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to provide a safe, functional, and sanitary, environment for the facilities census of 90 residents and its staff resulting in an increased chanc...
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Based on observation and interview, the facility failed to provide a safe, functional, and sanitary, environment for the facilities census of 90 residents and its staff resulting in an increased chance of harm, odor penetration into resident areas, and dissatisfaction with the living environment . Findings include:
On 10/30/23 at 9:36 AM, weeds were observed growing under the exit door from the Rainbow dining room. The weeds could be seen on both sides of the door and dirt, grit and pebbles had washed in from the outside and settled at the corners of the door. This was observed unchanged on 10/31/23 and 11/01/23.
On 10/30/23 at 10:19 AM, a urine odor was noted on the hall with rooms 17-25.
On 10/30/23 at 2:20 PM, the hydration room on the connecting hallway and across from the vending machines, was observed to have a cabinet with what appeared to be water damage to the kick plates around the cabinet. The kick plates had peeled and warped away in areas along the floor. Ice was observed to be piled a third of the way up the catch tray in the dispensing area of the ice machine. A plastic bin had been set on the floor below the dispensing area.
On 10/31/23 at 8:17 AM, a urine odor was noted on the hall with rooms 17-25.
On 11/01/23 at 8:00 AM, a stronger urine odor was noted on the hall with rooms 17-25.
On 11/1/23 at 12:57 PM, during an environmental tour of the facility the following observations were made:
The lack of personal protective equipment (PPE) was observed available for use in the C- wing's soiled utility room. Additionally in this room, the designated handwashing sink was observed blocked by three large sharps containers and a soiled linen cart, no paper towel was observed available for use for handwashing, and a strong odor was present in this room.
On 11/1/23 at 1:00 PM, upon interview with Housekeeping/ Laundry Supervisor, staff B, on the current state of the room to which they stated, It does smell in this room at times, and we could store these against the side wall to make more space around the sink. At this time the surveyor inquired with staff B, on who oversees the replenishing the PPE in the facility's soiled utility rooms to which they replied, It would probably go through me and the nursing staff.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne ...
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Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting all residents who receive oral food meal services out of the facility's census of 90 residents. Findings include:
On 10/30/23 at 9:08 AM, an initial tour of the kitchen areas was conducted with the Dietary Manager and Registered Dietitian. Initial observation of the red clay tile floor revealed signs of soiled grout lines and a dull and soiled appearance of the tiles in the main area of the kitchen. The dish machine area appeared soiled and unkept with areas of built up grease and soil under the counter areas at the floor level. The drain pipe for the three compartment sink was below the level of the upper rim of the drain. and without a one inch air gap. Black soil buildup with a slime appearance was observed in the catch bowl for the drain pipe. The steamer was observed to be leaking water on the pans stored below. On entry to the dry storage are debris was noted under the right hand shelf which held the noodles among other items. At the end of this rack was a puddle of cloudy white liquid about six inches wide. The puddle was on the storage room side of the door to the receiving area. The floor tile was missing in this area. the door was not sealed at the bottom and had a half to one inch gap between the bottom of the door and the floor. The outside door to the the receiving area had about a , six inch long gap (through which light could be seen) at the bottom/threshold area of the door which may allow for pest entry, It was reported that the receiving room floor had just been mopped and had left the puddle. A, graham cracker packet was on top of the meat freezer unit and some traces of debris lay under the left hand shelf for the dry goods.
On 11/1/23 between 9:52 AM and 10:06 AM, the floors, walls and plumbing in and around the dish machine area and three-compartment sink were observed with an accumulation of dust, debris, and with dark staining in multiple locations.
On 11/1/23 at 10:10 AM, upon interview with Dietary Manager, staff A, the surveyor inquired if the kitchen staff have required daily cleaning tasks to be completed each shift to which they responded, Yes. We have sign off sheets for our daily cleaning tasks. I can show you them now. On 11/1/23 at 10:12 AM, record review of a document titled, Daily Cleaning Schedule dated from 10/17/2023 through 10/23/2023, revealed a system in place to ensure a clean and sanitary environment in the kitchen. However, not all required tasks were observed initialed by staff verifying their completion. At this time the surveyor inquired with staff A on if this was the most recent cleaning schedule they could provide to review to which they replied, I'm not sure where last week's is now, but I'll try and find it for you. I think it was taken down because today is November 1st. At the time of the survey team's exit, no additional cleaning schedule documenting verification of the daily cleaning tasks required to be completed from 10/24/2023 through 10/31/2023 was received to review.
Review of 2017 U.S. Public Health Service Food Code, Chapter 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils directs that:
(C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.
Sept 2022
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure a mattress was in good, clean condition, affecting one sampled Resident (Resident #51), resulting in the potential for an unclean and ...
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Based on observation and interview, the facility failed to ensure a mattress was in good, clean condition, affecting one sampled Resident (Resident #51), resulting in the potential for an unclean and uncomfortable sleeping area. Findings include:
On 9/1/22 at 9:04 AM, R51 was observed sitting up in a geri chair. The linen had been stripped from the resident's bed. R51's mattress was observed with a large amount of staining in the middle and the waterproof fabric was noted to be worn off a large area of the mattress. The mattress was sunken in the middle consistent with loss of support. Nurse B was present in the room at the time and was asked what she thought about R51's mattress. Nurse B stated, It looks old. When queried regarding the process for obtaining a new mattress for a resident, Nurse B indicated that any staff could let central supply or maintenance know.
On 9/1/22 at 9:55 AM, upon asking for the resident equipment/mattress/replacement policy/procedure, the Nursing Home Administrator (NHA) stated, We do not have a policy for when to replace equipment .best practice is to replace as needed or use the lock out tag out policy if mechanical equipment requires repair.
On 9/1/22 12:45 PM, the Director of Nursing (DON) and NHA were interviewed and asked what was the expectation of staff if they see a resident's mattress is worn, sunken, and/or stained, the DON replied that staff should notify administration and they could likely get a replacement mattress from a bed that is vacant.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide medical justification for and assessment of the use of a restraint for one sampled Resident (R291) out of a total sam...
