The Manor of Novi
For profit - Corporation
130 Beds
CIENA HEALTHCARE/LAUREL HEALTH CARE
Data: November 2025
Trust Grade
25/100
#339 of 422 in MI
Photo by The Manor of Novi
Photo by The Manor of Novi
Photo by The Manor of Novi
1 / 5 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Manor of Novi has received a Trust Grade of F, indicating significant concerns about the facility's quality of care. It ranks #339 out of 422 nursing homes in Michigan, placing it in the bottom half of facilities statewide, and #27 out of 43 in Oakland County, meaning only a few local options are worse. The trend is worsening, with the number of issues increasing from 5 in 2024 to 13 in 2025. Staffing is rated average with a score of 3 out of 5, and the turnover rate is 46%, which is close to the state average. However, the facility has concerning fines totaling $153,602, higher than 89% of Michigan facilities, and it offers less RN coverage than 77% of the state facilities, which could affect the quality of care. Specific incidents noted by inspectors include the failure to appropriately transcribe wound care orders for a resident, which could lead to inadequate treatment, and a resident was found on the floor due to mobility issues without proper assistance. Another concern was a lack of standard procedures for changing water pitchers on the medication cart, indicating lapses in infection control practices. Overall, while there are some average aspects of staffing, the facility has serious weaknesses that families should consider.
- Trust Score
- F
- In Michigan
- #339/422
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 46% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $153,602 in fines. Higher than 67% of Michigan facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 26 minutes of Registered Nurse (RN) attention daily — below average for Michigan. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 52 deficiencies on record. Higher than average. Multiple issues found across inspections.
25/100
Bottom 20%
Review needed
5 → 13 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 5 issues
2025: 13 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Michigan average (3.1)
Below average - review inspection findings carefully
Staff Turnover: 46%
Near Michigan avg (46%)
Higher turnover may affect care consistency
Federal Fines: $153,602
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: CIENA HEALTHCARE/LAUREL HEALTH CARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 52 deficiencies on record
2 actual harm
Jul 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to respect a resident's right to choices for one resident (R601) of three residents reviewed for resident rights resulting in verbalized compla...
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Based on interview and record review the facility failed to respect a resident's right to choices for one resident (R601) of three residents reviewed for resident rights resulting in verbalized complaints, frustration, and dissatisfaction with an assigned caregiver. Findings include:A complaint received by the State Agency alleged a caregiver who was not supposed to be assigned to the resident's care was assigned to their care. On 7/15/25 at 11:30 AM, an interview was conducted with R601. They said they had a conflict with a Certified Nurse Aide (CNA) sometime in May. They said they were a new CNA, had a bad attitude, and they were rude. R601 was not able to identify the CNA in question by name but said they reported them to Unit Manager 'A'. They continued to say Unit Manager 'A' told them the CNA would no longer be assigned to their care. They went on to say the CNA they reported was again assigned to their care on the night shift of June 9th and so they made their complaint to the State Agency on June 10th.On 7/15/25 at 11:50 AM, an interview was conducted with Unit Manager 'A'. They were asked if R601 had reported a CNA's behavior and requested they not be assigned to their care. Unit Manager 'A' confirmed R601's complaint and identified them as CNA 'B'. They were asked if they were aware CNA 'B' had been assigned to R601's care after their complaint and said they were not.On 7/15/25 at 12:10 PM, a review of staffing sheets for R601's unit was conducted and revealed CNA 'B' had been assigned to their unit for the midnight shift on 5/28/25. Continued review of the staffing sheets further revealed CNA 'B' had again been assigned to R601's unit for the midnight shift on 6/9/25. On 7/15/25 at 1:36 PM, a review of R601's Documentation Survey Report (a report that shows CNA charting for care tasks provided) for June 2025 was conducted and revealed CNA 'B' signed off on R601's CNA tasks for the midnight shift.On 7/15/25 at 2:32 PM, an interview was conducted with the facility's Administrator, and they indicated CNA 'B' should not have been assigned to R601's care after their complaint. A review of a facility provided policy titled, Resident Rights was conducted and read, The facility protects and promotes the rights of each resident. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .Residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to implement their grievance process for one resident (R601) of three residents reviewed for grievances, resulting in an undesired caregiver be...
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Based on interview and record review the facility failed to implement their grievance process for one resident (R601) of three residents reviewed for grievances, resulting in an undesired caregiver being assigned to the resident's care after they requested they no longer be assigned to their care. Findings include: On 7/15/25 at 11:30 AM, an interview was conducted with R601. They said they had a conflict with a Certified Nurse Aide (CNA) sometime in May. They said they were a new CNA, had a bad attitude, and they were rude. R601 was not able to identify the CNA in question by name but said they reported them to Unit Manager 'A' after the incident. They continued to say Unit Manager 'A' told them the CNA would no longer be assigned to their care. They went on to say the CNA they reported was again assigned to their care on the night shift of June 9th. They were asked if they were assisted to fill out a grievance form and said they were not. On 7/15/25 at 11:50 AM, an interview was conducted with Unit Manager 'A'. They were asked if R601 had reported a CNA's behavior and requested they not be assigned to their care. Unit Manager 'A' confirmed R601's complaint and identified them as CNA 'B'. Unit Manager 'A' was asked if they recorded R601's complaint on a grievance/concern form and said they did not. They were then asked if they were aware CNA 'B' had been assigned to R601's care on 6/9/25 after their complaint, and said they were not aware.On 7/15/25 at 1:45 PM, a review of Resident Family, Employee, and Visitor Assistance Form(s) for R601 was conducted, however none of the forms provided indicated R601 had filed a form regarding CNA 'B's behavior.On 7/15/25 at 2:32 PM, an interview was conducted with the facility's Administrator regarding R601's concerns with CNA 'B'. They were asked if a grievance/concern form should have been filled out and said it should have. A review of a facility provided policy titled, Care Program was conducted and read, .To ensure that the facility actively resolves any concerns/grievances submitted orally or in writing to the Administrator, Director of Nursing, or any other member of the facility's staff .1. If a resident, a resident's representative, or another interested person has a concern .a staff member should encourage and assist the resident .to file a written concern/grievance with the facility .
Jan 2025
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
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 appropriate use of restraints, documented medi...
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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 appropriate use of restraints, documented medical symptoms for the use of restraints, and consent for use for two residents (R#'s 59 and 67), of two residents reviewed for restraints. Findings include:
R59
On 1/29/25 at 10:05 AM, R59 was observed in their room seated in a Merry [NAME] (a wheeled walker with a seat surrounded by a frame containing a hinged gate and belt to secure the user in the device that is not considered a restraint if the resident can exit the walker). At that time, R59 was asked of they could unbuckle the belt, lift the gate, and exit the framed walker. R59 responded Yes. They were asked to demonstrate their ability to exit the walker and repeated Yes. They were asked again to demonstrate their ability to get out of the walker and again repeated Yes, showing no indication they understood the request or their ability to physically complete the request.
A review of R59's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: dementia without behavioral disturbances, psychotic disturbance, mood disturbance, anxiety, and high blood pressure. Their most recent Minimum Data Set assessment dated [DATE] revealed they had severely impaired cognition and was not coded for the use of a restraint. Continued review of the record revealed a, Physical Device Evaluation- V 6 dated 7/17/24 indicated the use of a Merry Walker. Section three on the evaluation read, Restraint/Enabler and a box that read, Cannot easily be removed by the resident (cannot be removed intentionally) was checked. The evaluation further documented, release during supervised activities. A review of R59's physician's orders was conducted and revealed an order dated 7/17/24 for a Merry [NAME] that read, .to increase mobility dx (diagnoses) Dementia and ALZHEIMER's DISEASE, release during supervised activities .
On 1/29/25 at 10:28 AM, an interview was conducted with the facility's Director of Nursing (DON) regarding R59's Merry Walker. They were asked if it was considered a restraint and said no because, It promotes ambulation. They were then asked if R59 could intentionally remove themselves from the Merry [NAME] and said, No, she needs staff assistance to get in and out of it.
R67
On 1/28/25 at 11:30 AM, R67 was observed in their room seated in their wheelchair. A seatbelt was observed buckled across their lap. They were asked if they could undo the seatbelt and made no verbal or physical demonstration they understood the question or could unbuckle the belt.
On 1/28/25 at 12:48 PM, R67 was observed in the dining room being given one-to-one feeding assistance with the seatbelt observed to be buckled across their lap.
On 1/29/25 at 8:24 AM, R67 was observed in the dining room asleep in their wheelchair with the seatbelt buckled across their lap. Six staff members were present in the dining room serving breakfast. At 8:50 AM, Nurse 'L' was observed providing one-to-one feeding assistance to R67 with the seatbelt buckled across their lap.
A review of R67's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: kidney disease, falls, cataracts, delusional disorder, major depressive disorder, anxiety disorder, stroke, dementia and a femur fracture. Their Minimum Data Set assessment dated [DATE] revealed severely impaired cognition, substantial/maximal assistance with activities of daily living including transferring, wheelchair mobility, and bed mobility. It was further revealed R67 was coded as having a restraint in place.
Continued review of R67's record revealed an order created 7/18/24 revised on 12/20/24 that read, .Seatbelt dx (diagnosis) Dementia .release restraint during supervised activities . R67's care plan for the use of the seatbelt was reviewed and read, (R67) is at risk for complications due to they require the use of a: non-releasing seatbelt the devices is SPECIFY: restraint; related to Dx dementia .Interventions: Release and reposition q2 (every two) hours, with supervised meals, supervised activities and with toileting . R67's [NAME] (Nurse Aide Care Guide) was reviewed and also indicated release of the the seatbelt every two hours, with supervised meals, and supervised activities. A thorough review of the record (progress notes, medication administration records, treatment administration records, evaluations, certified nurse aide tasks) did not show evidence the restraint was released per the physician's orders, plan of care, or the [NAME] instructions.
On 1/29/25 at 10:15 AM, it was observed an activity was taking place in the activity room. At 10:19 AM and 10:36 AM, R67 was observed in their room asleep in their wheelchair with the seatbelt buckled across their lap.
On 1/29/25 at 10:28 AM, the Director of Nursing was asked about R67's seatbelt and said it was only to be released during meals and at supervised activities. They were asked why it was not released every two hours and had no explanation. At that time, the observations of the seatbelt being buckled during the meals on 1/28/25 and 1/29/25 were shared with them and they said it should have been unbuckled. They were further asked about any documentation to show the release of the belt and had no explanation. Finally, they were made aware R67 was asleep in their room in their wheelchair at 10:19 AM while an activity was being provided in the activity room. They were asked if R67 could have either been assisted to bed if they were sleepy, or afforded the opportunity to attend the activity and have the seatbelt unbuckled; to which the Director of Nursing agreed.
A review of a facility provided policy titled, Restraint Management revised 9/2022 was conducted and read, Restraints are not used unless the guest/resident has medical symptoms that warrant the use of the restraint .Physical Restraints are defined as any manual method, physical or mechanical device, material or equipment attached or adjacent to the guest's/resident's body that the individual cannot remove easily .Also included as a restraint are facility practices that meet the definition of a restraint, such as: .Placing a guest/resident in an enclosed framed wheeled walker, in which the guest/resident cannot open the front gate or if the device has been altered to prevent the guest/resident from exiting the device .5. Any guest/resident using a physical restraint or side rails must have a current, signed restraint consent .7. During the time a restraint is in place, the restraint is periodically removed and thee guest/resident assisted with change of position, range of motion, and/or stretching. Restraints should always be removed during supervised mealtimes and activities .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive care plan to address a residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive care plan to address a resident's use of a midline intravenous (IV) line, use of antibiotics, and multiple infections for one (R111) of two residents reviewed for infection care planning. Findings include:
On 1/30/25 at 8:34 AM, R111 was observed laying in bed asleep, with a blue wedge pillow under their right torso, and their left arm was observed swollen and propped on a pillow. There was a urinary catheter drainage bag secured to the side of the bed and an IV (Intravenous) pole with an empty bag of antibiotic medication placed next to their bed.
Review of the clinical record revealed R111 was admitted into the facility on [DATE] with diagnoses that included: acute gastritis with bleeding, pneumonia, urinary tract infection, and cellulitis.
According to the Minimum Data Set (MDS) assessment dated [DATE], R111 had intact cognition and had an indwelling urinary catheter.
Review of R111's physician orders included multiple antibiotics (both oral and intravenous) for multiple infections which included cellulitis to the right upper extremity, urinary tract infections (UTI), and pneumonia since the end of December 2024.
Further review of the care plans revealed there were none initiated for the resident's midline IV or use of antibiotics for the current UTI and pneumonia diagnoses. The only care plan that mentioned a UTI was an at risk for urinary tract infection initiated upon admission by the Director of Nursing (DON) that had not been revised since initiation on 12/20/24.
On 1/30/25 at 8:16 AM, an interview was conducted with the Infection Preventionist (IP 'A'). When asked about R111's infections and antibiotics, IP 'A' reported they were recently started on an IV antibiotic to treat both a UTI and pneumonia. When asked who was responsible to initiate or revise care plans as infections were identified or midline IV's were implemented, IP 'A' reported they and the nurses were responsible. They were unable to explain why that had not occurred for R111.
On 1/30/25 at 10:55 AM, an interview was conducted with the Director of Nursing (DON). When asked who was responsible for initiating care plans for infections, the DON reported that should've been IP 'A'. They were informed there was no care plan other than the one they initiated upon admission for being at risk for a UTI. They were also asked about a care plan for the use of a midline IV and the DON reported a care plan should've been initiated and that could've been done by any nurse.
According to the facility's policy titled, Care Planning dated 6/24/2021: .The care plan must be specific, resident centered, individualized and unique to each resident and may include .How to manage risk factors .Utilize current standards of practice .Treatment objectives should have measurable outcomes .Involve and communicate the needs of the resident with the direct care staff (i.e. CNA (Certified Nursing Assistant) [NAME]) .The care plan and resident [NAME] will be updated .with significant changes. This includes adding new focuses, goals, and interventions and resolving ones that are no longer applicable as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure care was provided per professional nursing standards for one resident, (R75) of five residents reviewed during the med...
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Based on observation, interview, and record review, the facility failed to ensure care was provided per professional nursing standards for one resident, (R75) of five residents reviewed during the medication administration observation. Findings include:
On 1/29/25 at 9:23 AM, Nurse 'J' was observed preparing medications for administration to R75 at the medication cart in the hallway. The medications prepared were placed in a medication cup and it was not observed Tylenol had been removed from the cart and placed into the cup. Upon completing the preparation, Nurse 'J' entered R75's room and handed them the medication cup. R75 looked at the pills in the cup and asked Nurse 'J' if one of the large pills in the cup was Tylenol. Nurse 'J' told them no and said, the little pill is the Tylenol. R75 then proceeded to take the medications.
On 1/29/25 at 9:39 AM, an interview was conducted with Nurse 'J'. They were asked why they told R75 one of the pills in the medication cup was Tylenol when no Tylenol had been prepared and taken into the room. In a defensive tone, Nurse 'J' said, I don't remember her (R75) asking me about Tylenol, so I won't confirm I said anything about that.
On 1/30/25 at 10:34 AM, The Director of Nursing (DON) was made aware of the observation and conversation between Nurse 'J' and R75. They said Nurse 'J' should not have told R75 there was a medication in the cup that was not there.
A review of a facility provided Charge Nurse Job description was reviewed and read, .2. Provides safe and accurate Medication Related interventions to residents. a. Administers and documents medications and treatments according to each resident's medication schedule using current standards of medication pass technique .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure routine showers/baths and hygiene care were pro...
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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 routine showers/baths and hygiene care were provided for two (R91 and R52) of five residents reviewed for activities of daily living (ADL's). Findings include:
R91
On 1/28/25 at 11:55 AM, R91 was observed seated in a wheelchair just outside of their room. When asked about their care and whether they received baths or showers per their schedule, R91 reported they were supposed to get a shower last Friday, but they never did and they further reported it had been a while since they had one. When asked if staff informed them of the reason they might not be able to get a shower on their scheduled days, R91 reported they say they'll be too busy.
Review of R91's shower/bath schedule in the task section of the Electronic Medical Record (EMR) documented and the resident was scheduled to have a shower/bath on Tuesdays and Fridays on the PM (evening) shift.
Review of the clinical record revealed R91 was admitted into the facility on [DATE] with diagnoses that included: wedge compression fracture of T11-T12 vertebra, other chronic pain, and adjustment disorder with mixed anxiety and depressed mood.
According to the Minimum Data Set (MDS) assessment dated [DATE], R91 had a Brief Interview for Mental Status (BIMS) exam score of 9/15 which indicated moderate cognitive impairment (however R91's recollections of discussions with staff were accurate during the resident interview), had no mood or behavior concerns, had impairment on both sides of lower extremities, and was dependent for shower/bathing. According to the profile information, R91 was currently their own responsible party.
Review of the task section of the Electronic Medical Record (EMR) for R91's shower/bath for the past 30 days (max look-back period available for review) documented the resident only received four showers on 12/31/24, 1/3/25, 1/7/25, 1/10/25 (most recent). The documentation on 1/14/25 and 1/28/25 had a check marked next to No for the prompt if the resident received a shower/bath, and the documentation on 1/17/25 had a check marked next to Not Applicable. There were no documented refusals on the task documentation or in the progress notes.
According to the care plan initiated on 11/25/24, revised on 11/27/24, interventions included:
BATH/SHOWER: Resident (SPECIFY: is .Dependent .Substantial/maximal assistance with two helper(s).
On 1/29/25 at 11:47 AM, the facility was requested via email to clarify where the bathing/shower documentation was kept and the facility reported that would be under the TASK section for bathing (same documentation that was reviewed above).
On 1/29/25 at 1:06 PM, an interview was conducted with the Director of Nursing (DON). When asked to confirm the process of where showers/baths were documented, the DON reported only in the TASK section. At that time, the DON reviewed the available documentation for R91 and confirmed the lack of showers documented. The DON was asked if there was any refusal if offered where would that be documented and the DON reported that should be indicated on the TASK documentation and if refused, it would send an alert. The DON reported they did not recall receiving any alerts like that for R91.
R52
On 1/28/25 at 10:32 AM, R52 was observed lying in their bed. Their face and hair had a shiny, greasy appearance and their teeth appeared with yellow/brown discoloration and debris caked on them.
On 1/29/25 at 11:55 AM, R52 was observed lying in their bed. Their hair and face remained with a shiny, greasy appearance. A green/yellow crusty material was observed in their nostrils and their teeth appeared with yellow/brown discoloration and debris. They were asked the last time anyone had cleaned them up such as washed their face or assisted them with oral care and they said they had a bed bath two days ago.
On 1/29/25 at 12:03 PM, a review of R52's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: acute renal failure, bipolar disorder, and psychotic disorder with delusions. Their most recently completed Minimum Data Set assessment dated [DATE] indicated moderately impaired cognition and required moderate to total assist for hygiene and bathing. A review of a Certified Nursing Aide (CNA) task for showering/bed bathing was reviewed and documented the task done on 1/2/25, 1/6/25, 1/13/25, and 1/16/25.
On 1/29/25 at 3:45 PM, a review of a CNA task for hygiene indicated hygiene care was provided on 1/29/25 at 12:34 PM, despite R52's appearances after that time with debris in their nostrils, greasy hair and face, and discolored teeth with debris.
On 1/29/25 at 3:49 PM, R52 remained in bed with yellow/green debris in their nostrils, a shiny, greasy face and hair and discolored teeth with debris.
On 1/30/25 at 10:34 AM, R52's appearance was brought to the DON's attention and they indicated they would look into it.
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 ensure wound care treatments were provided per physic...
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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 wound care treatments were provided per physician's orders for one resident (R46) of one resident reviewed for non-pressure ulcer wound care, resulting in verbalized complaints and the potential for the worsening of wounds. Findings include:
On 1/30/25 at 9:24 AM, R46 was observed lying in their bed. They had soft heel boots on both of their feet and bulky bandages were wrapped around their feet and ankles. The tape securing the bandaging was observed to be dated 1/28/25. At that time R46 was asked if staff provided them wound care per physician's orders and said they did not. They indicated the dressings on their feet were to be changed daily, however; it was not being done daily.
A review of R46's clinical record was conducted and revealed they admitted to the facility on [DATE] with diagnoses that included: chronic kidney disease, deep vein thrombosis (blood clots), diabetes, and high blood pressure. A review of a wound care consultation dated 1/24/25 revealed they had diabetic ulcers to both their left and right foot that was to be treated daily with Medi-honey (wound treatment) and wrapped with bulky dressings.
A review of R46's treatment administration record for January 2025 was conducted and the treatment scheduled for 1/29/25 had been signed off as completed, despite the dressings being dated 1/28/25.
On 1/30/25 at 10:34 AM, an interview was conducted with the facility's Director of Nursing (DON) and they said wound care treatments should be performed per physician's orders and only signed off on the treatment administration record if they had been completed.
A review of a facility provided policy titled, Skin Management revised 8/2024 was conducted and read, .Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated, and provided the appropriate treatment to promote prevention and healing .
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 observation, interview, and record review, the facility failed to implement interventions and provide care to prevent 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 implement interventions and provide care to prevent accidents for two residents, (R#'s 67 and 74) of three residents reviewed for accidents, resulting in a fall and the potential for injuries. Findings include:
On 1/28/25 at 11:30 AM, R67 was observed in their room. They were seated in their wheelchair equipped with a seatbelt fastened around their waist. The wheelchair was not equipped with anti-tipping devices. An interview was attempted with R67, however; they did not respond.
On 1/28/25 at approximately 4:00 PM, R67 was observed sleeping in their bed. Their wheelchair was placed in the hallway and the cushion was not observed with Dycem (a non-slip material used to stabilize surfaces) in place.
A review of R67's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included; falls, femur fracture, cataracts, anxiety, and dementia. Their most recent Minimum Data Set (MDS) assessment dated [DATE] indicated R67 had severely impaired cognition and was maximal assist to dependent on staff for transferring and ambulation. The MDS assessment further indicated R67 had a restraint device in place. Continued review of R67's record revealed a physician's order originating July 2024 for the use of a seatbelt restraint. A progress note dated 12/13/24 at 4:55 PM was reviewed and read, Writer was told by nurse aide, Resident was observed sitting on the floor with seat belt on chest and head on wheelchair facing forward .
On 1/29/25 at approximately 11:00 AM, a review of R67's incident/accident reports was conducted and revealed documentation on 12/13/24 that read, .Nursing Description: Writer was told by nurse aide, Resident was observed sitting on the floor with seat belt on chest and head on wheelchair facing forward .Immediate Action Taken Description: Education with the cna (Certified Nurse Aide) to check seatbelt & Keep <sic> within staff Vision <sic> while awake. education <sic>provided to the cna to ensure seatbelt is secured correctly . The Post Fall Evaluation form provided with incident/accident report read, .Factors observed at time of fall: Guest/resident slipped .What was the guest/resident doing during or just prior to the fall? Sliding out from wheelchair .New Interventions after IDT (interdisciplinary team) review: Education provided to CNA to ensure seatbelt is secured correctly .
A review of R67's care plans for falls was conducted and revealed the following, .Interventions .Non-releasing seatbelt (7/18/24) .Anti roll back on wheelchair (1/23/23) .Dycem to wheelchair (1/11/23) .
On 1/30/25 at 10:34 AM, an interview was conducted with the facility's Director of Nursing (DON) regarding the fall on 12/13/24 and they indicated the CNA did not have the seatbelt pulled tight enough around R67's waist so they were able to slide underneath and was found on the floor with the belt around their chest.
R74
On 1/30/25 at 9:48 AM, Certified Nurse Aide (CNA) 'I' was observed transporting R74 from the shower room to their room in the shower chair. CNA 'I' had R74 facing rearward and was pulling the chair in forward motion with their back to R74. When they arrived to the room they were asked if pulling a resident facing rearward was the appropriate way to transport someone in a wheeled chair. They said, It's not safe for me to push them in the chair. They were asked what was unsafe about having the resident face forward with them behind the chair pushing it in a forward motion and they pointed to the wheels and said it was, unsafe for me. They were asked if the chair needed maintenance or repair and said no. They further declined to give any additional explanation on why they transported the resident in the chair in the manner they did.
On 1/30/25 at 10:34 AM, an interview with the facility's Director of Nursing (DON) was conducted regarding the observation of CNA 'I'. They said CNA 'I' should not have transported R74 in the chair facing rearward pulling the chair, or have their back to the resident as it was a safety concern.
A review of a facility provided policy titled, Resident Dignity & Personal Privacy revised 3/2024 was conducted and read, .d. Roll wheelchairs/geri-chairs in a forward direction .
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 5% when two medication errors were made for two residents (R#'s 57 and 75) of five r...
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Based on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5% when two medication errors were made for two residents (R#'s 57 and 75) of five residents reviewed during the medication pass observation, resulting in a medication error rate of 7.69%. Findings include:
On 1/28/25 at 9:12 AM, Nurse 'K' was observed preparing medications for administration to R57. Nurse 'K' prepared multiple medications including a 600 mg (milligram) calcium supplement. Nurse 'K' entered the room, administered the medications to R57, exited the room and signed the medications out as given on the medication administration record.
On 1/30/25 at 11:22 AM, a review of R57's medication orders was conducted and revealed R57 did not have an order for a 600 mg calcium supplement, rather they had an active order for Calcium Carbonate-Vitamin D 500 mg-200 mg combination supplement.
On 1/29/25 at 9:23 AM, Nurse 'I' was observed preparing medications for administration to R75. The medications prepared included Dorzolamide eye-drop 2% (glaucoma treatment) with instructions on the pharmacy label attached to the box that indicated one drop was to be instilled in the left eye. After preparing the medications Nurse 'I' entered R75's room and when they administered the Dorzolamide eye drop they were observed to place one drop in R75's right and left eye.
On 1/29/25 at 9:39 AM, Nurse 'I' was asked how they administered the Dorzolamide and said they put one drop in each eye because that was, what the box said. They were asked to remove the box and confirm the pharmacy label instructions and when they did so, they said they should have only put a drop in R75's left eye.
On 1/30/25 at 11:38 AM, a review of 75's medication orders was conducted and revealed an active order for Dorzolamide eye drop 2% with instructions that indicated one drop was to be placed in the left eye.
On 1/30/25 at 1:42 PM, the Director of Nursing was interviewed regarding the medication errors and said the nurses must administer medications per the physician's orders using the, Five rights of medication administration (right patient, right medication, right dose, right route, right time).
A review of a facility provided document titled, Medication Administration revised 10/2023 was conducted and read, Resident medications are administered in an accurate, safe, timely, and sanitary manner .2. Verify the medication label against the medication administration record for resident name, time, drug, dose, and route .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0776
(Tag F0776)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to obtain physician ordered x-rays for one resident, (R69) of one res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to obtain physician ordered x-rays for one resident, (R69) of one resident reviewed for radiology/diagnostic services. Findings include:
Review of R69's physician orders included an order dated 12/28/24 for an x-ray of the right shoulder and hips related to pain. Review of the record did not reveal documentation that the x-rays had been obtained.
Further review of the record revealed that R69 was admitted to the facility on [DATE] with diagnoses that included: type 2 diabetes, insomnia, and end-stage renal disease.
On 1/29/25 at 8:44 AM, an interview was conducted with the Director of Nursing (DON). When asked about the timeframe for a diagnostic order (x-ray) to be completed, the DON reported if it was a STAT order, usually within 4 to 6 hours but if it was a general order the nurse practitioner would put it in for three days so it would not get missed. The DON was then asked if they could locate the results of R69's x-ray ordered on 12/28/24 of the right shoulder and hips but was not able to provide evidence the x-ray had been completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure a doorway frame was maintained in a safe manner for two (R36 and R54) of two residents reviewed for safe environment, r...
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Based on observation, interview and record review, the facility failed to ensure a doorway frame was maintained in a safe manner for two (R36 and R54) of two residents reviewed for safe environment, resulting in the potential for injury (laceration). Findings include:
On 1/28/25 at 11:35 AM, 1/29/25 at 2:15 PM, and 1/30/25 9:30 AM, observations of the C-Hall revealed the room occupied by R36 and R54 was observed to have a doorway frame that had a sharp metal strip around the bottom portion that was pulled away and exposed sharp metal edges (at about the ankle height of anyone that entered the room).
