The Orchards at Redford
For profit - Individual
88 Beds
THE ORCHARDS MICHIGAN
Data: November 2025
Trust Grade
50/100
#341 of 422 in MI
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Orchards at Redford has a Trust Grade of C, meaning it is average and sits in the middle of the pack among nursing homes. It ranks #341 out of 422 facilities in Michigan, placing it in the bottom half, and #55 out of 63 in Wayne County, indicating that there are only a few local options that perform better. The facility's trend is worsening, with issues increasing from 11 in 2024 to 12 in 2025. Staffing is a concern, as it has a rating of 2 out of 5 stars with a high turnover rate of 55%, above the state average of 44%. While it has not incurred any fines, which is a positive sign, the facility also has less RN coverage than 98% of Michigan facilities, meaning residents may not receive the level of care they need. Specific incidents reported by inspectors indicate serious issues, such as unsanitary kitchen conditions that could lead to foodborne illnesses affecting residents. For example, areas in the kitchen, including the fryer and oven, were found dirty and not cleaned adequately. Additionally, there was a broken window in the dining room and a lack of accessible paper towels for handwashing, both of which could pose safety risks. Overall, while there are some strengths, such as the absence of fines, the facility's numerous concerns about cleanliness and staffing make it essential for families to carefully consider their options.
- Trust Score
- C
- In Michigan
- #341/422
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 55% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Michigan facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 13 minutes of Registered Nurse (RN) attention daily — below average for Michigan. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 41 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Bottom 20%
No red flags
11 → 12 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 11 issues
2025: 12 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below Michigan average (3.1)
Below average - review inspection findings carefully
Staff Turnover: 55%
Near Michigan avg (46%)
Higher turnover may affect care consistency
Chain: THE ORCHARDS MICHIGAN
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 41 deficiencies on record
Jul 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
This citation pertains to Intake numbers 1293719 and 1293580.Based on observation, interview, and record review, the facility failed to answer a call light timely for one resident (R701) out of two re...
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This citation pertains to Intake numbers 1293719 and 1293580.Based on observation, interview, and record review, the facility failed to answer a call light timely for one resident (R701) out of two reviewed for call lights. Findings include:On 7/9/2025 at 12:11 PM, R701 activated their call light. R701 stated they never answer the call light when it is activated and sometimes it will be on all night until the next day. R701 reported, the screen at the desk barely works. R701 reported the call light does not light up over the door, but rather shows up on a screen at the desk.A review of the medical record revealed that R701 admitted into the facility on 4/5/2024 with the following medical diagnoses, General Anxiety Disorder and Chronic Kidney Disease. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 14/15 indicating an intact cognition. R701 also required assistance with bed mobility and transfers. On 7/9/2025 at 12:18 and 12:26 PM, R701's call light was noted to still be activated. No one was observed to come and address the call light. On 7/9/2025 at 1:28 PM, R701's call light was still observed to be activated. R701 reported no one came into the room to address their concern. On 7/9/2025 at 1:35 PM, Activities Aide (AA) C was observed to be charting in the hallway. AA C was asked how they knew if call lights were activated. AA C reported they know there is a system up front and that they can check it and answer call lights if necessary.On 7/9/2025 at 1:38 PM, an interview was conducted with Licensed Practical Nurse (LPN) A. LPN A reported they look at the system behind the nurses' station and check if there are lights activated, as long as the system is working properly. On 7/9/2025 at 1:40 PM, an interview was conducted with Unit Manager (UM) B. UM B was shown that R701's call light had been activated since 12:11 PM and it was now 1:43 PM. UM B reported the call light should have been addressed and deactivated within 15 minutes of it going off, unless there is a dire emergency. UM B reported they would have to see what happened with R701's call light been addressed in a timely manner. A review of resident council notes from the last six months revealed that call lights being answered in a timely manner, particularly during the midnight shift, was a concern for the following months: January, February, March, May, and June. On 7/9/2025 at 2:54 PM, an interview was conducted with the Director of Nursing (DON). The DON indicated they have followed up on concerns with call light wait times and their expectation is that they are answered in a timely manner. The DON reported they believe that everyone should answer call lights and that it is everyone's responsibility. A review of a facility policy titled, Call Light Policy noted the following, .1.Call lights should be answered by available staff as promptly as possible.
Apr 2025
11 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 review, the facility failed to ensure urinary catheter care, assessment and monitori...
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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 urinary catheter care, assessment and monitoring was provided for one resident, (R66) of three residents reviewed for catheter care, resulting in the development of a urinary tract infection. Findings include:
On 3/31/25 at 2:13 PM, R66 was observed in their bed. R66 was awake and alert, however; they did not respond to attempts at verbal conversation. It was observed R66 had an indwelling urinary catheter. The tubing connected to the collection bag revealed dark, cloudy urine with sediment built up in the tubing.
A review of R66's clinical record revealed they admitted to the facility on [DATE] and most recently re-admitted on [DATE]. R66's diagnoses included: respiratory failure, epilepsy, protein calorie malnutrition, neuromuscular dysfunction of the bladder and urinary tract infection. A review of R66's physician's orders, medication administration records, treatment administration records, and certified nurse aide tasks was conducted and did not reveal any orders or documentation for catheter care, assessment and monitoring.
R66's physician's orders were noted to include an order dated 3/28/25 for Ciprofloxacin (antibiotic treatment for UTI) 500 milligrams every 12 hours for, UTI (urinary tract infection) for 7 days.
Continued review of R66's record revealed the following notes:
A nurses note dated 3/24/25 at 9:03 PM that read, .Urine collected this shift for U/A (urinalysis) C&S (culture and sensitivity) .
A nurses note dated 3/27/25 at 3:36 PM that read, UA (urinalysis) returned, Large <sic> amount of Blood <sic> and Leukocytes <sic> (white blood cells) .Doc (Doctor) made aware order given to await Culture <sic> .
A nurse note dated 3/28/25 at 12:54 PM that read, .Urine Culture High for bacteria, with susceptibility of Cipro (ciprofloxacin, antibiotic medication), Doc made aware order given to initiate ABT (antibiotic therapy) .
On 4/1/25 at 3:05 PM, an interview was conducted with the facility's Director of Nursing. They were asked about catheter assessment, care and monitoring and said an order should be written and documentation of the care provided would be entered by the assigned nurse on the treatment administration record.
A review of a facility provided policy titled, Indwelling Catheter Care was conducted and read, .Routine catheter care helps prevent infections and other complications, and is usually performed daily . The policy did not include documentation of the care provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure nutritious meals, and provide ongoing assessme...
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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 nutritious meals, and provide ongoing assessment and monitoring for weight loss for one resident, (R44) of four residents reviewed for nutrition resulting in weight loss. Findings include:
On 3/31/25 at 12:27 PM, an observation of the lunch meal on the Transitional Care Unit was conducted. R44 was observed seated at the table with their pureed lunch meal in front of them. Their meal consisted only of a pureed sweet potato and an unidentifiable light greenish/tan pureed food. R44 was observed to be given one-to-one assistance from Certified Nurse Aide (CNA 'B') with the meal. CNA 'B' was asked what the unknown pureed item was and said they did not know. They further indicated R44 was a vegetarian and did not receive pork that was on the menu for that day. Staff in the satellite kitchen on the unit were asked what R44 was served and said they were served a pureed sweet potato and pureed cabbage with green beans.
On 4/1/25 at 8:15 AM, R44 was observed in their bed asleep. At their bedside their breakfast meal contained only a bowl of grits and a bowl of a pureed waffle.
On 4/1/25 at 12:20 PM, a second observation of the lunch meal on the Transitional Care Unit was conducted. R44 was observed seated in the dining room receiving one-to-one assistance with their lunch meal from Nurse 'A'. Nurse 'A' was asked what R44 received for lunch and said they received tomato soup and pureed lima beans. At the conclusion of the meal at approximately 12:45 PM, it was observed R44 was not provided with the dessert on the menu for the day.
A review of R44's clinical record revealed the admitted to the facility on [DATE] and most recently re-admitted on [DATE] after a less than twenty-four hour stay at the hospital. R44's diagnoses included: stroke, high blood pressure, anemia, major depressive disorder, and vascular dementia. R44's Minimum Data Set assessment indicated they had severely impaired cognition and required substantial/maximal assistance with eating. A review of R44's care plan for nutrition was reviewed and indicated they liked eggs and cottage cheese.
A review of R44's documented weights was conducted and revealed the following:
10/3/24 118.8 lbs.
11/6/24 115.0 lbs.
12/13/24 108.0 lbs.
1/06/25 105.4 lbs.
1/15/25 105.4 lbs.
A review of a Nutrition/Dietary Note dated 12/30/25 was reviewed and read, .Weight Loss: recommend weekly weight x four weeks to monitor. It was noted R44 had only two weights obtained in the four week recommendation period. It was further noted there were no re-weights obtained when there were deviations from the previous obtained weight.
A review of a Nutrition/Dietary Note dated 2/24/225 was reviewed and read, .Annual Assessment .Diet: Regular, Pureed textures, nectar thick liquids. Prefers Vegetarian meals .CBW (current body weight) 105.4# (pounds) .-7.5% change [ Comparison Weight 11/6/2024, 115.0 Lbs, -8.3% , -9.6 Lbs]-10.0% change [ Comparison Weight 7/23/2024, 121.0 Lbs, -12.9% , -15.6 Lbs] . It was noted this assessment conducted February 2024 used the previously documented weight from January 2024 since there was no weight obtained in February.
A review of a Nutrition Dietary Note dated 3/21/2025 was reviewed and read, Note Text: Significant Weight loss .Diet Regular, Pureed textures, nectar thick liquids. Prefers Vegetarian meals .CBW (current body weight) 93# (93 lbs) .-7.5% change [ Comparison Weight 1/6/2025, 105.4 Lbs, -11.8% , -12.4 Lbs ]; -10.0% change [ Comparison Weight 10/3/2024, 118.8 Lbs, -21.7% , -25.8 Lbs ] . Res. (Resident) was triggered for significant weight loss at 3 and 6 months. Res. remains on pureed textures, nectar thick liquids, r/t Dysphagia .
On 4/2/25 at 10:20 AM, an interview was conducted with Certified Dietary Manager (CDM) 'E'. They were asked about R44's vegetarian diet and said R44 received the starch and vegetable menu offerings but not the meat. They were asked if they replaced the protein from the meals with any other menu items such as yogurt or cottage cheese and said they had in the past and they should again. They were then asked if they thought a sweet potato and cabbage or tomato soup and lima beans would be considered a nutritious meal and said no. They were also asked if R44 should have received the dessert item on 4/1/25 and said they should. CDM 'E' was then asked why R44 did not have weekly weights recommended 12/30/24, a documented weight in February 2024, and why their assessment dated [DATE] used the weight obtained in January, and they had no responsive. Finally, CDM 'E' was asked about the facility's policy regarding re-weights and said they didn't know how many pounds deviation required a re-weight but they would find out.
A review of a facility provided policy titled, Weight Management was conducted and read, Residents will be monitored for significant weight change on a regular basis. Residents are expected to maintain acceptable parameters of nutritional status .2. Weight residents upon admission .then monthly .3. Monthly weights will be completed by the 10th of the month .6. Ensure that each resident identified with significant weight change is on a weekly schedule .
A review of a second facility provided policy titled, Unintended Weight Change was conducted and read, .Resident with unintended weight loss/gain will be assessed by the interdisciplinary team and interventions will be implemented to prevent further weight loss/gain .3. Re-weights are initiated for a five pound variance if the resident is > (greater than) 100 pounds and for a three pound variance if < (less than) 100 pounds. Re-weights will be done within 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
Tube Feeding
(Tag F0693)
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 tube feeding formula was delivered at the physi...
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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 tube feeding formula was delivered at the physician ordered rate for one resident, (R73) of two residents reviewed for tube feeding. Findings include:
On 3/31/25 at 11:00 AM, R73 was observed in their room in bed, asleep. R73 was receiving tube feeding formula via pump. The pump was observed to be programmed to deliver the formula at a rate of of 70 mL (milliliters) per hour.
On 4/1/25 at 8:19 AM and 11:00 AM, additional observations were made of R73 receiving tube feeding via pump. The pump was observed to be programmed to deliver the formula at 70 mL per hour. The bottle of formula being delivered was observed to have a delivery rate of 75 mL per hour written on it.
A review of R73's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: acute respiratory failure, stroke, aspiration pneumonia, presence of a tracheostomy and a feeding tube. A review of R73's physician's orders was conducted and revealed an order dated 3/27/25 for tube feeding formula to be delivered at a rate of 75 mL per hour.
On 4/2/25 at 10:20 AM, an interview with Certified Dietary Manager (CDM) 'E' was conducted and they were asked to confirm R73's tube feeding rate. They reviewed the orders and said the delivery rate was supposed to be 75 mL per hour. They were made aware of the rate programmed into the pump on 3/31/25 and 4/1/25 and said it was programmed incorrect and the pump should have been set to deliver the formula at 75 mL per hour.
A review of a facility provided policy titled, Enteral Nutrition Guidelines was conducted and read, .6. Once an enteral tube (feeding tube) is in place, a physician's order should be obtained for the type of enteral fluid to be used including: The name of product to be used. The rate and/or timing of administration .9. The nurse administers the enteral feeding regimen according to formula, system type, and method of delivery ordered by the physician .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an incapacitated resident (R17) was provided a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an incapacitated resident (R17) was provided a legally authorized representative to make informed healthcare decisions of one residents reviewed for medically related Social Services.
Findings include:
On 3/31/25 at approximately 10:55 a.m., R17 was observed in room up in wheelchair. R17 was observed to have difficulty communicating and was unable to answer questions.
On 4/1//25 the medical record for R17 was reviewed and revealed the following: R17 was initially admitted to the facility on [DATE] and had diagnoses including Cerebral Palsy and Polyneuropathy. A review of R17's MDS (minimum data set) with an ARD (assessment reference date) of 3/18/25 revealed R17 needed assistance from facility staff with their activities of daily living. R17's BIMS score (brief interview for mental status) was 10 indicating moderately impaired cognition.
A review of R17's comprehensive careplan revealed the following: Focus-Cognition: I have impaired cognitive functioning or impaired thought processes related to a diagnosis of cerebral palsy and vascular dementia, moderate, with mood disturbance. I display short term memory impairment. Date Initiated: 06/29/2023 .Interventions-I need assistance with all decision making. Date Initiated: 06/29/2023 .
A facility document titled decision making capacity signed by the Physician on 7/24/24 and the Psychologist on 7/19/24 was reviewed and documented that R17 did not have the capacity to make informed medical decisions.
A review of the Social Service progress notes revealed the following: 10/16/2023-Writer called resident's niece in regard to POA (Power of Attorney) documentation. Resident's niece had previously provided financial POA documentation but not medical. Writer left a voicemail inquiring about documentation.
A review of R17's provided POA documentation in their record revealed R17 did not have any POA-H (healthcare decision making) documentation. Further review of the record revealed no letters of guardianship or any other documentation authorizing a legal representative to make informed healthcare decisions on behalf of R17.
A review of R17's demographic face sheet indicated R17 had no legally authorized representative for healthcare decision making. R17's niece was noted as only being responsible party
On 4/2/25 at approximately 9:39 a.m., during a conversation with Social Worker H (SW H), SW H was queried regarding what department had the responsibilities of obtaining a legal representative for decision making and they reported it was the Social Services. SW H was queried if R17 had a DPOA-H (durable power of attorney-healthcare) or legal guardian in place to make informed healthcare decisions for them since they had been deemed incapacitated since July 2024. SW H reported that R17 did not have any healthcare-power of attorney or legal guardianship in place and that R17's niece was making healthcare decisions for them without any legal documentation. SW H indicated that R17's nice could make informed decisions but could not withdrawal any treatments on behalf of R17. SW H was queried why the Social Services department had not secured a legally authorized representative to make or decline consent for healthcare decisions and they reported that they had just started the process to get residents guardianship.
On 4/2/25 a document provided by the facility was reviewed and revealed the following: 400.66h Hospitalization; consent to surgical operation, medical treatment; first aid. Sec. 66h.
Nothing in this act shall be construed as empowering any physician or surgeon, or any officer or representative of the state or county departments of social welfare, in carrying out the provisions of this act, to compel any person, either child or adult, to undergo a surgical operation, or to accept any form of medical treatment contrary to the wishes of said person. If the person for whom surgical or medical treatment is recommended is not of sound mind, or is not in a condition to make decisions for himself, the written consent of such person's nearest relative, or legally appointed guardian, or person standing in loco parentis, shall be secured before such medical or surgical treatment is given. This provision is not intended to prevent temporary first aid from being given in case of an accident or sudden acute illness where the consent of those concerned cannot be immediately obtained.
Further review of the act language that was provided, indciated the provided section was for hospitalization and did not include any language that absolved the responsibility of the facility to advocate for and obtain a legally authorized representative for a long term care resident that had been deemed incapacitated to make informed decisions.
No documentation that R17 was been provided a legally authorized representative to consent/decline/withdrawal informed healthcare decisions was provided by the end of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to attempt non-pharmacological interventions prior to PRN (as needed) a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to attempt non-pharmacological interventions prior to PRN (as needed) anti-anxiety medication administration for one resident (R32) of six residents reviewed for unnecessary medication. Findings include
On 3/31/25 at 9:00 AM, R32 was obsereved sitting in a chair in the dining room at a table with head down in breakfast plate. Resident appeared to be sleep and not easily aroused.
On 3/31/25 at 1:00 PM, R32 was observed at table in the dining room with head on table and eyes closed. R32 was not easily aroused when name was called.
On 04/01/25 at 2:06 PM, R32 was observed in dining room with head down on the table and eyes closed.