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Based on observation, interview, and record review, the facility failed to provide medical justification for and assessment of the use of a restraint for one sampled Resident (R291) out of a total sample of 18, resulting in the potential for inadequate monitoring and injury. Findings include:
A review of R291's record revealed that the resident was admitted into the facility on 8/27/22 for a hospice respite stay. R291's diagnoses included Alzheimer's Disease, Dementia without behavioral disturbance, Abnormal weight loss, and Encounter for palliative care. R291's care plan identified the resident as having limited mobility and being at risk for falls. The nursing admission assessment for R291 identified the resident as being confused and dependent on staff for activities of daily living.
On 8/30/22 at 10:02 AM, R291 was observed in their room, sitting in a transport chair (similar to a wheelchair). The chair had a seat belt which was observed to be buckled across R291's lap. R291 appeared very thin and was observed to be non-interviewable. R291 was talking to themselves and responding to their television.
On 8/30/22 at 1:03 PM, R291 was observed in their room, still sitting in their transport chair with the seat belt fastened. Nurse Aide D was feeding the resident their lunch.
On 9/1/22 at 8:37 AM, R291 was observed in their room, sitting in their transport chair with the seat belt loosely fastened. R291 continued to be unable to answer any interview questions.
At this time, R291's record was reviewed and did not reveal a physician or hospice admission order for the seat belt, care plan area, consent for use, nursing assessment, nor justification for the use of the device.
On 9/1/22 at 8:41 AM, Nurse Aide D was queried regarding the seat belt fastened across R291's lap. Aide D stated that the resident came in with that particular chair and knows that during previous respite stays, the resident was a fall risk. When queried, Aide D indicated that R291 was unable to unbuckle the belt themselves and unable to follow directions.
On 9/1/22 at 9:19 AM, Nurse Manager C was shown the fastened belt on R291. Nurse C unfastened the belt and indicated that the resident did not need it buckled if someone was with them. When queried regarding the use of the belt, Nurse C indicated there should be an assessment for it and was going to check and see if it was part of the resident's care plan. When queried, Nurse C indicated that R291 was unable to unbuckle the belt themselves.
On 9/1/22 at 12:45 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were interviewed and queried regarding the lack of consent, assessment, care planning, and order/medical justification for the use of the belt on R291's chair. The DON stated that R291's spouse is adamant that the facility is consistent with the same care the resident receives at home, which includes the belt attached to the chair, and that it's more for security. When queried, the DON indicated that she did not believe the resident could unbuckle the belt themselves. The DON stated she was not aware of the belt but as soon as it was brought to the facility's attention, an assessment was done.
A review of the facility's policy/procedure titled, Restraints, revised 2/28/2020, revealed, It is the policy of this facility that the resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms .Physical Restraints- Defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body 1. A physician's order is necessary for the use of a physical restraint. 2. The use of the restraining device must first be explained to the resident, family member, or legal representative. Each resident requiring physical restraints shall have the restraint released every two (2) hours. Each resident requiring physical restraints shall be checked by a staff member at least every thirty (30) minutes. 3. The facility must explain, in the context of the individual resident's condition and circumstances, the potential risks and benefits of all options under consideration including using a restraint, not using a restraint, and alternatives to restraint use. 4. Explain the potential negative outcomes of restraint use which include, but are not limited to, declines in the resident's physical functioning (ability to ambulate) and muscle condition, contractures, increased incidence of infections and development of pressure ulcers, delirium, agitation, and incontinence. Resident may also face a loss of autonomy, dignity and self-respect, and may show symptoms of withdrawal, depression, or reduced social contact .6. Medical symptoms that warrant the use of restraints must be documented in the resident's medical record, ongoing assessments, and care plans.
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 observation, interview and record review the facility failed to revise a nutrition care plan following weight loss, and...
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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 revise a nutrition care plan following weight loss, and revise a fall care plan following a fall for two sampled Residents (R19 and R81) of two residents reviewed for care plan revisions resulting in a care plan that did not reflect the specific resident condition and interventions. Findings include:
Resident #19 (R19)
On 8/30/22 at 10:00 AM, R19 was observed in their room sitting in their Geri char with their tube feeding pump infusing. The resident was able to answer basic questions with garbled speech.
A review of R19's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that include Cerebral Palsy, Dysphagia, and Unspecified Calorie Protein Malnutrition. A review of R19's Minimum Data Set assessment revealed that the resident was cognitively impaired and required total dependence of facility staff for Activities of Daily Living.
Further review of R19's medical record revealed the following:
8/24/2022 11:27 (11:27am) Nutrition/Weight Note Text: WEIGHT WARNING: Value: 90.2
Vital Date: 2022-08-19 11:23:00.0 -5.0% change [ 5.6% , 5.4 ]
Resident is triggering for significant weight loss (-5.6%, -5.4lbs x 30 days).
CBW: 90.2lbs. Current BMI: 22.6. Wt hx (weight history): 8/19: 90.2lbs, 8/2: 92.2lbs, 7/20: 91.8lbs, 7/11: 95.6lbs, 6/8: 95.8lbs. Current diet order: Regular diet, pureed texture, honey-like consistency.
Current enteral order: Jevity 1.5 @ 50 ml/hr x 20 hrs (hours) until 1000 ml formula infused to provide 1500 kcals, 64g pro, and 760ml H2O (water) . With Autoflush @ 40ml/hr x 20 hrs while pump infuses. Start at 6pm, stop at 2pm or when dose completed. PMH: Cerebral palsy, hx of COVID-19, dysphagia, hx of protein-cal (calorie) malnutrition, epilepsy, HTN, delirium, muscle weakness .RD discussed weight change with IDT (interdisciplinary team). Resident is often disconnected from EN (enteral nutrition) throughout the day and may not be receiving full amount. IDT agreed to trial nocturnal feeding to support resident in meeting 100% of [their] nutritional needs. Physician notified. Recommendations: Jevity 1.5 Cal @ 85ml/hr x 12 hours to provide 1020 ml of formula, 1530 kcals, 65 grams of protein, 775 ml of fluid with autoflush @ (at) 65 ml/hr x 12 hours while pump infuses to provide 780ml of additional water per day. Up at 8pm, down at 8am or when dose completed .