On 1/30/25 at 9:55 AM, an interview was conducted with Unit Manager (UM 'F') who reported they were in their role since Friday 1/24/25. When asked about the process if staff identified concerns with the environment such as broken door frames, UM 'F' reported they used the TELS (an electronic reporting system). UM 'F' was asked about the state of R36 and R54's doorframe and confirmed the sharp metal and stated they would have to be covered right away. They denied being aware of this before this discussion.
On 1/30/25 at 10:34 AM, the facility was requested to provide TELS documentation for the past 3 months.
Review of the TELS documentation provided from 11/30/24 - 1/29/25 revealed no identification of the doorway frame for the room occupied by R36 and R54.
On 1/30/25 at 11:40 AM, an interview was conducted with the Maintenance Director (Staff 'C'). When asked if they were aware of any concerns with doorframes, they reported (Name of Staff 'B' who was their Maintenance Assistant) was informed by a nurse (UM 'F') when they were making rounds with the fire inspector. (After this concern was identified during the survey.)
When asked if they conducted any environmental rounds to identify concerns such as unsafe items, they reported they did and had not seen anything like that before. Staff 'C' was informed the concern was identified during the past three days of the survey and concerns remained since no staff had identified a concern until it was identified by this surveyor. Staff 'C' was requested to provide their environmental audits for the past month.
Review of the documentation provided by Staff 'C' for their Facility Audit Tool from 1/2/25 - 1/29/25 revealed no identification of what specific areas of the facility were observed/audited. There was no documentation the facility had identified any concerns with the sharp metal doorframe.
According to the facility's policy titled, Environmental Rounds Policy and Procedure dated 4/29/2022:
.The purpose of environmental rounds is to ensure facility standards reflect federal, state, and local regulations .When issues are found they will be corrected and addressed by the appropriate department head .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to protect personal health information for nine residents (R#'s 89, 45, 266, 71, 73, 26, 38 and 42) of nine residents reviewed fo...
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Based on observation, interview, and record review the facility failed to protect personal health information for nine residents (R#'s 89, 45, 266, 71, 73, 26, 38 and 42) of nine residents reviewed for personal privacy. Findings include:
On 1/28/25 at 9:18 AM and 1/29/25 at 4:15 PM, an observation of the nursing station on the A unit revealed a bulletin board visible from anyone passing by that listed R89, R45, R266, R71, R73, R26, R38, and R42's names and the times they were to attend dialysis treatments.
On 1/30/24 at 10:45 AM, an interview was conducted with the Director of Nursing regarding resident's private health information observed on the A unit and they indicated the Unit Manager posted the schedules but it should not be visible to anyone passing by and could have had a privacy cover placed over it.
According to the facility's policy titled HIPAA (Health Insurance Portability and Accountability Act) Policy Regarding Use and Disclosure of PHI (Protected Health Information) for Treatment dated 9/30/2021: .Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records .
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
Water Pitcher:
On 1/30/25 9:20 AM observation of the C-hall medication cart had a clear plastic pitcher filled with water and ice stored on top of the cart. There was a sticker that had a handwritten ...
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Water Pitcher:
On 1/30/25 9:20 AM observation of the C-hall medication cart had a clear plastic pitcher filled with water and ice stored on top of the cart. There was a sticker that had a handwritten date of 1/28.
On 1/30/25 at 9:26 AM, Nurse 'E' was observed to return to the medication cart and confirmed they were assigned to the entire unit. When asked about the process for changing the water, ice, and plastic pitchers stored on the medication cart, Nurse 'E' reported they forgot to change the pitcher. When asked how often that gets changed, Nurse 'E' reported they would get a fresh pitcher every two to three days and further stated We don't have a standard of when we change our pitchers. Nurse 'E' was then observed to remove the existing sticker dated 1/28 and placed a new sticker dated 1/30.
On 1/30/25 at 9:55 AM, an interview was conducted with Unit Manager (UM 'F') who reported had been in their role since Friday 1/24/25. When asked about the changing of the water pitchers on the medication carts, UM 'F' reported those should be changed out at the end of each night shift and the water and ice should be changed out every shift. They were informed of the observation and interview with Nurse 'E' and reported that should not have occurred.
According to the facility's policy titled, Cleaning Water Pitcher & Drinking Utensils dated 4/20/2023:
.Nursing is responsible for collecting and delivering soiled water pitchers and drinking utensils to the dietary department .Send water pitchers and trays to the dietary department for cleaning and sanitizing daily and when soiled .
Based on observation, interview, and record review, the facility failed to maintain the kitchen in a sanitary manner, and failed to maintain the C hall medication cart water pitcher in a sanitary manner. This deficient practice had the potential to affect all residents that consume food and water orally. Findings include:
On 1/28/25 between 8:40 AM-9:15 AM, during an initial observation of the kitchen, the following items were observed:
In the walk-in cooler, there was pooled milk underneath the crates of milk cartons. There was a tray of raw chicken with blood pooled in the bottom of the tray and blood spilled on the floor underneath the rack. There was raw ground beef and raw pork stored directly next to the tray of raw chicken. When queried, Certified Food Manager (CFM) D stated the spills would be cleaned up right away. When queried about the storage of the raw meats, CFM D stated, they should have been separated.
According to the 2017 FDA Food Code section 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation, (A) Food shall be protected from cross contamination by: .(2) Except when combined as ingredients, separating types of raw animal foods from each other such as beef, fish, lamb, pork, and poultry during storage, preparation, holding, and display by: .(b) Arranging each type of food in equipment so that cross contamination of one type with another is prevented,.
According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean.
Next to the toaster, there was an uncovered, unlabeled 4 quart container of a white powder, and an unlabeled 4 quart container of a light tan powder. CFM D confirmed the containers should be covered and labeled with the contents.
According to the 2017 FDA Food Code section 3-302.12 Food Storage Containers, Identified with Common Name of Food, Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD.
On the lower shelf of a food preparation table, there were 3 uncovered bins of clean ladles, scoops, whisks, and various utensils.
According to the 2017 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, (A) Except as specified in (D) of this section, cleaned equipment and utensils, laundered linens, and single-service and single-use articles shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted.
Nov 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0576
(Tag F0576)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake# MI00147133
Based on observation, interview and record review the facility failed to ensure the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake# MI00147133
Based on observation, interview and record review the facility failed to ensure the residents right to receive unopened and private mail delivery for one (R701) out of four residents reviewed for resident rights. Findings include:
A complaint was filled with the State Agency (SA) that alleged the facility opened R701's postal package containing items from a pharmacy a week prior to them receiving the package. In addition, they alleged that some of the items, including mouth wash and bed pads, were missing from the package.
On 11/12/24 at approximately 11:28 AM, R701 was observed lying in bed in their room. The resident was alert and able to answer questions asked. R701 was asked if they had had any concerns regarding mail acceptance. The resident noted that they receive items via the mail monthly that contain items like mouth wash and disposable pads. R701 noted that in early September 2024, a package was delivered to the facility with their name on it. The box was brought to their room approximately one week or so after it arrived, and they noted the box was open and three bottles of mouth wash and a pack of bed pads were missing.
A review of R701's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: chronic kidney disease and dependent on renal dialysis. The resident's most recent Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 13/15 (intact cognition).
A grievance form provided by the facility was reviewed and documented, in part, the following: .Name: R701 .Information about your concern: Delivered Wednesday - 6 bottles of Listerine (mouth wash) only received 3-Bag of large pads missing .When did the problem or incident occur .Last week .Date: 9/11/24 .Facility response: Facility was searching for missing items .Action: facility purchased new items to replace what was missing .
On 11/12/24 at approximately 2:28 PM, an interview was conducted with the Administrator regarding the resident's missing items from the package that was delivered in September 2024. The Administrator reported that they believed R701's package got mixed up with other items sent to the facility and was opened by staff and some of the items were missing by the time the package was located. The Administrator noted that staff should not open resident's mail and/or packages without permission.
A review of the facility policy titled, Resident Mail (2/16/24) noted, Policy: Residents have the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service Procedure: .mail will be delivered to the resident unopened unless otherwise indicated by the resident or resident's representative .staff members will not open mail for residents unless residents request them to do so. Requests to open mail will be documented in the medical record .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation is pertains to intake MI00147430.
Based on observations, interview, and record review the facility failed to notif...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation is pertains to intake MI00147430.
Based on observations, interview, and record review the facility failed to notify appropriate discipline wound physician/practitioner and implement and update interventions for one (R704) resident of one resident reviewed for pressure injuries. Findings Include:
On 11/12/24 at 9:30 AM, the Complainant was interviewed via phone called and stated that residents are not being turned every two hours as they should, because they are short staffed and are contracting bad wounds because of the lack support on the midnight shift. The Complainant was then asked could they provide a specific resident who had been affected by the lack of staffing and stated R704 is someone who had been affected.
A review of the medical record revealed that R704 was admitted to the facility on [DATE] with the diagnosis of type two diabetes, sleep apnea, and muscle wasting and dystrophy. R704's most recent Brief interview for mental status score was a 3, indicating impaired cognition. The record also revealed that R704 had a stage IV pressure wound on their sacrum area, which was originally identified as a skin injury on 09/15/24 upon admission from a hospital stay. There was a treatment put into place by the director of nursing (DON), however, after the treatment was put into place there was no evidence of interventions implemented or the wound care practitioner being notified. On 10/9/24 the area was noted to have worsened and on 10/17/24 a week later the wound had declined greatly, and resident was sent to hospital on the 10/18/24 due to a change in condition.
A review of the Care plan revealed no updated interventions for the change in skin integrity since 2023.
On 11/12/24 at 10:22 AM the Unit manager(UM) was interviewed, she was asked about the history of R704's wounds. The UM stated that she did not really know the background but the Wound care coordinator(WCC) would be able to answer that.
On 11/12/24 at 11:00AM the WCC was interviewed and asked about R704's wounds. The WCC explained that the wound was not that bad prior to them going out to the hospital. R704 returned to the facility with the wound that way and they have just been trying to keep on top of it and ever since R704 had their stroke the wound has been declining rapidly. The WCC was asked how often does wound care (wound team/practitioner) round at the facility and when is wound care consulted for a resident. The WCC replied that the wound rounds were weekly on Fridays and that anytime a new skin area is notified on a resident they are put on the list for wound rounds.
On 11/12/24 at 12:10 PM the DON was interviewed and was asked about R704's wounds. The DON replied that R704 had been declining rather quickly after their stroke on 10/18/24 but she had put in a treatment for the open area that she had assessed on the resident's sacrum and it was expected that wound care should have followed up with a consult but it did not happen. She also stated she was not aware that the care plan had not been up dated since 2023. The DON stated that they are working on the consistency of the wound care program.
There was no additional information provided by the exit of the survey.
Aug 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes #MI00146313 and MI00146302
Based on observation, interview and record review the facility fail...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes #MI00146313 and MI00146302
Based on observation, interview and record review the facility failed to protect the resident's right to be free from physical abuse by another resident resulting in R501 hitting R502 in the head out of four residents reviewed for abuse. Findings include:
A facility reported incident (FRI) was submitted to the State Agency (SA) that documented on 6/30/24, R502 entered R501's room and when R502 would not leave, R501 hit R502 on the head/face causing redness.
A review of the facility's Incident report documented, in part, the following: .Summary of incident: On 6/30/24, (R502) entered (R501)'s room. (R501) asked (R502) to leave (R501) hit him on his head .(R501): He came into the room. I didn't want him to take anything and asked him to leave. He wouldn't leave so I hit him on the side of the head. He was standing at the end of the bed. He hollered out, and the nurse came down .Nurse K interview statement: (R502) went into (R501)'s room. I heard shouting and went in there. I saw (R502) had redness on his head. I asked (R501) what happened, he said (R502) was going in his room so he pop (R502)'s head with his fist .The facility conducted a thorough investigation .could not substantiate abuse. It was confirmed that (R501) did hit (R502) .
On 8/27/24 at approximately 9:50 AM, R501 was observed in their wheelchair on the A-unit hallway. The resident was alert and able to answer questions asked. When queried as to the incident that occurred on 6/30/24, R501 reported that R502, who continues to wander in and out of their room, entered into their room and got too close to them so they punched them in the face/head. R501 noted that if the resident does it again and gets too close to them, they would hit them again. A review of R501's clinical record noted the resident had a Brief Interview for Mental Status (BIMS) score of 13/15 (cognitively intact cognition).
On 8/27/24 at approximately 9:58 AM, R502 was observed walking down the hallway near the B-Hall. R502 was pushing another resident (hereinafter their wife) in a wheelchair. R502 opened the door to another resident's room and attempted to enter. The other Resident yelled out and told R502 to leave the room. R502 left and continued pushing the resident in their wheelchair. No staff were observed to redirect the resident. An attempt to interview R502 was made. The resident was alert but unable to answer questions asked.
On 8/27/24 at approximately 10:07 AM, an interview was conducted with the other Resident. When asked about R502 trying to enter their room, they reported that they do that all the time. When asked if they feel safe when that happens, the Resident stated that they do because if the resident were to get to close to them, they would hit them and held up their fist to demonstrate how they would hit R502.
A review of R502's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that include adjustment disorder with depressed mood, adjustment insomnia and dementia. A review of the resident Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 0/15 (severe cognitive impairment).
Continued review of R502's clinical record documented, in part, the following:
Social Service Note(3/20/24): .Resident .pleasantly confused .Resident speaks Russian as native language; resident able to communicate with use of some basic English .Resident displays wandering behaviors throughout facility, CP (care plan) and wander-guard in place, resident is easily redirectable .Russian stop sign located at each exit door in facility as precaution .
Nurse Notes (3/26/24): Resident was caught naked from the waist down urinating in room (D-3A) trash can The resident in room D3 is very disgusted and furious about the incident.
Nurse Notes(4/13/24): Resident wandering into other residents' rooms .
Nurse Notes (4/14/24): Resident wandered into B unit and tried to open the emergency exit door .
Nurses Notes (4/18/24): Patient is ambulating more this afternoon and wandering around facility and going into different rooms .
Nurses Notes (4/27/24):Writer observed resident to resident contact. [Perpetrator} begin yelling profanities telling R502 to get the F out of his room. R502 stood confused as [Perpetrator] pushed him multiple times. When writer went over to separate the two [Perpetrator] began chest bumping R502 still yelling profanities .Instructed [Perpetrator] to stop pushing R502 .
Social Service Note (5/15/24): .SW(social worker) spoke with rep (representative) .on psych visit yesterday .feels a secured unit would be in resident's best interest .
Behavior Note (6/1/24): Resident was wandering the halls went inside another residents room .It was reported to writer that R502 opened the bathroom door on the resident while she was in there undressed .staff was made aware to monitor resident closely and redirect him from going on other units.
Behavior Note (6/22/24): res (resident) was seen .walking into res .room. Res was seen grabbling and tugging on R (right) arms .
Encounter (6/30/24): .resident wandered into another residents room and was punched in the head .
A review of R502's care plan documented, in part: Focus: R502 is at risk for elopement r/t (due too) wandering throughout the building, impaired cognition .he displays wandering behaviors going into rooms looking for family (created 3/15/24) .5/24 .Stop signs and Caution signs in Russian place at Exits and rooms resident frequently attempts to enter .Interventions: Apply Russian stop signs and caution signs on Exit doors and rooms residents frequent (initiated 5/20/24) Wanderguard to Ankle (initiated 3/15/24) .Approach in a slow, calm manner and redirect away from exit doors as needed (initiated 3/15/24) Observe wandering behavior and attempted diversion interventions when wandering into inappropriate locations such as other residents rooms when not invited, behind nurses stations, shower rooms, attempts at exiting facility (initiated 3/15/24) .Provide structured activities .as needed (initiated 3/15/24) Resident observation Q (every) 30 min (minutes)checks (initiated 7/21/24) . *It should be noted that R502's [NAME] did indicate Q 30 min checks however there were no logins for time checks in the electronic TASK section.
On 8/27/24 at approximately 10:30 AM, an interview was conducted with Nurse I who was assigned to the hall where R502 resided. Nurse I was asked as to R502's wandering in and out of other residents' rooms. Nurse I reported that they were aware the resident wanders throughout the building either trying to exit and/or enter other resident's rooms. Nurse I stated that they do try to redirect but can't always get to them soon enough.
On 8/27/24 at approximately 11:31 AM, a phone interview was conducted with Nurse K. Nurse K was asked about the FRI incident that occurred on 6/30/24 and additional information pertaining to R502. Nurse K confirmed that R502 was punched in the head by R501 on 6/30/24. Nurse K stated that they were aware of R502 wandering in and out of other residents' rooms and the intervention regarding redirecting but noted that staff often loses track of R502's location as they ambulate quickly.
On 8/27/24 at approximately 1:16 PM an interview was conducted with the Administrator/Abuse Coordinator regarding the incident that occurred on 6/30/24 between R501 and R502 as well as other incidents that occurred when R502 entered other resident's rooms. The Administrator confirmed that R501 did hit R502 on 6/30/24 however they felt it was not intentional as R501 just wanted R502 out of their room. When asked what additional interventions had been put into place to ensure R502's safety as they had been pushed by another resident in April 2024 and observed trying to enter other resident's room during the survey, the Administrator noted that they continue to try to redirect the resident, but they do not always track them prior to entry. When asked if R502 received 30-minute checks, the Administrator was not certain.
On 8/27/24 at approximately 2:13 pm, a phone interview was conducted with Social Worker (SW) J. SW J was queried as to R502's wandering into other resident's rooms including the room where R501 resided. They reported that they were very aware of R502 wondering throughout the building and noted that while there were interventions to prevent and redirect staff were not always around to redirect the resident. SW J noted that R502 was not aggressive however was aware that the other residents, including R501, where aggressive with R502 as they did not like them entering their room.
A review of the facility policy titled, Abuse Prohibition Policy (9/9/22) documented, in part: Policy: each resident shall be free from abuse, neglect .To assure guests/residents are free from abuse, neglect .It is the responsibility of all staff to provide a safe environment for all guests/residents .Definitions: Abuse means the willful infliction of injury .intimidation or punishment resulting in physical harm, pain or mental anguish .Willful as used is this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation has two deficient practices.
Deficient Practice #1-This citation pertains to Intake MI00146302
Based on observatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation has two deficient practices.
Deficient Practice #1-This citation pertains to Intake MI00146302
Based on observation, interview and record review, the facility failed to protect a likely accidental opioid ingestion for one (R503) of three residents reviewed for narcotic medications. Findings include:
A complaint was filed with the State Agency (SA) that alleged in part that R503 does not take any narcotic medications, but on 6/23/26, R503 was found unresponsive and EMS (emergency medical services) administered Narcan (opioid reversal agent) and then R503 became responsive.
Review of a National Institute on Health (NIH) article titled, Naloxone (Narcan) DrugFacts dated January 2022 read in part, .Naloxone is a medicine that rapidly reverses an opioid overdose. It is an opioid antagonist. This means that it attaches to opioid receptors and reverses and blocks the effects of other opioids . But, naloxone has no effect on someone who does not have opioid in their system .
On 8/27/24 at 9:01 AM, R503's Guardian was interviewed by phone and asked about what happened on 6/23/24. The Guardian explained they were notified on 6/23/24 that R503 was taken to the hospital because R503 had been unresponsive and that EMS had given Narcan . R503 does not take any narcotic medications . they were very concerned about what had happened . and were concerned of it happening again . and had not received any answers from the facility.
On 8/27/24 at 9:45 AM, R503 was observed lying in bed. R503 was asked if they had been in the hospital recently. R503 happily explained they had gone to the hospital in high school when they hurt their arm.
Review of the clinical record revealed R503 was admitted into the facility on 4/12/24 with diagnoses that included: chronic obstructive pulmonary disease (COPD), depression and dementia. According to the Minimum Data Set (MDS) assessment dated [DATE], R503 had severely impaired cognition and was independent for most activities of daily living (ADL's).
Review of R503's physician orders revealed no opioid medications had ever been ordered at the facility for the Resident.
Review of R503's progress notes revealed a nurse note dated 6/23/24 at 6:25 PM by Licensed Practical Nurse (LPN) B that read in part, res (resident) was laying in bed CNA (Certified Nursing Assistant) tried to awake (them) for dinner. res was lethargic, slurred speech with pin point pupipls [sic], writer entered the room and took res vs (vital signs) . res still looked lethargic with minimum speech. 911 was dispatched and 1 Narcan was administered .
Review of R503's EMS Patient Care Record dated 6/23/24 read in part, .Primary Impression: Overdose - Unspecified . Protocols Used: General-Overdose/Poisoning/Toxic Ingestion - Adult Only . Onset Time: 16:30:00 (4:30 PM) 6/23/24 . Chief Complaint: UNRESPONSIVE . Patient's Level of Distress: Moderate . Signs & Symptoms: Unspecified drug or medicament (substance used in therapy) - adverse effect (Primary) . Narrative: .(R503) laying in bed fully clothed with feet hanging off side of bed. Pt (patient) breathing shallow and slow. Pt not responding to voice or pain. Pts eyes pinpoint . Pt given 2mg (milligrams) Narcan slow push and line flushed . Pt became responsive and alert. Pt denies taking anything besides what staff gave (them) . Pt transported to (hospital) . Condition of Patient at Destination (hospital): Improved .
Review of R503's hospital paperwork dated 6/23/24 at 6:34 PM read in part, .Hx (history) of Present Illness/Mech (mechanism) of Inj (Injury)/Onset: from (facility) for unintentional OD (overdose) - pt received 2mg narcan, and became alert after. pt a&o (alert and orientated) x 4 now, states not on any narcotic medication .
On 8/27/24 at 10:48 AM, LPN B was contacted by phone and a voice mail was left. No return call was received by the end of the survey.
On 8/27/24 at 11:53 AM, CNA D, R503's assigned CNA on 6/23/24, was interviewed and asked about R503 on 6/23/24. CNA D explained she was going to take R503 to the dining room, but they were lying on the bed and was not acting like themselves, they were very groggy, normally if R503 was sleeping, they would wake up immediately and talk . she immediately got the nurse, LPN B, and LPN B took R503's vital signs then called 911. When asked if R503 had been groggy all day, CNA D explained R503 had been their normal self all day, she had seen them about an hour or so earlier, and they had been fine. CNA D was asked if R503 would wander into other resident rooms or in the hallways. CNA D explained R503 liked to stay mostly in their room, but would walk to the nurse station and ask for the snacks that were kept behind the desk at the nurse station.
Review of a facility census on 6/23/24 revealed Unit D, R503's Unit, had seven residents. An adjacent Unit, Unit C, had 31 residents.
Review of a nursing schedule for 6/23/24 revealed LPN F had been assigned to Unit C.
On 8/27/24 at 12:55 PM, LPN F was interviewed and asked on 6/23/24 when Unit D had seven residents, was LPN B assigned to any of Unit C's residents. LPN F explained yes, LPN B was assigned to the residents in rooms 1, 2, 3 and 4.
Review of the closed record for R504 revealed R504 was admitted into the facility on [DATE] with diagnoses that included: lymphoma (cancer), diabetes and depression. According to the MDS (Minimum Data Set) assessment dated [DATE], R504 had moderately impaired cognition and was independent for most ADL's (activities of daily living).
Review of R504's June 2024 Medication Administration Record (MAR) revealed a physician order for Norco (Hydrocodone-Acetaminophen) 7.5-325 mg (milligrams), 1 tablet three times a day at 9:00 AM, 2:00 PM and 9:00 PM. The MAR was documented by LPN B as given at 2:00 PM on 6/23/24. (It should be noted that Hydrocodone is an opioid medication.)
Review of R503's picture in the electronic medical record (eMR) revealed the resident looked very similar to another resident that were of similar age.
On 8/27/24 at 1:30 PM, the Administrator was interviewed and asked about the investigation into R503 becoming unresponsive and receiving Narcan. The Administrator explained when R503 was interviewed, they said they did not take any medications not given by staff and the Director of Nursing (DON) checked and verified all the narcotic medication on the D Unit were accounted for and the DON had also checked the backup supply of narcotics, but those narcotic medications were also accounted for. The Administrator was asked if she was aware LPN B was also assigned residents on the C Unit and at least one resident, R504, had received narcotic medications. The Administrator explained she had not been aware of LPN B being assigned other residents. The Administrator was asked if R504 had been interviewed to ensure they had received their 2:00 PM Norco on 6/23/24 that was documented as given. The Administrator explained they had not interviewed R504. When asked if LPN B was still employed by the facility, the Administrator explained LPN B no longer worked there. The Administrator was asked if the DON was at the facility. The Administrator explained the DON was not working that day.
On 8/27/24 at 1:48 PM, Dr. G, R503's attending physician, was interviewed by phone and asked what would cause R503 to have pin point pupils and lethargy to unresponsiveness. Dr. G explained the symptoms would suggest the presence of an opioid, but it would not be known for sure without a drug screen. When asked if he had ordered a drug screen for R503, Dr. G explained he had thought one was ordered in the hospital, so had not ordered one.
On 8/27/24 at 2:24 PM, Human Relations (HR) H was interviewed by phone and asked why LPN B did not work at the facility anymore. HR H explained LPN B had resigned without notice on 6/30/24 when she put a resignation letter under her office door on 6/30/24.
Review of a facility policy titled, Incidents and Accidents for Guests/Residents or Visitors revised 4/29/22 read in part, .Potential witnesses shall be interviewed and the occurrence of such interviews will be documented .
Deficient Practice #2
Based on observation, interview and record review the facility failed to ensure timely interventions were implemented to prevent a resident, with a known history of elopement and wandering, from exiting out of the facility, for one (R502) out of three residents reviewed for accidents/elopement. Findings include:
A review of the facility's Incident and Accident Investigation Form (I/A) was reviewed and documented, in part, the following: Alleged Incident .Date: 7/21/24 .Resident involved: R502 .Location - D wing (*The hall where R502 resided) .Brief Description of the incident: R502 opened the fire exit door on the D-wing and exited through the door. Staff redirected him back into the building .Conclusion:the facility conducted a thorough investigation through staff interviews and camera review. It was determined that R502 did exit through the fire exit door on D-wing, but staff responded appropriately and was able to redirect R502 into the facility .Summary of Staff Interviews: .(Nurse M): Was in a resident's room providing care .when the C-Wing nurse told her that she heard alarm and saw R502 going out the D-wing door .(Certified Nursing Assistant - CNA N): was in a resident's room providing care with the nurse .I did not hear the alarm going off .(CNAO) .Was on the C-wing when she heard alarm go off .Saw R502 down the hall at the door. I ran down the hall with the nurse. He went through the door
On 8/27/24 at approximately 9:58 AM, R502 was observed walking down the hallway near the B-Hall. R502 was pushing another resident (hereinafter their wife) in a wheelchair. R502 opened the door to another resident's room and attempted to enter. The Resident yelled out and told R502 to leave the room. R502 left and continued pushing the resident in their wheelchair. No staff were observed to redirect the resident. An attempt to interview R502 was made. The resident was alert but unable to answer questions asked.
A review of R502's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that include adjustment disorder with depressed mood, adjustment insomnia and dementia. A review of the resident Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 0/15 (severe cognitive impairment).
Continued review of R502's clinical record revealed the following:
3/13/24 (Nurses Notes): Resident arrived at 9:15 PM .Resident does not speak or understand English .he is a fall risk and continues to get up without assistance .is here for rehab.
3/18/24 (Nurse Note): Resident keeps putting on roommates' clothes and eating his food .caught resident trying to cut off his wanderguard with a butterknife .
3/26/24 (Nurses Note): Resident was caught naked from waste down urinating in D-3A trash can .resident in room D-3A is very disgusted .
4/1/24 (Nurses Note): Resident was seen wandering the hall naked while urinating on the floor .
4/10/24 (Social Service Notes): Resident was observed at lobby door with visitor attempting to open door for resident to enter lobby .
4/14/24 (Nurses Notes): Resident wandered to B unit and tried to open emergency exit door .
4/27/24 (Nurses Notes): .notified that resident went into another residents room .the other resident pushed R502 against the wall 3 times .
5/13/24 (Social Service Note): .Spoke with R502's daughter .via phone r/t (related to) POC (plan of care) exit seeking, safety, psych referral, wandering behaviors .suggested with daughter .placement at a secured facility .expressed facility was too far from where she lived .SW (social worker) suggested reviewing alternative placement .
5/24/24 (Social Service Note): SW (Social Worker) spoke with SW at facility daughter was supposed to tour and they report that they never showed up for scheduled appointment .PA (physician assistant) spoke with daughter and she declined to meet with SW at this time .