On 4/1/25 the medical record for R32 was reviewed and revealed the following: R32 was admitted to the facility on [DATE] with a readmit date of 2/10/25 with multiple diagnoses including Dementia, Delusional Disorder, Depression, and Anxiety. A review of the minimum data set assessment (MDS) dated [DATE] revealed a brief interview of mental status score of 99 indicating severe cognitive impairment.
Further review of R32's medical record revealed a physician's order for Alprazolam .5 mg to give one tablet by mouth every 8 hours as needed for Anxiety. A review of the medication administration record revealed that Alprazolam .5 mg had been given on 3/29/25, 3/30/25, and 3/31/25. Progress notes for R32 were reviewed for 3/29/25, 3/30/25, and 3/31/25. There were no non-pharmacological interventions documented prior to administering the PRN (as needed).
On 4/1/25 at 10:00 AM, an interview occurred with the Nursing Home Administrator (NHA) discussing R32 and concerns about the psychotropic medications. The NHA stated that R32 was from another program which controlled the medical services and there had been difficulty getting in contact with the responsible party to change psychotropic meds and have psychologogical re-evaluation prior to this date.
On 4/2/25 at 9:30 AM, an interview ocurred with the Director of Nursing (DON). When asked about the expectation of nursing and ensuring psychotropic medications are given appropriately, the DON stated that psychotropic medications should be administered properly per policy and all residents have a right to be free from unecessary medications.
A review of the facility policy titled, Psychotropic Medication and Assessment Monitoring revealed the purpose of the poilicy is to administer, and monitor the effects of psychotropic medications. The criteria for psychotropic medication use is the following: Preventable causes of behavior have been ruled out; Behavior interventions have been attempted first without adequat resolution; The behavior presents a danger to the resident or to others or is a source of distress or dysfunction for the resident; The drug use mintains or improves the residents functional capacity; Dosage is appropriat for the resident and is not inexcess of the suggested daily dose maximum, unless specifically documented by the attending physician;; Dosage reductionor re-evaluations are provided.
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
Based on observation, interview and record review, the facility failed to ensure a dignified dining experience for six residents, of 13 residents reviewed for dining, resulting in the potential for em...
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Based on observation, interview and record review, the facility failed to ensure a dignified dining experience for six residents, of 13 residents reviewed for dining, resulting in the potential for embarrassment and disappointment with the dining experience. Findings include:
On 4/1/25 from 12:16 PM until 12:55 PM, an observation of the lunch meal was conducted on the Transitional Care Unit. It was observed R#'s 59, 75, and 21 were seated together at a table. R59 and R75 were served their meals and began eating. R21 was not served their meal with R59 and 75. R59 and R75 finished their meals at 12:30 PM and their plates were collected and returned to the satellite kitchen. At approximately 12:35 PM, R21 was finally served their lunch meal.
On 3/31/25 at approximately 12:15 p.m., Observations of the lunch meal were made and the following was observed: R44 was observed in the TCU (transitional care unit) dining room seated at a table. R44 was observed to have the front of their shirt completely covered in wetness with no clothing protector observed to be on them. The other residents surrounding them were observed to be eating their lunch meal with R44 watching them eat.
At approximately 12:19 p.m., R44's meal ticket was observed and revealed the following: feeding assist No straws. At that time, three other residents observed at R44's table eating the lunch meal. R44 was still observed to be watching the other residents eat without being assisted with their meal. Only one resident at table was provided a beverage with the meal at that time.
At approximately 12:24 p.m., R21 was observed in the TCU dining room seating at the dining table. R21 was observed to have their food in front of them without any feeding assistance being provided and unable to consume the meal on their own. Multiple other residents were observed eating their lunch meal.
At approximately 12:26 p.m., R44 was finally served a beverage, but it contained a straw with it.
At approximately 12:29 p.m., Nurse C observed trying to assist R44 with eating their meal, but was observed standing up next to them while proving the eating assistance to R44.
On 3/31/25 at approximately 12:30 p.m., observations of the main dining room's lunch meal was conducted and the following was observed:
At approximately 12:34 p.m., Two residents were observed eating the lunch meal with two other residents (R36 and R53) were observed to be watching them eat without being served their meal.
At approximately 12:38 p.m., Certified Nursing Assistant G (CNA G) was queried why R36 and R53 had to watch other residents at their table eat the meal when they were not and CNA G reported (within hearing range of R36 and R53) that they were both feeders and have to wait for staff to help them.
On 4/2/25 at approximately 11:43 a.m., during a conversation with the Administrator, The Administrator was informed of the observations that had been noted in both of the dining rooms on 3/31/25. The Administrator indicated that clothing protectors should be provided and that residents seated at the same table should be served the meal at the same time and staff should be mindful of who needs assistance with eating. The Administrator indicated they had recently started in the facility and they were looking at refining some processes for the dining rooms and communication with the resident Greenhouses.
On 4/2/25 a facility document titled Resident Dignity and Personal Privacy was reviewed and revealed the following: Policy-The facility provides care for residents in a manner that respects and enhances each resident ' s dignity, individuality, and right to personal privacy. Fundamental Information Each resident ' s right to personal privacy includes the confidentiality of his or her personal and clinical affairs. Dignity means that when interacting with residents, staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected multiple residents
On 3/31/25 at 12:27 PM, an observation of the lunch meal on the Transitional Care Unit was conducted. R44 was observed seated at the table with their pureed lunch meal in front of them. Their meal con...
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On 3/31/25 at 12:27 PM, an observation of the lunch meal on the Transitional Care Unit was conducted. R44 was observed seated at the table with their pureed lunch meal in front of them. Their meal consisted only of a pureed sweet potato and an unidentifiable light greenish/tan pureed food. R44 was eventually offered one-to-one assistance from Certified Nurse Aide (CNA 'B'). CNA 'B' was asked what the unknown pureed item was and said they did not know. They further indicated R44 was a vegetarian and did not receive pork that was on the menu for that day. Staff in the satellite kitchen on the unit were asked what R44 was served and said R44 was served a pureed sweet potato and pureed cabbage with green beans.
On 4/1/25 at 12:20 PM, a second observation of the lunch meal on the Transitional Care Unit was conducted. R44 was observed seated in the dining room receiving one-to-one assistance with their lunch meal from Nurse 'A'. Nurse 'A' was asked what R44 received for lunch and said they received tomato soup and pureed lima beans. At the conclusion of the meal at approximately 12:45 PM, it was observed R44 was not provided with the dessert on the menu for the day. During the observation of the lunch meal, eight residents were observed in the dining room. At the conclusion of the meal, only two of the eight residents received the dessert (chocolate cake) item on the menu. At 12:55 PM, an interview was conducted with R281 and they were asked if they received dessert and said they did not, stating, That's not fair.
On 4/2/25 a facility document titled Menus was reviewed and revealed the following: Standard: Menus will be planned in advance to meet the nutritional needs of the residents/
patients in accordance with established national guidelines. Menus will be developed to meet
the criteria through the use of an approved menu planning guide. Guidelines: 1. Menu cycles will be developed and tailored to the needs and requirements of the facility. 2. Menus will be periodically presented for resident review, including the resident council, menu review meetings, or other review board as indicated by the center. The menu will identify the primary meal, the alternate meal, and any always offered food and beverage items. 3. Menu cycles will include standardized recipes. Recipes must be followed and scaled apporiately. 4. Menu cycles will include nutrient analysis to ensure that all client (adolescent, adult, geriatric) nutritional needs are met in accordance with the most recent edition of the Food and Nutrition Board, Institute of Medicine, National Academies, and the Dietary Guidelines for Americans, 2015-2020 edition. 5. A Registered Dietitian/Nutritionist (RDN) or other clinically qualified nutrition professional reviews and approves the menus. The RDN or other clinically qualified nutrition professional will adjust the individual meal plan to meet the individual requests, including cultural, religious, or ethnic preferences, as appropriate. 6. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal.
7. A menu substitution log will be maintained on file. 8. Menus will be posted in the Dining Services department, dining rooms and resident/patient care areas. 9. Menus are kept on file per state regulations .
Based on observation, interview and record review the facility failed to ensure two residents (R44 and R69) were provided the option of an alternate entree, beverages and preferred deserts during the scheduled meals. This deficient practice has the potential to affect all of the 78 residents who eat meals prepared and served by the kitchen.
Findings include:
On 3/31/25 at approximately 12:15 p.m., Observations of the lunch meal were made and the following was observed:
R44 was observed in the TCU (transitional care unit) dining room seated at a table. R44 was observed to have the front of their shirt completely covered in wetness with no clothing protector observed to be on them. The other residents surrounding them were observed to be eating their lunch meal with R44 watching them eat.
At approximately 12:19 p.m., R44's meal ticket was observed and revealed the following: feeding assist No straws. At that time, three other residents observed at R44's table eating the lunch meal. R44 was still observed to be watching the other residents eat without being assisted with their meal. Only one resident at table was provided a beverage with the meal at that time. None of the other residents were provided a desert or beverage for the meal.
At approximately 12:26 p.m., R44 was finally served a beverage, but it contained a straw with it.
On 4/01/25 at approximately 12:31 p.m., during observations of the lunch meal in the Redford House Certified Nursing Assistant I (CNA I was queried why none of the residents eating the lunch meal were offered a desert with their lunch and they reported they (the staff) are never provided the deserts from the kitchen so the residents who live in the greenhouses do not get them. CNA I was queried pertaining to any alternate menus/entrees in the greenhouses and they reported that they get the ingredients/food from the main kitchen and then cook the entree in one of the houses. CNA I reported there are no alternate menus for the residents that resident in the Greenhouses. CNA I indicated all they had to offer the greenhouse residents was a bacon sandwich because that's all they had in the refrigerator. CNA I was queried again if they had an always available list of items or an alternate entree and they indicated they did not and all they had was bacon and if the residents did not want that, then they did not have anything else to offer them.
On 4/01/25 at approximately 12:34 p.m., R69 was observed at the dining room table with their lunch meal not consumed. R69 was queired why they were not eating, and they reported they did not like the pot pie that was served. R69 indicated they would have some of the bacon that CNA I was going to make because that's the only thing they had left to eat. R69 was queried if they would have liked some desert and they indicated they would have, but did not get any.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
On 4/1/25 at 12:30 PM, the kitchen in the Garfield House was observed with [NAME] House Manager (GHM) F. It was observed that there was an empty basket on the counter for snacks. In the refrigerator, ...
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On 4/1/25 at 12:30 PM, the kitchen in the Garfield House was observed with [NAME] House Manager (GHM) F. It was observed that there was an empty basket on the counter for snacks. In the refrigerator, there were 2 apple sauce cups, an opened package of bacon and a jar of mayonnaise. When queried about snacks for the residents, GHM F stated that the main kitchen will not give them any snacks. GHM F stated that they only give them enough food to prepare for the meals. GHM F stated, Even those 2 apple sauce cups in the refrigerator are saved for medication pass. GHM F stated that the residents are hungry, and that staff often buy snacks with their own money to feed the residents. Further review of the cupboards and dry storage area revealed no other food items. GHM F stated they don't even have a jar of peanut butter or lunch meat to make sandwiches. GHM F showed this surveyor a text message that had been sent to Certified Dietary Manager (CDM) E asking when they were going to get snacks for the [NAME] Houses, because the residents were hungry. There was no response from CDM E.
On 4/1/25 at 1:45 PM, CDM E was queried about the provision of snacks to the residents that reside in the [NAME] Houses. CDM E stated that snacks were not really her responsibility, and referred this surveyor to speak to someone in the main kitchen.
Based on observation, interview and record review, the facility failed to ensure post-dinner snacks were available and offered for 18 residents residing in the Green Houses of a total of a total census of 78. Findings include:
On 4/01/25 at approximately 12:31 p.m., during observations of the lunch meal in the Redford House Certified Nursing Assistant I (CNA I) was queried regarding post-dinner snacks for the residents in the [NAME] Houses. CNA I reported they did not have any snacks because the kitchen never sends them over to the houses. CNA I indicated that the kitchen is run by different staff and they do not give any snacks to the residents.
On 4/01/25 at approximately 12:51 p.m., [NAME] House Manager F (GHM F) was queired regarding snacks for after the dinner meal and they reported the [NAME] Houses are not provided snacks from the Kitchen because the kitchen staff do not have a contract with the [NAME] Houses. GHM F was queried if they could remember the last time the [NAME] houses were provided evening snacks, and they indicated they have not had any snacks in a long time and could not remember the last time the main kitchen had been able to provide them with snacks.
On 4/2/25 a facility document titled HS (evening) snacks was reviewed and revealed the following: Standard: Snacks and beverages will be provided as identified in the individual plans of care. Bedtime (a.k.a. HS) snacks will be provided for all residents. Additional snacks and beverages will be available upon request for all residents who want to eat at non-traditional times. Guidelines: 1. The Dining Services department will collaborate with the residents/patients, nursing and management team to identify necessary beverage and snack items to be provided to each resident/patient. 2. The Dining Services department assembles on a daily basis snack items (food and beverages) for delivery to each resident/patient care area. 3. Snacks will be assembled, labeled, and dated in accordance with the individual plan of care for each resident and those items will be delivered to patient care areas in a timely manner. 4. The Dining Services department will assemble and deliver to each unit the individually planned snack items and bulk snack items to be offered at bedtime. 5. The Dining Services department provides a listing of the current diet orders and snacks for each resident to each care area. 6. Nursing Services is responsible for delivering the individual snacks to the identified residents and for offering evening snacks to all other residents. 7. All snacks will be properly stored for time and temperature control, as appropriate.
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
Food Safety
(Tag F0812)
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 prepare food in accordance with professional standard...
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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 prepare food in accordance with professional standards for food service safety. This deficient practice had the potential to result in food borne illness among all residents of the [NAME] House that consume food from the kitchen. Findings include:
On 04/01/25 at 12:45 PM, the [NAME] House dish machine was checked with [NAME] House Manager F. The dish machine was a low temperature, chemical sanitizing dish machine. When asked how staff checks the dish machine for sanitization, [NAME] House Manager F pointed to a dish machine log, and some Smart Power test strips (test strips used to test the levels of DDBSA and lactic acid sanitizer). Observation of the chemicals for the dish machine showed 1 bottle of liquid detergent, and 2 bottles of liquid rinse aide, hooked up to the automatic chemical dispenser for the dish machine. There was no sanitizer attached to the dish machine, to ensure that dishes were being sanitized. When asked how staff was checking for sanitizer level, when there was no liquid sanitizer hooked up to the dish machine, [NAME] House Manager F had no explanation. When asked why staff were using Smart Power test strips, which were for a chemical that was not being used, [NAME] House Manager F stated I'm not sure where those test strips came from. [NAME] House Manager F retrieved a bottle of chlorine sanitizer from the [NAME] House, and brought it to the [NAME] house. [NAME] House Manager F replaced the bottle of liquid rinse aid with the bottle of liquid chlorine sanitizer. [NAME] House Manager F then turned on the dish machine and tried to test with a chlorine test strip, but the strip did not change color to denote the presence of sanitizer. [NAME] House Manager F stated she would call maintenance to fix it.
According to the 2017 FDA Food Code section 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization-Temperature, pH, Concentration, and Hardness, A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under ¶4-703.11(C) shall meet the criteria specified under §7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, P and shall be used as follows: (A) A chlorine solution shall have a minimum temperature based on the concentration and PH of the solution as listed in the following chart; P.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice #1
Based on observation, interview and record review, the facility failed to ensure enhanced barrier precaut...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice #1
Based on observation, interview and record review, the facility failed to ensure enhanced barrier precautions (EBP) were in place and implemented by staff for one resident, (R66) of one resident reviewed for EBP, resulting in the potential for the development of infection. Findings include:
On 3/31/25 at 10:45 AM, R66 was observed in their bed. R66 was not responsive to attempts at verbal communication. At that time, R66 was observed to have a urinary catheter, a feeding tube, a tracheostomy, and was receiving oxygen through a tracheostomy mask. An observation of the door to R66's room from the hallway did not reveal any signage to indicate R66 was on enhanced barrier precautions.
On 3/31/25 at 1:55 PM, Nurse 'C' and Certified Nurse Aide (CNA) 'B' were observed entering R66's room; they did not don an isolation gown or gloves prior to entering the room. At approximately 1:59 PM, entry was made into the room. Nurse 'C' was observed in the room and CNA 'B' had used the adjoining bathroom to enter the room next door. At that time, Nurse 'C' was asked what type of care was being provided and said they were in the room cleaning the tube feeding pump and pole. They were asked if they provided any care to R66 and said they did not, but CNA 'C' had provided incontinence care prior to going next door. An observation of the trash can did not reveal any used personal protective equipment (PPE).
On 4/1/25 at 9:56 AM, Nurse 'A' was observed in R66's room preparing a nebulizer treatment. After the preparation of the treatment, Nurse 'A' was observed to administer the breathing treatment via a facemask through R66's tracheostomy. Nurse 'A' was not observed to be wearing an isolation gown.
On 4/1/25 at 3:05 PM, an interview was conducted with the facility's Director of Nursing (DON)/Infection Control Nurse. They were asked if R66 should be identified as requiring EBP and said they should.
A review of a facility provided policy titled, Enhanced Barrier Precautions (EBP) was conducted and read, .The Enhanced Barrier Precautions (EBP) guidance expands to residents that trigger the use of EBP and indicates it should be followed for any resident in the facility ' s with: .Has an indwelling catheter for the duration of their stay .The EBP requires the use of gowns and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .Examples of high-contact resident care activities requiring gown and glove use among residents that trigger EBP use include: .Device care or use: central line, urinary catheter, feeding tube, tracheostomy care/ventilator .
