The Orchards at Roseville
For profit - Corporation
169 Beds
THE ORCHARDS MICHIGAN
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
13/100
#342 of 422 in MI
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Orchards at Roseville has received a Trust Grade of F, indicating significant concerns and a poor overall quality of care. Ranking #342 out of 422 facilities in Michigan means they are in the bottom half, and their county rank of #29 out of 30 suggests only one local facility performs worse. The facility is showing an improving trend, with the number of issues decreasing from 17 in 2024 to 10 in 2025. Staffing is a notable weakness here, with a rating of only 2 out of 5 stars and a concerning turnover rate of 68%, much higher than the state average. Additionally, the facility has faced $101,905 in fines, indicating repeated compliance issues, and has less RN coverage than 90% of Michigan facilities, which could compromise care quality. Specific incidents include a resident who was able to leave the facility unsupervised, posing a serious safety risk, and another resident who was physically abused by another resident, leading to hospitalization. While the facility has some strengths in quality measures, these troubling incidents and overall ratings make it a concerning option for families.
- Trust Score
- F
- In Michigan
- #342/422
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 68% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $101,905 in fines. Higher than 61% of Michigan facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 21 minutes of Registered Nurse (RN) attention daily — below average for Michigan. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 47 deficiencies on record. Higher than average. Multiple issues found across inspections.
13/100
Bottom 19%
Review needed
17 → 10 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 17 issues
2025: 10 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Michigan average (3.1)
Below average - review inspection findings carefully
Staff Turnover: 68%
22pts above Michigan avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $101,905
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: THE ORCHARDS MICHIGAN
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (68%)
20 points above Michigan average of 48%
The Ugly 47 deficiencies on record
1 life-threatening 1 actual harm
Jun 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 F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00153342.
Based on observation, interview, and record review, the facility failed to ensure...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00153342.
Based on observation, interview, and record review, the facility failed to ensure coordination of care between the facility and hospice services, implement a plan of care regarding hospice services, and ensure a signed agreement between all hospice entities and the facility was obtained for three (R's 303, 304 & 305) of three residents reviewed for quality of care. Findings include:
R303
On 6/10/25 at 10:39 AM, R303 was observed laying back in a chair in the community room. An interview could not be conducted with the resident due to their cognitive impairment.
A review of the medical record revealed R303 was admitted to the facility on [DATE], with a readmission date of 12/29/22 and diagnoses that included: Alzheimer's disease and vascular dementia. A Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognition for R303. R303 was dependent on staff for all Activities of Daily Living (ADLs).
A review of a hospice document revealed R303 was enrolled in hospice services on 5/15/25.
A review of a hospice care plan implemented on 6/4/25 noted the following intervention, . Collaborate care with Hospice service, MD (medical doctor), IDT (interdisciplinary team) . The care plan did not contain interventions on the care of services provided by the hospice entity or the plan of care expected from the facility staff.
Further review of the Electronic Medical Record (EMR) and hospice binder revealed no documentation of a collaborative plan of care implemented for R303.
R304
On 6/10/25 at 10:48 AM, R304 was observed with their eyes closed lying on their back in bed. R304 was easily awakened by verbal prompts. An interview could not be conducted with the resident due to their cognitive impairment.
A review of the medical record revealed R304 was admitted to the facility on [DATE], with diagnoses that included: multiple sclerosis and dementia. A MDS assessment dated [DATE], noted a Brief Interview for Mental Status (BIMS) score of 03, which indicated severely impaired cognition and was dependent on staff for all ADLs.
A review of a hospice document revealed R304 was enrolled in hospice services on 7/24/24.
A review of a hospice care plan implemented on 9/10/24, noted one intervention . Provide my medications as scheduled and report any changes to (hospice name) .
Further review of the Electronic Medical Record (EMR) and hospice binder revealed no documentation of a collaborative plan of care implemented for R304.
R305
On 6/10/25 at approximately 11:00 AM, R305 was observed sleeping in bed and did not awake to verbal stimuli.
A review of the medical record revealed R305 was admitted to the facility on [DATE], with a diagnosis that included dementia. A MDS assessment dated [DATE], noted severely impaired cognition and was dependent on staff for all ADLs.
A review of a hospice document revealed R305 was enrolled in hospice services on 5/23/24.
A review of a hospice care plan implemented on 5/30/24, noted the following intervention . Consult with my physician and Social Services to have hospice care for me while I am staying with you .
Further review of the Electronic Medical Record (EMR) and hospice binder revealed no documentation of a collaborative plan of care implemented for R305.
A review of the hospice agreement for the hospice group assigned to R305, revealed an unsigned agreement from both parties- the hospice entity and the facility.
On 6/10/25 at 11:57 AM, Licensed Practical Nurse (LPN) C (the nurse assigned to R's 303, 304 & 305) was interviewed and asked if they knew the hospice role and responsibilities of care for R's 303, 304 & 305. LPN C stated they weren't really sure but could ask someone in leadership.
At 12:00 PM, Certified Nursing Assistant (CNA) D (assigned to R304) was interviewed and was asked if they knew what days hospice visited R304 and what care/services was provided for each visit. CNA D stated in part . I'm not sure of the days. Typically, I just catch them washing or feeding (the residents) . CNA D confirmed this is the only way they knew if they were responsible to bathe or provide feeding assistance to the residents or if hospice was responsible for the task, is by walking into the room and observing the hospice staff providing the service.
At 12:07 PM, CNA E was interviewed and asked how they were made aware of hospice visits and what care hospice was expected to provide that day (bathing, feeding assistance etc.) CNA E stated, they really don't know until they see the hospice staff in the resident rooms. CNA E stated in part . in other facilities it's usually written down and we know .
At 12:12 PM, CNA F (assigned to R's 303 & 305) was interviewed and asked if they knew the days hospice staff were expected to visit R's 303 & 305 and what care/services the hospice staff was expected to provide. CNA F stated they never know when hospice is coming. CNA F stated in part . I don't know unless I walk in the room and see them (hospice staff) . CNA F was unsure of the collaboration of care with hospice services.
On 6/10/25 at 12:57 PM, the facility's Administrator and Director of Nursing (DON) was interviewed and asked about the lack of coordination of care with hospice services and the inadequate hospice care plans for R's 303, 304 & 305 and acknowledged the concerns. When asked about the hospice agreement for R305, the Administrator explained the hospice company had changed their name and the signed agreement they had on file was under the previous company name. When asked, the Administrator stated a new agreement had not been signed under the new company name.