A review of R19's care plan revealed the following: Focus: The resident has nutritional problem or
potential nutritional problem r/t (related to) dysphagia, aphasia, HTN (hypertension), cerebral palsy, hx (history) of malnutrition, need for enteral feeds. Date Initiated: 12/03/2018. Created on: 12/03/2018. Revision on: 06/21/2022 .Interventions: Enteral nutrition/flushes per order. Date Initiated: 03/10/2022 .Monitor/record/report to MD PRN s/sx (signs/symptoms) of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Date Initiated: 03/10/2022
Further review of R19's care plan did not reveal that their care plan was updated regarding new interventions implemented for R19's weight loss.
On 9/1/22 at 1:22 PM, the Director of Nursing was interviewed and asked about R19's weight loss and explained that they did identify R19's weight loss and it was currently being carefully watched by the dietician. Regarding expectations for a resident receiving tube feeding, the DON explained that the resident should be receiving the ordered amount to ensure their nutritional needs are being met.
On 9/1/22 at 2:11 PM, the Registered Dietician (RD) was asked about R19's weight loss and explained that the resident's weights have stabilized and they have an oral pleasure tray in place. The RD explained that he changed R19's feedings to the nighttime as the resident likes to be unhooked from their tube feeding throughout the day because they like to be out of their room. The RD was asked if the tube feeding being unhooked throughout the day contributed to R19's weight loss, and stated, It's hard to say that [R19] wasn't getting [their] full nutrients .
Resident #81 (R81)
A review of R81's medical record revealed that the resident was admitted into the facility on 7/26/22 with medical diagnoses that included Cerebral Palsy, Hereditary Spastic Paraplegia, Gastrostomy Status, Protein-Calorie Malnutrition, and Developmental Disorder of Speech and Language. A review of R81's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's cognitive skills for daily decision making were severely impaired and that the resident required total assistance from staff for activities of daily living (including bed mobility and transfers).
-8/18/2022 12:52 (PM) .Resident observed on the floor by writer; it appeared that she had slid on the floor off of a hoyer pad. Resident appeared distraught. Writer asked if she hit her head and resident responded yes; writer also asked was she in pain and resident also responded yes. Resident had no noticeable injuries, bruises/lacerations. DON (Director of Nursing), physician, and family notified. Per physician request, writer sending resident out to ED (emergency department) for CT (computed tomography) scan.
-8/18/2022 18:51 (6:51 PM) . Resident returned from hospital, alert, oriented, and in stable condition. vitals wnl (within normal limits). Resident denies having pain/discomfort. No abnormal findings per report and hospital discharge documentation. Resident is comfortably in bed at the lowest, safest position. Physician and family notified.
A review of R81's care plan revealed:
-Resident at risk for falls r/t (related to) cerebral palsy & spastic paraplegia. Date Initiated: 07/27/2022, Revision on: 07/27/2022.
-Anticipate and meet resident's needs. Date Initiated: 07/27/2022 .
-Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Date Initiated: 07/27/2022 .
-Follow facility fall protocol. Date Initiated: 07/27/2022 .
R81's care plan was not updated to reflect the fall that occurred on 8/18/22 nor intervention(s) initiated post-fall to ensure the incident does not recur.
On 9/1/22 at 12:45 PM the Director of Nursing (DON) and Nursing Home Administrator (NHA) were interviewed. When queried regarding care planning after the fall R81 experienced on 8/18/22, the DON indicated that the care plan should have been updated.
A review of the facility's policy/procedure titled, Care Planning, updated 01/15/2020, revealed, .8. The Care Plan will be reviewed and revised by the IDT after each assessment and as the resident's care needs change .
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** This citation is related to intake MI00129450.
Based on observation, interview, and record review, the facility failed to provid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation is related to intake MI00129450.
Based on observation, interview, and record review, the facility failed to provide repositioning and timely incontinence care and bed linen change for one sampled Resident (R51) of two reviewed for activities of daily living, resulting in unmet care needs, and feelings of discomfort and shame utilizing the reasonable-person concept. Findings include:
On 8/30/22 at 9:13 AM, R51 was observed lying in bed on their back, head of the bed slightly elevated, with knees up and bent and feet resting on the mattress. No positioning devices or pillows were noted. R51 appeared to be sleeping. R51 was noted to be receiving enteral nutrition (tube feeding).
On 8/30/22 at 12:01 PM and 2:37 PM, R51 was observed lying in bed on their back, head of the bed slightly elevated, with knees up and bent and feet resting on the mattress. No positioning devices or pillows were noted.
On 8/31/22 at 9:14 AM and 12:29 PM, R51 was observed lying in bed on their back, head of the bed slightly elevated, with knees up and bent and feet resting on the mattress. No positioning devices or pillows were noted. R51's enteral feeding was not observed to be infusing per the order. R51's record indicated the resident had been experiencing vomiting so the tube feeding was held.
The following progress note was found:
-8/31/2022 12:36 (PM) .when writer entered the room of the resident to Administer medication writer observed that resident had some vomit on him. Writer Cleaned the vomit and administered medication. Writer will check back up for zofran and will continue to monitor resident for vomiting.
On 8/31/22 at 2:02 PM, Nurse Aide F was observed preparing to provide activities of daily living (ADL) care to R51. R51's face was mostly expression-less, and the resident was unable to answer interview questions. R51 moaned in response to being happily greeted by Nurse Aide E. On R51's fitted sheet behind their head/back, a large, dried stain with a tan outline was noted. Aide F removed towels with vomit on them from R51's chest and stated that the resident had thrown up a few times today. When queried, Aide F stated R51 was changed, around two hours ago, but explained that she had trays to pass and other tasks she had been busy completing. Aide E and Aide F explained they were called into work because of short-staffing, and that they normally worked the afternoon shift, not the day shift.