Deficient Practice #2
Based on observation, interview, and record review, the facility failed to store linens in a sanitary manner. This deficient practice had the potential to affect 13 residents on the [NAME] Unit.
On 4/1/25 at 9:25 AM, a clean linen cart with a light blue plastic style covering was parked in the hallway outside room [ROOM NUMBER]. The top of the linen cart was observed to have a foam cup of a red beverage sitting on it. The back of the cover was lifted up and draped over the the top of the cart revealing supplies on the cart. Among the clean linen supplies was a large, blue plastic water bottle with ice water sitting on a stack of towels. Further inspection of the linen cart cover revealed brown stains drip dried down the side toward the bottom and on the back of the cover. It was further noted the cover had numerous holes. During the observation of the cart, Certified Nurse Aide (CNA) 'D' came out of room [ROOM NUMBER]. They were asked if they were using the cart and said they were. They were then asked if the water bottle stored in the cart was theirs and said it was. Next, they were asked where would be an appropriate place to store their personal water bottle and said it should have been in refrigerator, not on the clean linen cart.
On 4/1/25 at 2:55 PM, the linen cart was again parked outside room [ROOM NUMBER]. The cover remained with the soiled brown stains and numerous holes. The top of the cart had two boxes of gloves, a toothbrush, and a tube of toothpaste stacked on it.
On 4/1/25 at 3:05 PM, an interview was conducted with the facility's Director of Nursing (DON)/Infection Control Nurse. They were asked about the condition of the linen cart and cover and said nothing should be stored on top of the cart, staff should not store any of their personal items in the cart and the cover would be inspected for replacement.
On 4/2/25 at approximately 1:30 PM, an observation of the linen cart on the [NAME] unit was conducted. The cover remained with the soiled brown stains and holes. At 1:33 PM, the DON said the Contract Company for housekeeping services tried to replace the cover but they did not have one that fit correctly. They were asked if anyone attempted to clean the brown stains from the cover and said they told housekeeping staff to clean it when it was brought to their attention on 4/1/25. They were made aware the linen cover remained with the stains and then said they were going to clean the cover themselves.
A review of a facility provided policy titled, Sanitizing Linen Carts was reviewed, however; the policy did not address the cleanliness of the cart covers, staff storing food/beverages in the cart, or storage of items on the top of the cart.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure an environment with a functioning resident call system for four residents (R10, R16, R17 and R41) of seven residents re...
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Based on observation, interview and record review, the facility failed to ensure an environment with a functioning resident call system for four residents (R10, R16, R17 and R41) of seven residents reviewed for environmental concerns, of a total census of 78.
Findings include:
On 3/31/25 at approximately 9:11 a.m., R10 was observed in their room, up in their bed. R10's bathroom was observed to have an alert pull-cord tied to a non functioning piece of plastic on the alert box next to their toilet, rendering the cord to be unable to be used to call for assistance if needed.
On 3/31/25 at approximately 10:55 a.m., R17 was observed in their room, up in their wheelchair. R17's bathroom was observed to have the Shower pull-cord that was connected to the alert system tied to a solid plastic piece on the box in a non-functional position, rendering the cord to be unable to be used to call for assistance if needed.
On 3/31/25 at approximately 11:18 a.m., R41 was observed in their room, laying in their bed. R41's bathroom was observed to have a shower with the shower pull-cord detached from the alert system rendering it unable to be used by R41 or staff to call for assistance if needed.
On 4/1/25 at approximately 8:44 a.m., R10 was observed in their room, laying in their bed. R10's pull-cord located next to their toilet was still observed tied to the end of the box in a non functioning position. R10's pull cord activator was not observed to have a cord attached to it to pull for assistance.
On 4/1/25 at approximately 9:20 a.m., R41 was observed in their room, up in their bed. R41's shower was observed to contain their wheelchair and geri- chair. R41's shower pull-cord was not observed present on the alert activator.
On 4/1/25 at approximately 9:25 a.m., R17's pull-cord for their call/alert system in their shower was observed wrapped around the grab bar and detached from the activator.
On 4/1/25 at approximately 9:31 a.m., R17's call light in their room was tested with no response. the system did not flash on the door or on the system monitor.
On 4/2/25 at approximately 11:57 a.m., The room for R10 was observed with Maintenance Director K (MD k). MD K was shown the alert pull-cord not attached to the activator on the toilet and they indicated that whoever installed the cord did it wrong and did not put it through the right hole on the alert box.
On 4/2/25 at approximately 12:03 p.m., MD K was shown R41's room that did not contain a pull-cord attached to there alert box on the shower. MD K reported that they would have to put a new cord on it to make it functional.
On 4/2/25 at approximately 12:04 p.m., R17's room pull-cord was reviewed with the MD K and they reported that the alert box next to R17's bed had a dead battery and that was why why alert system was not working.
On 4/2/25 at approximately 12:06 p.m., R16's pull-cord was tested in their room and was observed to be non-functioning with the light next to the door and the monitor not indicating the cord had been pulled. MD K indicated it was the same thing that had occurred in R17's room in which the battery was dead in the alert light box. MD K reported that nobody had made them aware of the need for the alert systems to be fixed in any of the resident rooms.
Feb 2024
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one resident (R17) of three residents reviewed ...
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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 one resident (R17) of three residents reviewed for dignity, were treated in a dignified manner during dining. Findings include:
On 2/14/24 at 8:42 AM, R17 was observed in the dining area sitting in a reclined geri chair. Observed on the table in front of R17 was a covered plate. R17 was asked about their meal and was unable to be interviewed due to having a impaired cognition.
On 2/14/24 at 12:16 PM, R17 was observed reclined in their geri chair with a Certified Nursing Assistant (CNA C), feeding R17 fruit from a small bowl. CNA C was standing on the side of R17, feeding and leaning over towards R17.
A review of R17's medical record noted, R17 was admitted to the facility on [DATE] with diagnosis of Alzheimer's Disease. A review of R17's Minimum Data Set (MDS) assessment dated [DATE] revealed, R17 with a severely impaired cognition and total dependent of staff for eating assistance and other Activities of Daily Living (ADLs).
A review of R17's care plan noted, Focus: I need assistance with my ADL's r/t (related to) Alzheimer's Disease, Hip Fx (fracture), Dementia, Hx (History) of Falls. Date Initiated: 11/10/2023. Goal: I will continue to assist with my daily care as tolerated. Date Initiated: 11/15/2023. Interventions: EATING: I am totally dependent staff for eating. Date Initiated: 11/10/2023.
On 2/14/24 at 12:40 PM, CNA C was observed to pull a chair over after the Director of Nursing (DON) was noticed to talk to them. CNA C was asked if they normally sit while assisting with a meal. CNA C stated, Yes, it's sometimes hard to find chairs.
On 2/15/24 at 3:23 PM, the DON was asked the facility's expectations for feeding assistance. The DON stated, Set up, sit down, and one on one feed. The DON was asked why it was important to sit while feeding a resident. The DON explained that it was more intimate to be right there with them and not standing over them. That it was also important, because staff can't see if something is happening to the resident if they are standing over them.
A review of the facility's policy titled, Meal Service Dining Room undated revealed, Policy: It is the policy of this facility to provide a dining room service that encourages residents to eat in a communal setting. A comfortable, attractive atmosphere will be maintained in the dining room area. Procedure: . 5. Residents will be assisted to the dining room as needed by the nursing staff. Positioning and assistance at mealtime will be appropriate for the resident's needs and is the responsibility of the nursing staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
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 a clean environment for one resident (R46) of o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a clean environment for one resident (R46) of one resident reviewed for homelike environment. Findings include:
On 2/13/24 at 9:46 AM, R46 was observed lying in bed, a tube feeding pole was observed as visibly soiled, with dried tube feed formula observed dried and caked to the floor. The surrounding areas of R46's bed was observed to also have a dried yellow unknown substance underneath the bed, in addition to trash. Attempts to interview R46 were unsuccessful, as they were confused.
On 2/13/24 at 1:58 PM, R46's room remained in the same condition as observed that morning.
A review of R46's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Paraplegia, Peripheral Vascular Disease, and Depression. Further review revealed that the resident was severely cognitively impaired, and was totally dependent on staff for Activities of Daily Living.
On 2/14/24 at 9:37am, 11:50am, 12:29pm, 1:51pm, and 3:22pm, R46's room was observed as it had been the day prior.
On 2/15/24 at 9:01 AM, R46 was observed in bed. Their room was observed in need of cleaning as it had been two days prior.
On 2/15/24 at 1:06 PM, the Director of Nursing (DON) was informed of observations made of R46's room, and was asked for her expectations for the cleanliness of residents' rooms. The DON explained that she is aware that R46's floors do get sticky, and that she would expect their room to be cleaned.
On 2/15/24 at 1:23 PM, the DON was observed in R46's room. The surveyor pointed out the tube feeding formula dried and caked to the floor, and overall lack of cleanliness of the resident's room, which she acknowledged.
A review of the facility's Resident Rights policy revealed the following, 9. Safe environment. The resident has a right to a safe, clean, comfortable, and Homelike environment, including but not limited to receiving treatment and supports for daily living safely .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
This citation pertains to Intake: MI00136948.
Based on interview and record review, the facility failed to thoroughly investigate an injury of unknown origin for one sampled resident (R34) of one res...
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This citation pertains to Intake: MI00136948.
Based on interview and record review, the facility failed to thoroughly investigate an injury of unknown origin for one sampled resident (R34) of one resident reviewed for injury of unknown origin. Findings include:
On 2/13/24 at 12:08 PM, R34 was observed sitting in their geri chair in the common area alert and confused.
On 2/14/24 at 10:00 AM, an interview was completed with Confidential Witness M regarding R34's fractured femur, and they explained that the resident sustained a fractured femur April 2023, and explained that the facility didn't appear to have completed a thorough investigation regarding what occurred.
A review of R34's medical record revealed that they were admitted into the facility on 9/20/20 with diagnoses that included Dementia, Chronic Obstructive Pulmonary Disease, and Anxiety. Further review revealed that the resident was severely cognitively impaired and required extensive assistance for Activities of Daily Living.
Further review of the medical record revealed the following progress notes:
4/26/2023 22:33 (10:33pm) Nurses Note: LATE ENTRY from 4/24/23 at 6:01am. Resident complain of leg pain (right) resident was not able to rate pain verbally. painful to touch and pain with movement.
4/24/2023 17:18 (5:18pm) Nurses Note: Daughter in to visit, nurse met with daughter, daughter voiced concerns of [R34] 'not acting the same.' Resident assessed upon doing so resident seemingly lethargic, not as interactive with peers as usual and slow to respond, displaying s/s (signs and symptoms) of pain in RLE (right lower extremity). NP (nurse practitioner) notified of findings, order given . Xray to RLE
4/25/2023 07:43 (7:43am) Nurses Note
Note Text: Received X-Ray report from the [Xray company] regarding patient's x-ray of [their] RLE which was done last night. The result said Supra condyle fracture of the distal Right femur. Dr.(doctor) and the DON (director of nursing) notified and ordered to send patient to the hospital .
4/26/2023 10:27 (10:27am) Quality of Life Note Text: IDT (interdisciplinary team) met and discussed plan of care, medication reviewed, Care Plan updated, reassess for pain. Skin assessed and treatment in place. Right immobilizer to right lower extremity .
On 2/15/24 at 1:03 PM, an interview was completed with the Director of Nursing (DON) regarding R34's femur fracture. The DON explained that that they hadn't ruled out whether the fracture was from a fall or not, and that they interviewed staff in an effort to identify how the fracture occurred. The investigation regarding the injury was requested from the DON at that time.
A review of the facility investigation was reviewed and indicated the following, Upon investigation, the root cause analysis was concluded, resident self-transferring and mobile via wheelchair. IDT has concluded there is no evidence of abuse or falls. Staff from the weekend was interviewed .
Further review of the investigation revealed six written interviews of staff members. Two of the written interviews did not have a name on them, and the remainder of the interviews were either missing the date of their interview, had ineligible signatures, or did not identify who interviewed the staff. In addition, there were no resident interviews noted.
On 2/15/24 at 3:42 PM, the DON was asked about the thoroughness of their investigation. The DON explained that the Nursing Home Administrator was looking for additional information, and they would provide the schedule of who worked the weekend they believe the fracture may have occurred. This information was not provided by the end of survey.
A review of the facility's Abuse policy revealed the following, .D. Identification. 1. The facility will monitor residents for changes in behavior, bruises/injuries of unknown origin or of a suspicious nature .E. Investigation. 5. The facility will investigate patterns, trends, or incidents that suggest the possible presence of abuse, neglect or misappropriation of property identified through analysis .6. The facility administrator, or designee will conduct interviews with like residents to assess for patterns of abuse or to collect witness statements .
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 and implement care plan interventions to meet...
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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 and implement care plan interventions to meet the needs for two residents (R46 and R74) of 19 residents reviewed for care planning. Findings include:
On 2/13/24 at 9:46 AM, R46 was observed lying in bed without heel protectors on, or floor mats in place. Attempts to interview R46 were unsuccessful, and they were confused.
On 2/13/24 at 1:58 PM, R46's room was observed without heel protector boots or floor mats observed in place.
A review of R46's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Paraplegia, Peripheral Vascular Disease, and Depression. Further review revealed that the resident was severely cognitively impaired, and was totally dependent on staff for Activities of Daily Living.
Further review of R46's medical record revealed the following order: Order Summary: 6/1/23 Heel protector boots at all times.
A review of R46's skin management care plan revealed the following, Focus: I was admitted with Stage 4 Pressure Ulcer and I am at further risk r/t (related to) Paraplegia, DM II (Diabetes Mellitus, type II), Cachexia, Low Protein Malnutrition, impaired mobility, Anemia, Encephalopathy and I prefer to position myself to the right side .Interventions: Apply heel boots as tolerated. Date Initiated: 10/26/2023 .
A review of R46's fall care plan revealed the following, Focus: I have had actual falls r/t Paraplegia; hx (history of) seizure, anemia, dementia. poor decision skills .Interventions: Place a floor mat beside me on the floor when I am in bed. Check for placement. Date Initiated: 07/05/2023 .
On 2/14/24 at 9:37am, 11:50am, 12:29pm, 1:51pm, and 3:22pm, R46 was observed lying in bed with their heels lying flat on the bed. There were no floor mats observed on the floor.
On 2/15/24 at 9:24 AM, Certified Nursing Assistant J (CNA J) was asked about R46's heel protector boots. She looked at the resident's feet, and around the room, and stated they're usually in here. CNA J was asked about floor mats for R46, and them being a fall risk, and she stated, I don't think [R46] is a fall risk.
On 2/15/24 at 9:30 AM, Wound Care Nurse A was asked about R46, and their heel protector boots, and she explained that the resident is supposed to have them in place per their care plan for pressure ulcer prevention, and that the heel boots were in laundry.
R74
On 2/13/24 at 1:31 PM, R74 was observed in their room lying down. Attempts to interview the resident were difficult due to their difficulty hearing the surveyor. R74 was asked if they had seen an audiologist since admission, and explained that they had not.
A review of R74's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Dysphagia following Cerebral Infarction, Acute Respiratory Failure, and Unspecified Hearing Loss, Left Ear. Additional review of the medical record revealed that the resident was cognitively intact, and according to their quarterly Minimum Data Set assessment dated [DATE] revealed that the resident's hearing was highly impaired.
A review of the admission social service assessment dated for 10/9/23 revealed that the resident's hearing was checked off as Poor.
Further review of R74's medical record did not reveal a care plan for the resident's hearing loss.
On 2/15/24 at 9:32 AM, R74 was asked if anyone had ever asked them if they wanted to be seen by the audiologist, and she indicated that they had not, and was not sure that they could be seen while in the facility. R74 further explained that they have a history of wearing hearing aids, but had lost them prior to coming to the facility. R74 further explained that the last time they had their ears checked, they were advised that they had complete hearing loss in their right ear, and very little hearing in their left ear. During this interview, R74 was observed to have to ask for the surveyor to repeat questions, and was also observed reading the surveyors lips.
On 2/15/24 at 1:06 PM, the Director of Nursing (DON) was informed of the observation made of R46's lack of floor mats and heel protector boots. The DON explained that the floor mats should be in place, and regarding the resident's heel boots, she explained that the resident can be resistive to the boots, but acknowledged that refusals should be documented in the progress notes, and care planned followed.
A review of the facility's Comprehensive Plan of Care did not address how the facility will ensure the implementation of care planned interventions however, it did reveal the following, The comprehensive care plan must be patient centered, be in the 'I' care plan format and consistent with resident's rights and describe that each resident is provided the necessary care and services including resident's choices to attain or maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident ' s comprehensive assessment or quarterly review. The comprehensive plan of care must be consistent with resident's rights and:
·Address the resident ' s individual needs, strengths, and preferences in an 'I' format
·Reflects current standard of professional practice;
·Include goals with measurable objectives;
·Reflect intervention to meet both short and long term resident goals
·Include interventions to prevent avoided decline in function or functional level;
·Reflect the facility's efforts to provide alternative methods when a resident wishes to refuse certain treatments or services;
·Include intervention to attempt to manage risk factors .
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** Deficient Practice #2.
R17
Based on observation, interview, and record review the facility failed to coordinate care between fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice #2.
R17
Based on observation, interview, and record review the facility failed to coordinate care between facility, hospice, and outside healthcare service, for one (R17) of one reviewed for hospice, resulting in inaccurate paperwork. Findings include:
A review of R17's electronic medical record (EMR) noted, R17 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease. A review of R17's Minimum Data Set (MDS) assessment dated [DATE] revealed R17 had a severely impaired cognition and required total assistance by staff for Activities of Daily Living (ADLs). A view of R17's advance directive revealed, R17 as a default full code (all resuscitation procedures will be provided to keep them alive).