A review of a facility policy titled Hospice Services Facility Agreement revised November 2017, documented in part . If hospice care is furnished in the facility through an agreement, the facility will . Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC (long term care) facility before hospice care is furnished to any resident . The facility will, under a written agreement, ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the facility to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being .
Apr 2025
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to offer a mirror of appropriate height visible from a wheelchair level ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to offer a mirror of appropriate height visible from a wheelchair level to perform their shaving/grooming for one of one resident (R83) reviewed for accommodation of needs. Findings include:
R83
R83 was recently admitted to the facility after hospitalization on 3/19/25. R83's admitting diagnoses included recent left above knee amputation, Chronic Obstructive Pulmonary Disease (COPD), and peripheral vascular disease. Based on the Minimum Data Set (MDS) assessment dated [DATE], R83 had Brief Interview for Mental Status (BIMS) score of 15/15, indicative of intact cognition.
An initial observation was completed on 4/29/25 at approximately 7:55 AM. R83 was in their bed. R83 had a wheelchair, parked next to their bed. An interview was completed during this observation. R83 was asked about their care and if they had any concerns. R83 reported that they were unable to stand up because of their recent amputation and they used their wheelchair. They added they were not able to see themselves in the mirror. When asked to explain further, they reported the mirror in the bathroom was too high and they were not able to see themselves to be able to shave or groom. R83 had facial hair and they stated they would like to shave. When they were queried if they had notified the staff, R83 reported that they had spoken to nursing staff members about the mirror and needing a shave. R83 stated I don't know they can't get this fixed. The was observed the mirror in bathroom was approximately 2 feet higher from the sink level and there was a soap dispenser installed in between the mirror and sink.
Follow-up observations were completed on 4/30/25 at approximately 9:10 AM, 12:35 PM and 2:30 PM. R83 was in their room and had facial hair. When asked if any facility staff member had assisted in providing a mirror to assist with their shaving. R83 reported they did not get any assistance and they were still waiting. During these observations R83 stated that I don't need any help to shave and reiterated they just needed a mirror of right height so they could shave and groom on their own. During the observation at 12:35 PM, R83 reported a man came over and asked them if they needed a shave and added, just talk to maintenance. They added I can't even see how I look.
Review of R83's Electronic Medical Records (EMR) revealed an Occupational Therapy evaluation dated 3/5/25 documenting R83 needed supervision/set up assistance with grooming. R83's Activities of Daily Living (ADL) care plan revealed R83 needed set up assistance for grooming and personal hygiene.
An interview with Unit Manager (UM) I was completed on 4/30/25 at 12:45 PM. They were asked how they would accommodate the needs of a resident who needed a mirror to shave/groom when they were unable to use one in the bathroom. UM I reported they (facility staff) would offer assistance to shave and made sure that they were safe. When queried further on R83's preferences and the current set up they reported they would speak with their Director of Nursing (DON) and management to get a mirror or fix the set up.
An interview with Certified Nursing Assistant (CNA) L was completed on 4/30/25 at approximately 2:35 PM. CNA L was assigned to care for R83 during that shift. They were queried about the concerns R83 had and if they were aware. They added that they had not heard anything about the mirror.
On 4/30/25, at approximately 9:35 AM, the facility Administrator was notified of the concern. They reported they were unaware of this issue and they would follow up with the Maintenance Director.
A facility provided undated document titled Resident Rights read in part, The facility will inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules governing resident conduct and responsibilities during the stay in the facility
Respect and Dignity: The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health and safety of the resident or other residents .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility failed to update a care plan timely on transfer (from one surface t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility failed to update a care plan timely on transfer (from one surface to anther) ability based on the comprehensive assessment for one (R10) of one resident reviewed for care plans. Findings include:
R10
R10 was originally admitted to the facility on [DATE]. R10 had a recent admission to hospital and they were recently readmitted back to the facility on 3/23/25. R10's admitting diagnoses included heart failure, end stage renal failure, conversion disorder with seizures, and protein calorie malnutrition. Based on the Minimum Data Set (MDS) assessment dated [DATE] R10 had a Brief Interview for Mental Status (BIMS) score of 13/15, indicative of intact cognition. Review of R10's care plan revealed that R10 needed a mechanical/total body lift with 2-person for their transfers.
During an observation completed on 4/29/24 at approximately 3 PM, Certified Nursing Assistant (CNA) H was observed transporting R10 in a shower chair from room to the shower room. Approximately 15 minutes later CNA H was observed transporting R10 back to the room and closed the door. CNA H was asked how they were going to assist R10 with their transfer and if they had a mechanical lift in the room. CNA H reported R10 did not need a mechanical lift and could stand up and transfer with their assistance.
Review of R10's [NAME] (care plan for CNAs) read under transfer status (name of mechanical) lift - always 2-person assist and total dependent. Further review of R10's care plan revealed the following interventions for R10 to transfer safely, Call for assistance with leg rest and self-transferring initiated on 1/28/25 and mechanical lift - always 2-person assist and total dependent initiated on 7/2/24. Further review of R10's Electronic Medical Record (EMR) revealed a comprehensive MDS (Minimum Data Set) assessment dated [DATE], completed after R10 returned from the hospital. The assessment revealed R10 needed substantial staff assistance (more than 50% assistance) for transfers, not a mechanical lift with 2-person assistance as noted in the care plan and [NAME].
An interview with the covering Unit Manager (UM) I was completed on 4/29/25 at approximately 4:20 PM. They were queried how the CNAs obtained the information to care for their resents. UM I reported that they received the information form the [NAME] and if they also received reports from the previous shift CNA. They were asked what their process was if there was a discrepancy in the care plan, they reported that CNA would report the nurse and nurses were expected to check the care plan and follow up with therapy if resident needed a further assessment.
An interview with the Director of Nursing (DON) was completed on 4/29/25 at approximately 3:15 PM. They were asked to explain their process and expectations on how CNAs received the care information and how they were updated. DON reported that CNAs received their information [NAME] and they were expected to follow [NAME]. If a resident had a change in their condition and or during routine periodic assessment any change in resident's plan of care/interventions were updated accordingly in care plan and [NAME].
An interview with MDS Coordinator K was completed on 4/20/25 at approximately 12:50 PM. They were queried about the care plan update process and they reported they had completed R10's comprehensive assessment after they returned from the hospital and did not update the care plan for transfers.