R51's incontinence brief was observed to be completely full and saturated with urine, and upon moving the resident it was noted that their fitted sheet was wet from the middle of their thighs to their upper back and soaked through to the mattress. The resident's pillowcase appeared wet towards the bottom as well, and when queried, Aide F stated that was from the resident throwing up.
A review of R51's record revealed that the resident was initially admitted into the facility on [DATE] and most recently re-admitted on [DATE] with medical diagnoses of Respiratory Failure, Dysphasia, Cerebral Palsy, Anxiety, Ileus, Muscle Wasting, Gastrostomy Status, Heart Failure, Contractures, and Abnormal Posture. Review of R51's Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was unable to speak, rarely/never able to express ideas/wants, rarely/never able to understand verbal content, had highly impaired vision, along with a severely impaired cognition and required total assistance from staff for ADLs.
A review of R51's care plan revealed:
-ADL Self care deficit as evidenced by [R51] requires total care related to DX (diagnosis) of CVA (stroke), and Cerebral Palsy. His mobility, and cognition are impaired. He is dependent for all transfers, and requires assistance with bed mobility/repositioning needs. He has aphasia and is unable to communicate his needs. Date Initiated: 10/25/2017, Revision on: 07/27/2022
-Assist to reposition frequently with 2 person assist. Date Initiated: 05/17/2018, Revision on: 05/24/2019.
-Incontinence related to debility and impaired cognition. Date Initiated: 10/25/2017, Revision on: 07/27/2022.
-Will be maintained in as clean and dry dignified state as possible. Date Initiated: 10/25/2017, Revision on: 07/19/2022.
-Provide prompt incontinent care PRN (as needed), Date Initiated: 11/08/2018.
On 9/1/22 at 12:45 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were interviewed and queried regarding the observation of ADL care for R51. The DON explained that what was observed, and for R51's bed to be soiled through to the mattress, was not her expectation. The DON also explained at this time that interventions for R51 include turning, repositioning, keeping the resident clean and try, and moving him as much as he can tolerate.
A review of the facility's policy/procedure titled, Incontinent Care, dated 7/11/2018, revealed, It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition .
A review of the facility's policy/procedure titled, Skin Monitoring and Management, dated 7/11/2018, revealed, .In order to prevent the development of skin breakdown .nursing staff shall implement the following approaches as appropriate and consistent with the resident's care plan: .Reposition the resident .If the resident is incontinent, make sure that his/her skin remains clean and dry with regular pericare and toileting when appropriate .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow a physician's order for a PM&R (Physician Medic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow a physician's order for a PM&R (Physician Medicine and Rehabilitation) evaluation for one sampled Resident (R19) of one reviewed for physician orders resulting in the potential for unmet care needs. Findings include:
On 8/30/22 at 10:00 AM, R19 was observed in their room sitting in their Geri char and able to answer basic questions with garbled speech. R19's hands were observed as contracted, with no hand splints or braces in place.
A review of R19's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that include Cerebral Palsy, Dysphagia, and Unspecified Calorie Protein Malnutrition. A review of R19's Minimum Data Set assessment revealed that the resident was cognitively impaired and required total dependence on facility staff for Activities of Daily Living.
Further review of R19's medical record revealed the following progress notes:
5/9/2022 01:00 (1:00 AM) Encounter. Date of Service: 05/09/2022
Visit Type: Acute . Chief Complaint / Nature of Presenting Problem:
Cerebral palsy/spasticity. History Of Present Illness: Resident is evaluated per resident's mothers request. Resident was on LOA (leave of absence) with mother, she did not have access to baclofen and resident is not returned with increase in spasticity and stiffness.
Resident at one time had a baclofen pump, this was removed several years ago due to malfunction and infection. She woule (would) like to have resident reeevluated (sic) by [physician] feasibility of reimplantation. In meantime, will request PM &R for botox injections for contractions. Was previously evaluated by in house PM &R, there is new PM&R. Will request evaluation
A review of R19's physician orders noted the following dated for 5/9/22 and discontinued on 5/11/22: PM&R consult, evaluate for botox for contractions, has had in past. Please contact residents mother for information about resident hx (history).
On 8/30/22 at 2:31 PM, the PM&R evaluation was requested for R19 however, it was not received by the end of this survey.
On 9/1/22 at 1:25 PM, an interview was completed with the Director of Nursing (DON) regarding R19's PM&R evaluation. The DON explained that she is unsure what happened regarding the order not being carried through.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00129450.
Based on observation, interview and record review, the facility failed to place he...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00129450.
Based on observation, interview and record review, the facility failed to place hearing aides in the ear daily for one Resident (Resident #64) of one reviewed for sensory/communication, resulting in frustration related to difficulty hearing. Findings include:
On 08/30/2022 at 11:40 AM, Resident #64 was up in their wheelchair brushing their teeth. Resident #64 was interviewed in regard to the care received in the facility. The Resident had clear speech and stated, They don't put my hearing aides in. The nurses are supposed to bring them in every morning to put them in. Resident #64 did not have hearing aides in at the time of the interview. Resident #64 further explained that they were hard of hearing and the hearing aides helped them. During conversation, this Surveyor was able to communicate to the Resident while talking about three feet at face level in a slightly raised voice.
On 08/30/2022 at 01:48 PM, Confidential Witness H was interviewed via phone. Confidential Witness H had explained that the facility does not put in Resident #64's hearing aides everyday. Confidential Witness H stated, They are supposed to be keeping the hearing aides in the cart (nursing medication cart). Confidential Witness H further explained that when they come in to visit the Resident, they have to often go to the nurse to get the hearing aides because no one has put them in for the day.
On 08/31/2022 at 01:49 PM, Resident #64 was dressed and groomed in their wheelchair. The Resident did not have hearing aides in. Resident #64 was asked about their hearing aides and stated, They (the nurses) didn't put them in. They are still in the nurses cart. Resident #64 was asked if they ever ask the nurse for their hearing aides and stated, I shouldn't have to remind them. The Doctor told me the nurses are to put them in for me.