6/16/24 (Behavior Note):Res (Resident) attempted to open B wing exit door causing alarm to disengage .writer interceded before res could open door .
6/21/24 (Behavior Note): Res was seen pushing on the service hall exit door .res was redirected from door 30 minute checks initiated.
6/24/24 (Behavior Note): Resident tried to open C unit's emergency exit door.
6/30/24 (Encounter): .R502 wandered into another residents room and was punched in the head .
7/21/24 (Nurses Notes): Writer was notified regarding resident exiting the building .heard the alarm on D wing exit door Both staff were on C wing when observed .
7/30/24 (Behavior Note): res observed pushing on back doors on b wing setting off alarm .
A review of R502's care plan documented, in part: Focus: R502 is at risk for elopement r/t (related to) wandering throughout the building, impaired cognition .he displays wandering behaviors going into rooms looking for family (created 3/15/24) .5/24 .Stop signs and Caution signs in Russian place at Exits and rooms resident frequently attempts to enter .Interventions: Apply Russian stop signs and caution signs on Exit doors and rooms residents frequent (initiated 5/20/24) Wanderguard to Ankle (initiated 3/15/24) .Approach in a slow, calm manner and redirect away from exit doors as needed (initiated 3/15/24) Observe wandering behavior and attempted diversion interventions when wandering into inappropriate locations such as other residents rooms when not invited, behind nurses stations, shower rooms, attempts at exiting facility (initiated 3/15/24) .Provide structured activities .as needed (initiated 3/15/24) Resident observation Q (every) 30 min checks (initiated 7/21/24) . *It should be noted that R502's [NAME] did indicate Q 30 min checks however there were no logins for time checks in the electronic TASK section .
On 8/27/24 at approximately 10:30 AM, an interview was conducted with Nurse I who was assigned to the hall where R502 resided. Nurse I was asked as to R502's wandering in and out of other residents' rooms. Nurse I reported that they were aware the resident wanders throughout the building either trying to exit and/or enter other resident's rooms. Nurse I stated that they do try to redirect but can't always get to them soon enough.
On 8/27/24 at approximately 1:16 PM an interview was conducted with the Administrator/Abuse Coordinator. The Administrator was queried as to R502's history of wandering into other resident's room along with elopement seeking behaviors and actual elopements. The Administrator reported that they were aware of R502's behaviors and the staff were working on redirecting the resident, but noted that staff were not always present to check and redirect the resident prior to the elopement attempt and wandering incidents. continue to try to redirect the resident, but they do not always track them prior to entry. When asked if R502 received 30-minute checks, the Administrator was not certain.
On 8/27/24 at approximately 2:13 pm, a phone interview was conducted with Social Worker (SW) J. SW J was queried as to R502's wandering into other resident's rooms including many elopement attempts and the actual elopement. SW J reported that they were very aware of R502 wandering throughout the building, elopement attempts and actual elopement and noted that while there were interventions to prevent and redirect R502, however staff were not always around to redirect the resident. When asked as to attempt to transfer R502 to a locked unit facility, SW J did report that suggestions were made to the resident's daughter, but they did not follow through on looking at other facilities. When asked if R502's daughter was the DPOA (durable power of attorney) or guardian for R502, SW J reported that they were not as the DPOA document provided pertained to financial only. SW J did report that there was no current guardian for the resident but that attempts were being made by daughter to obtain guardianship.
A review of the facility policy titled, Elopement Policy documented, in part: Policy: it is the policy of this facility to prevent to the extent reasonably possible, the elopement of guests/residents from the facility .Definitions: Wandering is random or repetitive locomotion/ambulation .Unsafe wandering may occur when the guest/resident at risk enters an area that is physical hazardous .while alarms can help to monitor a guest/resident activities, staff must be vigilant in order to respond to them in a timely manner. Alarms do not replace necessary supervision .Elopement occurs when guest/resident who needs supervision leaves a safe area without authorization .Procedure:The Behavior Management Committee at minimum will review all plans of care .the care plan will have revisions as appropriate .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00146302
Based on observation, interview and record review, the facility failed to ensure a u...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00146302
Based on observation, interview and record review, the facility failed to ensure a urine drug test was collected per physician orders for one (R503) of three residents reviewed for narcotic medications. Findings include:
A complaint was filed with the State Agency (SA) that alleged in part that R503 does not take any narcotic medications, but on 6/23/26, R503 was found unresponsive and EMS (emergency medical services) administered Narcan (opioid reversal agent) and then R503 became responsive.
Review of a National Institute on Health (NIH) article titled, Naloxone (Narcan) DrugFacts dated January 2022 read in part, .Naloxone is a medicine that rapidly reverses an opioid overdose. It is an opioid antagonist. This means that it attaches to opioid receptors and reverses and blocks the effects of other opioids . But, naloxone has no effect on someone who does not have opioid in their system .
On 8/27/24 at 9:01 AM, R503's Guardian was interviewed by phone and asked what happened on 6/23/24. The Guardian explained they were notified on 6/23/24 that R503 was taken to the hospital because R503 had been unresponsive and that EMS had given Narcan . R503 does not take any narcotic medications . after R503 had returned from the hospital, they had stayed at the facility for a week . they had repeatedly asked for a urine drug test to be done . it was finally ordered, and they had been told it had been done, but it was never done . had been told R503 would not pee in a cup . as they had been there, they could have gotten R503 to pee in a cup if anyone had tried to collect the sample.
On 8/27/24 at 9:45 AM, R503 was observed lying in bed. R503 was asked if they had been in the hospital recently. R503 happily explained they had gone to the hospital in high school when they hurt their arm.
Review of the clinical record revealed R503 was admitted into the facility on 4/12/24 with diagnoses that included: chronic obstructive pulmonary disease (COPD), depression and dementia. According to the Minimum Data Set (MDS) assessment dated [DATE], R503 had severely impaired cognition and was independent for most activities of daily living (ADL's).
Review of R503's progress notes revealed a nurse note dated 6/23/24 at 6:25 PM by Licensed Practical Nurse (LPN) B that read in part, res (resident) was laying in bed CNA (Certified Nursing Assistant) tried to awake (them) for dinner. res was lethargic, slurred speech with pin point pupipls [sic], writer entered the room and took res vs (vital signs) . res still looked lethargic with minimum speech. 911 was dispatched and 1 Narcan was administered .
Review of R503's EMS Patient Care Record dated 6/23/24 read in part, .Primary Impression: Overdose - Unspecified . Protocols Used: General-Overdose/Poisoning/Toxic Ingestion - Adult Only . Chief Complaint: UNRESPONSIVE . Patient's Level of Distress: Moderate . Signs & Symptoms: Unspecified drug or medicament - adverse effect (Primary) . Narrative: .(R503) laying in bed fully clothes with feet hanging off side of bed. Pt (patient) breathing shallow and slow. Pt not responding to voice or pain. Pts eyes pinpoint . Pt given 2mg (milligrams) Narcan slow push and line flushed . Pt became responsive and alert. Pt denies taking anything besides what staff gave (them) . Pt transported to (hospital) . Condition of Patient at Destination (hospital): Improved .
Review of R503's hospital paperwork dated 6/23/24 revealed no blood or urine drug testing was ordered.
Review of R503's physician orders revealed an order for a urine drug screen with a start date of 6/25/24 and an end date of 7/2/24 that was ordered by Psychiatric Nurse Practitioner (NP) L. The order had a status of completed.
Review of R503's laboratory results revealed no results of the urine drug screen.
On 8/27/24 at 1:30 PM, the Assistant Director of Nursing (ADON) was interviewed and asked why there were no results of the urine drug screen for R503. The ADON explained it was never collected, the nurse said she could not get the sample. When asked why the order said it was completed, the ADON explained when the order reached the end date, it was automatically changed to completed. The ADON was asked if the order was put in for multiple days, could any nurse that worked on those days have collected the urine. The ADON agreed all the nurses that worked from 6/25/24 to 7/2/24 could have collected the urine.
On 8/27/24 at 1:48 PM, Dr. G, R503's attending physician, was interviewed by phone and asked what would cause R503 to have pin point pupils and lethargy to unresponsiveness. Dr. G explained the symptoms would suggest the presence of an opioid, but it would not be known for sure without a drug screen.
Review of a facility policy titled, Physician's Order revised 10/20/23 read in part, .Orders given by a physician or state permitted health care professional must be accepted by a licensed nurse .
Dec 2023
13 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** Deficient Practice #2
Based on observation, interview and record review the facility failed to ensure Nurse Practitioner orders ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice #2
Based on observation, interview and record review the facility failed to ensure Nurse Practitioner orders for wound care were transcribed appropriately and completed for one resident (R91) of one residents reviewed for non-pressure wound care. Findings include:
On 12/19/23 at approximately 9:50 a.m., R91 was observed in their room, laying in their bed. R91 was observed to have pressure relieving booties on the ground next to them and the resident was laying in the supine position on their bed.
On 12/20/23 the medical record for R91 was reviewed and revealed the following: R91 was initially admitted to the facility on [DATE] and had diagnoses including open wound of right breast, muscle weakness, and depression.
A Nursing progress note dated 10/16/2023 at (21:33) revealed the following: Observed small skin tear on right breast in addition to inflamed stretch marks across the chest. Applied TAO (Triple Antibiotic Ointment) to skin tear and covered. Notified on call NP (Nurse Practitioner).
A Skin/Wound progress note dated 10/17/23 revealed the following: Upon wound/skin assessment writer observed resident right breast top area with dime size abrasion, no drainage or foul smell noted at this time, tx (treatment) in progress per facility protocol .
A review of R91's comprehensive plan of care revealed the following: Focus-[R91] has Actual impairment to skin integrity r/t (related to) pressure injury to the right ankle, PEG, incontinence .10-17-23 Top of right breast noted with dime size abrasion .Interventions-Observe location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. to physician. Date Initiated: 08/22/2023 .Treatment to skin impairment per order. Date Initiated: 08/22/2023 .
A treatment order for R91's right breast revealed the following: Start date-11/21/23-Cleanse Right Anterior Breast abrasion with n/s (normal saline), pat dry, apply Eucerin cream 50g (grams) + Betamethasone Valerate 45g + Gentamicin ointment 45g to wound bed and cover with Border Gauze QD (every day) and Prn (as needed) every day shift for 7 Days AND as needed for Abrasion for 7 Days
A review of R91's Wound Care Nurse Practitioner (NP) Evaluations revealed the following: 11/24/23-Wound Assessment(s) Wound #1 Right, Anterior Breast is a chronic Partial Thickness Nonspecific Wound and has received a status of Not Healed. Subsequent wound encounter measurements are 1cm (centimeter) length x 1.5cm width x 0.01 cm depth, with an area of 1.5 sq (square) cm and a
volume of 0.015 cubic cm .There is a Small amount of sere-sanguineous drainage noted which has no odor .The wound margin is well defined Wound bed has 90%, pink, granulation, 10 slough .Additional Orders: Treatment(s). Other - Apply Maxorb AG + Eucerin Cream 50g + Bethamethasone Valerate 45g + Gentamicin Ointment 45g QDay/ PRN x 7 days Secondary Dressing(s) Cover with secondary dressing(s) .
12/1/23-Wound Assessment(s) Wound #1 Right, Anterior Breast is a chronic Partial Thickness Nonspecific Wound and has received a status of Not Healed. Subsequent wound encounter measurements are 1.7cm length x 3cm width x 0.1 cm depth, with an area of 5.1 sq cm and a
volume of 0.51 cubic cm .There is a Small amount of sere-sanguineous drainage noted which has no odor . The wound margin is well defined Wound bed has 90%, pink, granulation, 10% slough. The wound is deteriorating .Additional Orders: Treatment(s). Other - Apply Maxorb AG+ Eucerin Cream 50g + Bethamethasone Valerate 45g + Gentamicin Ointment 45g QDay/ PRN x 7 days Secondary Dressing (s) Cover with secondary dressing(s) .
A review of R91' November and December 2023 Treatment Administration Records (TAR) was reviewed and revealed no treatments to R91's right breast wound were documented as being completed for 11/28, 11/29, 11/30, 12/1 and 12/2.
Further review of R91's treatment orders for their right breast wound revealed no treatment orders were in place until 12/3/23 which revealed the following: 12/3/23- cleanse effected area to right breast with normal saline pat dry with 4x4 then apply Eucerin cream 50g+ Betamethasone Valerate 45g+ Gentamicin ointment 45g mixture and Maxorb AG COVER WITH BORDER GAUZE Q day/PRN for 7 days every day shift for wound for 6 Days -Start Date12/03/2023 0700 -D/C Date12/08/2023
On 12/21/23 at approximately 12:08 p.m., during a conversation with the Director of Nursing (DON), a review of R91's right breast wound treatments was completed for November and December 2023 and the DON indicated that R91 was seen by the wound doctor on 11/24/23 and on 12/1/23 but that no new orders were transcribed to R91's electronic medical record (EMR) after they were seen by the wound NP on 11/24/23. The DON indicated that a new order should have been transcribed and implemented on 11/24/23 for seven more days as ordered by the wound care NP, but was not done which was why the treatments ended on 11/27/23 and no new orders were implemented until they were seen by the wound care NP again on 12/1/23. The DON reported that R91 should have had their treatments continued and uninterrupted but the Nurse had not transcribed the order into the electronic medical record for the Nursing staff to administer the treatment.
There was no documentation that R91 received treatments to their right breast wound on 11/28/23 through 12/2/23 were provided by the end of the survey.
This citation has two deficient practices.
DPS #1
This citation pertains to Intake #MI00140460.
Based on observation, interview and record review the facility failed to ensure a resident with Type 1 diabetes was timely assessed for low blood sugar for one (R84) of three residents reviewed for change in condition/hospitalization resulting in R84's being found unconscious and hyperventilating with a blood sugar level of 34 causing a transfer to the emergency room and a six day stay at the hospital. Findings include:
A Complaint was filed with the State Agency (SA) that alleged the facility failed to ensure R84's low blood sugar was timely addressed causing the resident to become unconscious and in need of hospitalization.
On 12/19/23 at approximately 4:00 PM, R84 was observed lying in bed. The resident was alert and able to answer some questions. R84 was asked questions about the facility nursing staff's ability to monitor their blood sugar levels. During the interview R84's roommate chimed in and reported an incident that occurred in October 2023. The roommate reported that R84 returned from Dialysis and reported to a Certified Nursing Assistant (CNA) that their blood sugar was low, and they needed to see a nurse. At that time the CNA (identified a CNA J) told R84 that the Nurse was on break, and they would have to wait until the Nurse returned. The roommate noted that R84 was found unconscious and was transferred to the Hospital and that CNA was terminated and no longer works at the facility.
A review of R84's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included, in part: Type 1 Diabetes, heart failure and bipolar disorder. A review of the resident Minimum Data Set (MDS) indicated R84 had a Brief Interview for Mental Status (BIMS) score of 11/15 (moderately cognitively impaired) and had been deemed incompetent and had a court appointed legal guardian.
Continued review of R84's clinical record noted, in part, the following:
10/19/23 SBAR (5:52 PM) Situation: The Change in Conditions/reported on this .Evaluation .Unresponsive .vital signs blood pressure 187/23 .Pulse Oximetry 91% .BS (blood sugar) .34 .Neurological Status Evaluation: Altered level of consciousness .Observed resident unresponsive while hyperventilating. Took vitals and they were not within normal limits, BS was 34 .
10/25/23 Nursing Summary (4:28 PM): .readmit from hospital with diagnosis of hypoglycemia .
*It should be noted that there were no hospital records pertaining to the incident noted 10/19/23 in the resident's clinical record. The last BS noted in R84's clinical record prior to 5:52 PM was from a Dialysis sheet that indicated at 10:26 AM, R84's BS was 322.
On 12/20/23 at approximately 10:00 AM, a request was made for any Incident/Accident (I/A) reports and/or grievances for R84. The facility did not provide any IA's/Grievances that pertained to the alleged incident/change in condition on 10/19/23.
A review of CNA's personnel record revealed a form titled Separation of Employment that noted CNA J's last day worked was 10/20/23 and the effective date of separation was dated 11/3/23. The form had a handwritten note that read Too many resident complaints regarding care.
On 12/21/23 at approximately 8:26 AM, the Director of Nursing (DON) was asked if they were able to locate to provide R84's Hospital records from 10/19/23 through 10/25/23 in the resident's electronic record. The DON was not able to locate the documents in the electronic record and but did provide a paper document titled Patient Discharge Summary. The document contained limited information and no physician notes. However, there was a document indicating information as to hypoglycemia (low blood sugar).
On 12/21/23 at approximately 9:20 AM, a phone interview was conducted with Nurse K. Nurse K was asked as to the change in condition that occurred on 10/19/23. They reported that they were familiar with R84 and recalled that in the afternoon on 10/19/23 the resident returned from Dialysis, and they took their blood sugar, and it was 109 and then went on break. (*It should be noted that the there was no documentation that indicated R84 had a blood sugar of 109 following their return from Dialysis). Nurse K then reported that while they were on break, R84 told CNA J that they were not feeling well, and they needed to see a nurse. Nurse K noted that CNA J did not attempt to find them, nor did they attempt to get another nurse to assist. Nurse K reported that they were on break for 30 minutes and had no idea as to what time R84 told CNA J they needed assistance. Nurse K then went to see R84 and they were unresponsive with a BS level of 34 and the resident was sent via 911 to the Hospital. Nurse K reported that CNA J was terminated following the incident.
On 12/21/23 at approximately 9:53 AM, an interview and record review were conducted with the Administrator. Another request was made for any IAs regarding the incident that occurred on 10/19/23 leading to the hospitalization of R84. The Administrator reported that an IA was not completed. When asked why CNA J was terminated, the Administrator reported that following an interview with R84's Roommate and other residents they determined CNA J was not providing residents with the care they needed, including R84. A handwritten, unsigned document written by the Administrator was provided. The Note documented, in part: (Roommate) Yesterday: Nurse on break, back from Dialysis asked for sandwich gave to her within 20 minutes. My sugar is low. Your nurse is on break in a rude tone. Didn't do anything to bring it up. The Administrator reported that based on the Roommate's statement they determined that CNA J should have attempted to locate another nurse to assist R84.
On 12/21/23 at approximately 10:30 AM, an interview was conducted with the DON regarding the change in condition for R84. The DON was asked if CNA J should have found either Nurse J or another nurse after the resident reported their sugar was low. The DON noted that they should have.
On 12/21/23 at approximately 12:14 PM a phone interview was conducted with CNA J. CNA J reported that they were no longer employed by the facility and had not worked since October 19, 2023. When asked what occurred on 10/19/23, CNA J stated that the resident returned from Dialysis in the afternoon and told them that they were not feeling well, and they wanted to see a nurse. CNA J stated that Nurse K was on break, and they tried to find them and another nurse, but they could not find anyone. CNA J stated that they recalled Nurse K was gone for at least one hour.
The facility policy titled, Diabetic Management (9/23/23) was reviewed and documented, in part, Diabetic Management involves both preventative measures and treatment of complications .Blood glucose measurements are taken per physician order .Sings of Hyporglycemia-High Blood Sugar Levels .Weakness, dizziness or faintness .change in consciousness .If a resident is observed with, or complains of any symptoms of hyperglycemia, report to the nurse immediately .If the resident becomes unconscious and BS level is below 70 mg .call 911 .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, (based on the reasonable person standard), the facility failed to ensure two residents (R49 and R59) of five residents reviewed for dignity, were tre...
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Based on observation, interview and record review, (based on the reasonable person standard), the facility failed to ensure two residents (R49 and R59) of five residents reviewed for dignity, were treated in a dignified manner during dining. Findings include:
On 12/21/23 at approximately 8:25 a.m., during a dining observation of the assisted dining room, six residents were observed eating the breakfast meal with cafeteria style trays underneath their plates. R49 and R59 were observed to each be seated at separate tables with with clothing protectors on and watching the other residents in the room eat their breakfast meals.
On 12/21/23 at approximately 8:37 a.m., Certified Nursing Assistant H (CNA H) was queried why R49 and R59 had not been served the breakfast meal and were still waiting to eat. CNA H reported out loud in the dining room that R49 and R59 were feeders and that they both had to wait because there were not enough staff to help them eat and they needed assistance. Further observation of the residents in the dining room, revealed six residents that were served their meals on a cafeteria style meal tray.
On 12/21/23 at approximately 8:42 a.m., CNA I was observed to enter the dining room, looked around and asked CNA H out loud if everyone in the room were feeders and then left the room. At that time, R59 and R49 were still sitting at their tables without any breakfast until 8:49 AM, when R49 was observed to be starting to eat.
On 12/23/23 at approximately 9:11 a.m., during a conversation with the Director of Nursing (DON), the DON was informed of the observations in the assisted dining room and they reported that CNA H and CNA I should not have been referring to the residents in the room as feeders and that CNA H should have called for help to ensure R49 and R59 were served timely and provided the appropriate eating assistance with their meal.
On 12/23/23 a facility document titled Guest/Resident Dignity and Personal Privacy was reviewed and revealed the following: Policy The facility provides care for guests/residents in a manner that respects and enhances each guest's/resident's dignity, individuality, and right to personal privacy .
Information: Each guest's/resident's right to personal privacy includes the confidentiality of his or her personal and clinical affairs. Dignity means that when interacting with gusts/residents, staff carries out activities that assist the guest/resident in maintaining and enhancing his or her self-esteem and self-worth .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Resident's personal preference for care was honored for on...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Resident's personal preference for care was honored for one (R26) of one resident reviewed for self-determination/choices.
Findings include:
On 12/19/23 at 12:19 PM, an interview was completed with R26. When asked about whether they had any concerns about the care they received, R26 reported they did have a concern with an aide that worked with them last night on the midnight shift. R26 reported they had complained to administration about this aide a couple of times before and had requested to not have them assigned to care for them. R26 further reported this initial incident with this aide was about two or two and half months ago and had concerns with how the aide talked to them and felt it was rough at times and that they slept most of the night while working and their perception was when they came in to answer their call light, it's like they don't want to work. When asked what administration told them to address their concern at that time, R26 reported they were informed the aide was told not to come back and that they wouldn't be assigned to care for them anymore but that it fell on deaf ears.
Review of the clinical record revealed R26 was initially admitted into the facility on 9/29/18 and readmitted on [DATE] with diagnoses that included: end stage renal disease and dependence on renal dialysis.
According to the Minimum Data Set (MDS) assessment dated [DATE], R26 had intact cognition and was their own responsible party.
On 12/20/23 at 9:37 AM, the Administrator was requested to provide any grievance/concern forms for R26.
Review of R26's documentation provided by the facility included two concern forms titled Guest/Resident, Family, Employee, and Visitor Assistance Form.
The first concern form (undated) read, .What is your concern about? Midnight aid last night was lazy and unwilling to help .When did the problem or incident occur? Last night .9/18-9/19 .Who else knows about the problem or incident? .Told my nurse .How can we address your issues? I never want [unnamed staff] as my aid again . The section of the form with FACILITY RESPONSE read, Spoke with resident regarding the situation. Assigned CNA (Certified Nursing Assistant) will receive education & training on resident care, customer service & professionalism. The section which read, ACTION TO BE TAKEN read, Employee to receive education 1:1 on providing care to residents & customer service. Remove the CNA from providing care to the resident. This form was signed by the Assistant Director of Nursing (ADON) on 10/18/23.
The section of this concern form that prompted a response for I am satisfied with the response to my request for assistance and I am not satisfied with the response to my request for assistance. I request that the administrator review my complaint and provide me with a response was left blank. The Administrator's signature was completed on 10/28/23.
The second complaint form dated 10/18/23 read, .What is your concern about? Aid is rude and won't help - Asked for my dentures before 8AM - she ignored me then sent someone else in after 9 so I had to wait to eat my breakfast .How can we address your issues? I want to see Admin & DON (Director of Nursing) .Is this an ongoing problem? Yes (Marked with an X) Second time this aid won't help me .Have you contacted us in the past about this issue? Yes (Marked with an X) If Yes, to whom? (this section was left blank) .
The section of the form which read, FACILITY RESPONSE read, Investigation started, staff inserviced CNA's inserviced .ACTION TO BE TAKEN ongoing education to nursing staff regarding resident care and customer service. This was signed by the ADON on 10/24/23. The Administrator signed off on the form on 10/29/23.
On 12/20/23 at 10:11 AM, an interview was conducted with the Administrator. When asked about R26's concern forms and what follow-up had been done, the Administrator reviewed the concern forms and confirmed both forms did not identify the specific names of the staff involved. The Administrator further reported the ADON that completed the form was on vacation and unavailable for interview, but they would attempt to find out who the specific staff were since the form identified education was provided. (There was no further information provided by the end of the survey.)
When asked how the facility acknowledged and enforced resident preferences such as not having specific staff assigned, the Administrator reported the actual staff member would be educated and told not to care for that specific resident, as well as the scheduler. When asked why that had not occurred for R26, the Administrator reported they would attempt to get additional information to discuss further.
On 12/20/23 at 5:00 PM, the Administrator reported they were still trying to identify the specific staff and were also working with the Director of Nursing, but were unable to find any specific write up or education but would continue to look. The Administrator further reported they would be following up with R26 to review their concerns and acknowledged the resident's choices were not followed.
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 implement effective pressure ulcer interventions for o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement effective pressure ulcer interventions for one Resident (R34) of three residents reviewed for pressure ulcers, resulting in the worsening of a facility-acquired pressure ulcer, infection, and hospitalization. Findings include:
A review of the clinical record revealed R34 was most recently admitted to the facility on [DATE] after hospitalization related to sepsis (serious condition when the body responds improperly to an infection) as a result from a stage four (full thickness skin and tissue loss) medial sacral (lower back, end of spine) pressure ulcer with osteomyelitis (infection in the bone). Further review of the record revealed that R34 had the following diagnoses: seizures, multiple strokes, left sided paralysis, dysphagia (difficulty swallowing), aphasia (impaired understanding of language as well as reading and writing), gastrostomy tube, and dementia Further review revealed that R34 was bedbound, nonverbal, and contracted.
Record review of the Minimum Data Set (MDS) Section M dated 8/23/2023 indicated R34 did not have one or more unhealed pressure ulcer(s) at stage 1 (intact skin with non-blanchable redness) pressure ulcers. MDS Section M record review dated 10/27/2023 documented one stage four (full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer that was not present on admission.
On 12/19/2023 at 10:15 AM, R34 did not respond to this surveyor's introduction and was observed laying on their back with no pressure relieving device. R34 was observed with a tan colored shirt on with their mouth slightly opened and had the appearance of dry chapped lips.
On 12/19/2023 at 1:02 PM, R34 was observed lying in bed with the same tan colored shirt, mouth open, appearance of dry mouth and lips, staring up at ceiling. There was one small, thin, flat pillow tucked under the right hip area. No pressure relieving devices noted.
Review of the facility documentation on the matrix noted R34 as having a facility acquired stage two (partial-thickness skin loss with exposed layer of skin) pressure ulcer on their medial sacral area. This facility first identified this wound on 9/19/2023 at 00:00 as described in a progress note. The progress note indicated that a pea sized coccyx wound was found, and a hydrocolloid dressing was applied.
Review of R34's care plan (revised 09/19/2023) indicated that R34 is at risk for impaired skin integrity/pressure injury related to incontinence, immobility, hypertension, peg tube (tube that is surgically placed in the stomach to administer nutrition). Interventions included: Braden score, weekly head to toe assessment, document and report, float heels, pressure mattress or specialty bed, turn/reposition.
Record review of R34 Braden Score, dated 9/22/2023 scored 11 which placed R34 at high risk for developing pressure ulcers.
On 12/20/23 at 08:45 AM, R34 was observed with their eyes closed, appeared asleep, noted one thin, flat bed pillow under right hip, facing towards window. No pressure relieving devices noted.
On 12/20/23 at 10:45 AM, a wound care observation of R34's medial sacral dressing was conducted with Nurse F. Nurse F stated that R34 was pre-medicated with Tylenol prior to this dressing change . R34 was observed positioned on their left side, and two pillows were tucked under both hips with right pillow more prominent in upward position than the left. R34 was observed to be contracted bilaterally in a fetal position wearing bilateral green colored inflated boots. Nurse F was observed to remove a white colored dressing from the medial sacrum of R34. The wound bed was red and pink in color. Depth of the wound was noted when Nurse F cleansed the wound with gauze and observed that the gauze was pushed, into the cavity of the wound, using fingers and then required inserting fingers back to retrieve the gauze out from the wound. Once cleansed, the area was covered with a dry dressing, secured with bandage tape, dated, and initialed by Nurse F. R34 was then turned from the left lateral position to their back with one pillow placed under each hip.