An undated facility provided document titled Comprehensive Plan of Care read in part, Each resident we'll have a comprehensive care plan developed within seven days after the completion of a comprehensive or quarterly assessment. The comprehensive care plan is prepared by the interdisciplinary team and to the extent practicable the participation of the resident or the resident's representative. The quarterly care plans are reviewed and updated by the interdisciplinary team and to the extent practicable the participation of the resident or residence representative .
The comprehensive plan of care must be consistent with resident's rights and address the residents' 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 avoidable decline in function or functional level.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident showers were provided as scheduled for two resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident showers were provided as scheduled for two residents (R18, R59) of six reviewed for care completions and documentation. Findings include:
R18
On 04/28/25 at 1:49 PM, R18 reported they had not received their shower one day last week, Tuesday 04/22/25.
A review of the record for R18 revealed R18 was admitted into the facility on [DATE]. Diagnoses included Stroke, Mood Disorder and Chronic Pain. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 13/15 Brief Interview for Mental Status score, and R18 required substantial/maximal assistance of staff for showers/bathing, upper and lower body dressing, and R18 was dependent for personal and toileting hygiene and transfer.
A review of the April 2025 shower/bathing task in the Electronic Medical Record (EMR) documented bathing was Monday and Thursday between 7:00 PM and 7:00 AM. The documentation which did not correspond with the designated shower days indicated total dependence and the amount of staff needed for assistance but did not indicate if the shower/bath had been completed. On five of the eight days the task was indicated as activity did not occur. A review of the paper shower sheets for April 2025 recorded bathing of R18 on 04/18/25, 4/25/25, and 4/29/25. Documentation of additional showers was requested from the facility, but not received prior to survey exit.
R59
On 04/28/25 at 2:01 PM, R59 reported the previous week on Tuesday 04/22/25 staff said the mechanical lift battery was not charged and they could not get them out of bed for their shower and nobody came to give them a shower on Friday 04/25/25. R59 reported their shower was usually in the afternoon.
A review of the record for R59 revealed R59 was admitted into the facility on [DATE]. Diagnoses included Alzheimer's, Dementia and High Blood Pressure. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 13/15 Brief Interview for Mental Status score, impaired range of motion of the upper and lower extremities and R59 was dependent on staff for showers/bathing, upper and lower body dressing, personal and toileting hygiene and transfer.
A review of the April 2025 shower/bathing task in the Electronic Medical Record (EMR) documented bathing was Tuesday and Friday between 7:00 AM and 7:00 PM. The documentation which corresponded with the designated shower days indicated total dependence and the amount of staff needed for assistance but did not indicate if the shower/bath had been completed. On 04/18/25 the task was indicated as did not occur. A review of the April 2025 paper shower sheets recorded bathing of R59 on 04/18/25. Documentation of additional showers was requested from the facility, but not received prior to survey exit.
On 04/30/25 at 10:30 AM, concerns were reviewed with the Director of Nursing (DON). The DON reported it was the nurse's and aide's responsibility to complete the shower and skin assessment for the resident. The nurse must go in and complete a skin assessment at the time of the shower. The resident does have the right to refuse, and it must be documented. The location of the documentation for showers was reviewed and the task area was confirmed that it did not allow a shower to be documented as completed.
On 04/30/25 at 12:55 PM, the facility reported they did not have a policy specific to documentation of showers.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
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 the medications acyclovir (treatment for vira...
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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 the medications acyclovir (treatment for viral infections) and mupirocin ointment (treatment for skin lesions) as ordered, for one resident (R26) of five reviewed related to medication administration. Findings include:
On 04/28/25 at 2:10 PM, R26 reported they had not been consistently treated for their urinary tract infections and impetigo (reddish itchy sores, often around the nose and mouth which may rupture, ooze, and then crust). R26 reported they had not refused any treatments for these conditions. R26 was observed to have two raised areas about the size of a pencil eraser on the forehead. Both were pink in color and one had a scabbed ring around the base. R26 reported the areas itched and had needed to scratch them.
On 04/28/25 at 3:04 PM, Licensed Practical Nurse (LPN) C was asked about potential causes of missed medications and reported some history of difficulty with getting medications from the pharmacy and resident insurance.
On 04/30/25 at 12:39 PM, R26 appeared with a similar pink/red raised area on the right side of their chin.
A review of the record for R26 revealed R26 was admitted into the facility on [DATE]. Diagnoses included Pulmonary Disease, Heart Disease and Chronic Pain. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 15/15 Brief Interview for Mental Status score, and was dependent on staff assistance for showers/bathing, upper and lower body dressing, personal and toileting hygiene and transfer.
A review of the physician orders and the April 2025 Medication Administration Record (MAR) revealed Acyclovir had been ordered on 04/02/25 for the face and then discontinued on 04/04/25 with no administrations documented.
The mupirocin ointment 2% had been ordered for three times a day on 04/04/25 and discontinued on 04/19/25 as completed. 30 administrations had been documented as not given. 12 administrations had been documented as provided, even though the medication had not been sent from the pharmacy. Further review of the MAR notes did not indicate the physician was contacted related to the unminstered doses.
On 04/30/25 at 10:30 AM, concerns were reviewed with the Director of Nursing (DON). The DON reported the Acyclovir was ordered 04/02/25 then discontinued 04/04/25 and the Mupirocin was ordered on 04/04/25 and discontinued as completed on 04/19. Upon review of the progress notes, there was no documented contact with the pharmacy about the missing medications. At 11:06 PM, the DON called the pharmacy and asked if the medications had been delivered and the pharmacy reported they had not been sent.
A review of the facility policy titled, Medication Administration and General Guidelines dated 03/2025 revealed, medications are administered as prescribed, in accordance with state regulations and good nursing principles . Medications are administered in accordance with written orders of the attending physician . The physician must be notified when a dose of the medication has not been given .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure, insulin and eyedrops were dated when opened, expired insulin discarded, in three of four medication carts and tubercu...
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Based on observation, interview, and record review, the facility failed to ensure, insulin and eyedrops were dated when opened, expired insulin discarded, in three of four medication carts and tuberculin was dated when opened and the refrigerator temperature was maintained within normal limits in one of three medication rooms. Findings include:
On 04/29/25 at 9:45 AM, the second floor north front medication cart was observed with Licensed Practical Nurse (LPN) B. The cart contained a Lispro insulin pen dated opened 03/16/25.
On 04/29/25 at 10:08 AM, the second floor back cart was reviewed with LPN D. A timolol brimonidine eye dropper was out of the box, open and not dated when opened.