A review of R17's physician orders noted, Date 1/16/24 . Admit to (hospice company): Admitting DX (diagnosis): Alzheimer's Disease. Hospice documentation/order noted, R17 DNR (do-not-resuscitate) .
A review of R17's care plan noted, Focus: CODE STATUS: I do not have the cognitive capacity to understand my code status form, and do not have a legal representative who can make decisions regarding life sustaining treatment. I will remain a full code by default at this time. Date Initiated. 11/07/2023. Goal: I will remain a full code by default until I regain ability to understand my code status form or until I have a legal representative who can make decisions regarding life sustaining treatment for me. Date Initiated: 11/07/2023. Focus: COGNITION: I have impaired cognitive functioning or impaired thought processes r/t (related to) Dx (Diagnosis) Dementia in other diseases classified elsewhere, moderate, with mood disturbance.
Further review of R17's medical consents revealed, Psychotropic Medication Consent Form Antidepressant medication: Lexapro. Antipsychotic medication: Depakote. I have also been informed of the purposes and benefits of the medication: To relieve depression Sign: Resident, Guardian, POA-HC or Patient Advocate Signature: [R17] Unable to sign verbal consent, 11/8/23, self.
On 2/15/24 at 12:50 PM, the Regional Social Worker (RSW) was asked if R17 had a guardian. The (RSW) reviewed R17's EMR and stated, I don't see a guardianship letter in chart, so that would be a no. The RSW was asked who signed R17 on to hospice, the RSW stated, I am not sure. I will contact the company to get the contract.
A review of the county's guardianship website did not reveal R17 with an appointed guardian.
A review of R17's medical record noted, 12/12/2023 16:11 (4:11 PM) Physician Progress Notes . Patient is full code per daughter who is the POA (Power of Attorney). Progress notes, GOC (goals of care) d/w (discussed with) daughter She does not want PEG tube or artificial means of feeding. Agree with current POC (plan of care). Will revisit GOC and may consider hospice if patient continues to decline in weight and or refuse po intake. Also d/w daughter code status. Currently full code.
On 2/15/24 at 2:41 PM, the RSW reported that R17 did not have a legal guardian. The RSW provided the hospice contract that noted, R17's daughter's signature on the admission contract. RSW was asked how R17 was competent to consent to psychotropic medication, but needed their daughter to sign the hospice contract. The RSW explained that they were going to educate the contingent Social Worker that completed the psychotropic medication consent. The RSW also explained that she would not have allowed R17 to sign consent. The facility was asked if R17 had been deemed incompetent by a physican. The facility reported that R17 was still there own person.
On 2/15/24 at 1:44 PM, the Director of Nursing (DON) was observed to call the outside Healthcare Service to request guardianship paperwork. The DON reported that they had made the request, but had not received the paperwork. The DON was asked if R17's all healthcare services were on the same page with R17's code status, and stated they will be addressing this in the calls to the outside healthcare services in regards to R17's consents and code status.
This citation has two deficient practices.
Deficient Practice #1.
This citation pertains to MI00142209.
Resident R57
Based on observation, interview and record review, the facility failed to ensure a dependent resident (R57) of three whose skin management was reviewed, was repositioned timely resulting resident distress and the potential for further skin tissue breakdown. Findings include:
On 02/13/24 at 10:26 AM, 11:29 AM, 1:03 PM and R57 was observed to be in bed on their back in bed. A pillow was not observed to be at the side of the torso to turn R57 left or right. At 1:03 PM, a therapy staff exited the room, the head of the bed was up around 60 degrees. At 4:26 PM, a nurse was in the room to set up R57's tube feeding. R57 was observed to be on their back in bed uncovered without any pillows/device at the sides of the torso to turn the resident of their back.
On 02/14/24 at 8:16 AM, R57 was observed to be on their back in bed. R57 moved their head around slowly but did not respond to queries.
On 02/14/24 at 10:35 AM, R57 was observed to be dressed and seated in a wheelchair next to the lower half of the bed. R57 faced out the window, had non-slip style socks on and was without foam boots on. R57's head moved around slightly and intermittently. The body was calm.
On 02/14/24 at 12:14 PM, R57 was observed to be dressed, wearing non slip socks and seated in a wheelchair next to the bed. R57 faced out the window, had non-slip style socks on, without the foam boots on. R57's was moving their head side to side and up and down more consistently.
On 02/14/24 at 1:05 PM, R57 was observed to be dressed, wearing non slip socks and seated in a wheelchair next to the bed. R57 faced out the window. R57 had their left arm hooked over the back of wheelchair. R57 was moving their torso side to side and lifting themselves up slightly with their right arm.
On 02/14/24 at 3:08 PM, R57 was seated in a wheelchair as before. R57 was heard to be calling out from behind the closed door. R57 was observed to be moving side to side and lifting themselves out of the wheelchair. R57 was calling out 'help me, get me up', and made an 'aaah aaah' moaning sound. This was repeated and R57 asked would you help me calling out 'aaah' again and 'help me up, can you help me get into this bed.' Licensed Practical Nurse (LPN) B entered the room and addressed R57 and R57 continued to call out 'aaah, somebody help me get in this bed right here.' At 3:14 PM, LPN B reported to the resident that they had to go and get a (mechanical) lift and some help and exited the room. The resident did not respond to queries about having any pain and asked again to get into the bed. R57 continued to shake their head and move their body side to side.
On 02/14/24 at 3:20 PM, multiple staff returned to room without the lift. Staff attempted to query R57, but R57 continued to say they wanted to get back to bed. At 3:26 PM, four staff assisted R57 back to bed with a lift and R57 quieted and their body calmed. A staff member asked R57 if they were in pain and R57 nodded yes. R57 was asked again and did not respond. A nurse note dated 02/14/24 at 3:50 PM, documented, .resident up in wheelchair yelling out .
On 02/14/24 at 3:44 PM, a skin check of R57's buttocks area was completed with the wound care nurse Staff A and it was noted that a foam pad was on the left buttock and the skin around the tailbone did not blanch visibly on palpation by the nurse.
On 02/15/24 at 8:15 AM, the observations of R57 were reviewed with the Director of Nursing (DON). The DON reported R57 was assessed for pain afterward and the nurse and a nurse aide had identified a skin tear on the left buttock and had placed a foam pad over it. The DON further reported the process for resident was to get residents back to bed to check and change them and then get them back up if desired.
On 02/15/24 at 9:58 AM, a skin check of R57's buttocks area was completed with the wound care nurse Staff A. R57 was observed to be in bed on their back without the heel boots on. Staff were observed to enter the room prior. A pea sized open area with a pink base was observed on the left buttock. R57 moaned and moved slightly on palpation of the area around the tailbone by the nurse. The walnut sized areas on each side of the tailbone were darkened and did not blanch.
A review of the facility record for R57 revealed R57 was admitted into the facility on [DATE]. Diagnoses included Hemiplegia (paralysis) of the right side, Disorder of the Brain, and Heart Failure. The active care plan documented, My transfer status two person total assistance hoyer (2 person mechaical) lift .I have the potential for pain/discomfort related to immobility .I have potential impairment to skin integrity related to fragile skin .follow your skin management program .
The Minimum Data Set (MDS) assessment dated [DATE] indicated R57 was dependent for self care and mobility (rolling left and right, sitting to standing, chair to bed transfer and bed to chair transfer). The MDS documented moisture associated skin damage but no pressure ulcers. The MDS defined a Stage Two pressure ulcer as partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red or pink wound bed .
A review of the skin/wound note dated dated 02/15/24 at 10:04 AM documented, Superficial opening to left upper buttock . A review of the skin/wound note dated 02/14/24 at 4:52 PM, documented, .resident has a superficial opening that measures 0.3 x 0.3 (centimeters). Treatment in place. Resident to use heel protectors as tolerated to protect heels.
A review of the facility Skin Management Facility Guidelines revealed, The facility is committed to providing care and services to residents to prevent the development of skin breakdown. The following guidelines are in place to reach this goal: 3. Residents admitted with skin impairments will have: Appropriate interventions implemented to promote healing .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide ancillary services related to a hearing impai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide ancillary services related to a hearing impairment for one resident (R74) of one reviewed for hearing services. Findings include:
On 2/13/24 at 1:31 PM, R74 was observed in their room lying down. Attempts to interview the resident were difficult due to their difficulty hearing the surveyor. R74 was asked if they had seen an audiologist since admission, and explained that they had not.
A review of R74's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Dysphagia following Cerebral Infarction, Acute Respiratory Failure, and Unspecified Hearing Loss, Left Ear. Additional review of the medical record revealed that the resident was cognitively intact, and according to their quarterly Minimum Data Set assessment dated [DATE] revealed that the resident's hearing was highly impaired.
Further review of R74's medical record did not reveal a care plan for the resident's hearing loss.
On 2/15/24 at 8:57 AM, Social Worker K was asked about the process for a resident to receive ancillary services, specifically hearing services, and she explained that upon admission a social services assessment is completed, and if the resident asks for specific services, it will be provided to them. Social Worker K was asked if R74 had been asked if they wanted to receive the services or knew it was available to them, and explained that she did not know as she is the corporate social worker and is unsure what the previous social worker asked the resident.
A review of the admission social service assessment dated for 10/9/23 revealed that the resident's hearing was checked off as Poor.
On 2/15/24 at 9:30 AM, Ophthalmologist L was observed in R74's room performing an eye exam. Ophthalmologist L was observed pulling down his mask down in effort to be understood by the resident due to them having difficulty hearing him. He was also observed speaking directly into the resident's left ear. Upon completing the exam, Ophthalmologist L was asked if he had difficulty communicating with the resident, and he explained that the resident did have difficulty hearing, and that it helped to speak directly into a specific ear, or allow the resident to read your lips.
On 2/15/24 at 9:32 AM, R74 was asked if anyone had ever asked them if they wanted to be seen by the audiologist, and they indicated that they had not, and was not sure that they could be seen while in the facility. R74 further explained that they have a history of wearing hearing aids, but had lost them prior to coming to the facility. R74 further explained that the last time they had their ears checked, they were advised that they had complete hearing loss in their right ear, and very little hearing in their left ear. During this interview, R74 was observed to have to ask for the surveyor to repeat questions, and was also observed reading the surveyor's lips.
On 2/15/24 at 1:12 PM, the Director of Nursing (DON) was asked about the process and expectations for ancillary services for residents. The DON explained that the social worker develops a list and sets up appointments if the resident or resident representative asks. The DON did not have anything further regarding the resident's hearing difficulty.
On 2/14/24 at 2:47 PM, a policy concerning ancillary services was requested from the facility however, it was not received by the end of this survey.
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 provide a safe number of staff during a 2 person mech...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe number of staff during a 2 person mechanical transfer with a Hoyer lift, as well as timely report and assess for potential injury for one resident (R30) of seven reviewed for accidents, resulting in pain in legs and feet. Findings include:
On 2/13/24 at 12:11 PM, R30 indicated that their feet hurt after an incident with a hoyer lift. R30 continued and stated, they have not seen the doctor concerning the pain and would like an X-ray.
On 2/14/24 at 9:56 AM, R30 was asked, when the incident happened. R30 stated, Three days ago. R30 reported Certified Nurse Assistant (CNA) E was alone during the transfer with a Hoyer lift. R30 said, their feet got stuck during the transfer and it felt like the CNA was trying to break their feet off. R30 was asked if they reported the pain or the incident to a nurse and stated, The night nurse.
On 2/15/24 at 7:58 AM, R30 was observed in bed and was asked how they were feeling and stated, My shins and feet hurt.
On 2/15/24 at 9:25 AM, Licensed Practical Nurse (LPN) D was asked if R30 reported the incident to them and the pain in their feet. LPN D stated, The first time she told me was yesterday. LPN D was asked if they reported the incident to the DON and if any investigation was started. LPN D stated, No. I didn't have a chance because I was busy. LPN D was asked if CNA E worked at the facility and stated, Yes, she works afternoons.
On 2/15/24 at 9:48 AM, R30 was asked if staff completed a pain assessment, R30 said sometimes they do. During the interview with R30, LPN D entered with R30's medication. LPN D was asked to observe R30's legs and feet. R30's feet were observed without bruising and LPN D reported that R30 has edema (swelling) in their feet.
On 2/15/24 at 10:35 AM, CNA E was interviewed via phone and was asked about the incident reported by R30. CNA E explained that during a Hoyer lift transfer R30's foot got stuck between the bar and the handle on the lift. CNA E explained that they moved R30's foot to get it unstuck. CNA E was asked if they transferred R30 with a partner or alone. CNA E stated, they had some help putting on the sling, but not with the entire transfer. CNA E was asked if they moved R30 from the chair to the bed alone and stated, Yes.
A review of R30's care plan revealed, Focus: My Transfer Status. Date Initiated: 09/05/2018. Goal: I will Transfer Safely. Date Initiated: 09/05/2018. Interventions: Transfer With 2 Person with Total Dependent Using Hoyer. Date Initiated: 04/01/2022.
Further review of R30's medical record noted, R30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease. A review of R30's Minimum Data Set (MDS) assessment dated [DATE] noted, R30 with an intact cognition and with impairment on one side upper (extremity), impairment on both sides lower (extremities).
On 2/15/24 at 10:25 AM, the Director of Nursing (DON) was asked the facility's expectation for reporting an incident to them. The DON state, Right away. The DON also explained that the incident would be reported to the resident's doctor for orders and responsible party.
On 2/15/24 at 3:27 PM, the DON was asked how many staff are required for a hoyer lift transfer. The DON stated, Two.
A review of the facility's policy titled, Lifting Policy - No tolerance safety undated, revealed, Policy: It is the policy of this facility to reposition, transfer, and/or lift residents safely and according to the resident care plan. The facility has a zero tolerance for employees that do not follow the resident's care plan. Employees who do not follow the resident's care plan related to repositioning, transfers and/or lifting may be subject to termination . Fundamental Information . 2. The type of equipment needed- . ALL HOYER-TYPE LIFTING. DEVICES REQUIRE AT LEAST TWO PEOPLE TO ASSIST IN THE LIFTING .
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 F0757
(Tag F0757)
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 review and document lab values for monitored medications (Digoxin a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and document lab values for monitored medications (Digoxin and Keppra) and follow medication administration recommendations (for cholestyramine and Digoxin) for one of one residents (R46) reviewed for therapeutic medications. Findings include:
A review of the facility medical record for R46 revealed R46 was admitted into the facility on [DATE] with a re-admission on [DATE]. Diagnoses included Atrial Fibrillation (irregular heart rate) and Epilepsy.
A review of the orders documented: an order dated 01/04/24 Digoxin oral tablet 125 mcg (micrograms) give one tablet one time a day . an order dated 04/12/23 Cholestyramine light packet 4 G (grams). Give one packet one time a day . and Levetiracetum (Keppra) oral solution 100 mg/ml (milligrams/milliliters). Give 20 ml every 12 hours .
Review of the care plans revealed a care plan which addressed the monitoring of the Digoxin was not found. A review of the I have altered cardiovascular status . care plan dated 01/17/23 did not address the use of Digoxin. A review of the care plan titled, I have the potential for fluid imbalance . dated 01/17/23 indicated, Obtain and monitor mylab/diagnostic work as ordered. Report my results to MD (medical doctor) and follow up as indicated .
A review of the lab result dated 08/07/23 documented a Digoxin level of .5 with the normal range as .8 to 2. A review of the nurse notes did not document notification of the physician. A note by the physician dated 08/10/23 did not include a review of the labs dated 08/07/23.
A review of the lab result dated 01/23/24 documented a Digoxin level of .4 and a potassium level of 6.7 with a reference range of 3.5 to 5.3. A review of the nurse notes did not document notification of the physician of labs until a progress note dated 01/30/24 documented, Lab results in with noted improvement. Doc made aware no new orders given at this time . A progress note by the Director of Nursing dated 02/02/24 documented, Pharmacy recommended for lab draw with dig (Digoxin) level and adjust dose as needed .
A review of the lab result dated 02/05/24 documented a Digoxin level of less than 0.19. A review of the nurse notes did not document notification of the physician until progress note dated 02/15/24. A note by the physician dated 02/15/24 at 9:21 AM documented, Patient's Digoxin level was .4 in Jan (January) then it was .19 in Feb (February). Therapeutic level is .5 to 2 .potassium level was high recently as well so no dose adjustment at this time. Recheck Digoxin level next week.
A review of the lab result dated 10/12/23 documented a Keppra level of 98.38 with a reference range of 6.0 to 46.0. A review of the nurse notes did not document notification of the physician and neither the nurse practitioner note dated 11/30/24 not the physician note dated 12/05/23 documented the out of range lab. An October physician or nurse practitioner note was not found in the progress notes.
On 02/15/24 at 8:15 AM, the identified concerns with Digoxin and cholestyramine were reviewed with the Director of Nursing (DON). The DON reported the facility did follow the pharmacy recommendation and that the result was shown to the primary physician Dr. I and they acknowledged the lab and thought it was OK. The DON revealed a text message which indicated the same. The DON confirmed a progress not had not been completed. The administration of the Cholestyramine and Digoxin were also reviewed with the DON and revealed the medication were documented as given at the same time 01/31/24 - 02/14/24. A pharmacy recommendation for the administration of Cholestyramine and Digoxin together we requested at this time but not received prior to survey exit.
A review of Cholestyramine and Digoxin at www.drugs.com revealed, Using cholestyramine together with Digoxin can decrease the effects of Digoxin. You should notify your doctor if you experience worsening of your heart symptoms. Cholestyramine should be administered at least eight hours before or after a Digoxin dose. You may need a dose adjustment or special test if you use both medications.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00139144.
Based on observation, interview, and record review, the facility failed to honor fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00139144.