On 09/01/2022 at 10:49 AM, Resident #64 was awake in bed watching TV (with an elevated volume). There were no hearing aides in.
On 09/01/2022 at 12:41 PM, Resident #64 was up dressed and groomed in their wheelchair. There were hearing aides in each ear. Resident #64 stated, The nurse came in and put them in today. They have to put them in (for me). The Resident further explained that they had just gotten the hearing aides about four months ago.
On 09/01/2022 at 12:42 PM, Licensed Practical Nurse (LPN) I was at the nurses cart and was asked about the hearing aides for Resident #64 and stated, I put them in when I am hear. They are kept here (opening the top drawer of the medication cart, revealing a black hearing aide case). We have to sign out (in the electronic medical record/EMR) when we put them (hearing aides) in.
A review of the EMR (the medication administration record/treatment administration record for August 2022) revealed Resident #64 had hearing aides that were to be signed out and placed in the Resident's ears daily. The records revealed no refusals or indication that the hearing aides were not placed in the ears.
A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was admitted to the facility on [DATE] with the diagnosis of Diabetes Mellitus and Hypertension. Resident #64 needed extensive assistance with bed mobility and transfers, and had an impaired cognition. The MDS did not reflect Resident #64's use of hearing aides or being hard of hearing in the vision and hearing section (B).
A review of the care plan for Resident #64 revealed the following:
Focus- Resident has hearing aides brought in by .daughter. Date Initiated: 03/23/2022.
Goals-Resident will wear .hearing aides daily thru next review .
Interventions- Nurses will assist resident with placement of her hearing aides daily. Staff to document refusals to wearing her hearing aides.
On 09/01/2022 at 01:05 PM, an interview was completed with the Nursing Home Administrator (NHA) in regard to Resident #64's hearing aides not being in the ears daily and stated, The nurses should be putting them in. Usually, (Resident #64) will ask for them, I am surprised (Resident #64) didn't ask for them.
A review of the AM (Morning) Cares facility policy dated 07/11/2018 revealed the necessity of placing eye glasses and dentures in for residents, but did not discuss hearing aides.
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** Based on interview observation, interview, and record review, the facility failed to provide adequate supervision for one sample...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview observation, interview, and record review, the facility failed to provide adequate supervision for one sampled Resident (R81) of three reviewed for falls, resulting in a fall and transfer to the emergency department (ED) for evaluation. Findings include:
A review of R81's medical record revealed that the resident was admitted into the facility on 7/26/22 with medical diagnoses that included Cerebral Palsy, Hereditary Spastic Paraplegia, Gastrostomy Status, Protein-Calorie Malnutrition, and Developmental Disorder of Speech and Language. A review of R81's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's cognitive skills for daily decision making were severely impaired and that the resident required total assistance from staff for activities of daily living (including bed mobility and transfers).
On 8/30/22 at 10:21 AM, R81 was observed lying in bed. The bed was in a low position and the resident was observed to have spastic movements. Pillows were in place on both sides of the resident. R81 smiled but was unable to verbally answer interview questions. The resident appeared thin and was noted to be receiving enteral feeding at this time.
Continued review of R81's medical record revealed:
-8/18/2022 12:52 (PM) .Resident observed on the floor by writer; it appeared that she had slid on the floor off of a hoyer pad. Resident appeared distraught. Writer asked if she hit her head and resident responded yes; writer also asked was she in pain and resident also responded yes. Resident had no noticeable injuries, bruises/lacerations. DON (Director of Nursing), physician, and family notified. Per physician request, writer sending resident out to ED (emergency department) for CT (computed tomography) scan. (Written by Licensed Practical Nurse G).
-8/18/2022 18:51 (6:51 PM) . Resident returned from hospital, alert, oriented, and in stable condition. vitals wnl (within normal limits). Resident denies having pain/discomfort. No abnormal findings per report and hospital discharge documentation. Resident is comfortably in bed at the lowest, safest position. Physician and family notified.
On 8/31/22 at 10:53 AM, Nurse G was interviewed regarding R81's fall on 8/18/22. Nurse G explained that R81 had been in bed and had a hoyer sling underneath her. Nurse G stated, They (hoyer slings) are slippery, and [R81] doesn't fall .[she] can't move like that. Nurse G explained that she had found R81 hanging off the bed onto the floor with one leg still up on the bed with her tube feeding still attached.
On 9/1/22 at 8:45 AM, Nurse Aide D was queried regarding what happened when R81 fell on 8/18/22. Aide D explained that she had put R81 onto the hoyer sling in bed and then left the room to get help so she wasn't using the hoyer lift by herself. Aide D stated, I guess [R81] slipped off, the tube feeding was still attached but kind of tugging.
A review of R81's care plan revealed:
-Resident at risk for falls r/t (related to) cerebral palsy & spastic paraplegia. Date Initiated: 07/27/2022, Revision on: 07/27/2022. R81's care plan was not updated to reflect the fall that occurred on 8/18/22 nor intervention(s) initiated post-fall to ensure the incident did not recur.
On 9/1/22 at 12:45 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were interviewed. When queried regarding the fall R81 experienced on 8/18/22, the DON explained that it was identified that R81 slipped off the hoyer sling while in bed. The DON stated she assumed the aide left to get someone to help her because hoyer lifts can only be used with two people. The DON explained that R81 has spastic movements with cerebral palsy and doesn't think R81 would intentionally be able to fall (i.e. trying to get up out of bed by herself).
A review of the facility's policy/procedure titled, Best Practice Fall Management, dated 2/13/2020, revealed, Licensed Nurse will implement the following: Complete FALL Risk Assessment within 2-4 hours of admission. Initiate plan of care for fall and/or fall risk .Ensure each identified risk factor has the appropriate intervention(s). Review plan of care for preventative fall interventions, ADL's, equipment or other individualized needs of the resident. Licensed Nurse or Clinical Manager will facilitate the huddle with appropriate disciplines. Discuss and analyze resident fall. Establish Root Cause, if possible. Discuss and implement a new preventative fall intervention(s) .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide adequate nutrition for a resident reliant on tu...