On 04/30/25 at 12:43 PM, the first floor north front cart was reviewed with LPN C. A Lantus insulin vial was not dated when opened and an Aspart insulin pen was not dated when opened. Three additional insulin pens were undated and undetermined (no plastic wrapper/seal in place) if opened and used. Three of the insulin pens in the cart were stored without the cap on.
On 04/30/25 at 12:54 PM, the one north medication room was observed with LPN E. The tuberculin had not been dated when opened on the box or the vial. The temperature on the thermometer for the medication refrigerator read 23 degrees Fahrenheit (F) when checked. The temperature log documented it at 40 degrees F that morning and the previous morning.
On 04/30/25 at 10:31 AM, concerns were reviewed with the Director of Nursing (DON). The DON reported the nurse should put a date on items when opened and check for expired medications when on the medication cart. It was further noted most insulins were good for 28 days once opened.
A review of the pharmacy policy titled, Medication Labels date 03/2025 documented, Medication are labeled in accordance with facility requirements .
A review of the prescribing information at Lantus.com revealed, .in-use (opened) (36°F-46°F) 10 mL multiple-dose vial 28 days Refrigerated or room temperature . Store unused Lantus in a refrigerator between 36°F and 46°F. Do not freeze. Discard
Lantus if it has been frozen .
A review of the prescribing information at Novopi.com revealed, .Put the pen cap on your device after each use to protect the insulin from light. How should I store my NovoLog Pen cartridge? Do not freeze NovoLog. Do not use NovoLog if it has been frozen. Keep NovoLog away from heat or light. If NovoLog is stored mistakenly outside of refrigeration between 47°F (9°C) to 86°F (30°C) prior to first use, it should be used within 28 days or thrown away . The NovoLog PenFill cartridge you are using should be thrown away after 28 days, even if it still has insulin left in it.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake number MI00151441.
Based on observation, interview, and record review, the facility failed to m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake number MI00151441.
Based on observation, interview, and record review, the facility failed to maintain a safe, sanitary, comfortable environment for one of one resident (R32), six confidential group residents, with the potential to affect the remaining 107 residents residing at the facility. Findings include:
R32
On 4/28/25 at 10:45 AM, R32 was interviewed and asked about their satisfaction with the care and services they were receiving at the facility. R32 indicated every time they received a shower in the 100 south unit shower room, the shower filled up with water and leaked out the door into the hallway. R32 further indicated that because of the large amount of water, the shower room floor could become very slippery. R32 stated, It's not safe.
A review of R32's electronic medical record (EMR) revealed that R32 was admitted to the facility on [DATE] with diagnoses that included Seizures, Schizophrenia, and Dementia. R32's most recent minimum data set assessment (MDS) dated [DATE] revealed that R32 had a moderately impaired cognition and required staff supervision for showers.
On 4/29/25 at 1:38 PM, the 100 south unit shower room door leading into the shower room was observed to have a blanket spread out by the bottom of the door and a yellow plastic sign by the door which stated, Caution Wet Floor. Observation of the floor by the door revealed water stains on the flooring.
On 4/29/25 at 1:41 PM, confidential staff F was asked about the 100 south unit shower room and confirmed at times, water ran out from the shower room into the hallway.
On 4/29/25 at 1:45 PM, certified nursing assistant (CNA) G was observed to enter 100 south unit shower room and proceeded to give a resident a shower. As the shower occurred, water was observed flowing under the door and into the hallway. A puddle of water was observed on the floor in the hallway outside of the shower room.
On 4/29/25 at 2:02 PM, CNA D was interviewed about the condition of the 100 south unit shower room and indicated the drain in the shower plugs up, water accumulates in the shower and sometimes runs out into the hallway of the unit. CNA D stated, Sometimes I have to take my shoes and socks off when I give a resident a shower.
On 4/30/25 at 10:46 AM, Maintenance Director (MD) A was interviewed regarding the condition of the 100 south unit shower room. MD A indicated they had plunged the drain in the shower room multiple times and it continued to plug up.
On 4/30/25 at 1:07 PM, the Administrator (NHA) was interviewed regarding the shower room on the 100 south unit. The NHA indicated the shower floods when staff drops the hand held shower on the floor with it running and had been educating them about putting the hand held shower back in the holder when not in use.
An observation of the 2nd floor was completed on 4/28/25 at approximately 12:00 PM. There were gnats observed in the hallway outside the dining room. The dining room walls had multiple scuffed areas that needed repair. A round dining table had large area (approximately ¼th of table surface) of missing veneer. The countertop with the sink in the dining room and the large countertop on the North end of the dining room had missing banding's with sharp areas of the countertop exposed. The cove base/trim under the sink and countertop were missing including other areas of the dining room. A considerable amount of dirt and debris were observed around the missing cove base/trim under the countertops with areas of broken/missing floor tile/laminate. Throughout the survey multiple follow-up observations were completed on 4/29/25 and 4/30/25 to confirm the initial observation.
At approximately 12:20 PM an observation of room [ROOM NUMBER] was completed. The room had a fly trap bag hanging from the ceiling tile that had a significant number of gnats. There were gnats observed outside in the hallway.
An observation of the 1st floor dining room was completed later that day at approximately 5 PM. The counter with sink was missing banding on both sides with sharp areas exposed. The cove base/trim under the sink and countertop were missing including some other areas of the dining room. A considerable amount of dirt and debris were observed around the missing trim/cove base under the countertops with areas of broken/missing floor tile/laminate. At approximately 5:20 PM, gnats were observed in the North unit hallway.
On 4/30/25, at approximately 7:40 AM, a piece of peeled laminate, approximately 5 to 7 inches in size was sticking out from the floor with areas of floor bucked around creating uneven walking surface down the North hallway.
An interview with the Maintenance Director (MD) was completed on 4/30/25 at approximately 7:45 AM. They were queried about their routine maintenance rounds process. The surveyor walked with the maintenance director to the 1st and 2nd floor and shared the observations. They confirmed gnats were an ongoing issue and they were trying to address the concern with their pest control vendor.
An interview with the facility Administrator was completed on 4/30/25 at approximately 9:30 AM. They were queried about their rounding process and they reported they rounded daily and were following up with maintenance of any concerns that were identified. They added that gnat concern was recently brought to their attention and their pest control vendor is addressing the concern.
On 04/30/25 at 2:00 PM a meeting was held with a confidential group of residents. Five of the residents expressed concern about dirty shower rooms. On 4/30/25 at 3:00 PM, the Director of Nursing (DON) toured the shower room on 1 north with surveyor. The following concerns were observed: a bath chair that was soiled with black substance all over the seat, several brown spots on the floor, tile was cracked in several place around the tub and in the shower area, the bathroom toilet was littered with dirt, molding around tub peeling away; grout in bathroom incomplete.