Based on observation, interview, and record review, the facility failed to honor food allergies during a dining observation for one (R15) resident of 19 reviewed for dining. Findings include:
On 2/13/24 at 12:34 PM, R15 was observed with their head down on the dining table. Observed in front of R15 was a cup of pink juice and a cup with a piece of uneaten frosted cake that had red fruit pieces baked into the cake. Certified Nursing Assistant (CNA C) was observed to come to the table and to pick up the cake and juice and stated, Wait, is this strawberries? CNA C was observed to take away the cake and juice. CNA C was asked if R15 was able to have strawberries and stated, No. [R15] is allergic to a lot of things. CNA C was asked if R15 was allergic to strawberries and stated, Yes. CNA C was asked if the items were strawberries and stated, I am not sure.
During an observation in the kitchen the frosted cake was confirmed that it was strawberry cake.
On 2/15/24 at 8:17 AM, R15 was asked if they are allergic to strawberries and stated, Yes. R15 was asked if they were aware that the caked that was served to them for lunch on Tuesday 2/13/24 had strawberries on it and stated, No.
A review of R15's meal ticket noted, Allergies: Oranges, Milk, Tomatoes, Strawberries, Blueberries.
A review of R15's medical record noted, under the allergy tab in the Electronic Medical Record (EMR) Allergen Strawberries. Reaction Manifestation Anaphylaxis, Severity Severe, date 7/30/2021. Further review of R15's medical record documented R15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of End Stage Renal Disease.
A review of R15's care plan noted, Focus: I am allergic to hydralazine, Niacin, Penicillin, Phenytoin, Naprosyn, ACE Inhibitors, Berry, Citrus, Milk, Orange Juice, Strawberries, Tomato. Date Initiated: 07/30/21. Goal: My risk for an allergic reaction will be minimized by the review date. Date Initiated: 7/30/2021. Interventions: Document my known allergies so all are aware. Date: Initiated: 7/30/2021. Minimize my contact with my known allergens as much as possible. Date Initiated: 7/30/2021. Observed my diet prior to serving and check for any known allergens. Date Initiated: 7/30/21.
On 2/15/24 at 10:28 AM, the Director of Nursing (DON) was asked about following meal tickets regarding allergies and explained that the staff should adhere to what is displayed on the meal ticket.
A review of the facility's policy titled, Meal Accuracy dated, August 2016. Policy: It is the policy of this facility to provide residents with meals that accurately reflect therapeutic diets including supplements and food preferences listed on their meal ticket. Procedure: (Form Provided) . 2. The items served to each resident will be checked against the meal ticket to verify accuracy before the meal is delivered to the resident .
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the primary kitchen, t...
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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 sanitary conditions in the primary kitchen, the [NAME] house, and [NAME] house resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 75 residents who receive meal services (2 nothing by mouth residents, or NPO) out of the facility's total census of 77 residents. Findings include:
1. On 2/13/24 between 9:45 AM, and 10:52 AM, the following non-food contact surfaces in the kitchen were observed soiled and with visible debris on their surfaces:
On the flooring underneath the fryer, the top and sides of the fryer, and sides of the oven next to the fryer.
On the ovens stainless steel backsplash.
On the flooring throughout the transitional care unit's serving kitchen. Upon observation the surveyor inquired with Dietary Director, Staff N, on if they thought these areas were being cleaned timely and sufficiently to which they replied, not to my liking. On 2/13/24 at 10:53 AM, the surveyor requested a copy of the kitchen's cleaning policy to review.
On 2/13/24 at 10:04 AM, the number ten can opener's cutting blade was observed with visible debris on its surface. Upon observation Dietary Director, Staff N, commented, I'll set it aside to be cleaned.
On 2/13/24 at 10:30 AM, five windows were observed with an accumulation of dust and debris consisting of leaves, grass clippings, twigs and cobwebs on the interior window screens backing up to the clean equipment and utensil storage rack.
On 2/13/24 between 11:32 AM and 12:57 PM, the following non-food contact surfaces in the [NAME] and [NAME] houses were observed deteriorated, soiled and with visible debris on their surfaces:
On the exterior and interior of all kitchen cabinetry.
On 2/13/24 at 11:41 AM, an accumulation of dark colored dust and debris was observed on and around the ceiling heat vents above the [NAME]'s kitchen food preparation area. At this time the surveyor inquired with House lead, Staff O, on the current state of the vents to which they stated, I'll need to call Maintenance for help with those, they are too tall for us to reach.
2/14/24 at 10:10 AM, record review of an untitled document referred to by Staff N as the facility's cleaning schedule revealed that the facility has a system in place to ensure a clean and sanitary environment in the kitchen.
Review of 2017 U.S. Public Health Service Food Code, Chapter 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, directs that:
(A) Equipment food-contact surfaces and utensils shall be clean to sight and touch.
(C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.
2. On 2/13/24 at 12:13 PM, the [NAME] house's kitchen dish machine was observed by the surveyor being tested by House lead, Staff O, via a chlorine test strip revealing no color change on the test strip. At this time the surveyor inquired with Staff O on what they would normally do in a situation like this to which they replied, test it again and check the chemicals. On 2/13/24 at 12:15 PM, the chlorine test strip revealed no color change. At this time the surveyor requested the dish machine sanitization log to review. On 2/13/24 between 12:16 PM and 12:21 PM, new containers of liquid chemicals were installed, and two additional tests were conducted by Staff O, all of which revealed no color change on the test strip. At this time Staff O stated, I'll call maintenance to come and look at it. We can use the [NAME] house's dish machine.
On 2/13/24 at 12:27 PM, the [NAME] house's kitchen dish machine was observed by the surveyor being tested by Staff O, via a chlorine test strip revealing no color change on the test strip. At this time Staff O was observed by the surveyor opening the lower cabinet doors to the right of the dish machine and stating, It's not hooked up. The surveyor asked for clarification to Staff O's statement to which they replied, there's only two bottles and it's supposed to be three. On 2/13/24 between 12:30 PM and 12:43 PM, new containers of liquid chemicals were installed and two additional tests were conducted by Staff O, all of which revealed no color change on the test strip. At this time Staff O stated, I'll have to call maintenance about this. We could use our main kitchen's machine, or at least get disposable cups and plates from them.
On 2/13/24 at 1:50 PM, upon record review of a policy titled, February 2024 [NAME] dishwasher temp log revealed places for refrigerator and freezer temperatures to be recorded with numbers ranging from 100 - 129. At this time the surveyor asked Staff O if they could explain the information present on the dish machine sanitization log, to which they stated, no. It must just be a mistake on our forms. I'll update this and the [NAME] house's later today.
On 2/13/24 at 9:57 AM, and at 2:11 PM, the surveyor confirmed the primary kitchen's dish machine
was sanitizing within required parameters per the current FDA food code, and the chemical manufactures instructions for correct use as a sanitizer.
Review of 2017 U.S. Public Health Service Food Code, Chapter 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization -Temperature, pH, Concentration, and Hardness, directs that:
A chemical SANITIZER used in a SANITIZING solution forA chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under §7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, P and shall be used as follows:
(2) Have a concentration as specified under § 7-204.11 and as indicated by the manufacturer's use directions included in the labeling.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to provide a safe, functional, and sanitary environment for the facilitie...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to provide a safe, functional, and sanitary environment for the facilities census of 77 residents and its staff resulting in an increased potential for harm. Findings include:
On 2/13/24 at 10:36 AM, cracked window glass was observed in the transitional care units dining room. At this time the surveyor inquired with Dietary Director, Staff N, on the current state of the window to which they stated, I was unaware of it. I will let the maintenance staff and our Director of Nursing know about it right away. On 2/13/24 at 12:07 PM, the surveyor observed the broken glass on this window covered with cardboard and taped over on its edges.
On 2/13/24 at 11:40 AM, in the [NAME] house, paper towels were observed not available for use at the dining rooms designated hand washing sink. On 2/13/24 at 11:42 AM, a visibly wet stack of paper towels was observed placed on a countertop next to the wall mounted paper towel dispenser adjacent to the kitchen's designated handwashing sink. Upon observation the surveyor inquired with the House lead, Staff O, on why the paper towel dispenser is not being used as designed they stated, I'm not sure. I will follow up with maintenance and get paper towels for it and the other sink.
On 2/13/24 at 1:20 PM, in the [NAME] house, paper towels were observed not available for use at the dining rooms designated hand washing sink. On 2/13/24 at 1:22 PM, a visibly wet stack of paper towels was observed placed on a countertop next to the wall mounted paper towel dispenser adjacent to the kitchen's designated handwashing sink.
On 2/13/24 between 11:56 AM and 1:22 PM, soiled and clean laundry entry doors were observed propped open, and clean linen carts were observed uncovered in the hallways in both the [NAME] and [NAME] houses.
On 2/13/24 at 2:34 PM, during a tour of the facility's laundry room, five windows were observed with an accumulation of dust and debris consisting of leaves, grass clippings, twigs and cobwebs on the interior window screens adjacent to washing machines and clean linens.
On 2/13/24 at 3:11 PM, The lack of personal protective equipment (PPE) was observed available for use in the transitional care unit's soiled utility room. Additionally in this room, lift batteries and charging stations were observed being stored, no paper towel was observed available for use for handwashing, the hopper sink was observed with a black/ brownish substance in its basin, the two compartment sink was observed soiled and debris covered, and a strong odor was present in this room. At this time the surveyor inquired with the Laundry and Housekeeping Supervisor, Staff P, on who is responsible to ensure rooms such as this are kept clean, and fully stocked with PPE to which they replied, a combination of going through Maintenance and the Nursing staff.
On 2/13/24 at 3:14 PM, the surveyor inquired with Staff P on if the lift batteries and charging stations would normally be stored in a soiled utility room to which they replied, I'm not really sure, but we can move them to a clean area.
On 2/13/24 between 3:19 and 3:30 PM, the lack of personal protective equipment (PPE) and means to conduct hand hygiene were observed unavailable for use by the surveyor and Staff P in both Certified Nursing Assistant's assigned laundry rooms.
On 2/14/24 at 11:03 AM, in the [NAME] house, paper towels were observed not available for use at the dining rooms designated hand washing sink.
Sept 2023
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00138500
Based on observation and interview, the facility failed to provide comfortable, warm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00138500
Based on observation and interview, the facility failed to provide comfortable, warm water temperatures in rooms 5,7, 13, 21, and Shower RM [ROOM NUMBER], and failed to provide a functional sink and home-like environment in room [ROOM NUMBER]. Findings include:
On 9/5/23 at 11:00 AM, hot water temperatures were measured with Maintenance Supervisor B with the following results:
room [ROOM NUMBER]: 95 degrees Fahrenheit
room [ROOM NUMBER]: 85 degrees Fahrenheit
room [ROOM NUMBER]: 85 degrees Fahrenheit
room [ROOM NUMBER]: 93 degrees Fahrenheit
Shower room [ROOM NUMBER]: 93 degrees Fahrenheit.
On 9/5/23 at 11:15 AM, the facility boilers and hot water tanks were observed. Maintenance Supervisor B stated the boiler was functioning because the red light was illuminated, but was unsure of the water temperature in the hot water tanks, and stated the building did not have a mixing valve.
On 9/5/23 at 1:30 PM, the running water at the bathroom sink in room [ROOM NUMBER] was observed to be non-functional. Resident C was queried about how long he had been without running water in his bathroom, and Resident C stated, It's been that way for a long time. In addition, there was a large area of deep gauges and missing plaster on the wall next to the resident's chair, the headboard on the bed was loose, wobbly, and sloped down to one side, and the cove base molding behind the bed was detached from the wall.
On 9/5/23 at 1:40 PM, Maintenance Supervisor B stated that some of the faucets on the resident's sinks were non-functional because they were old and new parts needed to be ordered.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
This citation pertains to intake MI00138500
Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the pote...
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This citation pertains to intake MI00138500
Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include:
On 9/5/23 between 10:30 AM-11:00 AM, during a tour of the kitchen with Dietary Manger (DM) A, the following items were observed:
There was a personal cell phone charging next to the food processor on the food preparation counter. On the door leading into the kitchen, there was a sign posted that stated, No cell phones past this point.
According to the 2017 FDA food code, Section 7-209.11 Storage, Except as specified under §§ 7-207.12 and 7-208.11, Employees shall store their personal care items in facilities as specified under 6-305.11(B), and Section 6-403.11 Designated Areas, .(B) Lockers or other suitable facilities shall be located in a designated room or area where contamination of food, equipment, utensils, linens, and single-service and single use articles can not occur.
The black rolling cart utilized for the storage of spices was observed to be heavily soiled with spilled spices and food debris. When queried about the soiled cart, DM A provided no explanation.
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 ice chute inside the ice machine was soiled with a pink, slimy substance. Review of the cleaning logs for the ice machine revealed the ice machine had last been cleaned on 3/4/23.
According to the 2017 FDA Food Code section 4-602.11 Equipment Food-Contact Surfaces and Utensils,
(E) Except when dry cleaning methods are used as specified under § 4-603.11, surfaces of utensils and equipment contacting food that is not potentially hazardous (time/temperature control for safety food) shall be cleaned: (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold.
In the walk-in cooler, there was an opened package of deli roast beef with a use by date of 9/2, an opened, undated package of deli turkey, an opened package of hot dogs with a use by date of 9/2, and a container of raw ground beef with a use by date of 8/30. DM A confirmed the opened items should be dated and discarded after the use by date.
According to the FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.
The low temperature, chemical sanitizing dish machine was tested with DM A. A chlorine test strip was used to measure the level of sanitizer in the dish machine. DM A ran numerous racks through the dish machine, but could not detect any measurable sanitizer with the test strips. While running the dish machine, the sanitizer hose line was observed to be spraying water out onto the clean side of the dish machine. When queried if staff kept a log for testing the sanitization of the dish machine, DM A retrieved the August 2023 log, which was on top of the dish machine. The log had last been completed 8/28/23. When queried about the September 2023 dish machine log, DM A stated he did not know where it was.
According to the 2017 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment, (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.
The single basin sink located at the soiled side of the dish machine room, was observed with a leak at the drain pipe. There was a full bucket underneath the pipe, which was being used to catch the leaking drain water.
According to the 2017 FDA Food Code section 5-205.15 System Maintained in Good Repair, A plumbing system shall be: (A) Repaired according to law; P and (B) Maintained in good repair.
Jan 2023
15 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0563
(Tag F0563)
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 allow unrestricted visitation, affecting two 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 allow unrestricted visitation, affecting two residents (R56 and R232), and potentially affecting all residents residing in the facility, resulting in the potential for decreased psychosocial well-being and quality of life. Findings include:
On 1/17/23 at 9:17 AM, during the initial tour of the facility, a sign was noted to be posted on the entrance of the Transitional Care Unit (TCU). The sign included the following:
Please be advised that visiting hours are between 8:00 AM - 8:00 PM daily. We cannot allow entry after 8:00 PM. For the safety of the residents, we ask all visitors to end visitation by 8:00 PM. Thank you for your cooperation in advance. -12/14/2022, Management.
On 1/17/23 at 9:58 AM, R56 was interviewed in their room in the TCU. When queried regarding visitation at the facility, R56 indicated that people do come to visit, but that the facility stops visitation at 8 PM. When queried as to why, R56 indicated they did not know.
A review of R56's record revealed the following progress note:
-12/5/2022 08:21 (AM) Nurses Note Note Text: The CNA (Certified Nursing Assistant) .informed the writer that the patient's visitor who came in at 2 PM [NAME] (sic) still in patient's room sitting on the bed with the patient at 10.00 PM. The visitor was asked to leave. The CNA said she observed the visitor kiss the patient.
A review of R56's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] and is cognitively intact with a medical diagnosis of Bone Fractures. Further review revealed that the resident requires supervision to extensive activities of daily living (ADL) assistance from staff.
On 1/17/23 at 12:32 PM, Confidential Witness A was interviewed regarding R232's care at the facility. Witness A stated, My biggest concern is that I can't seem to get a hold of anyone at the facility. Witness A explained that recently, on multiple occasions, they had attempted to call the facility and TCU to talk to someone about R232, and was unable to get anyone to answer the phone as well as unable to leave a voicemail. When queried regarding visitation at the facility, Witness A stated, They told me the visiting hours are 8 AM - 8 PM.
A review of R232's record indicated that the resident was admitted into the facility on 1/10/23, and the resident's Brief Interview for Mental Status (BIMS) assessment dated [DATE] indicated a severely impaired cognition.
On 1/18/23 at 8:55 AM, the same sign observed on 1/17/23 at 9:17 AM at the entrance to TCU was observed to also be hung at the side entrance to the TCU, as well as on the main entrance door into the [NAME] Unit.
On 1/19/23 at 1:18 PM, the Nursing Home Administrator (NHA) was interviewed and asked if she could elaborate on the visitation signs observed posted throughout the building. The NHA stated she was unaware of any signs that were posted. The NHA stated, [Visitors] can come in anytime. I need to go see where the signs are posted. When queried, the NHA indicated that visitors should not be getting asked to leave if it is after 8 PM.
On 1/19/23 at 2:30 PM, the Director of Nursing (DON) was queried regarding the posted visitation restriction signs throughout the building. The DON stated that the signs were posted due to concerns regarding resident family members, Essentially living here, as well as a domestic situation involving a staff member that happened in June, but did not elaborate. The DON added, Visitation is open, we just don't want anyone living here or any domestic situations.
A review of the facility's policy/procedure titled, Visitation and Access Rights, undated, revealed, Policy: Reasonable access to any resident is provided for individuals providing health, social, legal, or other services to the resident, subject to the resident ' s right to deny or withdraw access at any time. Procedure: 1. A resident may have visitors of his/her choice at any time, as long as visitation is not medically contraindicated .3. The facility reserves the right to impose restrictions on visitation to protect the rights and safety of other residents in the facility 7. Residents will be permitted to visit with any representative from federal and state survey agencies, resident advocates, and/or their personal physicians at any time .9. Inquiries concerning visitation and access to the facility should be referred to the Administrator and/or to the Director of Nursing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to document and provide recommended restorative services ...