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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 adequate nutrition for a resident reliant on tube feeding for one sampled Resident (R19) of two residents reviewed for nutrition resulting in a weight loss, potential for dehydration and unmet resident needs. Findings include:
On 8/30/22 at 10:00 AM, R19 was observed in their room sitting in their Geri char with their tube feeding pump infusing. The resident was able to answer basic questions with garbled speech.
A review of R19's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that include Cerebral Palsy, Dysphagia, and Unspecified Calorie Protein Malnutrition. A review of R19's Minimum Data Set assessment revealed that the resident was cognitively impaired and required total dependence on facility staff for Activities of Daily Living.
A review of R19's care plan revealed the following: Focus: The resident has nutritional problem or
potential nutritional problem r/t (related to)dysphagia, aphasia, HTN (hypertension), cerebral palsy, hx (history) of malnutrition, need for enteral feeds. Date Initiated: 12/03/2018. Created on: 12/03/2018 .Interventions: Enteral nutrition/flushes per order .Monitor/record/report to MD PRN s/sx (signs/symptoms) of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months
Further review of R19's medical record revealed the following progress notes:
6/2/2022 11:39 (11:39am) Nutrition/Weight Note Text: Resident continues to be followed by RD (registered dietician) Res (resident) with enteral feeds and puree/honey pleasure meal trays. Varied PO (oral) intake- consuming ~0-100% of meals per FAR (food acceptance record) with some refusals noted. Enteral feeds meeting all of estimated nutritional needs at this time. Order providing- 980 mL (milliliter) formula, 1470 kcal (calories) 62.5 g PRO (grams of protein), 1445 cc water (including flushes). Tolerating without difficulty . Magic cup supplement also in place BID (twice a day)- to provide an additional ~600 kcal and 18 g PRO if consumed 100%. Weights stable ~95# since last review. Meds reviewed. Continue with POC. Will continue to monitor and follow up as needed.
7/16/2022 12:13 (12:13pm) Nutrition/Weight. Note Text: Enteral Review: Current diet order: Regular diet, pureed texture, Honey-like consistency. Current Enteral order: Continuous Enteral Feeding: Formula: Jevity 1.5 ; Rate: 70ml/hour ; Start at 1800 (6:00pm) hours time and run until 980 mLs (milliliters) has infused (provides: 1470 kcals, 62 grams of protein, 745 ml of water). Current supplement: Nutritional treat BID (provides: 600 kcals and 18 grams of protein). Current Flush order: Flush with water: Amount: 50ml q (every) 1 hour while pump infusing .Nutritionally pertinent medications: lactulose. Weight hx (history): 7/11: 95.6 lbs (pounds) 6/8: 95.8 lbs, 5/13: 95.4 lbs, 4/20: 96.8 lbs - weight stable x 30, 90, 180 days .1. Continue current diet order and supplement as tolerated. 2. Jevity 1.5 @ 50 ml/hr x 20 hours to provide 1000 ml total formula, 1500 kcals, 64 grams of protein, and 760 ml of water. Start at 6pm, stop at 2pm or when dose completed.
3. Autoflush @ 40 ml/hr x 20 hours to provide an additional 800 ml of water.
Recommended EN regimen will likely meet 100% of residents nutritional needs. RD will continues to monitor residents po intake and weight and make adjustments prn (as needed).
8/24/2022 11:27 (11:27am) Nutrition/Weight Note Text: WEIGHT WARNING: Value: 90.2
Vital Date: 2022-08-19 11:23:00.0 -5.0% change [ 5.6% , 5.4 ]
Resident is triggering for significant weight loss (-5.6%, -5.4lbs x 30 days).
CBW: 90.2lbs. Current BMI: 22.6. Wt hx (weight history): 8/19: 90.2lbs, 8/2: 92.2lbs, 7/20: 91.8lbs, 7/11: 95.6lbs, 6/8: 95.8lbs. Current diet order: Regular diet, pureed texture, honey-like consistency.
Current enteral order: Jevity 1.5 @ 50 ml/hr x 20 hrs (hours) until 1000 ml formula infused to provide 1500 kcals, 64g pro, and 760ml H2O (water) . With Autoflush @ 40ml/hr x 20 hrs while pump infuses. Start at 6pm, stop at 2pm or when dose completed. PMH: Cerebral palsy, hx of COVID-19, dysphagia, hx of protein-cal (calorie) malnutrition, epilepsy, HTN, delirium, muscle weakness .RD discussed weight change with IDT (interdisciplinary team). Resident is often disconnected from EN (enteral nutrition) throughout the day and may not be receiving full amount. IDT agreed to trial nocturnal feeding to support resident in meeting 100% of [their] nutritional needs. Physician notified. Recommendations: Jevity 1.5 Cal @ 85ml/hr x 12 hours to provide 1020 ml of formula, 1530 kcals, 65 grams of protein, 775 ml of fluid with autoflush @ (at) 65 ml/hr x 12 hours while pump infuses to provide 780ml of additional water per day. Up at 8pm, down at 8am or when dose completed .
8/26/2022 01:00 (1:00am)
Encounter Date of Service: 08/26/2022
Visit Type: Follow Up Chief Complaint / Nature of Presenting Problem: Weight loss
Registered dietitian notified writer the patient is triggered for weight loss. Patient appears to have had approximately 5 pound weight loss since June. It was brought to his attention that patient was being unhooked early from [their] tube feed since [they] wanted to leave [their] room. RD (registered Dietician) reports that he will be switching patient to nighttime feedings .
On 9/1/22 at 1:22 PM, the Director of Nursing was interviewed and asked about R19's weight loss and explained that they did identify R19's weight loss and it was currently being carefully watched by the dietician. Regarding expectations for a resident receiving tube feeding, the DON explained that the resident should be receiving the ordered amount to ensure their nutritional needs are being met.
On 9/1/22 at 2:11 PM, the Registered Dietician (RD) was asked about R19's weight loss and explained that the resident's weights have stabilized and they have an oral pleasure tray in place. The RD explained that he changed R19's feedings to the nighttime as the resident likes to be unhooked from their tube feeding throughout the day because they like to be out of their room. The RD was asked if the tube feeding being unhooked throughout the day contributed to R19's weight loss, and stated, It's hard to say that [R19] wasn't getting [their] full nutrients .