On 12/21/2023, a record review of the facilities Skin and Wound assessments for R34 revealed the following measurements and progression of R34's medial sacral pressure ulcer:
Date
Stage
Area x Length x Width
9/22
2
0.3cm2x 0.9cmx0.6
9/29
2
0.3cm2x 0.9cmx0.4
depth 0.1cm
10/6
3
1.3cm2x 2.0cmx0.9
depth 0.2cm
10/12
3
10.8cm2x7.5cm4.2cm
10/19
4
6.4cm2x6.3cmx1.9cm
depth NA
10/26
4
1.0cm2x1.8cmx0.9cm
depth NA
The Director of Nursing (DON) was queried about how wounds or worsening of a resident's wound condition was communicated amongst staff. The DON reported every Thursday a skin and wound evaluation was performed and documented. The DON further reported Nurse F was the wound treatment nurse and rounded with the facility's Infection Preventionist (Nurse A). Nurse F took pictures of the wounds and the photo was uploaded into the resident's record. The wound assessments were done by Nurse A. The DON further clarified that Wound care consultant M came on Fridays to review the completed skin and wound evaluations, assess, treat, and order interventions for residents requiring wound care.
Review of the R34's Skin and Wound Evaluation dated Thursday, 10/19/2023 at 01:42 PM documented: Evidence of infection redness, inflammation, warmth, strong odor after cleansing, sloping edge, fragile skin, macerated, wet, white, waterlogged tissue, cleanse with normal saline, calcium alginate dressing, foam mattress, heel suspension, incontinent management, turning reposition program, moisture control, nutrition/dietary supplementation, progress deteriorating, currently on antibiotics for wound infection.
Review of the corresponding progress notes from Friday 10/20/23 from M (wound care consultant) did not include a progress note or evaluation for a wound on the sacral area of R34.
Review of the radiology results report taken on 10/25/23 at 6:10 MA of R34's sacrum/coccyx revealed, Question subtle bone loss of the dorsal aspect of the sacrum/coccyx. Soft tissues appear swollen with ulceration dorsally. Conclusion: Cannot exclude osteomyelitis, recommend MRI (Magnetic Resonance Imaging) for work up.
Review of R34's Skin and Wound Evaluation dated 10/26/2023 at 03:29 PM documented: Evidence of infection, increased drainage, warmth, odor noted after cleaning with moderate purulent (pus like) drainage, wound bed slough, sloping edge, fragile red skin surrounding cleanse with normal saline, calcium alginate dressing, foam mattress, incontinent management, turning reposition program, moisture control, nutrition/dietary supplementation, progress deteriorating, progress deteriorating, currently on antibiotics.
Review of R34's admitting hospital documentation on 10/27/23 at 1:10 PM identified an admission for a stage four sacral pressure ulcer with osteomyelitis (infection in the bone), and elevated white blood cell count.
According to the facility's policy for Skin Management (revised 7/14/2022, effective 12/15/2022), .Residents with wounds and/or pressure injury are identified, evaluated, and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. Practice guidelines include the Braden Scale (a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure injuries) will be completed admission/readmission, weekly for four weeks, quarterly and with a significant change of status .
On 12/21/2023 at 10:38 AM, an interview was conducted with the Director of Nursing (DON). When asked about the care plan interventions for R34, specifically the documented intervention to turn/reposition, the DON stated, We follow a standard of practice with turning and repositioning. When asked what the standard of practice meant, the DON responded, It is known as every two hours. At that time, the DON retrieved and reviewed R34's care plan and stated, Turning and repositioning intervention would not have prevented what happened to R34. The DON was asked if the facility followed a process for evaluating if an intervention was completed, such as turning and repositioning and the DON replied, The staff does not document turning and there is nothing to follow up on when they turn a resident. If we notice a resident in the same position for many hours, then we reposition. The DON further reported, When the Certified Nurse Assistants (CNA's) do check and changing, that is documented, and that would be reassurance that the resident was repositioned.
The DON was asked about whether the facility had implemented any additional changes/interventions upon the development and progressive worsening of the pressure ulcer and they reviewed the current wound care care plan and reported there had been no changes implemented and should have.
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 ensure adequate monitoring of weights for one resident ...
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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 adequate monitoring of weights for one resident (R1) of four residents reviewed for nutrition/weight loss, resulting in the potential for continued unidentified weight loss and implementation of timely dietary interventions. Findings include:
On 12/19/23 at approximately 9:50 a.m., R1 was observed in their room, laying in their bed. R1 was observed to be thin/frail.
On 12/20/23 the medical record for R1 was reviewed and revealed the following: R1 was initially admitted to the facility on [DATE] and had diagnoses including dementia, protein-calorie malnutrition and dysphagia.
A review of R1's careplan revealed the following: Focus-Potential for alteration in nutrition r/t (related to): [R91] was admitted to facility on a level 1 puree diet with large portions and 1:1
assist needed. [R91] has a dx (diagnosis) of Dementia, hyperlipidemia, encephalopathy,
dysphagia, depressive d/o (disorder) and convulsions. PO (by mouth) intake good per FAR (food acceptance record) and conversation with staff. Psych to follow r/t meds and dx. Monthly weights at this time. REs (resident) needs to be fed at meals. clonazepam r/t kicking/ screaming etc- psych cont to follow- h/o (history of) weight fluctuation New weight goal of 125-130 lbs +/- 3%. sig wt loss of
unknown etiology. weekly weighs/ labs ordered and ensure increased to tid (three times a day) Date Initiated: 03/30/2020 .Revision on 11/30/23 .Interventions-Monitor weights as ordered
Date Initiated: 03/30/2020 .
A review of R1's recent weights revealed the following: 12/11/2023-116.8 Lbs .12/4/2023-116.0 Lbs .11/30/2023-116.0 Lbs .11/1/2023-114.6 Lbs .9/11/2023-126.4 Lbs (noted -9.34% difference between 9/11/23 and 11/1/23) .8/10/2023-125.0 Lbs .8/1/2023-120.0 Lbs .7/17/2023-127.5 Lbs (noted -5.88% difference between 7/17/23 and 8/1/23).
A dietary note dated 8/1/23 revealed the following: WEIGHT WARNING: Value: 120.0 Vital Date: 2023-08-01 14:59:00.0 MDS (minimum data set): -5.0% change over 30 day(s) [ 6.3% , 8.0 ] -5.0% change [ 5.1% , 6.4 ] -7.5% change [ 7.6% , 9.8 ] rewt (re-weight) requested per policy.
A dietary note dated 9/13/23 revealed the following: RD (Registered Dietician) follow up: Res with PMH (previous medical history) of Convulsions, dysphagia, cataracts, iron deficiency, anemia, anoxic brain damage, anxiety, muscle spasms, encephalopathy, psychosis, dementia, hyperlipidemia, neuropathy, and depression. CBW (current body weight) stable at 126.4 lbs. Staff report good po intake most meals. Res needs to be fed at meals. Wt (weight) from 8/1 more than likely an error with re wt requested but not completed. Will weigh monthly at this time. Periods of refusing meds noted as well as a few falls. FAR (food acceptance record) and monthly weights to cont. RD to cont to follow.
A dietary note dated 11/8/2023 revealed the following: WEIGHT WARNING: Value: 114.6 Vital Date: 2023-11-01 14:59:00.0 MDS: -10.0% change over 180 day(s) [ 11.5% , 15.0 ] -7.5% change [ 8.3% , 10.4 ] -10.0% change [ 11.7% , 15.2 ] re wt requested per policy.
A dietary note dated 11/30/23 revealed the following: Received rewt (reweigh) of 116 lbs this day. Wt showing improvement from last wt but down when comparing the previous wt recorded of 126.4 on 9/11/2023. Res is not able to voice wants/needs and while awake in bed will kick right leg up and down all the time .Staff and nursing report good intake of meals with last labs above WNL's (within normal limits). Question etiology of wt loss when comparing CBW to wt recorded in 9/2023. Will cont (continue) with weekly weights and increase ensure to tid at this time. Level 1 puree diet cont (continue) with staff reporting no issues tolerating. Res (resident) stays in room for meals . Will recommend another panel of labs at this time of CMP (complete metabolic panel) with prealb. (prealbumin) RP (responsible party) notified as well as (Physician). Cont with current plan of care. Goal of no further wt loss. Weekly weights and FAR to cont.
On 12/21/23 at approximately 11:25 a.m., RD L was queried regarding the identification and lack of documentation of R1's weights between 9/11/23 and 11/1/23. RD L reported that they have had inconsistent weights being done and when the weight loss was identified on 11/1/23 they had requested staff to complete a re-weight that was not completed until 11/30/23. RD L reported they could not verify that R1 actually lost weight until the re-weight had been completed and subsequently could not implement added interventions until the weight loss had been verified. RD L was queired regarding the lack of weights for October 2023 for R1's monthly weights and they indicated they did not get that completed either and were not aware of any weight loss until the weight on 11/1/23. RD L reported they could only implement interventions when they are aware of actual weight loss and they have not been getting the appropriate weights and re-weights done in a timely manner to verify weight loss. RD L was queried regarding their note on 11/30/23 regarding the continuation of weekly weights and they reported that they had requested weekly weights after the weight loss noted documented on 11/1/23 but they were not done. RD L was queried how fast a re-weight should be done to ensure timely dietary interventions and they indicated it should be done ASAP (as soon as possible).
On 12/21/23 at approximately 12:08 p.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding the lack of weights being completed and the resulting weight loss identification on 11/1/23 and the lack of re-weight not being completed until 11/30/23 for R1 and the DON reported that getting weights done in a timely manner is an interdisciplinary team effort and everyone should have been made aware that weights were not being done.
On 12/21/23 a facility document titled Weight Management was reviewed and revealed the following: Policy -Residents will be monitored for significant weight changes on a regular basis. Residents are expected to maintain acceptable parameters of nutritional status, such as usual body weight and protein levels; unless the resident's clinical condition demonstrates that this is not possible. Since ideal body weight charts have not yet been validated for the institutionalized elderly, weight loss (or gain) is a guide for determining nutritional status. Therefore, the evaluation of significant weight gain or loss over a specific time period is an important part of the evaluation process Practice Guidelines: 1. All residents will have a baseline evaluation of their nutritional status within 7 days of admission/ readmission. The evaluation will identify risk factors for altered nutritional status. 2. Residents will be weighed upon admission/readmission; weekly x 4, then monthly or as indicated by the physician and/or the medical status of the resident and document the results in the medical record. Dialysis residents dry weight will be used. 3. Re-weights are initiated for a five-pound variance if the resident is > than 100 lbs and for a three-pound variance if < than 100 lbs. If a resident's weight is > than 200 lbs. a re-weight will be done for a weight loss or gain of 3% or consult with the Dietary Manager or RD/designee. Re-weights will be done within 48-72 hours.
4. Monthly weights will be completed by the 10th day of each month and documented in the medical record. 5. Residents determined to be at risk or have significant weight changes will be weighed on a weekly basis. Residents at risk are: a. Residents receiving total parenteral nutrition (TPN) for one month or until weights have stabilized b. Newly tube fed residents .f. Residents with insidious weight loss and; 5% in one month, 7.5% in three months,10% in six month .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain and routinely change the dressing for a Perip...
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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 and routinely change the dressing for a Peripherally Inserted Central Catheter (PICC-a long, thin tube inserted through a vein in the arm) for one resident (R106) of one resident reviewed for vascular access. Findings include:
On 12/29/23 at approximately 9:26 AM, R106 was observed lying in bed. The resident had a PICC in the right arm connected to a bag for TPN (Total Parenteral Nutrition-a high risk pharmaceutical nutritional preparation containing high concentration of vitamins, electrolytes, carbohydrates etc). The transparent dressing over the insertion site was dated 12/11/23. R106, who was alert and able to answer questions asked, was asked about care provided for their PICC line and other concerns. R106 reported that they have had significant digestive issues since they were a child including several surgeries. They had utilized a feeding tube, but it caused several problems They currently were receiving TPN via the PICC line and trying to eat a regular diet, however had several issues with the food provided by the facility based on allergies. When asked as to the care provided for the PICC line, R106 stated that they had some issues with staff not providing medication timely and as to the PICC line they often would use their own wipes to clean the site.
A review of R106's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Celiac Disease, GERD (Gastroesophageal reflux disease) and anxiety disorder. A review of the resident MDS (Minimum Data Set) documented R106 had a BIMS (Brief Interview for Mental Status) score of 15/15 (which indicated intact cognition).
Continued review of R106's clinical record documented, in part, the following:
11/4/23: Order: TPN Electrolytes Intravenous Concentrate .Use 1800 ml (millliters) intravenously (IV)every 24 hours .at 75 ML/HR (hour) for 24 Hours .
12/3/23: Order Change transparent dressing to PICC every night shift every Sun (Sunday) for IV maintenance. Document Arm Circumference.
12/3/23: Order: Measure PICC catheter length every night shift every Sun for IV maintenance.
R106's Medication Administration Record (MAR) noted that the resident's PICC dressing was completed only on 12/10/23 during the evening. There was no information that the PICC dressing was changed on Sunday 12/3/23 or 12/17/23. There was nothing noted in the MAR that attempts were made to measure the PICC catheter length every Sunday (12/3/23, 12/10/23 and 12/17/23).
On 12/21/23 at approximately 8:23 AM, an interview and record review were conducted with the Director of Nursing (DON). The DON was asked as to the facility's protocol regarding PICC line care. After reviewing the resident's record, the DON stated that dressing changes and additional PICC line care should be done per the physician's order.
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
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** REFER TO INTAKE # MI00141500
Based on observation, interview, and record review, the facility failed to ensure a medication erro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** REFER TO INTAKE # MI00141500
Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% when two (2) medication errors were observed from a total of 26 opportunities, affecting two (Resident #65 and Resident #562) of eight residents observed for medication administration, resulting in an error rate of 7.69%.
Findings include:
On 12/19/23 at 4:37 PM, Nurse X was observed for Resident #65's (R65) medication administration. The medications scheduled to be given at 5:00 PM were administered, and a blood sugar check (accucheck) was performed by Nurse X. The result of the accucheck was 153, and the nurse explained to R65 that since the result of the accucheck was 153, R65 would be receiving two (2) units of insulin. Nurse X then prepared the insulin pen and set it to 2 units ready to inject. Nurse X then asked which site R65 would prefer. The arm or tummy? R65 started removing the sleeve of their sweater. R65 then expressed confusion about the insulin they were about to receive. After Nurse X calibrated the insulin pen to administer two units, Nurse X replied that because the accucheck result was 153, according to the sliding scale, a result over 150 would require R65 to receive two (2) units of insulin. R65 immediately said, I don't usually get it (insulin) unless it's over 200. Was there a change? Nurse X then told R65, Let me recheck the order. Nurse X took the insulin pen and left the room. Nurse X returned to R65 and stated, You were right! You don't need insulin unless you (are) 200 and over. R65 expressed a feeling of relief after learning that there were no changes.
A record review of R65's Electronic Medical Record (EMR) revealed that the resident was initially admitted to the facility on [DATE], with a diagnosis of Type 2 Diabetes Mellitus without complications.
R65's December 2023 Electronic Medication Administration Record (EMAR) was reviewed on 12/19/2023 at 4:45 PM. An insulin sliding scale order was written for the resident as: Insulin Aspart FlexPen Subcutaneous Solution Pen Injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding Scale: if 201-250 = under 60 call; 251- 300= four (4) units; 301-400= eight (8) units over 400 call MD, subcutaneously before meals at bedtime for Diabetes Mellitus-Start date-11/11/2023 0730. The facility scheduled a time to perform blood sugar checks for the sliding scale at 0730 (AM), 1130 (AM), 1630 (4:30 PM) and 2100 (9:00 PM).
On 12/20/23 at 8:13 AM, an observation was made of Nurse X at the Hall D medication cart during medication administration for Resident #562 (R562). Nurse X prepared the R562's ordered Active Protein liquid, Gabapentin 300 mg (milligrams), and one tablet of Aspirin 81 mg. The resident's Aspirin order specified EC (enteric-coated), but the bottle Nurse X took out indicated Aspirin 81 mg (chewable). Nurse X validated their choice by pointing at the bottle with the aspirin chewable tablet. Nurse X proceeded with giving R562 the chewable Aspirin despite the order being for enteric-coated.
A record review of R562's Electronic Medical Record (EMR) revealed that the resident was initially admitted to the facility on [DATE], with a primary diagnosis of Acute Kidney Failure, Epilepsy, and Metabolic Encephalopathy, in addition to other diagnoses.
R562's December 2023 EMAR was reviewed on 12/20/23 at 4:15 PM. Record review confirmed that R562's was to receive: Aspirin EC (enteric Coated) tablet Delayed Release 81 MG (Aspirin). Give one (1) tablet orally once daily for stroke prevention -Start date- 12/09/2023 0900.
On 12/20/23 at 4:00 PM, an interview was conducted with the Director of Nursing (DON) regarding the house stock, specifically the different formularies of Aspirin 81 mg tablets. The DON took two Aspirin 81 mg formulations from the top drawer of the D Hall med cart. One bottle was Aspirin 81 mg chewable tablet (non-enteric coated), and the other bottle was Aspirin 81 mg EC (enteric-coated). When queried, the DON explained that the EC tablets must be given if the order specified enteric-coated.
According to research conducted by Sciencedirect.com on June 22, 2017, the study explained the two aspirin formulations. A plain aspirin is absorbed in the stomach, and enteric-coated (EC) aspirin is absorbed in the small intestine. The reason for the development of EC aspirin was to reduce aspirin side effects of the gastric mucosa .
A review of the facility policy entitled Medication Administration, with an effective date of 10/17/2023, revealed, .Medication Administration: 1. Medications are administered in accordance with written orders of the attending physician.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment timely for four (R8, R29, R49, R69 ) of 10 reviewed for timely assessments.
Find...
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Based on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment timely for four (R8, R29, R49, R69 ) of 10 reviewed for timely assessments.
Findings include:
Review of the triggered resident assessment task identified there were 10 resident MDS assessments noted as having an MDS record over 120 days, which meant they were either not completed and/or submitted as required.
Review of the incomplete comprehensive MDS assessments included:
R8
The annual MDS with an Assessment Reference Date (ARD) of 11/13/23 had a current status that read In Progress. Sections A, F, GG, H, I, J, L, M, N, O, P, and V were highlighted in red and/or yellow and showed as In Progress (incomplete). The previously completed/submitted MDS assessment had an ARD of 8/15/23.
R29
The annual MDS with an ARD of 11/13/23 had a current status that read, In Progress. Sections A, B, C, D, E, F, GG, H, I, J, L, M, N, O, P, Q ,and V were highlighted in red and/or yellow and showed as In Progress. The previously completed/submitted MDS assessment had an ARD of 8/15/23.
R49
The annual MDS with an ARD of 11/12/23 had a current status that read, In Progress. Sections A, GG, H, I, J, L, M, N, O, P and V were highlighted in red and/or yellow and showed as In Progress. The previously completed/submitted MDS assessment had an ARD of 8/14/23.
R69
The annual MDS with an ARD of 11/11/23 had a current status that read, In Progress. Sections A, GG, H, I, J, L, M, N, O, P and V were highlighted in red and/or yellow and showed as In Progress. The previously completed/submitted MDS assessment had an ARD of 8/13/23.
On 12/20/23 at 8:00 AM, an interview was completed with the MDS Coordinator (Nurse 'D'). They reported they had been in their role for nine years, but was the only MDS nurse since approximately 2021. When asked when should MDS assessments be completed and submitted, Nurse 'D' reported they had 14 days for the ARD to complete, then should be submitted once completed as soon as possible. When informed of the triggered information about multiple MDS assessments that had not been completed for over 120 days, Nurse 'D' reported they were aware of the concern with MDS assessments not being completed timely and they were currently working on MDS assessments with ARDs of 11/10/23. They reported they were trying to complete them as soon as possible and were supposed to receive additional help from corporate but no one had come this week.
On 12/20/23 at 10:00 AM, an interview was completed with the Administrator. When informed about the concern with timely completion/submission of MDS assessments, the Administrator acknowledged the concerns and reported they had been informed by Nurse 'D' and had discussion with corporate MDS staff as well.
According to the facility's policy dated PPS (Perspective Payment System) Assessments and Timeframes dated 12/1/2019:
.The Interdisciplinary Team will be held accountable to ensure that they complete their MDS's in accordance with assessment timelines .The MDS Coordinator or RN (Registered Nurse) designee will sign each PPS Assessment verifying timeliness and completion .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment timely for six (R17, R40, R47, R57, R67, and R93) of 10 reviewed for timely assessme...
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Based on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment timely for six (R17, R40, R47, R57, R67, and R93) of 10 reviewed for timely assessments.
Findings include:
Review of the triggered resident assessment task identified there were 10 resident MDS assessments noted as having an MDS record over 120 days, which meant they were either not completed and/or submitted as required.
Review of the incomplete quarterly MDS assessments included:
R17
The quarterly MDS with an ARD (assessment reference date) of 11/10/23 had a current status as Export Ready. The history section read, Batch Status .Assessment was never added to a batch . The previously completed MDS assessment had an ARD of 8/10/23.
R40
The quarterly MDS with an ARD of 11/11/23 had a current status as In Progress. Sections A, GG, H, I, J, L, M, N, O, and P were highlighted in red and showed as In Progress. The previously completed MDS assessment had an ARD of 8/11/23.
R47
The quarterly MDS with an ARD of 11/12/23 had a current status as In Progress. Sections A, GG, H, I, J, L, M, N, O, and P were highlighted in red and showed as In Progress. The previously completed MDS assessment had an ARD of 8/12/23.
R57
The discharge return not anticipated MDS with an ARD of 11/30/23 had a current status as Export Ready. The section for Complete MDS read, Completed 12/19/2023. The history read, Batch Status .Assessment was never added to a batch . The previously completed/accepted MDS was an admission MDS with ARD of 8/13/23. The MDS system identified a warning that read, ARD (Q1): 11/13/2023 22 days overdue. R57 did not have a quarterly assessment completed as required.
R67
The quarterly MDS with an ARD of 11/10/23 had a current status as In Progress. Sections A, GG, H, I, J, L, M, N, O, and P were highlighted in red and showed as In Progress. The previously completed MDS assessment had an ARD of 8/16/23.
R93
The quarterly MDS with an ARD of 10/7/23 had a current status as Exported (not accepted). The history section read, Batch Status Accepted .Batch Accepted Date 11/3/2023 .Assessment status in Batch (should show accepted or rejected) was grayed out and did not identify whether it had been accepted or rejected. The previously completed MDS assessment had an ARD of 7/7/23.
On 12/20/23 at 8:00 AM, an interview was completed with MDS Coordinator (Nurse 'D'). They reported they had been in their role for nine years, but was the only MDS nurse since approximately 2021. When asked when should MDS assessments be completed and submitted, Nurse 'D' reported they had 14 days for the ARD to complete, then should be submitted once completed as soon as possible. When informed of the triggered information about multiple MDS assessments that had not been completed for over 120 days, Nurse 'D' reported they were aware of the concern with MDS assessments not being completed timely and they were currently working on MDS assessments with ARDs of 11/10/23. They reported they were trying to complete them as soon as possible and were supposed to receive additional help from corporate but no one had come this week.
On 12/20/23 at 10:00 AM, an interview was completed with the Administrator. When informed about the concern with timely completion/submission of MDS assessments, the Administrator acknowledged the concerns and reported they had been informed by Nurse 'D' and had discussion with corporate MDS staff as well.
According to the facility's policy dated PPS Assessments and Timeframes dated 12/1/2019:
.The Interdisciplinary Team will be held accountable to ensure that they complete their MDS's in accordance with assessment timelines .The MDS Coordinator or RN designee will sign each PPS Assessment verifying timeliness and completion .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to CMS (Center for Medicare and Medicaid) timely for ten (R8, R17, R29, R40, R47...
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Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to CMS (Center for Medicare and Medicaid) timely for ten (R8, R17, R29, R40, R47, R49, R57, R67, R69, and R93) of ten residents reviewed during the Resident Assessment review.
Findings include:
Review of the triggered resident assessment task identified there were 10 resident MDS assessments noted as having an MDS record over 120 days, which meant they were either not completed and/or submitted as required.
Review of these MDS assessments included:
R8
The annual MDS with an Assessment Reference Date (ARD) of 11/13/23 had a current status that read In Progress. Sections A, F, GG, H, I, J, L, M, N, O, P, and V were highlighted in red and/or yellow and showed as In Progress (incomplete). The previously completed/submitted MDS assessment had an ARD of 8/15/23.
R17
The quarterly MDS with an ARD of 11/10/23 had a current status as Export Ready. The history section read, Batch Status .Assessment was never added to a batch . The previously completed MDS assessment had an ARD of 8/10/23.
R29
The annual MDS with an ARD of 11/13/23 had a current status that read, In Progress. Sections A, B, C, D, E, F, GG, H, I, J, L, M, N, O, P, Q ,and V were highlighted in red and/or yellow and showed as In Progress. The previously completed/submitted MDS assessment had an ARD of 8/15/23.
R40
The quarterly MDS with an ARD of 11/11/23 had a current status as In Progress. Sections A, GG, H, I, J, L, M, N, O, and P were highlighted in red and showed as In Progress. The previously completed MDS assessment had an ARD of 8/11/23.
R47
The quarterly MDS with an ARD of 11/12/23 had a current status as In Progress. Sections A, GG, H, I, J, L, M, N, O, and P were highlighted in red and showed as In Progress. The previously completed MDS assessment had an ARD of 8/12/23.
R49
The annual MDS with an ARD of 11/12/23 had a current status that read, In Progress. Sections A, GG, H, I, J, L, M, N, O, P and V were highlighted in red and/or yellow and showed as In Progress. The previously completed/submitted MDS assessment had an ARD of 8/14/23.
R57
The discharge return not anticipated MDS with an ARD of 11/30/23 had a current status as Export Ready. The section for Complete MDS read, Completed 12/19/2023. The history read, Batch Status .Assessment was never added to a batch . The previously completed/accepted MDS was an admission MDS with ARD of 8/13/23. The MDS system identified a warning that read, ARD (Q1): 11/13/2023 22 days overdue.
R67
The quarterly MDS with an ARD of 11/10/23 had a current status as In Progress. Sections A, GG, H, I, J, L, M, N, O, and P were highlighted in red and showed as In Progress. The previously completed MDS assessment had an ARD of 8/16/23.
R69
The annual MDS with an ARD of 11/11/23 had a current status that read, In Progress. Sections A, GG, H, I, J, L, M, N, O, P and V were highlighted in red and/or yellow and showed as In Progress. The previously completed/submitted MDS assessment had an ARD of 8/13/23.
R93
The quarterly MDS with an ARD of 10/7/23 had a current status as Exported (not accepted). The history section read, Batch Status Accepted .Batch Accepted Date 11/3/2023 .Assessment status in Batch (should show accepted or rejected) was grayed out and did not identify whether it had been accepted or rejected. The previously completed MDS assessment had an ARD of 7/7/23.
On 12/20/23 at 8:00 AM, an interview was completed with MDS Coordinator (Nurse 'D'). They reported they had been in their role for nine years, but was the only MDS nurse since approximately 2021. When asked when should MDS assessments be completed and submitted, Nurse 'D' reported they had 14 days for the ARD to complete, then should be submitted once completed as soon as possible. When informed of the triggered information about multiple MDS assessments that had not been completed for over 120 days, Nurse 'D' reported they were aware of the concern with MDS assessments not being completed timely and they were currently working on MDS assessments with ARDs of 11/10/23. They reported they were trying to complete them as soon as possible and were supposed to receive additional help from corporate but no one had come this week.
On 12/20/23 at 10:00 AM, an interview was completed with the Administrator. When informed about the concern with timely completion/submission of MDS assessments, the Administrator acknowledged the concerns and reported they had been informed by Nurse 'D' and had discussion with corporate MDS staff as well.