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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 document and provide recommended restorative services (resting hand splint) for two sampled residents (R59 and R39) of three residents reviewed for limited range of motion/restorative services, resulting in the potential decrease in mobility and comfort. Findings include:
On 1/17/23 at 2:47 PM, R59 was observed sitting in the common area in their wheelchair. Their left hand was observed as contracted, and there was no splint or brace observed in place. Attempts to interview R59 were made to no avail due to their cognition.
A review of R59's medical record revealed that the resident was admitted into the facility on 3/9/20 with diagnoses that included Vascular Dementia, Anemia and Anxiety. A review of R59's Quarterly Minimum Data Set assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status score of 4/15 indicating a severe cognitive impairment, and required extensive assistance for toileting, personal hygiene and transfers.
Further review of R59's medical record revealed the following care plan, I am on a Restorative Nursing Program r/t (related to) Weakness and joint mobility. Date Initiated: 11/18/2022 .Interventions: NURSING REHAB/RESTORATIVE: SPLINTS: Apply Left resting hand splint for up to 4 hours a day as tolerated. Program#1-RUE (right upper extremities) exercises with a 1 pound weight 1 set,15 reps (repetitions) as tolerated. 2 times a week x 8 weeks. Program#2- PROM (passive range of motion)/AAROM (active assisted range of motion) exercises 2 sets, 15 reps each as tolerated. 2 times a week x 8 weeks. Date Initiated: 11/18/2022 .
On 1/18/23 at 8:36 AM, 12:14 PM, and 12:51 PM, R59 was observed sitting in the common area without a splint on their left hand.
On 1/19/23 at 12:20 PM, R59 was observed sitting in the common area without a splint on their left hand.
Further review of R59's medical record's restorative documentation revealed that R59 had received restorative services four days in a 30-day period (12/28/22, 1/4/23, 1/11/23, and 1/16/23).
On 1/19/23 at 1:56 PM, Restorative Aide N was asked about R59's restorative services including the application of their splint. Restorative Aide N explained that R59 obtains restorative services six days a week, Monday-Saturday as tolerated. Restorative Aide N was asked if R59 is compliant with services, and explained that they are compliant, will wear the splint for an hour in the morning and then take it off themselves. Restorative Aide N was asked about the lack of documentation in the electronic medical record, and explained that she is unsure why the documentation is not there, as the services have been completed.
On 1/19/23 at 2:08 PM, the facility provided requested restorative notes for R59, and provided one progress note indicating the following, 11/18/2022 13:03 (1:03 PM) Restorative Weekly Progress Notes
Note Text: Writer received restorative nursing plan. Goal: Maintain current level of joint mobility and strength. Program#1-RUE exercises with 1 pound weight 1 set, 15 reps as tolerated. Program#2-PROM/AAROM to exercises 2 sets, 15 reps as tolerated. Program#3- Left resting hand splint for up to 4 hours as tolerated.
On 1/19/23 at 2:26 PM, the Director of Nursing (DON) was interviewed regarding expectations for staff implementation of Plan of Care goals and interventions and they stated, We expect residents' goals to be implemented.
Resident 39 (R39)
On 1/17/23 at 9:15 AM, during an initial tour of the facility R39 was observed in their bed with contracted fingers on their left hand. R39 was non interviewable.
On 1/17/23 R39's family member/guardian O was contacted by phone and interviewed about R39's care at the facility. Family member/guardian O indicated that they had been waiting for R39 to receive some therapy. Family member/guardian O stated, I've been asking about it for a year.
On 1/19/23 at 10:43 AM, a review of R39's electronic medical record (EMR) revealed an order dated 7/18/22 which documented, Admit to restorative nursing program.
On 1/19/23 at 10:45 AM, R39's restorative nursing care plan was reviewed and revealed the following, Focus: I am on restorative nursing program r/t [related to] joint immobility, weakness. Date Initiated: 07/18/2022 Revision On: 07/18/2022. Goal: I will allow staff to allocate interventions to prevent further decrease in mobility/ROM [Range of motion] of all planes and extremities. Revision On: 09/03/2022 Target Date: 04/29/2023. I will maintain current ROM strength, and joint mobility through next review date. Date Initiated: 07/18/2022. Interventions: .exercises 2 sets 10 reps each as tolerated . Apply left elbow extension splint and hand splint to be worn as tolerated .Date Initiated: 07/18/2022.
On 1/19/23 at 11:00 AM, a thirty day review of restorative activities completed for R39 revealed documentation that restorative exercises were documented to have been completed on 12/28/22. No additional restorative documentation was noted for R39.
On 1/19/23 at 11:25 AM, Restorative Aide (RA) N was interviewed regarding restorative therapy provided for R39. RA N indicated that they were frequently pulled from restorative care to help around the facility. RA N indicated that they did not use the splint on R39 because, I don't know how to put it on.
On 1/19/23 at 3:15 PM, a further review of R39's EMR revealed that R39 was admitted to the facility on [DATE] with diagnoses that included Dementia and Dysphagia (Difficulty swallowing). R39's most recent minimum data set assessment (MDS) dated [DATE] revealed that R39 had a severely impaired cognition and required extensive assistance to being totally dependent for all activities of daily living (ADLs).
A review of the facility's Establishing a Restorative Nursing Program policy did not address documenting restorative services or ensuring that the plan of care was being followed for residents in a restorative nursing program.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to monitor, supervise, and ensure two residents (R's 76 and 231) of two reviewed, who were known smokers, one of who had a histor...
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Based on observation, interview, and record review the facility failed to monitor, supervise, and ensure two residents (R's 76 and 231) of two reviewed, who were known smokers, one of who had a history of smoking inside the facility, maintained compliance with the facility's non-smoking status resulting in the potential for continued unsupervised and/or unsafe smoking. Findings include:
On 1/17/23 at 10:44 AM, a door alarm was heard going off. R76 and R231 were observed going into the courtyard though the door next to the chapel. The residents were then observed to be smoking cigarettes outside with an unidentified male staff member wearing maroon scrubs.
On 1/17/23 at 1:43 PM, the same male staff member in maroon scrubs was observed in the courtyard with R76 and R231. R76 was observed to have cigarettes in their pocket, and proceeded to pull one out and light it.
On 1/18/23 at 12:40 PM, R231 was interviewed. R231 admitted that they are a smoker but they refuse the nicotine patch. The resident stated their family will come sign them out to go smoke away from the facility, but they aren't always able to do it. The resident denied having any cigarettes but admitted to bumming them from others at the facility.
A review of R231's care plan did not include any information regarding the resident's smoking status.
On 1/18/23 at 12:45 PM, R76 was interviewed. When queried about smoking at the facility, the resident stated they go outside to smoke when everyone else goes out or whenever someone is willing to take them outside. When queried if staff holds onto their smoking paraphernalia, the resident asked why staff would hold onto their cigarettes, and indicated that they hold onto their own items. R76 became agitated when queried further about smoking and did not provide additional information.
A review of R76's progress notes revealed the following:
-10/5/2022 14:21 (2:21 PM), Nurse Practitioner Notes .Patient is independent with [their] care and walks with the help of cane .is a smoker and has been smoking in this facility at times as noted by staff .
-10/31/2022 18:24 (6:24 PM) Incident Note Note Text: CENA (CNA - Certified Nursing Assistant B) informed writer that resident was smoking cigarettes in bedroom, resident observed in hallway, walking unsteady with walker .Writer confiscated lighter and cigarettes .
-12/26/2022 11:03 (AM) Nurses Note Note Text: Resident observed smoking in room, writer attempted to get cigarettes and lighter, resident stated I don't got it and refused to give items.
On 1/18/23 at 3:20 PM, Certified Nursing Assistant (CNA) B was called and left a voicemail, however no call back was received prior to survey exit.
On 1/19/23 at 1:18 PM, the Nursing Home Administrator (NHA) was interviewed. When queried regarding the facility's smoking policy, the NHA indicated they do not have one because it is a non-smoking facility. When queried regarding the observations of R76 and R231 smoking outside in the courtyard, the NHA stated that the residents should not have been outside smoking with staff. The NHA acknowledged having to do a room sweep, in R76's room after the resident was found smoking in their room. The NHA stated, No one should be smoking here on this side at all .will have to correct that.
The facility indicated they did not have a smoking policy to provide for review.
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 F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00132324.
Based on interview and record review, the facility failed to ensure the completion...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00132324.
Based on interview and record review, the facility failed to ensure the completion of routine pre and post dialysis monitoring, assessments, and documentation of missed treatments for one resident (Resident #134) of one reviewed for dialysis, resulting in the potential for unidentified change in condition and complications post dialysis treatment.
A review of a complaint called into the State Agency noted, It was alleged staff failed to schedule dialysis appointments.
On 1/18/23 at 1:55 PM, R134 was admitted on [DATE] and discharged on 11/23/22.
An admission progress noted dated 10/26/2022 17:30 (5:30 PM) documented, Received resident alert responsive, ability to make needs known resident accompanied by 2 EMTs (Emergency Medical Technicians), resident requires max assist with ADLs (activities of daily living), resident with meds verified with MD (medical doctor), resident with amputation to left foot with sutures, resident denies pain or discomfort at this time, resident with no acute distress. vital signs 134/78, 82. 97.6. 18 Resident with no other skin issues noted.
A Physician's History and Physical (H&P) note dated 10/27/2022 documented, admitted for SAR (sub acute rehab) after recent hospitalization. [R134], [AGE] year old, was admitted with syncopal episode. [R134] had left foot wound necrosis, moderate purulent drainage, with surrounding swelling of L (left) foot and warm to touch, gangrene of the left 4th and 5th digits of the foot. (R134) received amputation of 4th and 5th digits on 10/12/22. On 10/18/22 (134) returned to OR (operating room) for transmetatarsal amputation and tendon achilles lengthening of the left foot with podiatry. Treated with IV (intravenous) Vanco (antibiotic) for infection .diagnosis .7) ESRD (end stage renal disease) on dialysis: ESRD , Schedule: TTS (Tuesday, Thursday, Saturday).
A review of R134's dialysis communication forms revealed the following:
10/27/22 no form or documentation for this Tuesday treatment.
10/29/22 form incomplete.
11/1/22 form incomplete.
11/3/22 form incomplete
11/5/22 no form or documentation for this Saturday treatment.
11/8/22 form incomplete.
11/10/22 form incomplete.
11/12/22 form incomplete.
11/15/22 form completed.
11/17/22 form completed.
11/19/22 form completed.
11/22/22 form completed
The dialysis communication forms were not fully completed and revealed no communication forms or documentation in the clinical record for two treatments (10/27/22 and 11/5/22).
On 1/19/23 at 3:27 PM, the Director of Nursing (DON) was asked if R134 received dialysis on 10/27/22 and 11/5/22. The DON explained that he was not sure and was observed to call the dialysis center to obtain information regarding the missing days of documentation. The documentation was not provided by the end of this survey.
A review of R134's care plan revealed, I need hemodialysis r/t (related to) ESRD Date Initiated: 10/27/2022.
A review of the facility's policy titled, Dialysis Transportation, dated 2/17/20 noted, Policy: It is the policy of this facility to facilitate and coordinate transportation for residents requiring dialysis at an external center. Procedure: Upon admission, residents requiring dialysis will be scheduled to attend dialysis at the center they used within the community whenever possible . 6. The dialysis communication form should accompany the resident to and from dialysis to assure continuity of communication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to document non-pharmacological interventions and ensure...
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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 document non-pharmacological interventions and ensure informed consent was obtained before initiating and administering a psychotropic medication (Xanax-an anti-anxiety medication with sedating effects) to a resident with cognitive impairment, affecting one resident (R232) of five reviewed for unnecessary medications, resulting in the potential for adverse reactions, delirium, and/or negative psychosocial outcomes. Findings include:
On 1/17/23 at 9:52 AM, R232 was observed lying in bed wearing a hospital-type gown. The resident appeared gaunt, drowsy, with overgrown fingernails. One side of the resident's bed was pushed up against the wall, and a fall mat was observed on the floor on the other side. R232 was unable to answer questions and non-interviewable.
On 1/17/23 at 12:32 PM, Confidential Witness A was interviewed regarding R232's care at the facility. Witness A explained that they were the main person involved in R232's care. Witness A stated, My biggest concern is that I can't seem to get a hold of anyone at the facility. Witness A explained that recently, on multiple occasions, he had attempted to call the facility to talk to someone about R232, and was unable to get anyone to answer the phone as well as unable to leave a voicemail.
A review of R232's record indicated that the resident was admitted into the facility on 1/10/23, and the resident's Brief Interview for Mental Status (BIMS) assessment dated [DATE] indicated a severely impaired cognition. R232's admitting medical diagnoses included Fracture of Left Femur, Encounter for Orthopedic Aftercare, History of Falling, Malignant Neoplasm of Liver, Glaucoma, and Cataract.
A review of R232's pre-admission hospital paperwork dated 1/7/2023 - 1/10/2023 did not include any antianxiolytic medication orders. The paperwork indicated that the resident had been hospitalized for repair of a left hip fracture.
A review of R232's progress notes revealed the following:
-1/11/2023 08:11 (AM) admission Note Note Text: received resident alert and responsive to verbal/tactile stimuli. however resident does appear lethargic family states that resident has been weaned off some medication from the hospital that has [them] lethargic .resident is difficult to redirect and does not follow instructions well. family remain at bedside. staff attempt to complete skin assessment and resident became combative and refusing. resident has Dx (diagnosis) of left hip fx (fracture) and is non compliant with nonweight bearing status .attempts several times to get out of bed .
-1/11/2023 14:40 (2:40 PM) Behavior Note: Resident noncompliant, unsuccessful to direct. Resident refused all meals during shift and care. Writer attempted to reeducate resident, resident did not comply.
-1/11/2023 16:59 (4:59 PM) Order Note: Physician changed orders for Xanax .5 (milligrams) Q12h (every 12 hours) for 14 days order carried out at 4pm.
-1/11/2023 21:48 (9:48 PM) [Psychiatric Services Note - Written by Physician Assistant (PA) F .Date: [DATE] pt (patient) was noticed with anxiety agitation resisting care combative to care, ask to evaluate pt and tx (treat) as indicate. According to pt, pt has denied .depression, and denies hx (history) of harm self, there are no mood C/O (complaints) however pt was noticed with anxiety agitation resisting care combative to care, pt look alert and verbal response with confused unable to give reliable hx (history) of information a+Ox 1-2 (alert and oriented times 1-2, meaning resident is confused) .ASSESSMENT & PLAN: Generalized anxiety disorder .Plan: Start Remeron (antidepressant) 15 mg qhs (at bedtime) for depression anxiety, Watch side effect such as dry mouth sedation, expected benefit will start in 2-3 wks (weeks) .give a trial of Xanax 0.5 mg q 12 h prn (as needed) for anxiety episode, psychosocial support, monitor mood change .Adjustment disorder with depressed mood, Dysthymic disorder .Dementia in other diseases classified elsewhere, moderate, with other behavioral disturbance noted .
Documentation of consent for psychiatric services and psychiatric medication initiation were not found in R232's record upon review.
On 1/18/23 at 8:59 AM, Licensed Practical Nurse (LPN) D was followed for the medication administration task and was observed preparing medications for R232. LPN E was present to oversee LPN D, as she was new to the facility. LPN D prepared an as-needed (PRN) Xanax for R232. When queried why the resident was going to be receiving the medication, LPN E stated because the resident was being combative this morning. LPN E stated that the resident was also getting ready to go out to an appointment and they wanted R232 to be relaxed. R232 required their medication to be crushed and administered with pudding. R232 was observed sitting calmly in their wheelchair in the main dining area of the Transitional Care Unit (TCU). During medication administration, R232 required assistance from staff to take their medications as well as to drink the ordered liquid supplements (Ensure and liquid protein) that were provided. The resident was not observed to be agitated, anxious, nor combative at this time. When queried regarding R232 requiring assistance, LPN D stated that staff should be helping the resident eat/drink. R232 took their medication after multiple staff attempts and only drank some of the liquid supplements with staff assistance.
A review of R232's Medication Administration Record (MAR) revealed that the resident had received the PRN Xanax on 1/17/23 as well as 1/18/23 (observed administration). R232's record did not indicate documentation of specific behaviors nor non-pharmacological interventions attempted prior to the Xanax administrations.
On 1/18/23 at 10:44 AM, Confidential Witness A arrived at the facility to see R232. Witness A informed staff that the unit manager was supposed to call him back yesterday regarding R232 but did not. Staff confirmed Witness A was on the resident's facesheet as the main contact person. Witness A told the nursing staff it was frustrating that no one answers the phone at the facility. R232 remained calmly in the TCU dining area at this time in their wheelchair. Staff Member G began putting R232's coat on when Witness A asked, Is [R232] on some type of meds now? .I'm trying to figure out is [R232] on something right now, 'cause this ain't [them]. R232 was observed at this time as somewhat lethargic, was having trouble keeping their eyes open and keeping their head up. When queried regarding R232's normal medications, Witness A indicated they cant remember what the resident takes. Prior to leaving for R232's scheduled appointment, Witness A again commented that R232 was not acting like their normal self.
A review of R232's care plan revealed:
-Focus: BEHAVIOR: At times, I can become combative at times r/t (related to) to intermittent confusion. Date Initiated: 01/11/2023, Revision on: 01/18/2023.
-Interventions: Anticipate and meet my needs. Date Initiated: 01/11/2023.