A review of the facility's, Nutrition Monitoring & Management Program revealed the following, POLICY: It is the policy of this facility to ensure that all residents maintain acceptable parameters of nutritional status, such as body weight and protein levels; unless the resident's clinical condition demonstrates that this is not possible. Notwithstanding the above, the facility recognizes that there are instances and circumstances where a resident's weight loss will be unavoidable Weight Loss Significant weight loss (5% in one (1) month, 7.5% in three (3) months, or 10% in six (6) months), as well as unplanned weight loss that occurs over time that does not meet the guidelines for significant weight loss, should be addressed in the care plan. Facility approaches to address weight loss may include an ongoing search for the cause(s) of weight loss, unless the Facility determined that the cause is known or the search for the cause has been exhausted or should be limited. Documentation reflects the reason why the search for the cause(s) was limited or discontinued. Once the cause(s) is/are identified, relevant care plan decisions are made and documented. Ongoing interventions are evaluated and modified as needed .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to justify the use and provide a stop date for a PRN (as needed) anti-anxiety medication for one sampled Resident (R29) of five r...
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Based on observation, interview and record review, the facility failed to justify the use and provide a stop date for a PRN (as needed) anti-anxiety medication for one sampled Resident (R29) of five residents reviewed for psychotropic medications, resulting in the potential for adverse reactions in the use of an unnecessary medication. Findings include:
On 8/30/22 at 11:19 AM, R29 was observed in bed asleep with a mattress laid next to their bed.
A review of R29's medical record revealed that they were admitted into the facility on 6/2/21 with diagnoses that included, Dementia, Parkinson's Disease and Diabetes. Further review of the medical record revealed that the resident was severely cognitively impaired and required extensive assistance for Activities of Daily Living and was enrolled into a hospice program.
A review of R29's medication orders revealed the following:
Lorazepam Tablet (Anti-Anxiety) 0.5 MG Give 1 tablet by mouth two times a day for anxiety/agitation HOLD IF LETHARGIC AND Give 1 tablet by mouth every 24 hours as needed for anxiety/agitation HOLD IF LETHARGIC. Ordered: 8/18/22
On 9/1/22 at 1:30 PM, the Director of Nursing (DON) was interviewed and asked about R29's duplicate anti-anxiety medications, and the PRN order not having a stop date. The DON explained that the hospice company has indicated that the resident needs the PRN order and are unwilling to change it.
A review of the facility's Best Practice Behavior and Psychotropic Medication Monitoring policy did not address PRN psychotropic medication orders having a 14 day stop date.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00129450.
Based on observation, interview, and record review the facility failed to serve mea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00129450.
Based on observation, interview, and record review the facility failed to serve meals in a palatable manner and at the preferred temperature for three sampled Residents (R55, R58 and R86) and two confidential group residents, of seven residents reviewed for food palatability, resulting in dissatisfaction during meals. Findings include:
Resident #58 (R58)
On 8/31/22 at 9:31 AM, R58 was interviewed about food palatability at the facility and stated, The food is [expletive]. R58's breakfast plate was observed with some type of ground up meat on it and a whitish/grayish substance that appeared to be either oatmeal or gravy. R58 was unable to identify what was on their plate.
On 9/1/22 at 9:00 AM, a review of R58's electronic medical record (EMR) revealed that R58 was originally admitted to the facility on [DATE] with diagnoses that included, Dementia with behavioral disturbance and Hypothyroidism (Thyroid gland issue). R58's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that R58 had a severely impaired cognition and was independent and/or required supervision for all activities of daily living (ADLs)
On 8/31/22 at 12:50 PM, a sample plate was obtained off of a food cart on unit one of the facility and temperature checked by Dietary Manager (DM) A. The results of the sample plate consisted of the following, chicken thigh: 119 degrees Fahrenheit; parsley buttered noodles: 107.8 degrees Fahrenheit and carrots: 111.3 degrees Fahrenheit. DM A was interviewed regarding the preferred serving temperatures for hot foods and stated, They should be at 150 degrees.
On 8/31/22 at 12:54 PM, the sample plate was taste tested and the results were the following, the chicken, noodles, and carrots all tasted tepid which had a negative impact on the palatability of the meal. The grapes on the sample plate were soft, and tasted overly ripe.
Resident #55 (R55)
On 8/31/22 at 2:02 PM, R55 was interviewed about food palatability at the facility and stated, It's lousy. The rice is bad. We get too much rice. R55 indicated that recently they were served a hamburger with Nothing on it. Just a bun and a burger.
On 8/31/22 at 2:15 PM, a review of R55's EMR revealed that R55 was originally admitted [DATE], with diagnoses that included End Stage Renal Disease and Major Depressive Disorder. R55's most recent MDS dated [DATE] revealed that R55 had an moderately impaired cognition and was independent/required supervision for all ADLs.
Resident # 86 (R86)
On 8/31/22 at 3:58 PM, R86 was interviewed about food palatability at the facility and indicated that the food was frequently cold. The hamburgers are served plain with nothing on them. The facility doesn't always serve what's listed on the menu. The toast at breakfast is usually cold.
On 8/31/22 at 4:15 PM, a review of R86's EMR revealed that R86 was originally admitted on [DATE], with diagnoses that included Type 2 Diabetes and Depression. R86's most recent MDS dated [DATE] revealed that R86 had an intact cognition and required extensive assistance and/or was totally dependent on 1-2 people for all ADLs other than eating.
On 9/1/22 at 10:36 AM, a confidential group meeting was conducted with four confidential group residents. The group was interviewed/asked about food palatability at the facility and two out of four of the group members indicated that the food did not taste good and that the temperature of the food tends to fluctuate.
On 9/1/22 at 1:05 PM, the Administrator (NHA) was interviewed about food palatability at the facility and stated, We know that the residents have issues with food, we are working on it.