A facility policy titled Resident Rights with no date, stated the following, Procedure 9. Safe environment. The resident has a right to a safe, clean, comfortable .environment .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0924
(Tag F0924)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure all corridor areas used by residents were provided with safe and secure handrails. This deficient practice has the potential to affect...
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Based on observation and interview, the facility failed to ensure all corridor areas used by residents were provided with safe and secure handrails. This deficient practice has the potential to affect all 115 residents who are independently ambulatory with, or without an assistive device, and residents who were able to self-propel in their wheelchairs living in the facility.
Findings include:
An initial observation of the 2nd floor was completed on 4/28/25 at approximately 12:00 PM. During this observation residents with cognitive impairment were observed walking in the hallway using the handrails as well as residents were using the rails to move around in their wheelchairs. The end caps for the handrails were missing with sharp areas of the handrails exposed in multiple areas throughout the 2nd floor hallway. There were 2 end caps missing near the elevator, near the doorways of rooms 218, 221, outside the unit manager's office. Throughout the survey multiple follow-up observations were completed on 4/28/25, 4/29/25 and 4/30/25 to confirm the initial observation.
An interview with the Maintenance Director (MD) was completed on 4/30/25 at approximately 7:45 AM. They were queried about their routine maintenance rounds process. When they were queried further on the observations, they confirmed the multiple missing handrail end caps.
During an observaiton with the Maintenance Director MD on the second floor, they said they had fixed the end caps on the first floor and they had placed the order for more.
An interview with the facility Administrator was completed on 4/30/25 at approximately 9:30 AM, they were notified of the observations of the missing end caps and they reported that the Maintenance Director MD had placed the order and waiting for shipment.
A facility provided undated document titled Resident Rights read in part, The facility will inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules governing resident conduct and responsibilities during the stay in the facility
Safe Environment: The resident has a right to a safe, clean, comfortable and home like environment, including but not limited to receiving treatment and supports for daily living safely .
Jan 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake M100148727.
Based on observation, interview, and record review, the facility failed to provide...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake M100148727.
Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, home-like environment for one (R704) of three residents reviewed for environmental concerns. Findings include:
Review of the facility record for R704 revealed an admission date of 11/30/24 with diagnoses that included Metabolic Encephalopathy, Sepsis and Urinary Tract Infection. R704 was discharged to another facility on 12/06/24.
On 01/08/25 at 12:30 PM, R704's former room (room [ROOM NUMBER]) was inspected. The bathroom sink had been caulked along the length of the top and side contact with the wall. This caulk line was broken along the entire length and had the appearance of the sink coming away from the wall. There were multiple holes in the wall with exposed drywall adjacent to the toilet where a toilet paper holder had been removed and not repaired. The heat register on the wall under the windows of the bedroom area was missing the cover plates of the heating coil leaving the coil exposed and easily able to be touched from a standing or seated height.
On 01/08/25 at 2:25 PM, room [ROOM NUMBER] was toured with the facility Administrator (NHA). The NHA acknowledged the appearance of the broken caulk line around the bathroom sink, the holes in the wall from the former placement of the toilet paper holder, and the condition of the heat register having exposed heating coils. The NHA reported their expectation was that the caulking and the holes in the bathroom wall should have been repaired and the heat coils should have the covering grid plates in place.
On 01/08/25 at 1:53 PM, a facility policy addressing homelike environment was requested and was not provided by the time of survey exit.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
This citation pertains to intake M100148727.
Based on interview and record review, the facility failed to complete an initial skin assessment and place initial wound care orders for one (R704) of thr...
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This citation pertains to intake M100148727.
Based on interview and record review, the facility failed to complete an initial skin assessment and place initial wound care orders for one (R704) of three residents reviewed for wound care services. Findings include:
Review of the facility record for R704 revealed an admission date of 11/30/24 with diagnoses that included Metabolic Encephalopathy, Sepsis, and Urinary Tract Infection. R704 was discharged to another facility on 12/06/24.
Review of R704's admission Note dated 11/30/24 documented, Patient received on unit at 1800 (6 PM) alert and oriented x 2-3, stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) wound reported on buttock .
There was no initial skin assessment, treatment orders, or documentation of wound care provided from 11/30/24 to 12/3/24.
Review of the physician orders dated 12/3/24 revealed wound care orders for the sacrum and bilateral buttocks, Cleanse with NS (normal saline)/wound cleanser, pat dry. Apply Medihoney and cover with dry dressing. R704's Treatment Administration Record (TAR) reflected the wound care was completed 12/04/24 thru 12/06/24.
On 01/08/25 at 12:53 PM, the facility wound care nurse, Licensed Practical Nurse (LPN) B was asked to describe the facility process for assessing and treating skin/wounds for newly admitting patients. LPN B reported the admitting nurse should complete a full skin assessment and if there is a wound they should put in orders, at minimum, for a dry dressing until the wound care nurse further assesses the wound.
On 01/08/25 at 1:12 PM, Wound Care Nurse Practitioner (NP) C reported they do weekly wound care rounds on Wednesdays. NP C said they had assessed R704's wound on 12/4/24 documenting the wound was staged as unstageable (100% eschar-dead skin tissue).
On 01/08/25 at 1:41 PM, the facility Director of Nursing (DON) reported they began working at the facility the previous week and therefore was not involved in or familiar with R704's stay at the facility.
Review of the undated facility policy Pressure Ulcer and Skin Care Management revealed the policy statement A resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcers developing. The procedure portion of the policy includes the entry A licensed nurse checks the resident's body for the presence of pressure ulcers, wounds and other skin conditions at admission or readmission to the facility.
Nov 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00148164.
Based on interview and record review, the facility failed to implement intervention...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00148164.
Based on interview and record review, the facility failed to implement interventions to reduce the risk for elopment for one resident (R700) of one reviewed for elopement, resulting in a R700 eloping out fire door to the front of the building and walking to the corner. Findings include:
On 11/12/24, a facility reported incident submitted to the State Agency was reviewed and indicated R700 had exited the facility on 11/12/24 at 4:15 AM. Door alarms had alerted staff someone had opened door and possibly left the building. R700 was found outside of the building after setting off alarms and leaving through a fire door.
On 11/21/24 the medical record for R700 was reviewed and revealed the following: R700 was admitted to the facility on [DATE] with the diagnoses of dementia, hypertension, hyperlipidemia, insomnia, and diabetes mellitus. A review of the minimum data set assessment (MDS) dated [DATE], R700 brief interview of mental status assessment indicated a score of 6 indicating moderate cognitive impairment. R700 was ambulatory without assistance.