-Assist me to develop more appropriate methods of coping and interacting. Encourage me to express feelings appropriately. Date Initiated: 01/11/2023.
-Explain procedures to me before starting and allow me to adjust to changes. Date Initiated: 01/11/2023.
-Observe my behavioral episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Date Initiated: 01/11/2023.
On 1/18/23 at 10:56 AM, Social Worker (SW) C was queried regarding R232's cognitive status and ability to consent to the initiation of new medication. SW C stated that it doesn't appear R232 is able to consent, and that the resident did not have a current guardian or durable power of attorney in place. SW C further explained that she spoke with Witness A, who is actively involved in the resident's care. When queried regarding who is responsible for obtaining psychiatric medication consents, SW C indicated that she is. When queried if she obtained consent from R232 or Witness A for psychiatric services/treatment/medication, SW C indicated she had not. When queried regarding the justification for the initiation of Xanax, SW C stated she believed the resident had behavioral issues and that in R232's care plan, it noted the resident could be combative. When queried where documentation of attempted non-pharmacological interventions would be found, SW C indicated that to her knowledge, they were not documented but to check the progress notes from nursing. SW C referenced R232 being seen by PA F and the resident's admission note that included a refusal of skin assessment as justification for the resident's new medications.
On 1/19/23 at 1:36 PM, Confidential Witness A was interviewed via phone and stated that when he saw R232 at the facility, the resident was not their normal self. Witness A accompanied the resident to their appointment on 1/18/23 and explained that the staff at the appointment were asking what was wrong with the resident. Witness A stated, [R232] wasn't talking to them or reacting at all. Witness A indicated that the appointment staff called the hospital emergency room (ER) and sent R232 from the appointment to the ER to be evaluated, and that they were now awaiting test results. When asked if the facility contacted him to obtain consent or information regarding psych services and or initiating new medication for R232, Witness A responded that the facility did not, and that staff told him they weren't giving the resident, anything but Tylenol. When asked if PA F contacted him regarding R232, Witness A stated, No.
On 1/18/23 at 2:41 PM, PA F was interviewed. When queried regarding the initiation of the Xanax order for R232, PA F initially indicated that R232 agreed to take Xanax. When queried regarding the reasoning for starting Xanax, PA F stated that she ordered the medication because staff had issues with the resident and that the resident had been combative. When asked if staff explained to her what they attempted to do to calm the resident down prior to starting medication, PA F stated, I think they tried to redirect [R232] but that's pretty hard .[the resident is] confused. PA F was then queried how R232 was able to consent to starting new medications if they were confused. PA F stated that she thought she talked to nursing staff and tried to call R232's family, but could not recall. When queried regarding what the recommended non-pharmacological interventions for managing R232's behaviors would be prior to initiating medication, PA F stated, Redirection .but patient has cognitive [decline] .hard to redirect .[the resident] had a behavioral problem that was brought to me. I think they (staff) already tried, at least to my knowledge. PA F stated that because the resident is cognitively impaired, that they were unable to verbalize feeling depressed, but she observed the resident as, Emotional stressed.
On 1/18/23 at 2:50 PM, the Director of Nursing (DON) was queried regarding the facility's policy/procedure for managing behaviors and documentation non-pharmacological interventions. The DON stated that nursing staff would write behavior progress notes and what they did to manage and respond to the behaviors. The DON also indicated that behavioral interventions would be located in the resident's care plan.
A review of the facility's policy/procedure titled, Behavior Management Program, undated, revealed, It is the policy of this facility that residents who are receiving medications to alter behaviors or who are exhibiting ongoing behavior issues be reviewed by a Mood and Behavior Management Team The team should discuss the resident ' s condition and develop a management program to address the behavior issues. A non-pharmaceutical approach should be attempted initially .The social worker should in-service staff on interventions to address observed behaviors for the resident .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
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 the meal ticket matched the meal for breakfast...
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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 the meal ticket matched the meal for breakfast and lunch for one sampled resident (R59) of one resident reviewed for accuracy of meals, resulting in the resident's food preferences not being honored. Findings include:
On 1/18/23 at 8:57 AM, R59 was observed sitting in the common area for breakfast. Their meal tray was observed to have a large amount of untouched eggs on the plate however, observation of the resident's meal ticket revealed a list of dislikes which included eggs. Attempts to interview R59 were attempted to no avail due to their cognition.
A review of R59's medical record revealed that the resident was admitted into the facility on 3/9/20 with diagnoses that included Vascular Dementia, Anemia and Anxiety. A review of R59's Quarterly Minimum Data Set assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status score of 4/15 indicating a severe cognitive impairment, and required extensive assistance for toileting, personal hygiene and transfers.
A review of R59's care plan revealed the following, Focus: I am at nutritional risk r/t (related to)dysphagia, Dementia. I have been placed on Remeron for my appetite. I prefer vegetarian meals. Date initiated 03/09/2021 .Interventions: Offer me my preferred choices of food. No meat, fish .Provide, serve me my diet as ordered - in addition to observing my intake and record per policy. I receive a Regular diet, thin liquids. I prefer vegetarian meals. Date initiated 03/9/2021 .
On 1/18/23 at 12:49 PM, R59's lunch tray was observed to have rice, a roll, dessert, and green beans. The green beans were observed to have meat mixed into the vegetable.
On 1/19/23 at 2:29 PM, Dietary Manager J was asked about the process to ensure that residents' receive meals per preference. Dietary Manager J explained that meal tickets are printed out each day and staff should be making sure everything is appropriate from the kitchen staff to the nursing staff to ensure accuracy. She further explained that her expectations are to ensure that resident's food preferences are being followed.
On On 1/19/23 at 2:26 PM, the Director of Nursing (DON) was interviewed regarding expectations for ensuring that residents' food preferences are honored. The DON explained that the expectations is that the residents' receive meals per their preference.
A review of the facility's Quick Resource Tool: Meal Frequency and Preferences revealed the following, .Dietary Staff Unit Food Carts: 1. Tray cards updated and correct with residents diet including likes and dislikes .Nursing Staff Unit Food Carts: 1. When food carts are delivered to the unit the Nurse assigned to tray service will open cart, observe tray for proper diet, likes and dislikes. The tray will then be served to the resident, providing set up and dining service as needed .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to serve food in a palatable manner and at the preferred ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to serve food in a palatable manner and at the preferred temperature for three residents (R9 and R73) of six residents reviewed for food palatability, resulting in resident dissatisfaction during meals. Findings include:
Resident 9 (R9)
On 1/17/23 at 9:30 AM, during an intitial tour of the facility, R9 was interviewed about food palatability at the facility and stated, The food is terrible. On 1/19/23 at 9:00 AM, a followup interview was conducted with R9 regarding food palatability and they stated, Yesterday they didn't put any sugar on my oatmeal and my grits had sugar on them. I'm not sure why. R9 indicated that they took a mouthful of their lunch yesterday and spit it out saying, I didn't like it.
On 1/9/22 at 3:13 PM, a record review of R9's electronic medical record (EMR) revealed that R9 had diagnoses that included Heart failure and Type 2 diabetes. A review of R9's most recent minimum data set assessment (MDS) dated [DATE] revealed that R9 had an intact cognition and required extensive assistance with all activities of daily living (ADLs) other than eating.
Resident 73 (R73)
On 1/17/23 at 10:29 AM during an initial tour of the facility R73 was interviewed about food palatability at the facility and indicated that the food was not good. R73 stated, I wouldn't feed this food to an animal.
On 1/19/23 at 3:08 PM, a record review of R73's EMR was completed and revealed the following, R73 had diagnoses that included Heart failure and Anxiety disorder. R73's most recent MDS dated [DATE] revealed that R73 had an intact cognition and required assistance with all ADLs.
On 1/18/23 at 8:56 AM, a random breakfast tray being delivered to a resident's room was temperature tested by Dietary Aide (DA) K and the results were the following: Scrambled eggs: 93.7 degrees Fahrenheit; Sausage: 84.0 degrees Fahrenheit; Oatmeal: 132 degrees Fahrenheit. DA K was requested to taste test the food and declined, stating, I don't eat that. Observations were made of the breakfast meal tray not being transported on a covered food cart and no heating device being used under the plate of food.
On 1/18/23 at 8:59 AM, a taste test of the breakfast test tray was completed by the Surveyor and the results were the following; the scrambled eggs tasted cold, the sausage was hard and tasted cold, and the toast on the plate was cold to the touch with no butter and/or any other condiment on it.
On 1/18/23 at 3:22 PM, Dietary manager (DM) J was interviewed regarding food palatability and temperature at the facility and indicated that the food should come off the Tray line at 135 degrees Fahrenheit or greater. DM J was asked about the lack of covered food carts and plate warmers. DM J stated, We serve directly to the residents so we don't use carts. DM J indicated that the facility does not use plate warmers.
On 1/18/23 at 3:25 PM, District Dietary Manager (DDM) L was interviewed regarding their expectations for food palatability and temperature involving meals being served to residents. DDM 'L stated, The food should be around 100 degrees Fahrenheit when it reaches the resident.
On 1/17/23 at 12:30 PM, during an observation at the [NAME] house, a CNA T was observed to serve resident hamburgers for lunch. A request was made to taste a hamburger, the hamburger tasted cold and dry, without moisture. CNA T was asked if they temp the food before serving the food and stated, No. A request was made for the hamburger temperature, the hamburger was noted to not raise higher than 85 degrees Fahrenheit. CNA T was asked for the temperature log for the lunch that was being served. The temperature log was noted to have a temperature logged for the hamburger that was being served that meal. CNA T was asked about the temperature number on the log and explained that she just wrote the temperatures that the food always temps at.
On 1/19/23 at 4:00 PM, a facility policy titled Food Palatability-Hot Food Temperatures Dated: 2018 was reviewed and stated the following, Policy: The healthcare community prepares and serves food .that [is] palatable, attractive and at safe and appetizing temperature[s]. Procedure: Hot foods will be held at or above 135 [degrees] [Fahrenheit] .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide a discharge summary for one resident (R78) of three resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide a discharge summary for one resident (R78) of three residents reviewed for discharge, resulting in an incomplete medical record. Findings include:
A review of R78's medical record noted, the last entry of R78's progress notes 1/26/2022 21:15 Behavior Note Text: Writer asked by other nurse to do resident treatment, writer gathered what was needed to do resident treatment and went to resident room to do treatment, resident want writer to go through paper work from hospital to look and see what treatment suppose to be, writer informed resident that treatment will be done according to what's in computer, resident became angry and said to writer (Expletive) get the (expletive) out writer immediately left resident room resident still continued to curse at writer and writer informed [R78's] nurse what had happened, resident then proceeded to follow behind writer, writer informed other nurse that I was leaving floor, writer went over to [another unit] to attempt to complete charting, 5 minutes later resident observed on [the other unit] talking to nurse on that unit and pointing at me as I am trying to chart, the nurse [R78] was talking to then said to resident I will write a complaint against her for you, resident informed her that [R78] called [R78's] family and they were on their way up here, resident proceed to say to writer wait until my family get here, writer logged off computer and left.
A review of R78's medical record noted, R78 was admitted to the facility on [DATE] and discharged on 11/26/22, diagnosed with Osteomyelitis. R78's Minimum Data Set (MDS) assessment dated [DATE] noted an intact cognition and required extensive assistance with activities of daily living.
On 1/19/23 at 3:32 PM, the Director of Nursing (DON) was asked for R78's discharged summary and stated, [R78] just left, [R78] called their family and left. The DON was asked if R78 signed a against medical advice form and stated No. We didn't have time for [R78] to sign the AMA form [R78] just left. The DON was asked if the was a final note that explained R78's discharged and explained that the there was not a discharge note, just the note about the incident with the Nurse.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure they consistently offered and administered pneumonia vaccine...
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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 they consistently offered and administered pneumonia vaccines with accessible and valid documentation of acceptance or declination in the medical record for three residents (R59, R67, R76) of five residents reviewed for vaccinations, resulting in the lack of vaccine tracking, the residents right to choose and receive vaccine treatment options, and the right to an informed consent. Findings include:
On 1/19/23 at 8:55 AM, Licensed Practical Nurse (LPN) H, the facility's designated Infection Control Nurse was asked about the location of consents for the influenza and pneumonia vaccines, and she indicated that the consents should be in the resident's electronic medical record (EMR).
R59
A review of R59's medical record revealed that they were admitted into the facility on 3/9/22 with diagnoses that included Vascular Dementia, Hypertension and Depression. Further review of the EMR revealed that R59 had declined the Pneumococcal vaccine however, a declination form or education was not located in the EMR.
R67
A review of R67's medical record revealed that they were initially admitted into the facility on [DATE] with diagnoses of Cancer, Heart Failure, and Alzheimer's Disease. Further review of the EMR revealed that R67 had not received the pneumococcal or flu vaccines, nor were there declination forms located in the EMR.
R76
A review of R76's medical record revealed that they were admitted into the facility on 8/11/22 with diagnoses of Hypertension, Malnutrition, and Acid Reflux. Further review of the EMR revealed that R76 had not received the pneumococcal or flu vaccines, nor were there declination forms or education located in the EMR.
On 1/19/23 at 10:50 AM, declinations for R59, R67, and R76 were requested from the facility and not received by the end of this survey.
On 1/19/23 at 3:51 PM, the Director of Nursing (DON) was asked about the lack of declinations for flu and pneumonia vaccines, and he explained that his expectation is that they are completed.
A review of the facility's Influenza policy and Infection Prevention and Control Overview did not address consents, declinations and education of residents for the Pneumococcal and Influenza vaccines.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure they consistently offered and administered COVID-19 vaccines...
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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 they consistently offered and administered COVID-19 vaccines with accessible and valid documentation of acceptance or declination in the medical record for three residents (R65, R67, R76) of five residents reviewed for vaccinations, resulting in the lack of vaccine tracking, the residents right to choose and receive vaccine treatment options, and the right to an informed consent. Findings include:
On 1/19/23 at 8:55 AM, Licensed Practical Nurse (LPN) H, the facility's designated Infection Control Nurse was asked about the location of consents/declinations and education for the COVID-19 vaccine. LPN H indicated that the consents should be in the resident's electronic medical record (EMR).
R65
A review of R65's medical record revealed that they were admitted into the facility 11/9/21 with diagnoses that included, Dementia, Diabetes and Hypertention. Further review of the EMR revealed that R65 had not received the COVID-19 vaccine. There was not a declination form or education located in the EMR.
R67
A review of R67's medical record revealed that they were initially admitted into the facility on [DATE] with diagnoses of Cancer, Heart Failure, and Alzheimer's Disease. Further review of the EMR revealed that R67 had not received the COVID-19 vaccine. There was not declination form or education located in the EMR.
R76
A review of R76's medical record revealed that they were admitted into the facility on 8/11/22 with diagnoses of Hypertension, Malnutrition, and Acid Reflux. Further review of the EMR revealed that R76 had not received the COVID-19 vaccine. There was no declination form or education located in the EMR.
On 1/19/23 at 10:50 AM, declinations for R65, R67, and R76 were requested from the facility and were not received by the end of this survey.
On 1/19/23 at 3:51 PM, the Director of Nursing (DON) was asked about the lack of declinations/documentation for the vaccinations, and he explained that his expectation is that they are completed.
A review of the facility's COVID-19 Vaccination policy revealed the folloiwng, .15. Prior to the offering the COVID-19 vaccine, staff, residents, or the resident's representative will be educated regarding the risks, benefits and potential side effect associated with te vaccine in a form and manner that can be accessed and understood 18. Resident or resident representatives retain the right to accept, refuse, or change their decision about COVID-19 immunization. If refused, the resident's will adhere to the protocols set forth by specific facility policy . 20. The residents medical record will include documentation of the following: a. Education to the resident or resident representative regarding the risks, benefits, and potential side effects of the COVID-19 vaccine. b. Each dose of the vaccibe administered to the resident, or; c. If the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the Resident Call Light System was functio...
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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 that the Resident Call Light System was functioning as designed for one resident (R73) of one resident reviewed for call light function, resulting in unmet resident care needs. Findings include:
On 1/18/23 at 3:56 PM, R73 was met in their room for observation and interview. R73 indicated that they needed a brief change and no one was helping them. An observation was made of R73 pressing their call light button. The call light was observed to light up inside R73's room which indicated that the call light was on.
On 1/18/23 at 3:57 PM, an observation was made that R73's call light was not indicating that it was activated on the screen located behind the nurses station on the unit.
On 1/18/23 at 4:04 PM, the Director of nursing (DON) was on the unit and was interviewed regarding R73's call light and indicated that the facility was having trouble with some resident's call lights and was working on fixing the issue.
On 1/19/23 at 1:50 PM, R73 was interviewed and asked how long their call light had not been working. R73 was unable to answer the question. It was observed that R73 has a small bell on their bedside table which had not been observed there during the prior two days of the survey.
On 1/19/23 at 3:08 PM, a record review of R73's electronic medical record (EMR) was completed and revealed the following, R73 had diagnoses that included Heart failure and Anxiety disorder. R73's most recent minimum data set assessment (MDS) dated [DATE] revealed that R73 had an intact cognition and required assistance with all ADLs.
On 1/19/23 at 2:10 PM, Maintenance supervisor (MS) M was interviewed regarding call light maintenance issues regarding R73's call light. MS M indicated that they were unaware of any call light issue related to R73. MS M was asked about any auditing currently being done of the facility resident call light system and stated I'm not aware of any auditing being done. I've only been here for approximately two weeks. MS M was interviewed regarding their expectations for maintaining the resident call light system and stated, I think there should be some type of auditing system in place to assure call lights are operating properly.