On 9/1/22 at 2:30 PM, a facility policy titled Preventing Foodborne Illness-Food Handling Adopted: 07/11/2018 was reviewed and stated the following, Policy: It is the policy of this facility that food will be .served so the risk of foodborne illness is minimized.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
This citation is related to intake MI00129257.
Based on interview and record review, the facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours a day seven days...
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This citation is related to intake MI00129257.
Based on interview and record review, the facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours a day seven days a week, resulting in the potential for inadequate coordination of emergent or routine care with negative clinical outcome affecting all residents in the facility. Findings include:
On 9/1/22 at 1:47 PM, the Nursing Home Administrator (NHA) provided daily nurse staffing information per the survey team's request. The NHA stated that they were missing a binder. Upon review, the staff postings for September 2021, October 2021, November 2021, and December 2021 were not found. This was confirmed by the NHA during interview at 2:18 PM. Further review of the staff postings revealed that no RN was on duty for the following dates: 2/19/21, 3/1/21, 3/5/21, 3/12/21, 3/20/21, 3/21/21, 4/26/21, 6/18/21, 7/2/21 and 7/5/21.
On 9/1/22 at 2:18 PM, the NHA was asked about no RNs being noted as on duty for the above dates. The NHA stated she would like to double check to see who was working. The NHA was informed that, that information would be accepted prior to survey exit. However, no additional documentation from the NHA was not provided by that time.
The facility's policy related to staffing did not address RN staffing requirements.
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 discard damaged or expired food, and wear a hairnet while in the kitchen, affecting all residents that eat food prepared from ...
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Based on observation, interview and record review, the facility failed to discard damaged or expired food, and wear a hairnet while in the kitchen, affecting all residents that eat food prepared from the kitchen, resulting in the potential to serve contaminated food. Findings include:
On 08/30/2022 at 09:33 AM, a tour of the kitchen was completed with Dietary Manager A and the Registered Dietician (RD). Initially, the Nursing Home Administrator (NHA) walked this Surveyor to the kitchen, and were both greeted by Dietary Manager A, whom proceeded to walk this Surveyor throughout the kitchen, viewing the entire kitchen. There were dietary staff moving all around in the kitchen, cooking and preparing for lunch time. The Dietary Manager did not offer this Surveyor a hairnet upon entry into the kitchen, and when this Surveyor brought up needing a hairnet, Dietary Manager A gave one to the Surveyor but did not put on one herself.
During the tour of the dried storage room, located near the kitchen, there were shelves that contained canned and boxed foods. On the second shelf, there was an opened case of pie crust with several pie crusts left over. The crust was labeled, use by 8/18 (2022), indicating it was expired. Dietary Manager A stated, Oh, yeah, that was for a special occasion, we just need to remove those (from the dry storage shelf to dispose of). On another shelf within the dry storage room, was a large dented can of chicken noodle soup.
On 09/01/2022 at 01:05 PM, The NHA was interviewed in regard to the expired food and dented can in the kitchen. The NHA explained that usually there was not a problem with discarding damaged or expired food and that there was a separate area where those foods were to be stored until discarded. The NHA did not comment on the non-use of hairnets during the tour of the kitchen.
A review of the facility policy titled Preventing Foodborne Illness- Food Handling dated 07/11/2018 revealed the following:
Policy-It is the policy of this facility that food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. PROCEDURES:
1.
This facility recognizes that the critical factors implicated in foodborne illness are:
a.
Poor personal hygiene of food service employees;
b.
Inadequate cooking and improper holding temperatures;
c.
Contaminated equipment; and
d.
Unsafe food sources.
2.
With these factors as the primary focus of preventative measures, this facility strives to minimize the risk of foodborne illness to our residents.
3.
All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents .
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
This citation is related to intake MI00129257.
Based on interview and record review, the facility failed to maintain 18 months of posted nurse staffing information, resulting in the potential for nurs...
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This citation is related to intake MI00129257.
Based on interview and record review, the facility failed to maintain 18 months of posted nurse staffing information, resulting in the potential for nursing staffing data not being available to the public upon request. Findings Include:
On 9/1/22 at 1:47 PM, the Nursing Home Administrator (NHA) provided daily nurse staffing information per the survey team's request. The NHA stated that they were missing a binder. Upon review, the staff postings for September 2021, October 2021, November 2021, and December 2021 were not found. This was confirmed by the NHA during interview at 2:18 PM.
The facility's policy related to staffing did not address daily nurse staffing retention requirements.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 38% turnover. Below Michigan's 48% average. Good staff retention means consistent care.
Concerns
- • 34 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • $45,429 in fines. Higher than 94% of Michigan facilities, suggesting repeated compliance issues.
- • Grade D (45/100). Below average facility with significant concerns.
Bottom line: Trust Score of 45/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Skld Livonia's CMS Rating?
CMS assigns SKLD Livonia an overall rating of 3 out of 5 stars, which is considered average nationally. Within Michigan, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Skld Livonia Staffed?
CMS rates SKLD Livonia's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 38%, compared to the Michigan average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Skld Livonia?
State health inspectors documented 34 deficiencies at SKLD Livonia during 2022 to 2025. These included: 2 that caused actual resident harm, 31 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Skld Livonia?
SKLD Livonia 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 SKLD, a chain that manages multiple nursing homes. With 110 certified beds and approximately 93 residents (about 85% occupancy), it is a mid-sized facility located in Livonia, Michigan.
How Does Skld Livonia Compare to Other Michigan Nursing Homes?
Compared to the 100 nursing homes in Michigan, SKLD Livonia's overall rating (3 stars) is below the state average of 3.1, staff turnover (38%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Skld Livonia?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Skld Livonia Safe?
Based on CMS inspection data, SKLD Livonia has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Michigan. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Skld Livonia Stick Around?
SKLD Livonia has a staff turnover rate of 38%, which is about average for Michigan nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Skld Livonia Ever Fined?
SKLD Livonia has been fined $45,429 across 1 penalty action. The Michigan average is $33,533. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Skld Livonia on Any Federal Watch List?
SKLD Livonia 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.