According to the facility's policy dated PPS Assessments and Timeframes dated 12/1/2019:
.The Interdisciplinary Team will be held accountable to ensure that they complete their MDS's in accordance with assessment timelines .The MDS Coordinator or RN designee will sign each PPS Assessment verifying timeliness and completion .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
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 store and handle medications in accordance with accept...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store and handle medications in accordance with acceptable pharmaceutical standards of practice: 1.) for four of four(4 of 4) medication rooms 2.) ensure medication refrigerator temperatures outside of acceptable parameters were addressed; 3.) ensure Hall A medication cart was secured and locked when unattended; 4.) ensure medications were not expired in D unit medication (med) storage room; and 5.) the freezers in the med room were maintained regularly without ice build-up, resulting in the potential for contamination of medications, incorrect administration of medications, a lack of therapeutic benefits necessary to promote healing for residents, increased potential for adverse effects, and resident, staff or visitor access to unsecured medication cart.
Findings Include:
On [DATE] at 11:54 PM, during an observation tour of the med storage room in C Unit, it was observed that the Refrigerator #1 storing medications had a temperature reading of 43 degrees Fahrenheit. These medications were Lantus, other liquid prescription formulations, insulin pens, TB (tuberculosis) skin test vials, and other medicines stored in Refrigerator #1. In the same refrigerator (refrigerator #1), two vials of the Tuberculin Purified Protein Derivative diluted Aplisol with a tampered seal were found with no open date. The License Practical Nurse LPN Y was queried about the open date and temperature monitoring policy. LPN Y had indicated that the midnight shift nurses were responsible for checking the temperature and signing into the log. LPN Y stated, I am unsure of the open date policy. When LPN Y was asked what temperature the medication refrigerator should be maintained at according to the facility policy, LPN Y did not answer. The supplemental refrigerator #2 in the C unit storage room had ice build-up in the freezer area. LPN Y agreed and described too much ice accumulated and reported it to the Nurse Unit Manager Z (RN Z).
On [DATE] 0218 PM, during an observation tour of the med storage room in D Unit, it was observed there were two refrigerators: one was dedicated to the medications (Refrigerator#1), and the other was for supplements (Refrigerator #2) such as protein shakes, apple sauce and other beverages (milk or juice). The tour observation was conducted with the Unit Nurse LPN X. Refrigerator #1 contained insulins, TB Test vials, and other medications requiring refrigeration by the manufacturer. There were two (2) multidose vials of Tuberculin Purified Protein Derivative diluted Aplisol with the same expiration date of 09/24. One vial of Aplisol had the protection seal tampered with, which means it has been opened but does not have an open date written. However, the second vial of Aplisol was observed with a handwritten open date on the vial. One (1) box labeled Bisacodyl Fast Acting Stimulant Laxative suppositories was also observed with an expiration date marked 02/2022 on each plastic-sealed protective cover. There were three (3) suppositories of twelve (12) in the box remaining. LPN X confirmed that the suppositories were expired and indicated no knowledge of when they were last administered or to whom they were administered.
On [DATE] at 2:30 PM, The second refrigerator #2 med storage room of D Hall was observed containing the supplements, such as Ensure protein drink (assorted flavors), lactose-free milk, and an unidentified large (24 ounces) styrofoam cup with a lid on found with no label, no description, and no date. LPN X revealed that it was one of the Resident #106 (R106) milk (lactose-free) poured into a styrofoam cup. LPN X could not tell when the milk was poured into the cup and placed in the refrigerator. LPN X indicated, Without the resident's name or identifier, staff would not know who it belongs to or the content. When LPN X was asked how long the milk had been there or when the milk should expire, LPN X replied, It will be difficult to determine when it was poured and placed in the refrigerator and when the appropriate time to discard it. LPN X knew that R106 drank that kind of milk and would ask for it. LPN X stated, It should have been labeled and dated.
During the tour observation on [DATE] at 2:45 PM, The D Unit med storage cupboard contained Over the Counter (OTC) medications. One of the bottles labeled TUMS (chewable tablets for heartburn relief) was unsealed, and a second jar of unsealed Ibuprofen (A nonsteroidal anti-inflammatory drug that treats minor aches and pains, headaches and muscle aches) was mixed with unopened or sealed bottles of OTC medications. The two opened jars of OTC medication did not have an open date written. When asked about the facility's policy, LPN X indicated, There should be an open date written on the bottle once it is opened. LPN X did not comment when asked why the unsealed /opened OTC was mixed with the unopened stock.
The observation tour in B Unit was conducted on [DATE] at 2:57 PM. During the observation tour of the medication storage room in B Unit, it was observed that there were two refrigerators in the room. One refrigerator (Refrigerator#1) was dedicated to medications, and the second (Refrigerator #2) was for supplements such as Ensure (protein shakes), apple sauce, and other beverages (milk or juice). The License Practice Nurse LPN W opened refrigerator #1 and found the freezer door partially open. It was stuck and could not closed due to extreme ice build-up in the freezer section. When LPN W attempted to close the freezer door, the door broke and fell out of the freezer. There were ice chips noted that fell out from the freezer and landed below where the plastic bags and (boxes) packaging of the medications in the refrigerator section. Some of the ice landed on the medication packages, melted, and formed into drops of water due to condensation. There were opened (unsealed) multidose suspensions for hypertension (belonging to a resident) next to other medications such as Tuberculin Purified Protein Derivative diluted Aplisol that no longer have the protected seal cap inside a carton packaging, Lisinopril Multidose injection with an expiration date was [DATE] with the protective sealed cap removed (open date [DATE]) and a styrofoam cup (32 ounces) with a handwritten labeled as thickener but was undated. LPN W confirmed that the suspension was for a peg tube resident and that they have always put them in the refrigerator with the rest of the refrigerated medications. LPN W has indicated being unsure of who is in charge of monitoring the temperature of the refrigerator (whether it is the midnight shift nurse or the day shift nurse) and the maintenance of the freezer (ice accumulation).
During the observation tour in A unit medication storage room conducted on [DATE] at 3:34 PM, the nurse, LPN V, was administering medication in the resident's room. Meanwhile, the medication cart (med cart) for A unit was observed parked outside the resident's room next to the doorway, with the drawers facing the nurses' station unlocked and accessible to all passersby from 3:25 PM until 3:35 PM. When queried, LPN V indicated that the resident had recently returned from dialysis and needed the medication. LPN V confirmed that the med cart was left unlocked for approximately 10 minutes. When asked what are you doing next? LPN V replied: I guess I should lock the med cart now, she walked to the A Hall Med cart and pressed the button to lock the cart.
On [DATE] at 3:38 PM, LPN V proceeded to the med storage room in A Unit and showed two (2) refrigerators. Refrigerator #1 stored medications like insulin pens, TB test multidose vials and other liquid formularies and injectables requiring refrigeration. While searching for the thermometer inside refrigerator #1, the Unit Manager RN Z at 3:45 PM came in the med storage room and located the thermometer inside the refrigerator and confirmed that the temperature reading of thermometer found in refrigerator #1 was 58 degrees Fahrenheit. RN Z was asked what temperature the insulin vials, insulin pens, and TB testing multidose vials should be stored at (per your policy)? RN Z could not give a specific acceptable temperature range per the facility policy. The temperature log posted outside the refrigerator wrote: Refrigerator: [vaccine must be stored between 35 degrees Fahrenheit and 46 degrees Fahrenheit to maintain potency.] If the temperature is in the gray area (shaded area shown in the log): above 47 degrees Fahrenheit up to greater than or equal to 49 degrees Fahrenheit and below 34 degrees to less than or equal to 32 degrees Fahrenheit: 1.) Store the vaccines under proper conditions as quickly as possible, 2.) Call the vaccine manufacturers to determine whether the vaccine's potency has been affected, and 3.) Call your VFC Consultant. RN Z confirmed that the thermometer read 58 degrees Fahrenheit and was too warm for the acceptable range. The RN Z was instructed to discuss these findings immediately with the DON and follow the facility pharmacy's recommendation since the refrigerator's temperature was not within the acceptable range.
Refrigerator #2, which holds supplementals such as protein shakes, milk, and apple sauce, had a crack in the thermometer's glass. It read below the line of 31 degrees Fahrenheit. The crack was touching the dial of the thermometer gauge. LPN V confirmed the refrigerator temperature reading was below the acceptable range and noted the crack on the thermometer, which can affect the accuracy of the temperature results.
A follow-up observation was conducted the following morning, on [DATE], at 6:45 AM. In A Hall med storage room, Refrigerator #2, which holds the supplemental drinks, had the same cracked thermometer was found in refrigerator #2 and noted at the same temperature below 31 degrees Fahrenheit.
The Director of Nursing (DON) was interviewed on [DATE] at 11:33 AM. The DON revealed that Unit B and Unit C refrigerators were defrosted. Staff received an in-service on monitoring and maintaining the refrigerator temperature log. The DON further explained that no one had mentioned the refrigerator discrepancy in Unit A and agreed that 58 degrees Fahrenheit was too high from the acceptable range. The unit nurse or nurse manager is responsible for monitoring all refrigerator temperature logs in each unit and reporting discrepancies (out of range) every shift.
A review of the facility policy titled Medication Administration, dated [DATE], provided, .8.) Make sure the medications cart is locked at all times when it is not in use or not within your constant vision .10.) Follow the pharmacy medication guidelines for storage .
During the interview with the DON conducted on [DATE] at 11:45 AM, Policies for Medication Storage Room Policy, Monitoring and Maintenance of Refrigerators for Med Storage Policy, and Proper labeling of opened multidose medication Policy were requested. The facility did not submit the policies requested during the exit.
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 monitor the dish machine for adequate sanitization, and failed to maintain the ice machines in a sanitary manner. This defici...
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Based on observation, interview, and record review, the facility failed to monitor the dish machine for adequate sanitization, and failed to maintain the ice machines in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include:
On 12/19/23 between 8:40 AM-9:30 AM, during an initial tour of the kitchen with Dietary Manager (DM), the following items were observed:
The ice machine in the main kitchen was observed with an accumulation of dust on the side ventilation slats.
The ice machine located in the [NAME] garden dining room was observed with a black mold-like substance on the drip tray. When queried regarding who was responsible for cleaning the ice machines, DM stated the kitchen staff cleans the outside of the ice machine in the kitchen, and housekeeping cleans the outside of the ice machine in the dining room.
According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.
According to the 2017 FDA Food Code section 4-602.13 Nonfood-Contact Surfaces, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
DM was queried about testing the sanitization of the high temperature dish machine, and stated that they did not currently have any test strips. DM stated it usually takes a while for the hot water in the dish machine to get up to temperature, because of the boiler. Staff was observed using the dish machine, and putting away dishware that had been run through the dish machine. This surveyor used an irreversible registering temperature indicator test strip to check if the dish machine was sanitizing with hot water. The strip did not change color to indicate the dish machine was properly sanitizing. 3 more strips were run through the dish machine, and again did not change color.
The dish machine testing log was observed on a clip board near the dish machine. Review of the log for December 2023 revealed 12/8-12/16 dates were blank, 12/18 and 12/19 were also blank.
On 12/19/23 at 10:20 AM, Dietary Staff were observed to be using the dish machine, and putting away the dishware that had just been run through the machine. This surveyor used another irreversible registering temperature indicator test strip in the dish machine, and the strip did not change color to indicate the dish machine was properly sanitizing.
On 12/19/23 at 10:45 AM, the Administrator was queried as to what kitchen staff should do if the dish machine was not sanitizing, and stated they should stop using the machine and should switch to disposable dishware for meals.
According to the 2017 FDA food Code section 4-701.10 Food-Contact Surfaces and Utensils, Equipment food-contact surfaces and utensils shall be sanitized.
According to the 2017 FDA Food Code section 4-703.11 Hot Water and Chemical, After being cleaned, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED in: (A) Hot water manual operations by immersion for at least 30 seconds and as specified under § 4-501.111; P
(B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under §§ 4-501.15, 4-501.112, and 4-501.113 and achieving a UTENSIL surface temperature of 71°C (160°F) as measured by an irreversible registering temperature indicator; P.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to maintain an antibiotic stewardship program and to ensure accurate monitoring and documentation of appropriate antibiotic use, with potentia...
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Based on interview and record review, the facility failed to maintain an antibiotic stewardship program and to ensure accurate monitoring and documentation of appropriate antibiotic use, with potential to affect all residents in the facility, and resulting in the potential for misuse of antibiotics and development of antibiotic resistance. Findings include:
Review of the facility's Infection Prevention and Control binder revealed that the line listing grid did not include information on whether criteria for antibiotic use was met. No documentation provided for each month included in the binder which covered January 2023 through November 2023.
On 12/20/23 at 11:00 AM, the Director of Nursing (DON) was queried regarding documentation of use of McGeer's criteria and whether or not they could show where that was documented in the facility's binder or in the electronic health record (EHR).
On 12/21/23 at 10:50 AM, an interview with the Director of Nursing (DON) was conducted. The DON reported that the Infection Prevention program consisted of an Infection Preventionist (Nurse A), with oversight from the DON. The DON oversees and will periodically spot check the antibiotic stewardship program. The DON stated that at quick glance of the line listings the antibiotic stewardship program appeared to be ok. It should be noted that the Infection Preventionist (Nurse A) was on vacation and unavailable during the time of the survey.
The DON reported that they could not find completed McGeer's criteria within the EHR or any physical/paper copies.
The DON confirmed they do use McGeer's criteria, and if criteria was not met the nurse will notify the doctor and go with their recommendation and rationale. The DON further stated that the criteria should be documented in an infection note, the facility used ABILITY for infection prevention data tracking however there should be a note outside of that system.
According to the facility's Infection Control Antibiotic Stewardship & MDROs policy dated 10/14/22, Protocols will be developed and followed that promote health & wellness through responsible use of antimicrobials in an effort to prevent unnecessary treatment and resultant antibiotic resistance .The program will encourage appropriate prescribing; and reduce adverse effects which often include gastrointestinal problems, C. Difficile diarrhea, yeast infections and antibiotic resistance in aging adults .The facility has adopted the McGeer's criteria for infection surveillance definitions.
Oct 2023
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00135477.
Based on observation, interview, and record review, the facility failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00135477.
Based on observation, interview, and record review, the facility failed to report an allegation of verbal abuse and misappropriation of property to the State Agency for one (R804) of four residents reviewed for abuse. Findings include:
Review of a complaint submitted to the State Agency in March 2023 revealed an allegation that Certified Nursing Assistant (CNA) 'R' had a verbal altercation with resident (R804), she came at her, other staff told (CNA 'R') to get out but she didn't get out and when she did leave she came back in and stood next to the resident yelling at her.
On 10/4/23 at 9:37 AM, R804 was observed lying in bed. When queried about any concerns with staff, R804 reported they were mistreated by CNA 'R' a few months ago. When queried about what happened, R804 explained they (the resident) made a sarcastic comment to CNA 'R' when they collected their meal tray because they remove them quickly which ended in a verbal argument. R804 reported they typically let stuff go but I couldn't let this go because she was arguing with me. I was loud with her and she was loud with me back. The nurse had to come in and ordered her to get out of my room and not to talk to me. Then she was complaining as she left the room, came back in, stood over me, and yelled at me. That was the only time I felt afraid being here. R804 explained CNA 'R' was not allowed to work with them anymore, but remained an employee at the facility. R804 stated, If I see her walk by, I almost start to have a panic attack. R804 further explained what got her (CNA 'R') really enraged was when I mentioned that she did not give me the money she owed me when I bought food for her. R804 reported CNA 'R' frequently talked on the phone in front of the resident and therefore R804 overheard conversations about money problems. R804 reported they were in a position to be nice and knew they should not have given CNA 'R' money, but they said they would pay it back. R804 reported they were not concerned about it, but they brought it up after CNA 'R' began arguing with them and then CNA 'R' got really mad when R804 brought up the money. R804 reported the facility spoke to them about the incident and stated, They want you to remember every little detail and sometimes it's hard to keep it all straight.
On 10/4/23 at 11:50 AM, all incident reports, grievance forms, and investigations regarding R804 from March 2023 was requested.
Review of a soft file investigation provided by the Administrator regarding R804 revealed the following:
A signed statement written by LPN 'R' documented, observed CENA and resident arguing in room. CENA stated to me that she was not going to take care of resident because she was cursing at her. Nurse went into room and observed CENA giving care to resident and asked her not to say anything to the resident. Nurse could here <sic> CENA and resident continue to argue. Nurse asked CENA again not to say anything to the resident. At this time she was coming out of the room. Nurse spoke with resident and was informed that CENA owes her $20.00 and she said part of the argument was about that. I could also here <sic> resident telling the CENA several times to leave the room. I went in the second time and CENA was coming out of the room. At this time CENA was asked to go home and talk with the DON (Director of Nursing) on Monday. The statement was signed by LPN 'L' and R804 on 3/12/23 at 9:10 AM. The statement documented, (Administrator) was texted, and left message also texted DON.
A Incident and Accident Investigation Form dated 3/11/23 around 10:30 PM (note that LPN 'R's statement was written on 3/12/23 at 9:10 AM, approximately 11 hours later) documented R804 was the resident involved in the incident and CNA 'R' was the alleged perpetrator. The form documented, Resident reported to the nurse that she had an argument with her CNA and she owed her $20. It was documented that the reporting person became aware of the incident on Sunday 3/12/23 and it was reported to the Administrator and DON through text on 3/11/23 at 11:04 PM. It was documented that the text stated the CNA was being sent home for arguing with resident. The action taken by the facility was documented as CNA was asked to leave the unit and go home for the night. It was documented the incident was not reported to the State Agency. In the interview section, it was documented to see interview sheets.
Review of a written statement by CNA 'R' on 3/12/23 revealed the following: Upon making rounds 3/11/23 3-11 (pm) shift between 10-10:30 pm I entered (R804's room), as soon as I entered the room (R804) was already agitated stating she doesn't like the nurse because she don't give her meds (medications) in a timely fashion. So I began to tell her I'm here to change you and she stated saying hurry up and get it done .raising her voice. I said Ok (R804) then let me change you, she was on and on about how she doesn't like the nurse and she hate she has to deal with her on the night shift very irate and loud. While changing her I'm telling her to turn she began yelling and screaming at me once again to hurry up and get out of her rm (room). At no time while yelling and screaming at me the nurse did not enter the rm. So I finished up and exited the rm and the nurse (LPN 'L') comes up to me and say you just need to shut up and say nothing and I'm like wow telling her the resident is the one yelling and screaming. By this time I'm coming up the hallway agitated by her telling me to shut up. SO I told her I was going outside to smoke for 5 min (minutes). Upon coming back into the building that's when she approached me and said (R804) is stating she was verbally abused accusing me of owing her $20.00 for lunch she brought the unit months ago and I'm like really are you serious that's not true I owe her nothing I've never taken anything from her. So (LPN 'L') goes on to tell me I have to leave because (R804) is stating that I verbally abuse her and she's calling the state, the DON, and the Administrator. So I'm like can I be switched off to another unit to avoid contact with her and she was irate .stating her license is on the line if she don't report it. So left and went outside and (names of three staff members) told me to come back and go to C-Wing and that's what I did.
Review of a document titled, Quality Assurance Interview Summary revealed the following Summary of Resident Interview given by R804 on 3/13/23, two days after the alleged incident: Resident states that she can not really remember what started the argument between her and (CNA 'R'). She states that she told the nurse (LPN 'L') that (CNA 'R') owed her $20 because she bought them both dinner one time in the past. Resident states at that time she told (CNA 'R') to keep the change from the $40 she gave her to buy their dinner. Resident states that when she was upset she said she wanted the money back out of spite. Resident stated that she cannot recall what either were saying to each other. Resident states that (CNA 'R') did not curse or call her any names or make any threats. Resident states that she yelled for CNA to get out of her room at this time .Resident stated she no longer wants (CNA 'R') as a care giver because she believes they are no longer friends.
An interview with CNA 'S' was documented on the above form. The date of the interview was 3/14/23, three days after the alleged incident. The summary of the statement read, When I walked up I overheard (LPN 'L') telling the resident to call state or DON about the situation and that (CNA 'R') shouldn't be working all of these days if she's stressed .
Further review of the Incident and Accident Investigation Form revealed the following documented conclusion: After further review and interviews the facility does not substantiate verbal abuse. The employee was however disciplined for the accusation of accepting dinner from a resident . The form was signed on 3/13/23 which was two days after the alleged incident occurred.
On 10/4/23 at 1:04 PM, a phone interview was conducted with Licensed Practical Nurse (LPN) 'L'. When queried about the incident between R804 and CNA 'R', LPN 'L' reported they heard R804 and CNA 'R' yelling and going back and forth arguing from the hallway. LPN 'L' intervened and asked CNA 'R' to stop talking to the resident while they were finishing care. LPN 'L' reported they heard R804 yelling for CNA 'R' to get out of their room which is why LPN 'L' intervened. After CNA 'R' left the room, LPN 'L' interviewed R804 who told them CNA 'R' borrowed money from them and did not pay them back and that CNA 'R' verbally abused them. LPN 'L' explained they texted the Administrator and did not hear back so they contacted the Director of Nursing (DON). They were told to write a statement and put it under the Administrator's door. LPN 'L' asked CNA 'R' to leave the building at that time and as far as they knew, CNA 'R' left.
On 10/4/23 at 4:09 PM, an interview was conducted with the Administrator, who was the facility's Abuse Coordinator. When queried about the facility's protocol when any type of abuse was alleged or witnessed, the Administrator reported they were to contact her immediately via phone call, text, or email and that the message should indicate that it was regarding abuse so they knew to call back immediately. When queried about when allegations or witnessed abuse were reported to the State Agency, the Administrator reported within two hours if there is any harm and within 24 hours is no harm is done. When queried about when they found out about the allegations of verbal abuse and misappropriation of resident money between CNA 'R' and R804, the Administrator reported the nurse informed them through text, but it was not seen immediately. The Administrator explained when they saw the text, they contacted the DON immediately and that the DON was already aware of the situation. When queried about whether the allegation was reported to the State Agency, the Administrator reported it was not and explained they did not report it immediately because if they did not think it would be substantiated, the the facility had 24 hours to investigate it and if was not substantiated it did not need to be reported. When queried about the documented interviews that were still being conducted on 3/14/23, the Administrator reported they had 24 hours to determine if it was abuse.
On 10/5/23 at approximately 9:15 AM, the Administrator provided a care plan for R804 that documented in 2018 R804 had a history of making false accusations. When queried about what the risk was for residents who did make false accusations against staff or who had difficult behaviors, the Administrator reported they understood, but because there was no serious bodily injury the facility had 24 hours to substantiate or unsubstantiate allegations of abuse. At that time, any guidance the Administrator was following that explained the rationale for not reporting the allegations was requested. No further information was provided prior to the end of the survey.
Review of R804's clinical record revealed R804 was admitted into the facility on 8/16/13 and readmitted on [DATE]. Review of Minimum Data Set (MDS) assessments dated 8/8/23 and 2/7/23 revealed R804 had intact cognition and no behaviors.
Review of a facility policy, effective 10/15/22, revealed, in part, the following:
.Verbal Abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the guest/resident to experience humiliation, intimidation, fear, shame, agitation, or degradation regardless of their age, ability to comprehend or disability .Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to guests/residents within hearing distance, regardless of age, ability to comprehend, or disability .Misappropriation of guest/resident property means that deliberate misplacement, exploitation, or wrongful, temporary or permanent use of guest's/resident's belongings or money without the guest's/resident's consent .The staff will report any allegations or suspicions of mistreatment, abuse, neglect, exploitation, misappropriation or property, and injuries of unknown source to the Administrator and DON immediately .The Administrator or designee will notify .any State or Federal agencies of allegations per state guidelines (2 hours if abuse allegation or serious injury; all others not later than 24 hours) .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation has two deficient practice statements (DPS).
DPS #1
This citation pertains to intake number(s): MI00136651.
Based ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation has two deficient practice statements (DPS).
DPS #1
This citation pertains to intake number(s): MI00136651.
Based on observation, interview, and record review, the facility failed to ensure there were physicians orders for a intrathecal baclofen pump (a device that delivers baclofen, a medication used to treat muscle spasms, directly into the spinal canal. It is surgically placed under the skin of the abdominal region of the body. Attached to the pump is a tiny catheter that extends into the spinal canal) that included instructions for maintenance and monitoring of the pump site for one (R803) of two residents reviewed for skin management. Findings include:
Review of a complaint submitted to the State Agency revealed an allegation that on 5/17/23 when R803 was seen by an outside doctor, it was noted that R803 had a baclofen pump with a band-aid over the pump site. The complainant alleged the band-aid was not dated and appeared to be old and dirty and that the residents care is being neglected at the facility.
On 10/4/23 at 9:19 AM, R803 was observed lying in bed on their back. When addressed R803 answered yes and no questions.
Review of R803's clinical record revealed R803 was admitted into the facility on 3/18/22 with diagnoses that included: spastic quadriplegic cerebral palsy. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R803 had severely impaired cognition and was totally dependent on staff for bed mobility, transfers, and all activities of daily living.
Review of R803's After Visit Summary (discharge instructions) from 3/18/22 when R803 was initially admitted into the facility revealed R803 had a Baclofen pain pump.
Further review of R803's clinical record revealed multiple outpatient visits since they were admitted into the facility to get the baclofen pump refilled, including, but not limited to the following dates: 6/27/22, 3/15/23, 5/4/23, and 6/27/23. The instructions on the After Visit Summary for those that's documented, Aftercare instructions for baclofen injection .When receiving ITB (intrathecal baclofen) Therapy Baclofen injection, make sure you follow your clinician's instructions closely. A sudden stop in therapy can result in serious baclofen withdrawal symptoms, such as high fever, changed mental status, muscle stiffness, and in rare cases, may result in the loss of function of many vital organs and death. It is critical that you clinician be called right away if you experience any of these symptoms .You should also know the early symptoms of baclofen withdrawal .Your pump will sound an alarm if there is a problem, it needs to be replaced, or it needs to be filled with baclofen injection. There are two different alarms .Single beep: Non-Critical Alarm. A single beep, repeating about once every hour, sounds when the amount of medication in the pump is getting low. Call your doctor right away to schedule a refill appointment. The single beep will also sound if your pump needs to be replaced within 90 days .Two-Tone Alarm: Critical Alarm. If you hear a two-tone alarm, call your doctor immediately. This alarm sounds when the medication is no longer flowing. The pump may be empty, need replacement, or have another problem. A sudden stopping of ITB Therapy with baclofen Intrathecal leads to baclofen withdrawal and a medical emergency, so act quickly.
Review of R803's Physician's Orders since admission into the facility on 3/18/22 revealed no order for a intrathecal baclofen pump or orders to monitor the site. Review of R803's care plans as of 10/4/23 revealed no care plan for the maintenance and monitoring of a baclofen pump or what to do if it alarmed.
On 10/5/23 at approximately 10:40 AM, Registered Nurse (RN) 'I', who was not R803's assigned nurse on that day but reported they were familiar with the resident was asked to observe R803's baclofen pump site. RN 'I' informed R803's assigned nurse, Licensed Practical Nurse (LPN) 'M' of the request. LPN 'M' reported they were not aware R803 had a baclofen pump. LPN 'E' was at the nurses station and reported they had been assigned to R803 before, but did not know they had a baclofen pump. When queried about how they would know if a resident had a baclofen pump, LPN 'M' reported there would be a physicians order and a care plan. At that time LPN 'M' reviewed R803's clinical record and confirmed there was no physician order and a care plan was initiated on that day, 10/5/23, documenting R803 had a intrathecal baclofen pump. The care plan initiated on 10/5/23, did not include any interventions on how to monitor the site or ensure proper functioning and maintenance of the device.
On 10/5/23 at 10:52 AM, an interview was conducted with the Director of Nursing (DON). The DON reported there should have been a physicians order for it and a care plan to monitor the site. The DON explained R803 went to an outside doctor to have the pump refilled.
Review of a document provided by the facility, titled, baclofen from 2023 [NAME] Advisor, that revealed, in part, the following: .Skeletal muscle relaxants .Boxed Warning: Consult the infusion system's technical manual for postimplant information .Watch for sensitivity reactions, such as fever, skin eruptions, and respiratory distress .Advise patient and caregivers, especially patients with spinal cord injuries .communication difficulties .of risks associated with abrupt discontinuation of intrathecal form. Tell them to keep scheduled refill visits and teach them the signs and symptoms of baclofen withdrawal .
Review of a facility policy titled, Physician's Order, revised 6/24/21, revealed, in part, the following: Physician orders are obtained to provide a clear direction in the care of the guest/resident .