On 1/19/23 at 3:21 PM, a facility policy was requested from the facility regarding call light maintenance. This policy was not received prior to survey 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a sanitary kitchen and proper hand washing, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a sanitary kitchen and proper hand washing, resulting in the potential for contamination of the physical facility and food products. These deficient practices affect all residents who consume food from the kitchen.
Findings include:
On 1/17/23 at 10:24 AM, black mold-like material was observed to be accumulating on the left wall of the walk-in cooler and the wire shelves in the walk-in cooler. At this time, Dietary Manager J stated they move the shelves around when they deep clean the cooler so they can access the walls.
According to the 2017 FDA Food Code Section
6-501.12Cleaning, Frequency and Restrictions.
(A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.
On 1/17/23 at 10:34 AM, the soiled side of the dish machine drain board was observed to not be properly sealed to the wall, allowing for food splash and water to accumulate on the wall behind the dish machine.
According to the 2017 FDA Food Code Section
4-402.11 Fixed Equipment, Spacing or Sealing.
(A) EQUIPMENT that is fixed because it is not EASILY MOVABLE shall be installed so that it is:
(1) Spaced to allow access for cleaning along the sides, behind, and above the EQUIPMENT;
(2) Spaced from adjoining EQUIPMENT, walls, and ceilings a distance of not more than 1 millimeter or one thirty-second inch; or
(3) SEALED to adjoining EQUIPMENT or walls, if the EQUIPMENT is exposed to spillage or seepage.
On 1/17/23 at 10:36 AM, the [NAME] tile grout underneath the three-compartment sink was observed to be dissolved away, allowing for moisture, debris to accumulate in the tile gaps. At this time, Dietary Manager J stated that they will put in a work order for maintenance.
On 1/17/23 at 10:53 AM, a large chaffing pan was observed to be stacked while wet, on the drying rack, not in a position to properly air dry.
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 SINGLEUSE 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.
On 1/17/23 at 10:58 AM, a reach-in cooler was observed to be out of order. At this time, Dietary Manager J was queried on how long the cooler was out of order and stated that it has not been working for approximately a year and maintenance plans on removing it from the facility.
According to the 2017 FDA Food Code Section
6-501.114 Maintaining Premises, Unnecessary Items and Litter.
The PREMISES shall be free of:
(A) Items that are unnecessary to the operation or maintenance of the establishment such as EQUIPMENT that is nonfunctional or no longer used; and
(B) Litter.
On 1/17/23 at 11:58 AM, the microwave, located in the meal service kitchen, was observed to have encrusted food debris covering the interior ceiling.
On 1/17/23 at 12:16 PM, Dietary [NAME] R was observed to open the trash can lid to discard trash, then proceeded to measure the temperature of the food on the steam table, without washing hands. After food temperatures were taken, Dietary [NAME] R was observed to sanitize hand with a hand sanitizer dispenser in the hall.
On 1/18/23 at 12:31 PM, District Dietary Manager L was observed to touch their facemask with their gloved hand, then proceeded to serve food on trays without washing hands and changing gloves.
On 1/18/23 at 12:44 PM, District Dietary Manager L was queried on where staff wash hands if hand contamination occurs, and stated they go to the nearest bathroom. At this time, the nearest bathroom was observed to be more than 20 feet away.
According to the 2017 FDA Food Code Section
2-301.14 When to Wash.
FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and:
(A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P
(B) After using the toilet room; P
(C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); P
(D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; P
(E) After handling soiled EQUIPMENT or UTENSILS; P
(F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P
(G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P
(H) Before donning gloves to initiate a task that involves working with FOOD; P and
(I) After engaging in other activities that contaminate the hands.P
According to the 2017 FDA Food Code Section
2-301.15 Where to Wash.
FOOD EMPLOYEES shall clean their hands in a HANDWASHING SINK or APPROVED automatic handwashing facility and may not clean their hands in a sink used for FOOD preparation or WAREWASHING, or in a service sink or a curbed cleaning facility used for the disposal of mop water and similar liquid waste. Pf
According to the 2017 FDA Food Code Section
5-204.11 Handwashing Sinks.
A HANDWASHING SINK shall be located:
(A) To allow convenient use by EMPLOYEES in FOOD preparation, FOOD dispensing, and WAREWASHING areas; Pf and
(B) In, or immediately adjacent to, toilet rooms. Pf
On 1/18/23 at 12:03 PM, two cartons of thickened water, located in the resident nourishment refrigerator, were observed to be opened with out a open date label on the carton to identify when to discard the product. At this time, Certified Nurse Aide Q was queried on the missing date label and stated, They should get dated. The manufacturers label of the product advises to discard the product within 7 days of opening.
On 1/18/23 at 12:24 PM, The reach-in freezer, located in the [NAME] House kitchen, was observed to be soiled with spills and food debris. [NAME] Houses Manager P stated they are waiting for a new refrigeration unit because the current refrigerator/freezer thaws sometimes.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to operationalize policies and procedures to accurately track and document staff COVID-19 vaccination status, implement a process ensuring all ...
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Based on interview and record review the facility failed to operationalize policies and procedures to accurately track and document staff COVID-19 vaccination status, implement a process ensuring all staff were fully vaccinated for COVID-19, and ensuring there was a contingency plan for staff not fully vaccinated. These deficient practices resulted in an inaccurate vaccination matrix, staff who were unvaccinated, and the potential for transmission of COVID-19. Findings include:
On 1/17/23 at 9:15 AM, an entrance conference was held with the Nursing Home Administrator (NHA). Requests for a list of contract companies that would be providing services to the facility/residents during the survey period, and information on how the facility ensures contractor staff are compliant with the vaccination requirement however, those documents were not provided by the end of the survey.
On 1/18/23 at 1:06 PM, Licensed Practical Nurse (LPN) H, the facility's designated Infection Control Nurse was asked about the provided staff vaccination matrix and the 43 staff members listed as having not received the COVID-19 vaccination. LPN H explained that the vaccination matrix provided was obtained from Human Resources (HR), and that she does not keep track of the staff's vaccination status as HR is responsible for the task.
Further review of the Staff Vaccination Matrix revealed employees who were identified as having received the COVID-19 vaccine however, the type of vaccine and proof of the vaccination were not available.
Regarding contract staff's vaccination statuses, LPN H explained that the Social Work Director obtains the vaccination cards, as they are responsible for ensuring ancillary services are provided to the residents. LPN H was asked about a contingency plan regarding unvaccinated staff members, and was unable to provide an explanation. LPN H was asked to obtain the vaccination statuses of the contract staff to provide to the surveyor. This information was not received by the end of the survey.
On 1/19/23 at 8:55 AM, LPN H was interviewed for a second time to review additional infection control documentation. Regarding the unvaccinated staff located on the vaccination matrix, she explained that HR indicated that some of the individuals on the matrix are no longer employed with the facility however, after review of the active employee list provided by the facility, there indeed were individuals on the list that were still employed with the facility.
On 1/19/23 at 9:43 AM, Human Resources Employee I was interviewed regarding the process for tracking the vaccination of employees. Human Resources Employee I explained that they are new to the position, and is in the process of obtaining the information but explained that the process is to obtain vaccination cards and/or exemption documentation upon the employee's hire.
On 1/19/23 at 3:51 PM, the Director of Nursing (DON) was asked about the lack of tracking and documentation of staff COVID-19 vaccination statuses, and admitted that the documentation had not been completed due to a vacancy in the position, and he himself not completing the task efficiently. The DON did explain that the expectation is for the documentation to be complete.
A review of the facility's COVID-19 Vaccination policy was reviewed and revealed the following, All staff are required to receive the COVID-19 vaccination series (one-dose or two-dose) as per CMS (Centers for Medicare and Medicaid Services) guidelines unless exempted for religious or medical reasons, or the vaccine needs to be delayed due to clinical considerations as outlined by the CDC (Centers for Disease Control). 21. Staff documentation related to the COVID-19 vaccination includes at a minimum: a. Education to the staff regarding the risks and benefits , and potential side effects of the COVID-19 vaccine; b. The offering of the COVID-19 vaccine or information on obtaining the COVID-19 vaccine; c. Documentation of any religious or medical exemption requests and the decisions rendered; and d. the COVID-19 vaccine status of staff related information as indicated by NHSN 9Nastional Healthcare Safety Network).
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a sanitary home-like environment, the domest...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a sanitary home-like environment, the domestic water system, proper handwashing facilities, and ventilation, resulting in the potential for a non-home like facility, contaminated water system, and odors and resident respiratory distress. These deficient practices affect all residents in the facility.
Finding include:
On 1/17/23 at 2:32 PM, food debris and food wrappers were observed to be on the floor in room [ROOM NUMBER] under bed 1. Additionally, the hot water pressure for the hand sink in the bathroom of room [ROOM NUMBER] was observed to be very low, less than a pencil width. A six inch diameter hole was observed in the cinder block underneath the bathroom hand sink. Additionally, the exhaust ventilation in the bathroom was tested using a paper towel to test the suction of the vent and was found to not be able to hold up the paper towel, indicating no exhaust suction functioning.
On 1/17/23 between 2:35 PM and 2:41 PM, the following bathroom exhaust vents were found to not be functioning, evidenced by using the paper towel test: Room #'s 44, 47, 50.
On 1/17/23 at 2:41 PM, the main bedroom ceiling light in room [ROOM NUMBER] was observed to be burnt out and not able to brightly light the room.
On 1/18/23 at 8:55 AM, the TCU mop sink (room [ROOM NUMBER]) was observed to be equipped with an atmospheric vacuum breaker (a plumbing device commonly used to provide backflow protection to prevent contamination of domestic water systems). The mop fixture handles were observed to be removed while the water was on allowing for the atmospheric vacuum breaker to remain under pressure for an extended period of time. The atmospheric vacuum breaker shall not be under pressure for an extended period to prevent the device from mineral build-up. At this time, Maintenance Supervisor M stated that they will replace the water fixture handles.
On 1/18/23 at 8:57 AM, the TCU shower room light fixture was observed to be not functioning, making the shower room appear very dim. Additionally, a paper towel dispenser was not provided at the hand sink.
On 1/18/23 at 9:01 AM, an approximately three inches by four inches hole was observed in the wall behind the door of room [ROOM NUMBER].
On 1/18/23 at 9:04 AM, a large patch of scrapes and etchings were observed in the wall behind the headboard of the bed in room [ROOM NUMBER].
On 1/18/23 at 9:05 AM, the built-in drawers, in room [ROOM NUMBER], were observed to be broken and unable to properly close.
On 1/18/23 at 9:10 AM, the handrail in the hall by room [ROOM NUMBER] was observed to be loose and able to be moved.
On 1/18/23 at 9:17 AM, food debris and food wrappers were still observed on the floor of room [ROOM NUMBER] at this time.
On 1/18/23 at 9:20 AM, the [NAME] nursing supply closet was observed to have two boxes of mouthpiece tubing stored on the floor. During an interview on 1/19/23 at 1:37 PM, the Administrator stated that the staff on that hall are new and need to be educated.
On 1/18/23 at 9:48 AM, a gray hose, connected to a spigot off of the water line for the laundry, was observed to not be provided with a backflow protection device to prevent the backflow of contaminated liquids into the domestic water supply.
On 1/18/23 at 9:57 AM, two hand sinks in the [NAME] House utility room were observed to not be provided with paper towel dispensers to properly dry hands after washing. Additionally, the atmospheric vacuum breaker at the mop sink was observed to be heavily leaking water out of the air-inlet valve.
On 1/18/23 at 10:00 AM, the bathroom hand sink, in room E20, was observed to have low hot water pressure. Additionally, the call light cord in the bathroom was wrapped around the handrail and could not be pulled to trigger the call light.
On 1/18/23 at 10:04 AM, no paper towel dispenser was observed to be provided for the bathroom hand sink of room E18. Additionally, the bathroom exhaust vent and the PTAC (Packaged Terminal Air Conditioning Unit) filters were observed to be caked with dust.
On 1/18/23 at 10:07 AM, the recessed light fixture in the bathroom of room E16 was observed to be missing a light bulb. Additionally, the bathroom exhaust vent and the PTAC filters were observed to be caked with dust.
On 1/18/23 at 10:10 AM, the recessed light fixture in the bathroom of room E15 was observed to be missing a light bulb.
On 1/18/23 at 10:13 AM, the bathroom door of room E2 was observed to swing open by itself if it is not latched closed. The bathroom was observed to have 4 fluorescent light bulbs leaning up against the wall in the corner.
On 1/18/23 at 10:19 AM, the call light in the bathroom of room E5 was observed to be knotted and can't be pulled to trigger the call light.
On 1/18/23 at 10:19 AM, a section of wallpaper about 18 inches long in the [NAME] house hall, next to room E6, was observed to be unglued to the wall. At this time, Maintenance Supervisor M stated they will fix the wallpaper and get the ventilation cleaned in the [NAME] and [NAME] Houses.
On 1/19/23 at 10:32 AM, staff in the [NAME] house were observed to be running water and were queried on why the water was left running. Multiple staff mentioned that it takes approximately 15 minutes for the water to warm to a comfortable temperature for a bed bath. During a phone interview on 1/19/23 at 2:10 PM, District Maintenance Director S stated that the circulation pump to [NAME] house is going out and they are going to have a technician come out to look at it.
On 1/18/23 at 1:51 PM, any logs for ventilation maintenance or audits were requested, but none were provided by the end of the survey.
MINOR
(C)
Minor Issue - procedural, no safety impact
Infection Control
(Tag F0880)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and implement a water management program to reduce the occ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and implement a water management program to reduce the occurrence of pathogens in premise plumbing, resulting in the potential for legionella harborage conditions, affecting all residents, staff, and visitors in the facility.
Findings include:
On 1/19/23 at 1:16 PM, During a review of the facilities, Water Management Program, no date, assisted by District Maintenance Director (DMD) S, it noted a water system diagram that did not include the entirety of the facility campus. At this time, DMD S was queried if the facility has conducted a risk assessment to identify vulnerable areas in the water system where legionella could grow, and he stated no. Additionally, DMD S was queried if there is any documentation, logs, or validation of flushing of the water system as a control measure, and he stated no.
On 1/18/23 at 9:13 AM, the hopper sink basin, in the [NAME] soiled utility room, was observed to be dry, indicating that the water fixture has not been flushed.
During an interview on 1/19/23 at 1:37 PM, the Administrator stated that the Water Management team has not met to review or revise the plan since she has begun working at this facility in May of 2022.
Nov 2022
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00131149.
Based on interview and record review, the facility failed to obtain a chest x-ray f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00131149.
Based on interview and record review, the facility failed to obtain a chest x-ray for one resident R704, out of one reviewed for physician order, resulting in the potential for undiagnosed health conditions and delay in treatment. Finding Include:
A review of the medical record revealed that R704 admitted into the facility on 7/15/2022 with the following diagnoses, Multiple Fractures following a Motor Vehicle Accident, Guillain-Barre Syndrome, Anemia, and Obstructive Sleep Apnea. A review of the Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R704 also required extensive two-persons assist with bed mobility and transfers.
Further review of the physician orders revealed the following, Order: cxr (chest x-ray) 2 view r/o (rule out) pna (pneumonia), c/o (complained of) uri (upper respiratory infection), cough. Date Ordered: 7/28/2022 at 9:38 AM.
A request for the results of the chest x-ray was requested, but not received prior to end of survey.
Further review of the progress notes revealed the following, Date:7/30/2022 at 9:04 AM. Note Text: .At 2 AM, patient called and said that back of [their] right leg was tight and that [they] needed massage at back of right leg to loosen it, patient was offered pain medication and refused. Patient said that they did not want to take any medication until tomorrow when [they] eat, so massage was not given .At 3 AM, the ambulance attendants were at the door saying that patient called 911, we all went to [their] room and patient was very sweaty and hypoxic. The ambulance attendants took patient out of the building at 3:15 AM.
On 11/30/2022 at 4:23 PM, an interview was conducted with the Director of Nursing (DON) regarding R704. The DON stated that they remembered R704 went to the hospital but did not know the details. The DON stated that if they order a chest x-ray STAT (as soon as possible) then they come within 4 hours, but with the lack of drivers the x-ray company has it can be a couple of days. The DON was asked if they could provide something to show how the order was called in. The DON stated that they were unable to find anything showing the chest x-ray was ever called in to be completed.
On 11/30/2022, an policy related to following physician orders was requested, but not received prior to exit of survey.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Michigan facilities.
Concerns
- • 41 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (50/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
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About This Facility
What is The Orchards At Redford's CMS Rating?
CMS assigns The Orchards at Redford an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Michigan, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is The Orchards At Redford Staffed?
CMS rates The Orchards at Redford's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 55%, compared to the Michigan average of 46%. RN turnover specifically is 57%, 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 Orchards At Redford?
State health inspectors documented 41 deficiencies at The Orchards at Redford during 2022 to 2025. These included: 40 with potential for harm and 1 minor or isolated issues.
Who Owns and Operates The Orchards At Redford?
The Orchards at Redford is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by THE ORCHARDS MICHIGAN, a chain that manages multiple nursing homes. With 88 certified beds and approximately 78 residents (about 89% occupancy), it is a smaller facility located in Redford, Michigan.
How Does The Orchards At Redford Compare to Other Michigan Nursing Homes?
Compared to the 100 nursing homes in Michigan, The Orchards at Redford's overall rating (2 stars) is below the state average of 3.1, staff turnover (55%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting The Orchards At Redford?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is The Orchards At Redford Safe?
Based on CMS inspection data, The Orchards at Redford has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Michigan. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at The Orchards At Redford Stick Around?
The Orchards at Redford has a staff turnover rate of 55%, which is 9 percentage points above the Michigan average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was The Orchards At Redford Ever Fined?
The Orchards at Redford has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is The Orchards At Redford on Any Federal Watch List?
The Orchards at Redford 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.