Further review of the medical record revealed elopment risk assessments with the following dates:
- 9/12/2024-ELOPEMENT ASSESSMENT- Low Risk 8.0
- 8/10/2024-ELOPEMENT ASSESSMENT- High Risk to Wander 12.0
- 8/4/2024-ELOPEMENT ASSESSMENT-High Risk to Wander 12.0
An interview was held on 11/21/24 at 12:19 PM via telephone with Licensed Practical Nurse (LPN) A, who worked the night of the incident. LPN A stated,Yes, I worked on 12/12/24. The midnight supervisor had just left at 3:30 AM and soon after I heard the door alarm go off. It was (R700) trying to open the door. The nursing assistant took the resident back to bed. LPN A confirmed no additional inverventions were put into place. The nurse went on to say, my nurse hall partner was off the floor on break. After about 10 -15 minutes later, as I was in the bathroom, I heard the alarms and the doors go off again. I hurried and got myself together to respond to the alarms. The nursing assistant told me R700 was not in their room and I initiated a Code [NAME] for missing residents. I alerted my nurse hall partner who was in their car to look out for the resident. The other nurse was able to pull in front of building and saw the resident walking to the corner. The resident was brought back into the building.
An attempt was made to contact the other nurse/hall partner and the Certified Nurse Assistants (CNA) who were on staff for R700 during the night of 11/12/2024, however there were no return phone calls by the end of the survey.
On 11/21/24 at approximately 2:30 PM, the Nursing Home Administrator (NHA) was interviewed pertaining to R700's elopement on 11/12/24. The NHA stated, the expectation is that all residents would be safe and facilty policies followed to keep the residents safe.
A review of the facility policy titled Potential Resident Elopement revealed the following,it is the policy of this facility to provide residents with a safe and secure environment and identify residents who may be at risk for unobserved exit from the facility. If the resident attempts to leave the facility without authorization and there is a witness: a. assist resident and redirect to safe area. B. Obtain assistance from other staff member in the vicinity if necessary .E. Determine what additional interventions are needed to minimize another attempt at an unauthorized leave.
Jul 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00145649
Based on interview and record review, the facility failed to ensure an allegation ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00145649
Based on interview and record review, the facility failed to ensure an allegation of abuse was immediately reported to the State Agency (SA) for one resident (R902) of one resident reviewed for abuse. Findings include:
A review of intake: MI00145649 revealed the following, [R902] was at a dialysis appointment today and she called police due to one of her caretakers assaulting her. The caretaker's name is [Certified Nursing Assistant (CNA) A .]
A review of R902's medical record revealed they were initially admitted into the facility on 3/7/24 with diagnoses that included Chronic Respiratory Failure with Hypoxia, Heart Failure, End Stage Renal Disease, and Schizoaffective Disease. The medical record revealed R902 was cognitively intact and required one person assistance for bathing, bed mobility and toilet use.
A review of the police report dated 7/12/24 from the local police agency where dialysis occurs revealed the following: .met with caller who was identified as [R902]. [R902] advised that her caretaker, later possibly identified as [CNA A], assaulted her at her dialysis appointment .
A review of the police report dated 7/13/24 from the local police agency where R902 resided (the facility) at the time of the incident revealed the following: I was dispatched to the [nursing facility]on an A&B (assault and battery) report. Dispatch advised the caller said her sister [R902] told her she was assaulted on 7/12/24 at a doctor's appointment [officer] spoke with [NAME] who was loud and was saying she wanted to press charges regarding the incident from 7/12/24 .
A request was made for a Facility Reported Incident (FRI)/Investigation for the allegations of employee to resident abuse, and the Nursing Home Administrator (NHA) provided this Surveyor with a file.
On 7/23/24 at 1:35 PM, the NHA was asked why a FRI had not been reported to the state agency. The NHA explained a discussion regarding whether the incident needed to be reported did occur during their investigation, and the incident was determined to be unsubstantiated.
A review of the facility's Abuse and Neglect Prohibition policy revealed the following,
G. Reporting and Response .3. The Administrator or designee is responsible for reporting to the State Agency all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of property:
a. Immediately but no later than 2 hours after the allegation is made if the allegation
involves abuse or result in serious bodily injury.
b. Or not later than 24 hours if the events that cause the allegation do not involve
abuse or serious injury .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
This citation pertains to Intake: MI00145702
Based on observation, interview, and record review the facility failed to consistently complete and document ordered wound care treatment, and timely impl...
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This citation pertains to Intake: MI00145702
Based on observation, interview, and record review the facility failed to consistently complete and document ordered wound care treatment, and timely implement treatment interventions for one Resident (R901) of one resident reviewed for pressure ulcers. Findings include:
A review of Intake MI00145702 revealed the following, .the facility isn't getting the
resident out of bed or turning him, so [they are] concerned that the bed sores are no longer healed and could potentially be getting worse .
On 7/23/24 at 9:38 AM, R901 was observed lying in bed on their back, head elevated, feet flat on the mattress. R901 was asked if they ever get repositioned and they stated, No. There were no pillows or wedges observed in the resident's room.
A review of R901's medical record revealed that they were admitted into the facility on 3/4/22 with diagnoses of heart failure, dementia, and gastrotomy status. The medical record revealed R901 was moderately cognitively impaired and required extensive assistance for bed mobility.
A review of the Progress Notes for R901 revealed the following:
7/1/2024 11:24 Skin/Wound Note
. Upon completing weekly skin assessment during shower writer observed open area to coccyx with minimal bleeding present. MD (medical doctor) notified rec'd (received) new orders given for wound consult and cleanse area with NS (normal saline) pat dry and apply dry drsg (dressing) daily and PRN (as needed) until seen by wound care nurse. New orders transcribed and treatment applied to affected area .
7/17/2024 14:42 (2:42pm) Skin/Wound Note
Encounter Date: 07-17-2024
Chief Complaint: Follow-up consult regarding coccyx .coccyx stage II pressure ulcer is was resolved and reopened 1.0 x 1.0cm 100% red pink tissue dry tissue scant serous drainage. The periwound is pink fragile. The wound edges are attached to the wound base. There is no odor .Assessments/Plans: Coccyx stage II pressure ulcer. Recommended treatment
Cleanse pat dry apply Triad to coccyx leave open to air apply daily and as needed. Reposition, Nutritional support to promote wound healing, Encouraged to float heels with heels, suspension boots while in bed .