DPS #2
This citation pertains to intake number(s): MI00136651.
Based on observation, interview, and record review, the facility failed to address a skin tear in a timely manner for one (R801) of two residents reviewed for wound care. Findings include:
On 10/4/23 at 9:25 AM, R801 was observed lying in bed saying Help me! while wrapping the incontinence pad around their body and gripping the bed sheet. R801's left hand was observed with an open area between the knuckles of the fourth and fifth fingers. The open area was observed with dried blood and appeared as a shallow wound. There was no dressing applied to the open area.
On 10/4/23 at 12:00 PM, R801 was sleeping in bed. A large white dressing with tape that was undated was observed applied to R801's left hand.
On 10/4/23 at 12:03 PM, an interview was conducted with Licensed Practical Nurse (LPN) 'F' who explained they were R801's assigned nurse. When queried about the dressing applied to R801's left hand, LPN 'F' reported R801 had a skin tear, it was not reported to them at shift change, and they had to ask the aide what happened. LPN 'F' explained they put a dry dressing on it because they did not see a physicians order for treatment. LPN 'F' stated, I didn't find out about it until you guys were in the room this earlier.
Review of R801's clinical record revealed R801 was admitted into the facility on 6/21/18 and readmitted on [DATE] with diagnoses that included: dementia, type 2 diabetes mellitus, and cerebral artherosclerosis. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had severely impaired cognition, physical and verbal behaviors that interfered with resident care, rejection of care, and required extensive physical assistance with bed mobility, transfers, hygiene and bathing. R801 was totally dependent on staff for toilet use.
Review of R801's Physician's Orders and Treatment Administration Record (TAR) revealed an order with a start date of 10/4/23 3:00 PM that read, TAO (triple antibiotic ointment) every evening shift for left hand 4th digit noted with small abrasion cleanse with NS (normal saline), pat dry, apply TAO and cover with Band-Aid Q (day shift) and PRN (as needed). The TAR indicated the treatment was scheduled for the evening shift. However, the order documented day shift and PRN. As of 10/4/23 at 12:15 PM, there was no documentation of the ordered treatment being completed. (It should be noted that the observed dressing on R801's left hand at 12:03 PM was not a Band-Aid). A second order for the same treatment was entered with a start date of 10/3/23 as a PRN order. The TAR indicated the treatment had not been administered on 10/3/23 or 10/4/23.
Review of R801's progress notes revealed a Nurses Note dated 10/3/23 at 5:42 PM, written by LPN 'E', revealed the following documentation: CNA (Certified Nursing Assistant) reported to writer that residents left hand was bleeding. Writer assessed residents left hand and observed a skin tear. Writer reported to treatment nurse. Treatment nurse stated 'I will put some triple antibiotic ointment on it.' .
On 10/4/23 at 2:12 PM, the Administrator and Director of Nursing (DON) were asked to provide all incident reports and associated investigations for R801 for the past six months.
Review of the incident reports provided by the facility did not include an incident report regarding the skin tear to R801's left hand.
On 10/4/23 at 2:24 PM, a phone interview was attempted with LPN 'E'. A message was left and LPN 'E' was not available for an interview prior to the end of the survey.
On 10/4/23 at 2:45 PM, an interview was conducted with CNA 'J' who was assigned to R801 on the afternoon shift on 10/3/23. CNA 'J' reported they arrived for their shift on 10/3/23 at 2:30 PM and saw R801 around 3:00 PM or 3:15 PM and at that time, R801 was observed to have the open area to their left hand. CNA 'J' notified the nurse.
On 10/4/23 at 2:57 PM, a telephone interview was conducted with CNA 'H' who was assigned to R801 on the day shift on 10/3/23. CNA 'H' reported the first time they entered R801's room, the nurse was giving medications. After the nurse finished, CNA 'H' changed R801's brief and did not notice any skin alterations to R801's hand. CNA 'H' explained they went in R801's room before lunch time and say the open area to R801's left hand and notified the nurse. CNA 'H' reported they did not know how it happened.
On 10/4/23 at 3:30 PM, an interview was conducted with the DON. When queried about the skin tear to R801's left hand, the DON reported she had not been made aware until she noticed it that afternoon. The DON reported the nurse on 10/3/23 should have completed an incident report so they could look into the cause. The DON explained there was a treatment in place, however, did not know why it was on the TAR to be administered in the evening.
Review of a facility policy titled, Skin Management, revised 7/14/21, revealed, in part, the following: .Treatment of Skin Tears .All skin tears will be evaluated, documented and treated based on physician's orders .Upon occurrence, all skin tears will be reported to the licensed nurse .An Incident and Accident Report is to be completed .Notify the attending physician and responsible party of the occurrence, document the notification in the medical record and initiate an order, as needed .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00137760.
Based on observation, interview, and record review, the facility failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00137760.
Based on observation, interview, and record review, the facility failed to transfer two (R802 and R801) of three residents reviewed for accidents, in a safe manner, resulting in R802 falling in the shower. Findings include:
R802
Review of a complaint submitted to the State Agency revealed an allegation that R802 fell on the floor during a transfer into the wheelchair during a shower on 6/8/23.
On 10/4/23 at 9:05 AM, R802 was observed seated on the edge of their bed, eating breakfast. R802 repeatedly leaned over and pointed to a bag of sodas located on the floor. When queried about any falls R802 had in the shower, R802 talked non-sensically and stated, Lies! R802 was unable to answer questions directly and clearly.
Review of R802's clinical record revealed R802 was admitted into the facility on 9/20/21 and readmitted on [DATE] with diagnoses that included: osteoarthritis of left hip, dementia, history of a right foot fracture, type 2 diabetes mellitus, and hypertension. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R802 had severely impaired cognition, no behaviors, and required limited assistance from staff for transfers and extensive assistance from staff for bathing. The MDS assessment indicated R802 had two or more falls with no injury during the assessment period. Review of the previous MDS assessment dated [DATE], in place at the time of the alleged fall, revealed R802 had severely impaired cognition, no behaviors, and required extensive assistance from staff for bathing. The MDS assessment indicated R802 had two or more falls without injury during the assessment period.
Review of R802's progress notes revealed a Nurses Note on 6/9/23 at 12:54 AM written by Registered Nurse (RN) 'C', that read, Writer was called to shower room by CENA (Certified Nursing Assistant), res (resident) was observed on floor on her right side, with feet towards shower chair and head towards W/C (wheelchair) .neuro checks initiated, skin assessment done, swelling and discoloration observed on right eyebrow/forehead .
Review of a Nurses Note dated 6/9/23 revealed, IDT (interdisciplinary team) met to discuss resident fall, resident was receiving a shower in the shower room when she was being transferred from the shower chair to the wheelchair she slipped and fell. Resident will wear non-slip socks or shoes before transferring .
Review of a Post Fall Evaluation dated 6/8/23, revealed R802 fell on 6/8/23 at 9:00 PM. It was documented that CNA 'G' was present during the fall and RN 'C' was present after the fall. It was documented that R802 slipped on shower floor while being transferred by staff. R802 had bare feet at the time of the fall and no gait assist devices were used. The root cause of the fall was identified as Footwear and the intervention to prevent futures falls was Ensure res (resident) has slip resistant socks or shows on during transfers.
Review of R802's care plans revealed a care plan initiated on 9/20/21 and revised on 12/15/21 that read, (R802) is at risk for fall related injury and falls . An intervention initiated on 9/20/21 read, Encourage the resident to wear appropriate footwear as needed. The intervention was revised on 1/3/23 and noted, Encourage the resident to wear appropriate footwear as needed when going from seated to standing position. On 6/9/23 the same intervention was initiated to Encourage the resident to wear appropriate footwear as needed when going from seated to standing position and to ensure slip resistant socks or shoes on during all transfers.
On 10/5/23 at 8:39 AM, a phone interview was conducted with CNA 'G'. When queried about what happened with R802 on 6/8/23, CNA 'G' reported they gave R802 a shower in the shower room and R802 was resistant to assistance when CNA 'G' tried to assist the resident into the wheelchair. CNA 'G' stated, The next thing I knew, she took a step over and slipped to the floor. When queried about what type of footwear R802 was wearing at the time of the transfer in the shower room, CNA 'G' reported R802 was not wearing any footwear and that they typically wore a rubber clog type shoe but R802 did not put them on that day.
On 10/5/23 at 3:55 PM, a phone interview was conducted with RN 'C'. When queried about R802's fall on 6/8/23, RN 'C' reported the aide came and got them and said R802 lost their footing while transferring because they did not want assistance. R802 stood up on their own and fell. When queried about appropriate footwear when in the shower, RN 'C' reported R802 should not have had bare feet and CNA 'G' was responsible to ensure R802 had the shoes on before she stood up.
On 10/5/23 at 4:30 AM, an interview was conducted with the Assistant Director of Nursing (ADON) in the absence of the Director of Nursing (DON). The ADON reported non-slip footwear was a standard intervention for all residents who were at risk of falls. The ADON reported R802 should not have had bare feet.
R801
On 10/4/23 at 9:25 AM, R801 was observed lying in bed saying Help me! An open area with dried blood was observed between R801's fourth and fifth knuckled on the left hand.
On 10/4/23 at approximately 1:30 PM, R801 was observed hanging their feet off the edge of the bed saying Help me!. Licensed Practical Nurse (LPN) 'F' responded to resident who requested to get out of the bed. LPN 'F' reported they would get R801's CNA.
On 10/4/23 at 1:42 PM, CNA 'T' came to R801's door with a wheelchair and expressed that R801 can't really sit in a chair. At that time, the DON came to unit. When asked if R801 was able to sit in a chair, the DON reported they were able to. The DON approached R801 who was saying Help me! and expressed that they wanted to get out of the bed and relayed that to the CNAs.
On 10/4/23 at approximately 1:45 PM, CNA 'T' attempted to sit R801 on the edge of the bed while CNA 'D' went to get the wheelchair. When CNA 'T' assisted R801 into a seated position on the edge of the bed, R801 yelled out and said their back hurt. R801 laid back down until CNA 'D' came back to the room. CNA 'D' assisted R801 into a seated position at the edge of the bed, then CNA 'D' and CNA 'T' had R801 stand up and they assisted him to pivot into the wheelchair while holding R801's forearms and waist band of their pants. The CNAs did not utilize a gait belt for the transfer of R801.
Review of R801's clinical record revealed R801 was admitted into the facility on 6/21/18 and readmitted on [DATE] with diagnoses that included: cerebral arteriosclerosis, cataract, heart failure, dementia, peripheral vascular disease, and type 2 diabetes mellitus. Review of a significant change MDS dated [DATE] revealed R801 required extensive two person assistance for bed mobility and transfers and did not walk.
On 10/4/23 at 3:30 PM, an interview was conducted with the DON. When queried about how the staff should transfer a resident who required extensive two person assist, the DON reported the staff were required to use a gait belt for safety.
On 10/4/23 at 3:44 PM, an interview was conducted with the Therapy Manager. When queried about R801's transfer assistance requirements, the Therapy Manager reported at the time of R801's last evaluation they required max assist which meant staff was doing 50-75 percent of the work and the resident was participating at 25 percent. The Therapy Manager reported the way the staff should transfer the resident would be to use a gait belt and the resident would hold on to the staff while they pivoted the resident into the chair.
Review of a document provided by the facility titled, Helping to Transfer Someone Safely from 2023 [NAME] Advisor, revealed, in part, the following: .Be sure to wear nonskid socks or shoes when moving .Moving from sitting to standing with help: .You helper should grab your gait belt underneath with one hand on the back .As you start to stand by leaning forward with you nose over your toes, have your helper gently lift up on the gait belt .If you need more help to stand .Have your helper stand in front of you. You helper should reach around your waist with both arms and grab your gait belt .You helper will count to 3 and then you start to stand as your helper lifts up on the gait belt .Your helper can hold your gait belt with both hands to help you sit down slowly .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
This citation pertains to intake number(s): MI00134971.
Based on observation, interview, and record review, the facility failed to ensure there was a physician's order for oxygen, ensure application o...
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This citation pertains to intake number(s): MI00134971.
Based on observation, interview, and record review, the facility failed to ensure there was a physician's order for oxygen, ensure application of a continuous positive airway pressure (CPAP) machine according to physician's orders, and ensure a physician ordered sleep study was completed for one (R805) of one resident reviewed for respiratory care. Findings include:
Oxygen
Review of a complaint submitted to the State Agency revealed an allegation that the facility was not putting him on his CPAP machine that he required for sleep apnea.
On 10/4/23 at 12:00 PM, R805 was observed sleeping in bed. R805 was receiving oxygen via nasal cannula. The oxygen concentrator was set for three liters per minute (3 LPM/ leader per minute) of oxygen.
On 10/5/23 at 12:15 PM, R805 was observed lying in bed awake. R805 did not verbally respond when spoken to, but made some eye contact. R805's oxygen concentrator was running and set to 3 LPM. The nasal cannula was observed out of R805's nostrils and was to the right side of the nose. At that time, Certified Nursing Assistant (CNA) 'H' was queried about R805's oxygen. When CNA 'H' moved the nasal cannula to R805's nostrils, a deep imprint from the oxygen tubing was observed across the left side of R805's cheek.
On 10/5/23 at 1:30 PM, R805 was observed receiving 3 LPM of oxygen via nasal cannula. At that time, Registered Nurse (RN) 'I', R805's assigned nurse, was queried about R805's oxygen requirements. RN 'I' reviewed R805's clinical record and reported there was no order for oxygen. When queried about whether R805 required oxygen, RN 'I' reviewed a care plan from 2/2023 and entered an order based on the care plan that documented and intervention initiated on 2/17/23 that read, Oxygen 2L via NC (nasal cannula) to maintain spO2 (saturation of peripheral oxygen) (greater than) 92 (percent) .
Further review of R805's Physician's Orders revealed R805 had an order for oxygen 2LPM via NC with a start date of 2/16/23 that was discontinued on 3/5/23.
Review of R805's progress notes revealed a note from the medical provider that documented, .Staff reports that patient is noncompliant with oxygen .He is improved significantly from his respiratory status .Pulse ox is well-maintained. We will discontinue oxygen at this time. Monitor closely .
Review of a Nursing Summary progress note dated 8/10/23 revealed, .readmission from .hospital. res (resident) was treated for aspiration and congestion .Both lungs have crackling lung sounds. Res is on 2L of O2 (oxygen) .
Review of a Nurses Note dated 8/31/23 revealed, .Observed the res playing with his nasal cannula using his teeth .
Review of a physician's Encounter progress note dated 9/10/23 mentioned the nurses note that said R805 was playing with the nasal cannula using his teeth. However, the note did not document whether R805 required oxygen therapy.
Review of a physician Encounter progress note dated 9/27/23 documented, .He does remain on oxygen .O2 Saturation 93 (percent) Room Air .
CPAP Machine
Further review of R805's Physician's Orders revealed the following orders:
An order for CPAP Only can be applied with supervised Care to avoid choking Please contact Doctor (name redacted) .at bedtime for dyspnea (shortness of breath). This order had a start date of 2/16/23 and was discontinued on 4/7/23. Review of R805's February 2023 Medication Administration Record (MAR) revealed the CPAP was not applied on 2/17/23 as evidenced by no nurses signature, and on 2/18/23, 2/19/23, and 2/22/23, 5 was documented which indicated Hold/See Nurse Note. Review of R805's Nurses Notes and Medication Administration Notes revealed, the CPAP machine was not available on 2/18/23, 2/19/23, and 2/22/23. There was no note regarding 2/17/23. Review of R805's March 2023 MAR revealed the CPAP was not applied as evidenced by no nurses signature on 3/2/23, 3/3/23, 3/6/23, 3/8/23, 3/11/23, and 3/26/23. On the following dates, 5 was documented: 3/4/23, 3/5/23, 3/7/23, 3/9/23, 3/12/23, 3/14/23, 3/15/23, 3/16/23, 3/17/23, 3/18/23, 3/19/23, 3/20/23, 3/21/23, 3/23/23, 3/25/23, 3/26/23, and 3/30/23. Review of R805's progress notes revealed multiple days where it was documented the CPAP was not available and multiple days where it was not documented why it was not applied. Review of R805's April 2023 MAR revealed the CPAP was not applied on 4/1/23, 4/2/23, 4/3/23, 4/4/23, 4/5/23, and 4/6/23. It was documented on a Medication Administration Note on 4/6/23 that the CPAP was not available. The MAR indicated the CPAP was held from 4/7/23 through 4/20/23 and restarted on 4/21/23.
An order for CPAP Only can be applied with supervised care at bedtime for dyspnea. This order had a start date of 4/21/23 and was discontinued on 6/4/23. It was documented (5) on 4/21/23 and 4/28/23 on the MAR. Review of the Medication Administration Notes for those dates revealed the CPAP was on order. It should be noted that it was documented on multiple dates that R805's CPAP machine was applied, despite other notes that documented it was not available. Review of R805's May 2023 MAR revealed the CPAP was applied on 5/1/23, 5/10/23, 5/13/23, 5/22/23, 5/24/23, 5/27/23, 5/29/23, and 5/31/23. The rest of the dates were left blank or 5 was documented. Review of R805's progress notes revealed no documentation of why the CPAP was not applied.
An order for CPAP Only can be applied with supervised care at bed time . This order had a start date of 6/4/23 and was discontinued on 7/27/23. Review of R805's MAR for June 2023 revealed the CPAP was not applied on 6/23/23 and 6/29/23, indicated by the documentation of 5. There was no progress note to indicated why it was not applied. Review of R805's July 2023 MAR revealed the CPAP was not applied on 7/8/23, 7/9/23, 7/10/23, 7/11/23, 7/13/23, 7/19/23, 7/20/23, 7/21/23, 7/22/23, and 7/23/23. Review of a Nurses Note dated 7/9/23 revealed, No C-pap machine in the room/med (medication) room. Review of a Medication Administration Note dated 7/11/23 revealed, No CPAP machine. On 7/19/23, a physician progress note documented, Patient does have cognitive deficits and may not be able to tolerate CPAP. However, prior to that date, there were no progress notes that indicated the physician was made aware that the CPAP machine was not being applied and/or not available for use per the orders.
On 10/5/23 at 3:15 PM, an interview was conducted with the Assistant Director of Nursing (ADON) in the DON's absence. When queried about R805's Physician's Orders for a CPAP between 2/2023 and 7/2023 and why the machine was not available, the ADON reported R805 had a CPAP ordered for a sleep study when he was discharged form the hospital on 2/15/23. When queried about when the sleep study was done, the ADON reported she would look into it. When queried about what should be done if a physician ordered treatment (CPAP) was not available, the ADON reported the nurses should have notified the physician that it was not available or seek clarification if the order was not clear. At that time, the ADON was asked to provide the date R805's sleep study was completed and the results.
Sleep Study
Further review of R805's Physician's Order revealed an order for Arrange for sleep study for underlying suspected sleep apnea. That order was started on 3/18/23 and discontinued on 7/27/23.
Review of R805's progress notes revealed the following:
On 3/20/23, a Nurses Note documented, Reminded/followed up Unit manager regarding the sleep study for resident; Unit Manager stated she's working on it and she is aware of it.
On 3/23/23, a Nurses Note documented, Writer has made an attempt everyday since 3/20/23 to get in contact with (physician name) office regarding picking up equipment for sleep study for resident. Writer has left voicemails and called within the hours stated on answering service .Writer is reaching out again this morning .
On 3/23/23, a Nurses Note documented, (Physician name) office returned call .states that the sleep study kit can be picked up on April 4th at 3pm and whomever picks up the kit they will show them how to use the equipment. The kit will need to be returned April 5th .MD (Medical Doctor) will decide on f/u (follow up) after the results are viewed .
On 7/19/23 (four months after the sleep study was ordered), a Physician's note documented, .He was also ordered to have sleep study which I was requested once again but appears to have not made any progress from facility standpoint .
Review of R805's complete electronic medical record revealed no results or evidence that the sleep study was conducted.
On 10/5/23 at 4:43 PM, the ADON followed up and reported they did not have results from R805's sleep study, the date that it was completed, or evidence that it was done.
Review of a facility policy titled, Physician's Order, revised on 6/24/21, revealed, in part, the following: Physicians orders are obtained to provide a clear direction in the care of the guest/resident .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00135477.
Based on observation, interview, and record review, the facility failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00135477.
Based on observation, interview, and record review, the facility failed to operationalize their abuse policy to protect residents during an investigation of abuse for one (R804) of four residents reviewed for abuse and residents assigned to the alleged perpetrator. Findings include:
Review of a complaint submitted to the State Agency in March 2023 revealed an allegation that Certified Nursing Assistant (CNA) 'R' had a verbal altercation with resident (R804), she came at her, other staff told (CNA 'R') to get out but she didn't get out and when she did leave she came back in and stood next to the resident yelling at her.
On 10/4/23 at 9:37 AM, R804 was observed lying in bed. When queried about any concerns with staff, R804 reported they were mistreated by CNA 'R' a few months ago. When queried about what happened, R804 explained they (the resident) made a sarcastic comment to CNA 'R' when they collected their meal tray because they remove them quickly which ended in a verbal argument. R804 reported they typically let stuff go but I couldn't let this go because she was arguing with me. I was loud with her and she was loud with me back. The nurse had to come in and ordered her to get out of my room and not to talk to me. Then she was complaining as she left the room, came back in, stood over me, and yelled at me. That was the only time I felt afraid being here. R804 explained CNA 'R' was not allowed to work with them anymore, but remained an employee at the facility. R804 stated, If I see her walk by, I almost start to have a panic attack. R804 further explained what got her (CNA 'R') really enraged was when I mentioned that she did not give me the money she owed me when I bought food for her. R804 reported CNA 'R' frequently talked on the phone in front of the resident and therefore R804 overheard conversations about money problems. R804 reported they were in a position to be nice and knew they should not have given CNA 'R' money, but they said they would pay it back. R804 reported they were not concerned about it, but they brought it up after CNA 'R' began arguing with them and then CNA 'R' got really mad when R804 brought up the money. R804 reported the facility spoke to them about the incident and stated, They want you to remember every little detail and sometimes it's hard to keep it all straight.
On 10/4/23 at 11:50 AM, all incident reports, grievance forms, and investigations regarding R804 from March 2023 was requested.
Review of a soft file investigation provided by the Administrator regarding R804 revealed the following:
A signed statement written by LPN 'R' documented, observed CENA and resident arguing in room. CENA stated to me that she was not going to take care of resident because she was cursing at her. Nurse went into room and observed CENA giving care to resident and asked her not to say anything to the resident. Nurse could here <sic> CENA and resident continue to argue. Nurse asked CENA again not to say anything to the resident. At this time she was coming out of the room. Nurse spoke with resident and was informed that CENA owes her $20.00 and she said part of the argument was about that. I could also here <sic> resident telling the CENA several times to leave the room. I went in the second time and CENA was coming out of the room. At this time CENA was asked to go home and talk with the DON (Director of Nursing) on Monday. The statement was signed by LPN 'L' and R804 on 3/12/23 at 9:10 AM. The statement documented, (Administrator) was texted, and left message also texted DON.
A Incident and Accident Investigation Form dated 3/11/23 around 10:30 PM (note that LPN 'R's statement was written on 3/12/23 at 9:10 AM, approximately 11 hours later) documented R804 was the resident involved in the incident and CNA 'R' was the alleged perpetrator. The form documented, Resident reported to the nurse that she had an argument with her CNA and she owed her $20. It was documented that the reporting person became aware of the incident on Sunday 3/12/23 and it was reported to the Administrator and DON through text on 3/11/23 at 11:04 PM. It was documented that the text stated the CNA was being sent home for arguing with resident. The action taken by the facility was documented as CNA was asked to leave the unit and go home for the night. It was documented the incident was not reported to the State Agency. In the interview section, it was documented to see interview sheets.
Review of a written statement by CNA 'R' on 3/12/23 revealed the following: Upon making rounds 3/11/23 3-11 (pm) shift between 10-10:30 pm I entered (R804's room), as soon as I entered the room (R804) was already agitated stating she doesn't like the nurse because she don't give her meds (medications) in a timely fashion. So I began to tell her I'm here to change you and she stated saying hurry up and get it done .raising her voice. I said Ok (R804) then let me change you, she was on and on about how she doesn't like the nurse and she hate she has to deal with her on the night shift very irate and loud. While changing her I'm telling her to turn she began yelling and screaming at me once again to hurry up and get out of her rm (room) .So I finished up and exited the rm and the nurse (LPN 'L') comes up to me and say you just need to shut up and say nothing and I'm like wow telling her the resident is the one yelling and screaming. By this time I'm coming up the hallway agitated by her telling me to shut up. So I told her I was going outside to smoke for 5 min (minutes). Upon coming back into the building that's when she approached me and said (R804) is stating she was verbally abused accusing me of owing her $20.00 for lunch she brought the unit months ago and I'm like really are you serious that's not true I owe her nothing I've never taken anything from her. So (LPN 'L') goes on to tell me I have to leave because (R804) is stating that I verbally abuse her and she's calling the state, the DON, and the Administrator. So I'm like can I be switched off to another unit to avoid contact with her and she was irate .stating her license is on the line if she don't report it. So left and went outside and (names of three staff members) told me to come back and go to C-Wing and that's what I did.
Review of a document titled, Quality Assurance Interview Summary revealed the following Summary of Resident Interview given by R804 on 3/13/23, two days after the alleged incident: Resident states that she can not really remember what started the argument between her and (CNA 'R'). She states that she told the nurse (LPN 'L') that (CNA 'R') owed her $20 because she bought them both dinner one time in the past. Resident states at that time she told (CNA 'R') to keep the change from the $40 she gave her to buy their dinner. Resident states that when she was upset she said she wanted the money back out of spite. Resident stated that she cannot recall what either were saying to each other. Resident states that (CNA 'R') did not curse or call her any names or make any threats. Resident states that she yelled for CNA to get out of her room at this time .Resident stated she no longer wants (CNA 'R') as a care giver because she believes they are no longer friends.
An interview with CNA 'S' was documented on the above form. The date of the interview was 3/14/23, three days after the alleged incident. The summary of the statement read, When I walked up I overheard (LPN 'L') telling the resident to call state or DON about the situation and that (CNA 'R') shouldn't be working all of these days if she's stressed .
Further review of the Incident and Accident Investigation Form revealed the following documented conclusion: After further review and interviews the facility does not substantiate verbal abuse. The employee was however disciplined for the accusation of accepting dinner from a resident . The form was signed on 3/13/23 which was two days after the alleged incident occurred.
On 10/4/23 at 1:04 PM, a phone interview was conducted with Licensed Practical Nurse (LPN) 'L'. When queried about the incident between R804 and CNA 'R', LPN 'L' reported they heard R804 and CNA 'R' yelling and going back and forth arguing from the hallway. LPN 'L' intervened and asked CNA 'R' to stop talking to the resident while they were finishing care. LPN 'L' reported they heard R804 yelling for CNA 'R' to get out of their room which is why LPN 'L' intervened. After CNA 'R' left the room, LPN 'L' interviewed R804 who told them CNA 'R' borrowed money from them and did not pay them back and that CNA 'R' verbally abused them. LPN 'L' explained they texted the Administrator and did not hear back so they contacted the Director of Nursing (DON). They were told to write a statement and put it under the Administrator's door. LPN 'L' asked CNA 'R' to leave the building at that time and as far as they knew, CNA 'R' left.
Review of CNA 'R's time punch report for March 2023 revealed CNA 'R' clocked in at 2:57 PM on 3/11/23 and clocked out at 7:22 AM on 3/12/23, which indicated they did not leave the facility per LPN 'L's request at or around 10:30 PM when the alleged incident occurred. CNA 'R' worked on 3/12/23 from 2:57 PM until 7:02 AM on 3/13/23 and 3/13/23 from 2:53 PM until 7:01 AM on 3/14/23. It should be noted that interviews included in the investigation were still being conducted on 3/14/23 and the investigation form was signed off by the administrator on 3/13/23.
On 10/4/23 at 4:09 PM, an interview was conducted with the Administrator, who was the facility's Abuse Coordinator. When queried on the steps taken by the facility to protect residents when allegations of abuse were made against a staff member, the Administrator reported the staff member would be sent home immediately and suspended pending the completion of the investigation. When queried about whether CNA 'R' was suspended during the investigation, the Administrator reported LPN 'L' sent them home, but the Administrator did not know CNA 'R' stayed and went to another unit until they gave their statement the following day. The Administrator reported CNA 'R' should have gone home and the staff members who told them to stay should not have done that. The Administrator did not offer a response regarding why CNA 'R' continued to work in the facility while the investigation was in progress.
Review of R804's clinical record revealed R804 was admitted into the facility on 8/16/13 and readmitted on [DATE]. Review of Minimum Data Set (MDS) assessments dated 8/8/23 and 2/7/23 revealed R804 had intact cognition and no behaviors.
Review of a facility policy, effective 10/15/22, revealed, in part, the following:
.Protection of Guests/Residents during the Investigation .If the accused is an employee of the facility, he/she will be suspended until the investigation has been completed .
Jan 2023
16 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R25
Review of the medical record revealed R25 was admitted to the facility on [DATE] with a readmission date of 11/27/22 and dia...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R25
Review of the medical record revealed R25 was admitted to the facility on [DATE] with a readmission date of 11/27/22 and diagnoses that included: Dementia, osteoarthritis of left hip, difficulty walking, muscle wasting and atrophy. A MDS assessment dated [DATE], documented a BIMS score of 06 indicating severely impaired cognition and required staff assistance for all ADLs.
Review of the progress notes revealed the following:
On 4/24/22 at 5:58 AM, . Res (resident) observed on buttocks on floor with her back against bed and legs out straight. No inward outward rotation noted, res able to move all extremities and denies pain at present .
On 10/12/22 at 6:27 AM, . Resident stated that she tried to get something from her recliner, her knees got weak and she lower <sic> herself to the floor. She also stated that she did not hit her head .
On 11/14/22 at 3:29 PM, . CNA (Certified Nursing Assistant) found resident on the floor sitting up. Came to get nurse. Assessed took VS (Vital Signs) and helped resident back into bed with the assistance of CNA and another nurse .
On 11/15/22 a physician progress note documented in part . Patient is seen today for an unwitnessed fall which occurred yesterday afternoon when she slid out of her wheelchair onto her buttocks on the floor. She stated to staff ?I wanted someone to come in?. She had slid out of bed onto her buttocks yesterday morning, making this her second fall of the day . 0900 Notified by Nursing that resident again had an unwitnessed fall. She was sitting on her buttocks on the floor of room beside her wheelchair . Nursing is aware of her recent frequent falls. She requires frequent supervision .
On 12/7/22 at 6:18 AM, . writer entered res room and observed res sitting on the floor on her buttocks legs straight in front of her and back leaning against the bed res educated on the use of call light .
On 12/30/22 at 4:24 PM, . Writer was alerted that resident was on the floor. Writer went into residents room and confirms <sic> resident on the floor, in a seated position with her back up against the bed . Resident states that she was attempting to go from a seated position to standing, as it appeared that resident did not have on her footwear . Resident further educated on the importance of complying with all safety measures .
On 1/17/23 at 8:32 AM, . Informed by staff that resident was observed sliding onto floor from bed. Received resident sitting on floor next to bed . Transferred back to bed with 2 person assist .
All fall Incident reports with the completed investigations for R25 were requested from the Administrator.
Review of the fall Incident reports revealed the following:
No fall incident report, IDT (Interdisciplinary team) evaluation or investigation received for the 4/24/22 fall.
10/12/22- . Immediate Action Taken . vitals were obtained and the resident was educated on the call light. The resident is diagnosed with dementia, educating the resident on the use of the call light is not an effective intervention. No IDT evaluation or investigation provided.
11/14/22 (two incident reports provided for two separate falls that occurred on this date), fall #1- . Immediate Action Taken . Skin Assessment, VS taken, assistance back into bed. Called family . and Fall #2- . Immediate Action Taken . Assessed. VS taken. Family called . No IDT evaluation or investigation provided for either fall.
12/7/22 . Immediate Action Taken . skin assessment done, no injuries noted, notified on call NP (Nurse Practitioner) no new orders, res educated on use of call light . This is a repeated and ineffective intervention. No IDT evaluation or investigation provided.
12/30/22 . Immediate Action Taken . Resident educated on the importance of wearing proper footwear when attempting to go from a seated position to standing . Resident further educated on the importance of complying with all safety measures . No IDT evaluation or investigation provided.
1/17/23 . Immediate Action Taken . ROM (range of motion) wnl (within normal limits) . OT (occupational therapy) to evaluate bed mobility and sage bed height for transfers . The resident is documented as Setup help only for Transfer on the MDS. Review of R25's ADL care plan documented . TRANSFER: Resident requires assistance with transfers with one staff assistance . Initiated: 09/21/2021 .
Review of R25's fall care plan revealed little to no review, modification or revision of the interventions implemented to prevent further falls. Further review revealed on 11/16/22 and intervention . Obtain labs as ordered, report abnormal findings to the physician . was implemented. On 1/3/23 and intervention was revised to . Encourage the resident to wear appropriate footwear as needed when going rom seated to standing position . the resident care plan documented a one person staff assistance with transfers, therefore staff should ensure that the resident is wearing the appropriate footwear at the start of the day and when transferring the resident. On 1/17/23 and intervention was documented to have OT to evaluate bed mobility and safe bed height for transfers. No further interventions were modified, revised or implemented for R25 despite the seven falls identified.
Further review of the medical record revealed one IDT note dated 1/17/23 at 10:21 AM, regarding the IDT team to have met and discussed the fall and the review of fall interventions for R25. No other IDT notes were documented for the prior falls.
Review of a facility policy titled Fall Management documented in part, . The facility will identify hazards and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls . If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls .
On 1/20/23 at 2:40 PM, the DON was interviewed and asked about each fall, the lack of identification of the root cause of the falls and the lack of interventions implemented to prevent further falls. The DON stated they were newly employed at the facility, however, would look into it and follow back up.
No further explanation or documentation was received by the end of survey.
This citation pertains to intake #MI00132456.
Based on observation, interview, and record review, the facility failed to perform a thorough root-cause analysis and investigation into falls and ensure interventions were implemented to prevent falls for two residents (R#'s 86 and 25) of three residents reviewed for falls, resulting in a fall with injury and transfer to the emergency room. Findings include:
On 1/18/23 at 11:36 AM, R86 was observed seated in a wheelchair at their bedside. It was observed R5 had a scab on their nose and the purple/yellow appearance of a healing bruise around their right eye. R86 was asked about the scab and bruise and said about a week ago they fell out of their bed. They continued to explain their remote control had fallen to the floor and they were reaching for it they rolled out of bed. They said they broke their nose, were transferred to the emergency room, and soon they were supposed to have a follow-up appointment with an ear, nose and throat doctor. R86 was asked if they put their call light on for assistance and said they did. They were asked to estimate how long the call light was on and said more than a half an hour. R86 said they got tired of waiting and said, I went for it, I shouldn't have, but I did.
On 1/19/23 at 10:14 AM, a review of R86's clinical record revealed they most recently re-admitted to the facility on [DATE] with diagnoses that included: right above the knee amputation, anxiety disorder, diabetes, and major depressive disorder. R86's most recent Minimum Data Set (MDS) assessment dated [DATE] did not have R86 assessed for cognition, revealed they were not ambulatory, and required extensive assistance from two staff members for bed mobility and total assistance from two staff members for transferring.
On 1/19/22 at approximately 10:45 AM, a review of a facility provided incident report for R86's fall was reviewed. The report documented R86's fall and read, .Resident Description: Res (resident) states she was looking for her TV remote and fell out of bed . The report further documented R86 was oriented to person and to situation and sustained an abrasion to their nose. It was noted that nowhere in the report did it address whether R86's call light was on or not on at the time of the fall.
On 1/19/23 at 10:51 AM, a follow-up interview was conducted with the resident. They were again asked to describe what they remembered from the fall. They said their remote control was on the floor, they activated the call light for assistance and when no one came to help them, they decided to retrieve it and fell out of the bed.
On 1/19/23 at approximately 12:30 PM, a review of R86's progress notes was conducted and revealed the following:
A nursing note dated 1/11/23 at 3:33 AM that read, .Laying on the floor face down. Stating 'I was looking for remote' .swelling and bleeding noted to nose during assessment .
A nursing note dated 1/11/23 at 10:05 AM that read, (X-ray company) in to obtain Nasal bone X-rays .
A nursing note dated 1/11/23 at 12:42 PM that read, .Received X-ray results: There is fracture of distal nasal bone .NP (Nurse Practitioner) notified and ordered transfer to (Hospital) .
A nursing note dated 1/11/23 at 12:54 PM that read, .Writer called residents RP (responsible party) .to notify her of nasal fracture and that resident will be transferred to hospital to see ENT (ear, nose, throat specialist) .
On 1/19/23 at 4:02 PM, an interview was conducted with the facility's Administrator regarding their policy and procedures for falls. They were first asked if they were able to pull any call light logs to see whether R86's call light had been on at the time of the fall. They said their system did not allow for tracking call light times. They were then asked if they interviewed any of the staff or the resident about the fall and whether the call light had been on. They said they did interviews, but no one said whether the call light had been on or not. At that time, R86's interview was shared with the Administrator where R86 said their light had been on at the time of the fall and when no one came to help them, that's when they fell out of bed sustaining their injury. The Administrator did not offer any further response, but acknowledged the concern about the investigation not addressing the call light.
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 F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00130660.
Based on interview and record review the facility failed to provide written notif...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00130660.
Based on interview and record review the facility failed to provide written notification of the facility's bed hold policy upon transfer to the hospital for one resident (R77) of two residents reviewed for hospital transfers. Findings include:
On 1/19/23 a concern submitted to the State Agency was reviewed which alleged R77 was not provided written procedures for the facility's bed hold policies upon transfer to the hospital.
On 1/19/23 the medical record for R77 was reviewed and revealed the following: R77 was initially admitted to the facility on [DATE] and had diagnoses including Congestive Heart Failure and Paraplegia. A review of R77's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/13/22 revealed R77 needed extensive assistance from facility staff with most of their activities of daily living. R77's BIMS score (brief interview of mental status) was 14 indicating intact cognition.
A review of R77's census data indicated that R77 was sent to the hospital on 8/18/22. Further review of the medical record revealed no documentation that a written bed hold information was provided to R77 with instructions on how to hold their bed in the facility upon transfer to the hospital.
On 1/20/23 at approximately 1:20 p.m., R77's medical record was reviewed with the facility Administrator and the Administrator was queried regarding the documentation that R77 was provided information on how to hold their bed upon transfer to the hospital. The Administrator indicated that the facility had no documentation that R77 was provided bed hold instructions. The Administrator indicated that if the bed hold information had been provided it would have been indicated in a progress note completed by the transferring Nurse. The Administrator indicated that the facility did not have any progress notes that documented R77 was given bed hold instructions upon transfer to the hospital on 8/18/22.
No documentation that R77 was provided written notification of bed hold policy/procedures upon transfer to the hospital on 8/18/22 was provided by the end of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R31
Review of the medical record revealed R31 was admitted to the facility on [DATE] with a readmission date of 8/12/2022 and di...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R31
Review of the medical record revealed R31 was admitted to the facility on [DATE] with a readmission date of 8/12/2022 and diagnoses that included: Alzheimer's disease, dementia and a psychotic disorder with delusions. A MDS assessment dated [DATE], documented a BIMS score of 03 which indicated severely impaired cognition and required staff assistance with all ADL's.
Review of a progress note dated 5/6/22 at 6:07 PM, documented in part . Writer notified by activity aid that resident was outside and taken inside by activity aid; admin (administration) and nursing notified by staff . Resident has 1:1 in place and new wander-guard was placed on resident .
Review of a facility Incident and Accident Report dated 5/6/2022, documented in part . Resident observed outside returned to facility by staff. Dressed weather appropriate in long sleeve jacket, long pants socks and shoes - wander guard on & functioning . 1:1 initiated .
Further review of the progress notes revealed R31 displayed wandering and exit seeking behavior before the elopement, as indicated in the following progress notes:
On 4/17/2022 at 3:12 AM, . res (resident) noted ambulating through out the night, res consistently closing her door and wandering into neighboring room .
On 4/17/2022 at 2:19 PM, . Resident noted to be ambulating more throughout the hallway and standing near exit doors. Resident was observed standing at the end of the hallway pushing on exit door when alarm began to beep and was redirected to room. Resident noted to have bouts of agitation upon redirection from exit doors .
On 4/17/22 at 3:22 PM, . Wander guard placed on resident R (right) ankle .
On 4/17/22 at 9:51 PM, . res was wandering halls and entering other res rooms .
On 5/6/22, . She is wandering the hallways. She occasionally needs redirection .
Review of a Risk for Elopement assessment dated [DATE], documented an At Risk score of 13.
Review of the R31's care plans revealed a care plan was never implemented for an elopement risk.
Review of a facility policy titled Elopement Policy last revised 4/26/22, documented in part . It is the policy of this facility to prevent to the extent reasonably possible, the elopement of guests/residents from the facility . The Guest/Resident Care Plan . will reflect if the guest/resident triggers as an elopement risk and any interventions initiated . Care plans are to reflect the potential for elopement of the guest/resident and will be reviewed, revised, and updated as needed by the interdisciplinary team .
On 1/20/23 at 10:42 AM, the Administrator was interviewed and asked why R31 did not have a care plan implemented for an elopement risk when they were exhibiting wandering and exit seeking behaviors prior to their elopement and the Administrator stated they reviewed the chart and realized the care plan was not in place at the time of the elopement. The Administrator stated a care plan should have been implemented. The Administrator stated they have started education with their staff.
No further information or documentation was provided by the end of survey.
Based on observation, interview, and record review, the facility failed to develop an individualized comprehensive plan of care for two residents (R31 and R92) including addressing oxygen therapy for R92 and elopement risk for R31. Findings include:
Resident #92
On 1/18/23 at approximately 10:21 a.m., R92 was observed in their room, up in their wheelchair. R92 was observed to have oxygen infusing at 2 LPM (liters per minute) via a nasal cannula. R92 was observed without any dating on the oxygen tubing. R92 was queried if they knew how much oxygen they were to be provided and they reported that it was somewhere between 2-3 liters.
On 1/18/23 at approximately 4:32 p.m., R92 was observed in their room, laying in their bed with oxygen infusing at 2 LPM.
On 1/19/23 at approximately 9:46 a.m., R92's room and bed was observed to have an oxygen concentrator infusing oxygen at 2LPM (liters per minute). A Nasal cannula was observed on the bed without R92 present in the room.
On 1/20/23 at approximately 8:24 a.m., R92 was observed in their room, laying in their bed. R92 was observed to have oxygen infusing via their nasal cannula. The concentrator was observed to be infusing at 2 LPM.
On 1/18/23 the medical record for R92 was reviewed and revealed the following: R92 was initially admitted to the facility on [DATE] and had diagnoses including Chronic obstructive pulmonary disease and End stage renal disease. A review of R92's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/23/22 revealed in section O that R92 was on oxygen therapy.
Further review of R92's comprehensive plan of care did not reveal any individualized specific plans of care for R92's oxygen therapy.
On 1/20/23 at approximately 8:57 a.m., during a conversation with the Director of Nursing (DON), the DON was queried why R92 did not have a plan of care addressing their oxygen therapy and they indicated that they would look into the concern.
On 1/20/23 at approximately 9:21 a.m., during a follow-up conversation with the DON, the DON indicated that R92 did not have a Physician's order or a plan of care for their oxygen therapy and would have to get one implemented. The DON was queried regarding the process implementing oxygen therapy into R92's plan of care and they indicated that Nursing staff or the MDS department creates the plans of care and any resident on oxygen therapy should have a plan of care implemented for them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Physician orders for treatments were accurately ...
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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 Physician orders for treatments were accurately transcribed and completed for one resident (R81) of three residents reviewed for pressure ulcers, resulting in the potential for worsening of R81's stage four pressure ulcer on their left trochanter. Findings include:
On 1/18/23 at approximately 10:30 a.m., R81 was observed in their room, up in their wheelchair. R81 was queried if they had any wounds and they indicated that they did. R81 was queried if they felt that the facility was adequately caring for their wounds and they indicated they did not know because they believed they were not healing.
On 1/19/2023 at approximately 3:58 p.m. R81 was observed in their room, laying in their bed. R81 was queried if any staff from the facility had completed their wound care and they indicated they were unsure.
On 1/18/23 the medical record for R81 was reviewed and revealed the following: R81 was initially admitted to the facility on [DATE] and had diagnoses including Pressure ulcer of left hip-Stage four and Muscle weakness. A review of R81's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/8/22 revealed R81 had multiple stage four pressure ulcers.
A Braden scale assessment dated [DATE] (used to predict pressure sore risk) revealed a score of 14 indicating moderate risk of pressure ulcer development.
A review of R81's comprehensive plan of care revealed the following: [R81] has Actual impairment to skin integrity r/t (related to) fragile skin, decreased mobility and choosing not to reposition and not to use wedge and low air loss mattress, has poor nutritional intake with diagnosis of protein calorie malnutrition, low hemoglobin, CHF (Congestive heart failure), bullous pemphigoid, and paraplegia. Sacrum stg (stage) 4, Left Trochanter .Interventions-Follow facility protocols for treatment of injury .Outside wound care consult .
A Physician's order with a start date of 11/16/22 and a D/C (discontinued) date of 1/18/23 revealed the following: Cleanse left trochanter w/ (with) wound cleanser, pat dry. apply prisma AG and cover w/ dry dressing every Mon,Wed, Fri daily and as needed.
A Physician's wound evaluation dated 12/28/22 from R81's outpatient wound Physician revealed the following: Purpose of visit-Wound care .Progress Notes:-May sit in wheelchair 2 hours at a time. Begin hydrofera blue and <indiscernible writing> await cx's (cultures) .Stage four left trochanter ulcer .
Further review of R81's Physician orders revealed no order history for the hydrofera blue wound care treatment ordered by R81's Physician on 12/28/22.
A review of R81's December 2022 TAR (treatment administration record) and January 2023 TAR revealed no documentation of R81's hydrofera blue treatments ordered by R81's Physician on 12/28/22 were administered.
A review of the history of R81's Wound comparison of their stage four wound located on their left trochanter in the electronic medical record revealed the following wound assessments: 12/26/22-Area-0.95cm, Length-1.49cm, Width-0.75cm, Deepest Point-0.2cm .1/6/23-Area-1.26cm (larger), Length-0.99 (longer), Width-1.35cm (wider), Deepest Point-0.3cm (deeper) .
On 1/20/23 at approximately 1:53 p.m., R81's wound care was reviewed with the facility wound care Nurse/ADON (Assistant Director of Nursing). The ADON was queried why the Wound evaluation from R81's outside wound Physician dated 12/28/22 was not transcribed into the medical record and the treatment started and administered. The ADON indicated that they never received the wound evaluation from the Physician and that a floor Nurse must have received it and put it into the scanning box without notifying them of the new treatment order. At that time, R81's wound measurements from 12/26/22 and 1/6/23 (latest available wound measurements) were reviewed with the ADON and they indicated that R81's left trochanter had worsened during that time. The ADON was queried what the treatment order should have been during that time period and they indicated that the treatment should have been changed to hydrofera blue and myplex powder as indicated on the Wound Care Physician's evaluation on 12/28/22 that had been missed.
On 1/20/23 a facility document titled Skin Management was reviewed and revealed the following: Policy-It is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries .Overview-Guests/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes .
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** Resident #30
On 1/18/23 at approximately 11:06 a.m., R30 was observed in their room, laying in their bed. R30 appeared to have c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #30
On 1/18/23 at approximately 11:06 a.m., R30 was observed in their room, laying in their bed. R30 appeared to have contratures in both of their hands. R30 was queried if the facility was applying any wedges or devices to their hands or arms to assist with the contractures and they indicated they thought the facility was trying to do something.
On 1/18/23 at approximately 4:34 p.m., R30 was observed in their room, laying in their bed. R30 was observed not to have any protective devices applied to their arms or hands.
On 1/18/23 the medical record for R30 was reviewed and revealed the following: R30 was initially admitted to the facility on [DATE] and had diagnoses including Spastic quadriplegic cerebral palsy and Functional quadriplegia. A review of R30's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/25/22 revealed R30 was dependent on staff for assistance with most of their activities of daily living. Section G indicated that R30 had impairments in both their lower and upper extremities on both sides.
A Physician's order dated 11/30/22 revealed the following: OT eval only for splint management on 11/30/22.
An Occupational Therapy evaluation and plan of treatment signed and dated by Occupational Therapist L (OT L) on 12/1/22 revealed the following: Assessment Summary: Limitations-Functional limitations as result of contracture(s): Skin integrity .Recs (Recommendations)-Splint/Orthotic Recommendations: Bilateral palm pillows and elbow wedge cushion for bilateral elbows for four hours .Skilled Justification-Reason for skilled services: eval only for caregiver education and reestablishing RNP (restorative Nursing program) .Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for decreased skin integrity .
A facility document titled Therapy to restorative Program Plan dated 12/1/22 revealed the following: 1. Restorative plan: Resident to maintain good skin integrity and prevent skin breakdown .2. Date of plan:12/1/2022 .3. Goal(s): Resident to maintain good skin integrity and to prevent skin breakdown. Bilateral palm pillows and bilateral elbow extension wedge on for up to four hours or as tolerated .4. Interventions: Resident to maintain good skin integrity and to prevent skin breakdown .Bilateral palm pillows and bilateral elbow extension wedge on for up to four hours or as tolerated .Wash and dry hands prior to donning palm pillows .
On 1/20/23 at approximately 11:35 a.m., OT L was queried regarding the OT evaluation order for R30 on 11/30/22. OT L indicated the therapy team did an evaluation on 11/3023 and made new interventions for R30's contracted hands and elbows. OT L reported that due to R30's contactures, they (the facility staff) are doing palm pillows and bilateral elbow extension wedges every day for 4 hours as tolerated for them. OT L was queried regarding the implementation of their interventions and they indicated that the facility Nursing staff should have implemented the orders and updated the careplan to reflect the new interventions for R30's contractures.
Further review of R30's medical record revealed no Physician orders for R30's palm pillows or elbow extension wedges.
Further review of R30's careplan revealed the following: [R30] has an ADL (activity of daily living) Self Care Performance Deficit and requires assistance with ADL's and mobility r/t (related to): cognitive and mobility deficits, b/b (bowel and bladder) incontinence, non-ambulatory, communication deficit .Interventions-Range of motion: Rue (right upper extremity) & Rle (right lower extremity) ROM (range of motion) impairment LUE (left upper extremity) & LLE (lower left extremity) ROM impairment. Elbow flexion contracture and LE (lower extremity) contractures . No inclusion of R30's palm pillows or elbow extension wedges were noted in the plan of care.
On 1/20/23 at approximately 11:48 a.m., during a conversation with the facility Administrator, the Administrator was queried regarding R30's palm pillows and bilateral elbow extension wedges and why there were no Physician orders, CNA (certified nursing assistant) documentation of application or interventions added to the care plan pertaining to them. The Administrator reported that the previous DON (Director of Nursing) was doing the restorative Nursing documentation and the the facility had a program coordinator in last four weeks and that the restorative aides who would be applying the pillows and extensions could be pulled to floor at times but the facility was trying get them done and would have to follow up regarding the concerns for the lack of R30's palm pillows and elbow wedges.
On 1/20/23 at approximately 1:50 p.m., the Administrator followed up regarding the identified concerns and reported that R30's therapy interventions including their palm pillows and elbow extension wedges were not communicated to the Nursing staff, were not being applied and there was no documentation to provide that they were being implemented. The Administrator indicated they would have to get the interventions implemented as soon as possible.
Based on observation, interview, and record review, the facility failed to ensure restorative services including range of motion (ROM) exercises and the application of splints for two residents (R#'s 87 and 30) of two residents reviewed for restorative services, resulting in the potential for functional decline. Findings include:
A review of a facility provided policy titled, Restorative Nursing revised 12/1/18 was conducted and read, The facility strives to enable the resident to attain and maintain the highest practicable level of physical, mental, and psychosocial well-being .A licensed nurse will help manage the restorative nursing process with assistance of nursing assistants trained in restorative care .Nursing Restorative is available up to 6-7 times per week .Procedure: .11. Document the resident's daily participation and actual number of minutes participating in the resident's EHR (electronic health record) .
On 1/18/23 at 2:25 PM, R87 was observed at the bedside in their wheelchair. R87's left and right hands appeared contracted. At that time, an interview was conducted with R87 and they confirmed they had some contractures in their hands. They were asked they had any splints for their hands and said they did. They were then asked if staff assisted them with any range of motion exercises or application of their splints and said not very often and usually their partner would put them on when they visited.
On 1/20/23 at 8:59 AM, a review of R87's clinical revealed they most recently re-admitted on [DATE] with diagnoses that included: quadriplegia, seizures, anxiety disorder, and pressure ulcers. R87's Minimum Data Set assessment dated [DATE] indicated R87 had intact cognition, was non-ambulatory, and required extensive to total assistance from one or two staff member for all activities of daily living. A review of R87's Certified Nursing Aide tasks was conducted and revealed the following:
A task that read, .NURSING REHAB: *Provide gentle PROM (passive range of motion) as tolerated to BLE (bilateral extremities) prior to splint application. Resident will be able to wear bil (bilateral) AFO (ankle, foot orthosis) splint for up to 2 hours/as tolerated . A review of a 30-day look-back for the task was conducted and revealed that of the last 30 days, five entries on the task documented it was completed, four documented zero minutes of providing assistance, and Not Applicable was documented for the remaining 21 days.
A task that read, .NURSING REHAB: Resident to tolerate BUE (bilateral upper extremity) WHFO (wrist, hand, finger, orthosis) and left elbow extension splint for 2 hours as tolerated .gentle PROM as tolerated to BUE (bilateral upper extremities) prior to splint application . A review of a 30-day look-back for the task was conducted and revealed that of the last 30 days, five entries on the task documented it was completed, one entry documented No, and Not Applicable was documented for the remaining 24 days.
A review of R87's care plans was conducted and revealed an activity of daily living intervention dated 4/22/22 that indicated R87 was to have both upper and lower extremity range of motion exercises.
On 1/20/23 at 11:48 AM, an interview was conducted with the facility's Administrator regarding the facility's restorative nursing program. They said the previous Director of Nursing (DON) had been overseeing it, but since they left, they had been doing their best by assigning a day shift CNA to perform the tasks. They were asked about the restorative care documented as Not applicable and said it should be documented as performed or refused.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews the facility failed to ensure an antibiotic was administered as prescribed by...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews the facility failed to ensure an antibiotic was administered as prescribed by the physician for a Urinary Tract Infection (UTI) for one (R39) of two residents reviewed for a UTI. Findings Include:
On 1/19/23 at 12:10 PM, R39 was observed lying on their back in bed. A brief interview was conducted with the resident at that time.
Review of the medical record revealed R39 was admitted to the facility on [DATE] with a readmission date of 10/7/22 and diagnoses that included: hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side, heart failure and neuromuscular dysfunction of bladder. A Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition and required staff assistance for all Activities of Daily Living (ADLs, MDS 11/7/22).
Review of a Nurse Practitioner (NP) note dated 1/12/23, documented in part . seen today to follow up on her evaluation in Emergency yesterday. She was sent to (hospital name) Emergency due to lack of output from her suprapubic catheter. Although her catheter was replaced by Nursing there was still no urine output and her abdomen was distended. The suprapubic catheter was replaced in Emergency and she now has adequate urine output . was also diagnosed with a UTI and started on Macrobid (antibiotic) .
Review of the January 2023 Medication Administration Record (MAR) revealed the following:
Macrobid Capsule 100 MG (Milligram) Give 1 capsule by mouth two times a day for UTI for 6 Days.
Further review of the January 2023 MAR revealed two doses of the Macrobid was administered on 1/12/23, no doses provided on 1/13/23 or 1/14/23 and only one dose provided on 1/15/23 and 1/16/23. The facility nurses failed to administer the twice a day antibiotic on 1/13/23 and 1/14/23 and only administered one dose on the days of 1/15/23 and 1/16/23. The resident missed six doses of their prescribed antibiotic.
On 1/20/23 at 11:49 AM, the DON was interviewed and asked why the antibiotic was not administered as ordered by the physician on the dates noted above and the DON replied they would look into it and follow back up. Shortly after, the DON stated they reviewed the record and could not identify the reason why R39 was not provided their antibiotic as prescribed. The DON stated they have talked to the practitioner and they will assess and extend the antibiotic order to ensure the resident receive all of their doses.