A review of R901's orders revealed the following ordered on 7/2/24, [Name Brand] Wound Dress External Paste (Wound Dressings) Apply to right buttock topically one time a day for wound care cleanse with wound cleanser or NS, pat dry, apply [name brand] cream and leave open to air AND Apply to right buttock topically as needed for wound care.
A review of R901's Treatment Administration Record (TAR) revealed missing treatments on 7/3/24, 7/4/24, 7/10/24, 7/13/24, 7/14/24, 7/18/24, and 7/19/24.
On 7/23/24 at 11:47am and 1:45pm, R901 was observed lying in the same position as they were observed in at 9:38am. R901 was again asked if someone had repositioned them, and they stated, No.
A review of R901's skin care plan revealed no updated treatment interventions or revisions related to the resident's new skin impairment and revealed the following, Focus: I have potential/actual impairment to skin integrity of the r/t (related to) Fragile Skin. Date Initiated: 04/25/2024. Revision on: 05/28/2024 .Encourage good nutrition and hydration in order to promote healthier skin. Date Initiated: 06/06/2024. Keep my skin clean and dry. Use lotion on dry skin. Date Initiated: 06/06/2024 .
On 7/23/24 at 1:50 PM, the Director of Nursing (DON) was asked what the expectations for repositioning and the completion of wound care treatments were and acknowledged they should be completed as ordered and care planned.
A review of the facility's Skin Management Facility Guidelines revealed the following, .3. Residents admitted with skin impairments will have:
. Appropriate interventions implemented to promote healing
. A physician ' s order for treatment.
. Treatment Record initiated, and
. Wound location and characteristics documented
. Identify any physical, functional, and/or psychological complications related to an
existing ulcer for examples, pain, cellulitis, osteomyelitis, or social isolation .5. A Care Plan is developed upon admission and may address:
. Identifying the contributing Risks for breakdown
. Hydration
. Nutrition
. Preventative devices
. Physical activity
. Positioning requirements
. Proper body alignment
. Education - when appropriate .
Jul 2024
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 MI00145171.
Based on observation, interview, and record review, the facility failed to ensure r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00145171.
Based on observation, interview, and record review, the facility failed to ensure resident rooms and shower rooms were maintained in a homelike/sanitary manner for four residents (R1, R111, R89, R87) of four whose environment was reviewed. Findings include:
On 07/02/24 at 8:25 AM, an odor of urine was noted at the middle to end of the low north hall. The shower was observed to have a wet washcloth on the floor at the doorway, two upside down loose tiles in the left corner and black spots from pin to pencil eraser size (which appeared to be mildew or black mold), along the base tiles along the back and sides of the shower area. A larger golf ball size area of the black mildew like substance was noted on the right side base tiles. The two curtains which hung across the entry to the shower area had the similar black mold like substance continuously along the bottom seam and up the curtains around two to three inches in places. The floor threshold for room the room of R89 had a build up of soil on both sides and particles of debris were built up in the corner at the hinge side of the door. R89 reported they saw some kind of insect run across the doorway just moments before. There was trash stuffed into sharps container and some other pieces under the resident's bed.
A review of the the record for R89 revealed R89 was admitted into the facility on [DATE]. Diagnoses included Diabetes and Anxiety. The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition with a 15/15 Brief Interview for Mental Status (BIMS) score and required some supervision or was independent for Activities of Daily Living (ADLs).
On 07/02/24 at 8:34 AM, in the first floor south shower room, two bath towels were observed to be on the floor in the entry area. Water had pooled next to the shower bed and a muddy residue was visible at the base of the puddle. The middle shower room for the first floor had closed signs posted on the door.
On 07/02/24 at 9:55 AM, R87 reported there was black stuff in the (first floor) north shower room. R87 also had vinyl flooring planks missing at the foot of their bed. The trim by the bathroom was taped to the wall with duct tape. R85 reported it has been like that a couple months.
A review of the record for R87 revealed R87 was admitted into the facility on [DATE]. Diagnoses included High Blood Pressure and Debility. The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition with a 15/15 Brief Interview for Mental Status (BIMS) score and required some supervision or was independent for Activities of Daily Living (ADLs).
On 07/02/24 at 9:57 AM, R111 room ceiling had missing tiles and water stains. room [ROOM NUMBER]'s bathroom hand wash was leaking from the faucet and the paint and covering on the ac/heater was peeling. The hand sink faucet in room [ROOM NUMBER] was leaking.
A review of the record for R111 revealed R111 was admitted into the facility on [DATE]. Diagnoses included High Blood Pressure and Schizophrenia. The Minimum Data Set (MDS) assessment dated [DATE] indicated impaired cognition with a 6/15 Brief Interview for Mental Status (BIMS) score and required some supervision or was independent for Activities of Daily Living (ADLs).
On 07/02/24 at 10:25 AM and 2:33 PM, the north shower room remained as before with the smell of mold and the dirty towel on the floor. Gnats were observed outside the shower room entry.
On 07/02/24 at 10:35 AM, R1 reported the north shower room is always dirty.
A review of the record for R1 revealed R1 was re-admitted into the facility on [DATE]. Diagnoses included High Blood Pressure and Anxiety. The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition with a 15/15 Brief Interview for Mental Status (BIMS) score and required set up to substantial assistance for most Activities of Daily Living (ADLs).
On 07/02/24 at 1:30 PM, CNA J reported that the condition of the shower room peaks the resident's irritation and commented one wouldn't want to give a loved one a shower in there or receive a shower.
On 07/02/24 at 3:43 PM, the first floor north shower room was observed with the Environmental Services Director Staff G. Staff G reported that the [NAME] cleans the shower rooms once in the morning and after that the CNAs were responsible to keep it tidy. Staff G reported the [NAME] was at the facility and had cleaned the shower. The black mold/mildew like substance on the curtains and tile was pointed out to Staff G. Four gnats were observed flying off the shower curtain when moved. Staff G reported they would need to have the shower room cleaned with bleach and the curtains washed.
A review of the April 2024 Resident council meeting minutes documented concerns with Housekeeping: floors and bathrooms need to be cleaned better and Maintenance: not fixing things they see broken.
A review of the May 2024 Resident Council meeting minutes documented concerns with: Maintenance: shower rooms not working.
A review of the June 2024 Resident Council meeting minutes documented concerns with: Housekeeping: floors still unclean. Maintenance: shower rooms not working.