No further information or documentation was provided by the end of survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
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 Physician orders were in place to administer oxy...
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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 Physician orders were in place to administer oxygen therapy for one resident (R92) of one resident reviewed for respiratory care. Findings include:
On 1/18/23 at approximately 10:21 a.m., R92 was observed in their room, up in their wheelchair. R92 was observed to have oxygen infusing at 2 LPM (liters per minute) via a nasal cannula. R92 was observed without any dating on the oxygen tubing. R92 was queried if they knew how much oxygen they were to be provided and they reported that it was somewhere between 2-3 liters.
On 1/18/23 at approximately 4:32 p.m., R92 was observed in their room, laying in their bed with oxygen infusing at 2 LPM.
On 1/19/23 at approximately 9:46 a.m., R92's room and bed was observed to have an oxygen concentrator infusing oxygen at 2LPM (liters per minute) A Nasal cannula was observed on the bed without R92 present in the room.
On 1/20/23 at approximately 8:24 a.m., R92 was observed in their room, laying in their bed. R92 was observed to have oxygen infusing via their nasal cannula. The concentrator was observed to be infusing at 2 LPM.
On 1/18/23 the medical record for R92 was reviewed and revealed the following: R92 was initially admitted to the facility on [DATE] and had diagnoses including Chronic obstructive pulmonary disease and End stage renal disease. A review of R92's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/23/22 revealed in section O that R92 was on oxygen therapy.
A review of R92's Physician orders did not reveal any orders to administer oxygen therapy to R92.
Further review of R92's comprehensive plan of care did not reveal any individualized specific plans of care for R92's oxygen therapy.
On 1/20/23 at approximately 8:57 a.m., during a conversation with the Director of Nursing (DON), the DON was queried why R92 did not have a plan of care addressing their oxygen therapy or any Physician orders for administration and they indicated that they would look into the concern.
On 1/20/23 at approximately 9:17 a.m., Nurse M was queried if R92 should be on oxygen and they indicated that they should. Nurse M was queried how many liters per minute was ordered for R92 and Nurse M was observed checking for an oxygen order from the Physician and reported that R92 did not have any Physician orders for oxygen and that they would have to call the Physician to see how many liters per minute R92 should be ordered.
On 1/20/23 at approximately 9:21 a.m., during a follow-up conversation with the DON, the DON indicated that R92 did not have a Physician's order or a plan of care for their oxygen therapy and would have to get one implemented. The DON was queried regarding the process of implementing oxygen therapy and they indicated that the Nursing staff should have received an order from the Physician and it should have been added to the plan of care.
On 1/20/23 a facility document titled Use of oxygen was reviewed. The facility document did not indicate how the Nurse obtains administration orders or how oxygen therapy is added to the comprehensive plan of care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure appropriate pain management was provided 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 appropriate pain management was provided for one resident (R250) of two residents reviewed for pain, resulting in the potential for pain to go untreated. Findings include:
On 1/18/23 at approximately 10:18 a.m., R250 was observed in their room laying in their bed. R250 was observed yelling out while laying in bed and was queried why they were yelling out. R250 reported they had pain in their legs.
On 1/19/23 the medical record was reviewed and revealed the following: R250 was initially admitted to the facility on [DATE] and had diagnoses including Osteoarthritis, Heart Failure and Hemiplegia and Hemiparesis following Cerebral infraction affecting left non-dominant side. A review of R250's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/16/23 revealed R250 needed assistance from facility staff with their activities of daily living.
An active Physician order with a start date of 1/10/23 revealed the following: Tramadol HCI tablet 50 MG Controlled drug-Give 1 tablet by mouth every 4 hours as needed for moderate pain.
A review of R250's careplans revealed the following: Focus-[R250] is at risk for pain and/or has (acute/chronic) pain r/t (related to) dx (diagnosis) of CVA (stroke) left hemiplegia, arthritis .Interventions-Anticipate resident's need for pain relief PRN (as needed) and respond immediately to any complaint of pain .Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain .
A Nurse Practitioner progress note dated 1/13/23 revealed the following: Date of Service: 1/13/2023 .She is seen today for pain management. She is complaining of pain across both of her shoulders. She has Tramadol 50mg q (every) 4 hours PRN (as needed) ordered for pain. She has a history of a disc protrusion at the C3-C4 level seen on MRI (magnetic resonance imaging). Will add lidocaine patches .She is very frail appearance and has a history of past falls .Associated Signs and Symptoms: Pain across both posterior shoulders .Assessment and Plans .Other chronic pain: Chronic neck/back pain. Tramadol PRN. Add lidocaine patches. Position of comfort. Monitor
A Nurse Practitioner progress note dated 1/17/23 revealed the following: Chief Complaint-Follow up on pain management .History of Present Illness-General: .seen today for pain management. She is very frail and reports chronic pain across her shoulders and in both of her arms. Tramadol 50 mg q (every) 4 hours PRN (as needed) and Lidocaine patches are ordered for pain. Will change Tramadol to q 6 hours, scheduled and monitor her response. Voltaren gel qid (four times a day) to painful areas has also been ordered .
A Nurse Practitioner progress note dated 1/19/23 revealed the following: Date of Service: 1/19/2023 .Chief Complaint-Follow up on pain management. She is up in a wheelchair this morning. She has a very frail appearance. Her mental status is variable. At times she is able to answer questions appropriately and at other times her conversation is confused .Her pain management regimen was recently changed to Tramadol 50 mg q 6 hours, scheduled, along with Voltaren gel qid to painful areas (right wrist, left shoulder, and bilateral LE?s) QID. Will monitor response .Assessments and Plans-Other chronic pain: Chronic neck/back pain. Tramadol 50 mg q 6 hours, scheduled Voltaren gel to painful areas qid. Position of comfort. Continue to monitor .
Further review of the medical record revealed R250's Physician order for scheduled tramadol 50mg Q six hours as indicated in the Nurse Practitioner note on 1/17/23 was never transcribed to the electronic medical record to be administered. A review of R250's January 2023 medication administration record revealed R250 had not been administered the scheduled Tramadol and that they were still ordered the PRN Tramadol Q 4 hours. Continued review of R250's Physician orders also revealed R250 was not ordered lidocaine patches as indicated in the Nurse Practitioners note on 1/13/23 and 1/17/23 and a review of the January 2023 MAR and TAR indicated no documentation of administration of the lidocaine patches.
1/20/23 10:09 a.m., During a conversation with the Director of Nursing (DON), the DON was queried regarding the concerns pertaining to R250 not being ordered the scheduled Tramadol and lidocaine patches. The DON indicated that the Nurse Practitioner who made those orders inputs her own orders into the medical record.
On 1/20/23 at approximately 10:16 a.m., Nurse Practitioner N (NP N) was queried regarding the lack of lidocaine patches and scheduled Tramadol in R250's medical record. NP N reported that they put their own orders in the medical record and have no explanation on why the lidocaine patches and scheduled Tramadol were not changed. NP N reported they have been busy lately and must have forgotten to put the orders into the record to being administration. NP N indicated that they would update R250 orders with the scheduled Tramadol that day but that they would not order lidocaine patches at this time because the resident has an order for Voltaren Gel.
On 1/20/23 a facility document titled Pain Management was reviewed and revealed the following: Policy-The facility will evaluate and identify guests/residents for pain, determine the type, location and severity and develop a care plan for pain management. Fundamental Information
The International Association for the Study of Pain (IASP) defines pain as 'Ian unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Persistent pain is defined as pain that continues for a prolonged period of time and that may or may not be associated with a well-defined disease process. The pain experience is very subjective; pain is whatever the guest/resident says it is .Individualized interventions related to that guest's/residents individual control of pain management should include both pharmacological, non-pharmacological and include Complementary and Alternative Medicine (CAM) pain management interventions .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure three of five Certified Nursing Aides (CNAs) whose education files were reviewed had the required annual competency skills evaluatio...
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Based on interview and record review, the facility failed to ensure three of five Certified Nursing Aides (CNAs) whose education files were reviewed had the required annual competency skills evaluation necessary to care for residents, resulting in the potential for the the lack of necessary skills and qualifications to adequately care for the needs of the residents. Findings include:
A review of a facility provided policy titled, Staff Development, revised 4/19/22 was conducted and read, .9. A competency evaluation will be completed annually for all certified nurse aides/sate tested nursing assistants .
On 1/20/23 at 2:21 PM a review of CNA 'A', CNA 'B', and CNA 'C's facility provided CNA Competency Evaluation sheets were reviewed and revealed CNA 'A's last competency evaluation was dated 8/19/21, CNA 'B's last competency evaluation was dated 8/19/21, and CNA 'C's last competence evaluation was dated 9/15/20.
On 1/20/23 at 3:53 PM, an interview was conducted with the facility's Administrator regarding the CNA competency evaluations. They indicated the evaluations were to be performed annually and acknowledged CNA 'A', CNA 'B', and CNA 'C' did not have updated competency evaluations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure pharmacy recommendations were timely identified,...
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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 pharmacy recommendations were timely identified, responded to and implemented for two (R's 31 & 86) of five residents reviewed for a medication regimen review. Findings include:
On 1/18/23 at 10:15 AM, R31 was observed walking around in their room eating an oatmeal pie. An interview was attempted with the resident however the resident was not responding appropriately.
Review of the medical record revealed R31 was admitted to the facility on [DATE] with a readmission date of 8/12/2022 and diagnoses that included: Alzheimer's disease, dementia and a psychotic disorder with delusions. A MDS assessment dated [DATE], documented a BIMS score of 03 which indicated severely impaired cognition and required staff assistance with all ADL's.
Review of the pharmacy Consultation Report for October and November 2022 documented a repeated recommendation, . irregularities were noted on the medication administration record (MAR) . Risperdal ordered was decreased to 0.5 mg (milligram) HS (hour of sleep) in August but directions still state to give 0.75 mg HS . Recommendation: Please clarify Risperdal 0.5mg directions to take 0.5mg HS .
Review of the October and November 2022 MAR's revealed the order remained . Risperidone tablet 0.5 MG . Give w (with)/0.25 MG tab dose is 0.75 mg q (every) HS . The order remained at Risperdal 0.75mg at HS for the whole month of October until November 16th 2022.
Review of a facility policy titled Timeliness of Medication Regimen Review (MRR) Reports last revised 9/30/2021, documented in part . The pharmacist will review and report any medication irregularities at least once a month . The attending physician is expected to review the guest's/resident's individual MRR and document and sign that he/she has reviewed the pharmacist's identified recommendations within 14 days of receipt . If the attending Physician does not respond to the guest's/resident's MRR report within 14 days, the Director of Nursing will notify the Medical Director to review and respond to the pending MRR reports .
On 1/19/23 at 2:35 PM, the DON was interviewed and asked why the facility failed to review, identify, notify the physician and implement the pharmacist recommendation for the month of October 2022 which was also the same repeated recommendation for the following month November 2022. The DON who is newly hired at the facility stated they were not employed with the facility on the questioned dates, however, will look into it and follow back up. On 1/20/23 at 8:43 AM, the DON returned and stated they also identified the delay in implementing the pharmacist recommendation and could not provide any further explanation.
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 three medication errors out of 25 opportunities for error were obse...
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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 three medication errors out of 25 opportunities for error were observed for one resident (R5) of five residents reviewed during the medication administration observation, resulting in a 12% medication error rate. Findings include:
A review of a facility provided policy titled, Medication Administration revised 9/9/22 was conducted and read, .Medications are administered in accordance with written orders of the attending physician .
On 1/19/23 at 9:31 AM, Licensed Practical Nurse (LPN) 'D' was observed preparing 9 AM medications for administration to R5. LPN 'D' prepared Tegretol (a medication for seizures), lorazepam (an anti-anxiety medication), and a Spiriva inhaler (for respiratory diseases). LPN 'D' entered R5's room, administered the medications and exited the room. Upon exiting the room, LPN 'D' signed the medications out as given in the electronic medical record. At that time, LPN 'D' was asked to confirm that all medications due at the time were given. LPN 'D' reported they were.
On 1/20/23 at 11:42 AM, R5's medications observed given by LPN 'D' on 1/19/23 were reconciled (compared) to R5's physician's orders. It was discovered R5 had orders for Miralax, (laxative), an Advair inhaler (for respiratory diseases), and Senna (a laxative) that were not observed given during LPN 'D's 9 AM medication pass.
On 1/20/23 at approximately 2:00 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding the medication administration observation. The DON acknowledged the concern and indicated they would be looking into it.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0773
(Tag F0773)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain and follow up on laboratory (lab) diagnostics ordered by the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain and follow up on laboratory (lab) diagnostics ordered by the physician for two residents (R92 and R249) of two residents reviewed for laboratory services. Findings include:
Resident #92
On 1/18/23 the medical record for R92 was reviewed and revealed the following: R92 was initially admitted to the facility on [DATE] and had diagnoses including Chronic obstructive pulmonary disease and End stage renal disease. A review of R92's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/23/22 revealed R92 needed assistance from facility staff with their activities of daily living.
A Physician's order dated 1/5/23 revealed the following: CMP (complete metabolic panel), CBC with Diff (complete blood count with differential) Vitamin D, A1c (Glycated hemoglobin).
A Nurse Practitioner progress note dated 1/5/23 revealed the following: .history of DM (Diabetes mellitus) COPD (Chronic obstructive pulmonary disease), 02 dependency, and ESRD (End stage renal disease) whois seen today for glycemic management. Her recent blood sugars have run from 141-227 and are lowest in the morning .No baseline lab results are available. Will reorder .
A review of the results of the ordered labs with a collection date of 1/10/23 and a reported date of 1/11/23 revealed no values for R92's A1c or Vitamin D. Further review of the lab results panel revealed no indications that an A1c or Vitamin D diagnostic was completed.
Resident #249
On 1/18/23 the medical record for R249 was reviewed and revealed the following: R249 was initially admitted to the facility on [DATE] and had diagnoses including Fracture of unspecified part of neck of left femur and Rhabdomyolysis.
A Physician's order dated 1/6/23 revealed the following: CMP, CBC with Diff, Vitamin D, Vitamin B12, TSH (thyroid-stimulating hormone).
A review of R249's lab results ordered on 1/6/23 with a collection date of 1/10/23 and a reported date of 1/11/23 revealed no value for R249's TSH level. Further review of the lab results panel revealed no indications that a TSH diagnostic was completed.
A Nurse Practitioner progress note dated 1/6/23 revealed the following: .Results-laboratory: Baseline lab studies ordered .
On 1/20/23 at approximately 1:24 p.m., The Director of Nursing (DON) was queried regarding the lack of A1c and Vitamin D results for R92 and no TSH results for R249 for the respected lab draws on 1/5/23 and 1/6/23. The DON reported that the diagnostic's for the A1c, Vitamin D and TSH were not done and that the labs would have to be reordered to obtain the results and provide them to the provider. The DON indicated that it is the responsibility of the Nursing staff to ensure accuracy of the laboratory requisitions and ensure the correct laboratory diagnostics are completed and reported to the medical providers.
On 1/20/23 a requested for the facility's policy/procedures for laboratory diagnostics was requested however the facility Administrator indicated that the facility does not have a laboratory diagnostics policy.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
This citation pertains to intake #MI00133304.
Based on observation, interview, and record review, the facility failed to ensure resident's dignity during dining for 13 residents (R#'s 59, 200, 78, 54,...
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This citation pertains to intake #MI00133304.
Based on observation, interview, and record review, the facility failed to ensure resident's dignity during dining for 13 residents (R#'s 59, 200, 78, 54, 75, 1, 42, 12, 74, 29, 250, 15, and 67) of 22 residents reviewed for dignity during the dining experience, resulting in the potential for frustration, embarrassment and dissatisfaction with the dining experience. Findings include:
A review of a facility provided policy titled, Guest/resident Dignity & Personal Privacy revised 4/19/22 was conducted and read, The facility provides care for guests/residents in a manner that respects and enhances each guest's/resident's dignity, individuality, and right to personal privacy .
On 1/18/23 at 12:36 PM, in the main dining room, Certified Nursing Assistant (CNA) 'F' was overheard twice to refer to R59 as a, feeder, saying R59 needed to be moved to the other dining room.
On 1/18/23 at 12:40 PM, an observation of the restorative dining room was conducted. It was observed R200 was seated at a table with R78. R200 had their meal and was independently eating while R78 watched them. At 12:51 PM, CNA 'F' was overheard to tell R78 they were going to feed them their meal. At 1:05 PM, CNA 'F' sat down to feed R78 their meal. R200 was still picking at the food on their tray and CNA 'F' was observed to alternately feed both R78 and R200.
On 1/18/23 at 12:48 PM, R54 and R75 were observed seated together at the dining room table. They were asked if they had received their lunch and neither offered a verbal response. When no response was received, CNA 'G' said they had not received their meals because they were both, feeders.
On 1/18/23 at 12:50 PM, CNA 'H' was observed to be standing and feeding R1.
On 1/18/23 at 12:54 PM, R75 was observed being fed their meal by a staff member. R54 remained seated at the table with R75 with no meal in front of them. At 1:00 PM, a staff member moved R54 to another table.
On 1/19/23 at 12:15 PM, an observation of the restorative dining room was conducted. Throughout the observation, CNA 'G' was overheard referring to several different residents as Momma and Papa. R42 was observed in the dining room making loud, disruptive, guttural grunts and noises. R42 finished their meal at approximately 12:30 PM but was not removed from the dining room and remained making the noises through the entire meal service until 1:05 PM, when staff removed them from the room.
On 1/19/23 at 12:22 PM, R12 and R74 were observed seated at the same table. CNA 'J' was seated and feeding R12. R74 did not have a meal served to them. At 12:38 PM, CNA 'J' finished feeding R12, retrieved R74's tray and began feeding them.
On 1/19/23 at 12:26 PM, Licensed Practical Nurse (LPN) 'K' was overheard from across the dining room to ask CNA 'G' to set-up three resident's trays. LPN 'K' referred to each of the three the resident's by their last name.
On 1/19/23 at 12:29 PM, R29 was observed seated with R250 and R15. R29 was overheard asking where their lunch meal was. at 12:30 PM, R29's meal tray was delivered and they began to eat. R250, and R15 were not served a meal tray at that time.
On 1/19/23 at 12:32 PM, LPN 'K' was overheard telling a CNA that R29 could feed themselves, but R250, and R15 were, feeders. At 12:33 PM, R250 was overheard to say ask Where's my food? At 12:44 PM, it was observed R29 had finished their meal, R15 had been served their meal and was eating, and R250 still had not been served a meal tray. At 12:52 PM, R250 was finally served their lunch meal.
On 1/19/23 at 12:34 PM, 22 residents were observed in the dining room, of the 22; ten still had not been served a meal tray.
On 1/19/23 at 12:35 PM, CNA 'G' was observed feeding R78. At 12:39 PM, CNA 'G' left from feeding R78, helped deliver some meal trays to other residents, and stopped to re-position a resident in their wheelchair. At 12:41 PM, CNA 'G' returned to R78 and continued to feed them their lunch meal.
On 1/19/23 at 12:45 PM, R54 was observed seated at a table with R67. R67 was being fed their meal by Activity staff 'I'. R54 did not have a meal tray at that time. At 12:57 PM, CNA 'J' arrived to the table and began feeding R54. Throughout the meal, CNA 'J' was overheard several times to refer to R54 as Momma.
On 1/20/23 at 11:53 AM, an interview was conducted with the facility's Administrator regarding the observations of the dining experience. They acknowledged the concern and said they were aware of problems in the dining room, mainly related to staffing. They were then asked if it was appropriate to refer to residents as feeders, by their last names, or to address the residents as Momma and Papa. The Administrator indicated it was not appropriate.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected multiple residents
Based on observation and interview the facility failed to ensure sufficient staff were provided to serve meals and help assist multiple residents that required staff assistance with meals. Findings in...
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Based on observation and interview the facility failed to ensure sufficient staff were provided to serve meals and help assist multiple residents that required staff assistance with meals. Findings include:
On 1/19/23 at 12:18 PM, an observation of the facility lunch meal was completed in the dining room. At that time a count of 22 residents occupied the lunch room area with three staff in attendance. Observed were multiple residents eating while other residents were sitting at the same table without a lunch tray and watched the other residents eat their meals. Of the 22 residents, 12 remaining residents required assistance with eating and were waiting for the staff members to finish feeding the other residents their meals before helping to assist them.
At 12:37 PM, Licensed Practical Nurse (LPN) K (one of the staff members in the dining room assisting a resident with their meals) asked this surveyor if it was an issue that other residents are not eating while watching people at their table eat and this surveyor responded that the facility dining experience is a concern.
At 12:38 PM, three additional staff members entered into the dining area to help feed the remaining residents.
At 1:08 PM, a staff member was observed to have sat down next to the last resident who waited almost an hour for a staff member to assist them with their lunch tray and was now getting assistance from staff to eat their lunch meal.
On 1/20/23 at 11:53 AM, the Administrator was interviewed regarding the observations of the 1/19/23 lunch meal dining room experience and acknowledged the concern. The Administrator stated they have interviewed various staff members that attended the lunch meal in the dining room and the facility will figure out how to provide a comfortable homelike meal experience for all residents moving forward.
No further explanation was provided by the end of survey.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to educate and offer the Pneumococcal vaccine to four (R's 14, 31, 92 &...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to educate and offer the Pneumococcal vaccine to four (R's 14, 31, 92 & 250) of five residents reviewed for the Pneumococcal vaccine. Findings include:
R14
Review of the medical record revealed no documentation or consent of the resident and or resident representative to have been educated, offered or administered the pneumococcal vaccine. Further review of the medical record revealed the resident was admitted to the facility on [DATE] with a readmission date of 8/14/22.
R31
Review of the medical record revealed no documentation or consent of the resident and or resident representative to have been educated, offered or administered the pneumococcal vaccine. Further review of the medical record revealed the resident was admitted to the facility on [DATE] with a readmission date of 8/12/22.
R92
Review of the medical record revealed no documentation or consent of the resident and or resident representative to have been educated, offered or administered the pneumococcal vaccine. Further review of the medical record revealed the resident was admitted to the facility on [DATE].
R250
Review of the medical record revealed no documentation or consent of the resident and or resident representative to have been educated, offered or administered the pneumococcal vaccine. Further review of the medical record revealed the resident was admitted to the facility on [DATE].
On 1/20/23 at 12:22 PM, the Director of Nursing (DON) was interviewed and asked when residents are offered the pneumococcal vaccine and the DON stated upon admission. The DON was then asked to provide the education and consents that were provided to R's 14, 31, 92 & 250. The DON stated they would look for them and follow back up. At 1:28 PM, the DON returned and stated the facility was unable to locate any education and consents that were provided to R's 14, 31, 92 & 250.
Review of a facility policy titled Immunizations: Pneumococcal Vaccination (PPV) of Guest/Residents last revised 2/25/22, documented in part . Recognizing the major impact and mortality of pneumococcal disease on guests/guest/residents of nursing homes and the effectiveness of vaccines in reducing healthcare costs and preventing illness, hospitalization and death, the facility has adopted the following policy statements . Each guest's/resident's pneumococcal immunization status will be determined upon admission or soon afterwards, and will be documented in the guest's/resident's medical record . All guests/residents with undocumented or unknown pneumococcal vaccination status will be offered the vaccine .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure food items were labeled and dated, failed to store potentially hazardous food items in a sanitary manner, and failed to...
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Based on observation, interview and record review, the facility failed to ensure food items were labeled and dated, failed to store potentially hazardous food items in a sanitary manner, and failed to maintain the kitchen in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include:
On 1/18/23 between 8:45 AM-9:30 AM, during an initial tour of the kitchen with Dietary Manager (DM) O, the following items were observed:
There was no handwashing signage at the handwashing sink.
According to the 2017 FDA Food Code section 6-301.14 Handwashing Signage, A sign or poster that notifies food employees to wash their hands shall be provided at all handwashing sinks used by food employees and shall be clearly visible to food employees.
The scoop holder at the ice machine in the kitchen, was observed with a dried, black substance on the bottom inner surface. DM O confirmed the soiled scoop holder and stated she would run it through the dish machine.
The scoop holder for the ice machine located in the service hallway outside the kitchen, was observed with black debris on the bottom inner surface.
According to the Food & Drug administration (FDA) 2017 Model Food Code, Section 3-304.12 In-Use Utensils, Between-Use Storage, During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: .(E) In a clean, protected location if the utensils, such as ice scoops, are used only with a food that is not potentially hazardous (time/temperature control for safety food) .
The lower shelf where the cutting boards were stored was observed with paint peeling on the surface and a buildup of debris on the surface.
According to the 2017 FDA Food Code section 4-602.13 Nonfood-Contact Surfaces, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
The vent hood was observed with a buildup of grease. There was a service tag on the side of the hood, which noted that the hood was last cleaned 10/6/22.
According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.
The filter for the steamer was observed with a handwritten date of 4/2022. The manufacturer's recommendation on the filter noted replace cartridge when indicator reaches 6 months or sooner.
There was an unlabeled white garbage can with a white powder stored inside. In addition, there was a red liquid spilled on the lid of the container. DM O confirmed the bin should be labeled with the contents, and stated they would clean up the lid right away.
There was an uncovered white bucket on the counter labeled instant puree bread mix with a white powder inside. DM O confirmed it was thickener, not bread crumbs, and stated she would get it labeled and covered.
According to the 2017 FDA Food Code section 3-302.12 Food Storage Containers, Identified with Common Name of Food, Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD.
The mixer was observed to be covered with a plastic bag, to denote it was clean. When the bag was lifted, there was a dried on food substance on the splash guard. DM O confirmed the mixer was supposed to be clean before they cover it with a plastic bag.
In the True reach in cooler #1, there was a container of whipped spread with a use by date of 1/16, a container of bacon bits with a use by date of 1/16, and an opened, undated container of sour cream.
In the True reach in cooler #2, there was an opened container of almond plant based beverage with a use by date of 1/08.
In the dry storage room, there was a bin of white powder that was unlabeled. DM O' confirmed the bin should be labeled with the contents.
According to the 2017 FDA Food Code section 3-302.12 Food Storage Containers, Identified with Common Name of Food, Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD.
In the walk in cooler, there was a box of raw chicken stored on a rack directly above 2 boxes of bacon. DM O confirmed that the raw chicken should be stored on the bottom shelf.
According to the 2013 FDA Food Code section 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation, (A) Food shall be protected from cross contamination by: .(2) Except when combined as ingredients, separating types of raw animal foods from each other such as beef, fish, lamb, pork, and poultry during storage, preparation, holding, and display by: .(b) Arranging each type of food in equipment so that cross contamination of one type with another is prevented.
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
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 2 harm violation(s), $153,602 in fines, Payment denial on record. Review inspection reports carefully.
- • 52 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • $153,602 in fines. Extremely high, among the most fined facilities in Michigan. Major compliance failures.
- • Grade F (25/100). Below average facility with significant concerns.
Bottom line: Trust Score of 25/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is The Manor Of Novi's CMS Rating?
CMS assigns The Manor of Novi an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Michigan, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is The Manor Of Novi Staffed?
CMS rates The Manor of Novi's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 46%, compared to the Michigan average of 46%. RN turnover specifically is 62%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at The Manor Of Novi?
State health inspectors documented 52 deficiencies at The Manor of Novi during 2023 to 2025. These included: 2 that caused actual resident harm and 50 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates The Manor Of Novi?
The Manor of Novi 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 CIENA HEALTHCARE/LAUREL HEALTH CARE, a chain that manages multiple nursing homes. With 130 certified beds and approximately 98 residents (about 75% occupancy), it is a mid-sized facility located in Novi, Michigan.
How Does The Manor Of Novi Compare to Other Michigan Nursing Homes?
Compared to the 100 nursing homes in Michigan, The Manor of Novi's overall rating (2 stars) is below the state average of 3.1, staff turnover (46%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting The Manor Of Novi?
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 The Manor Of Novi Safe?
Based on CMS inspection data, The Manor of Novi has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Michigan. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at The Manor Of Novi Stick Around?
The Manor of Novi has a staff turnover rate of 46%, which is about average for Michigan nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was The Manor Of Novi Ever Fined?
The Manor of Novi has been fined $153,602 across 2 penalty actions. This is 4.4x the Michigan average of $34,615. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is The Manor Of Novi on Any Federal Watch List?
The Manor of Novi 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.