A review of the Deep Cleaning schedule for July 2024 indicated each room was scheduled for a deep cleaning monthly. room [ROOM NUMBER] was scheduled for 07/01. room [ROOM NUMBER] for 07/02. room [ROOM NUMBER] for 07/03. A deep cleaning for room [ROOM NUMBER] was not observed on 07/02.
A review of the closed work orders for 06/01/24 to 07/01/24 revealed the identified concerns were not included.
A review of the housekeeper job description documented, .The housekeeper is responsible for satisfactory and timely completion of assigned cleaning area according to the schedule . This did not directly include the shower rooms.
A review of the Housekeeping Care Plan documented, .The Deep Clean room schedule ensures that each resident room is deep cleaned at least monthly . This care plan did not address the shower rooms.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00145171.
Based on observation, interview, and record review, the facility failed to ensure care nee...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00145171.
Based on observation, interview, and record review, the facility failed to ensure care needs and or incontinence care was provided for nine residents (R105, R87, R71, R95, R48, R34, R22, R1, R2) of 13 reviewed for activities of daily living (ADLs). Findings include:
On 07/02/24 at 8:25 AM, an odor of urine was noted at the middle to end of the low north hall.
R105
On 07/02/24 at 9:55 AM, R105 reported the facility needs more help because they wait a long time to get to get cleaned up when they are wet and soiled. At 12:23 PM, R105 was observed to be slouched over to the left side of the bed asleep. R105 reported they were wet with urine and had put their light on and no one came and must have fallen asleep. R105 did not recall the time they were last checked.
At 2:32 PM, R105 was observed to be slouched to the left in bed asleep.
A record review for R105 reveals that R105 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure. Further record review of R105's care plan revealed the following: I am incontinent of bowel and (related to) r/t impaired mobility and muscle weakness. My skin will possibly become impaired r/t incontinence of bladder bowel and imobilility. Check me frequently during the day and change my brief if needed. Keep me as clean and dry as possible. The Minimum Data Set (MDS) assessment dated [DATE] indicated moderately impaired cognition and R105 was dependant for toileting hygiene, to roll left and right and substantial/maximal assistance for personal hygiene.
R87
On 07/02/24 at 9:55 AM, R87 reported not getting water passed daily on the morning and afternoon shifts.
Review of R87's record revealed they were admitted to the facility on [DATE] with a diagnosis of aftercare following joint replacement surgery. Further record review of R87's care plan revealed the following: I have the potential for fluid imbalance. I will maintain moist mucous membranes, good skin turgor with an adequate fluid intake by next review. I need your assistance with fluid intake in order to meet daily requirements.
R71
On 07/03/24 at 10:30 AM, R71 reported there are times every week they sit in a wet brief waiting for hours to get changed and the second shift is the worst for this.
A review of R71's record revealed R71 was admitted to the facility on [DATE] with hemiplegia and hemiparesis (paralysis/weakness of one side of the body) following cerebral infarction (stroke) affecting left non-dominant side. Further record review of R71's care plan revealed the following: I am incontinent of bowel and bladder. My skin will not become impaired (related to) r/t incontinence by next review. Keep me as clean and dry as possible.
R95
On 07/02/24 at 10:38 AM, R95 reported there are times at night when they are not checked and their brief not changed when soiled. R95's fingernails were beyond the end of the fingers at irregular lengths.
Review of R95's record revealed they were admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD). Further record review of R95's care plan revealed the following: I need assistance with my ADL's as I have cardiorespiratory issues and am in a weakened condition. check my nail lengh-file and clean them on my bath days and as necessary. I have potential for impairment to skin integrity r/t limited mobility. Keep my skin clean and dry.
R48
On 07/02/24 at 10:15 AM R48 reported it takes a long time to get the call light answered and staff doesn't like it when they put the call light on.
A review of R48's record revealed R48 was admitted to the facility on [DATE] with a diagnosis of multiple sclerosis. Further record review of R48's care plan revealed the following: I am incontinent of bowel and bladder. Check me frequently during the day and change my brief if needed. Keep me as clean and dry as possible.
R34
On 07/02/24 at 10:20 AM, R34 was observed to be in bed sleeping. a vague odor of urine was noted. At 12:11 PM, R34 reported they were in a wet brief and had not been changed since five AM because they need help to get back into bed so they can be changed. R34 reported that staff knew they were waiting to be changed, but went to get supplies and it had been 45 minutes. R34 commented that the (certified nursing assistant ) CNA was trying to take care of all three of the residents in the room at the same time. At 12:18 PM, staff entered the room and confirmed what R34 said and had to get a sling for the lift.
A review of R34's record revealed that they were admitted to the facility on [DATE] with a diagnosis of rheumatoid arthritis with rheumatoid f of multiple sites. Further record review of R34's care plan revealed the following: I am occasionally incontinent of bowel and bladder r/t immobility. Transfer with one person with extensive assist. Keep my skin clean and dry.
R22
On 07/02/24 at 10:20 AM, R22 was observed with a family member at bedside. The family member reiterated R22's reported concerns for the facility being short staffed, the call light may take forever to be answered, sits in a wet brief for a long time and fresh water was not routinely passed. R22 commented one of the showers was broken and the water was off for a couple of days about a month ago and therefore some shower/baths were missed. (The middle shower room on the first floor had multiple signs on the door that it was broken.) At 12:14 PM, R22 reported their brief was wet and did not know how long they had been waiting. R22 reported they preferred to get up to go in the bathroom but the aide just put a brief on them.
Review of R22's record revealed they were admitted to the facility on [DATE] with a diagnosis of sequelae of other cerebrovascular disease and cognitive communication deficit. Further record review of R22's care plan revealed the following: I am incontinenet of bowel and bladder r/t weakness and imited mobility. I will be free of odor while maintaining my dignoty. keep me as clean and dry as possible.
R1 and R2
On 07/02/24 at 8:20 AM, R1 and R2 were observed to be in bed and faced out toward the doorway. R1 appeared asleep with their head over toward their left shoulder and the head of the bed up 45 to 60 degrees. There was water on the floor at the foot of R1's bed.
On 07/02/24 at 9:48 AM, R1 and R2 were observed to be in bed with gnats flying around. They also reported having seen ants. R1 had food spilled down onto the chest area of their hospital style gown. R1 and R2 commented the facility was understaffed (worse on nights and weekends) and that it may take hours to change their briefs when soiled with urine and feces. R1 reported having chronic uncontrolled diarrhea. R1 reported they were last changed at 2:00 AM and felt that when they put the call light on for help between 8:00 AM and 9:00 AM.
At 11:50 AM, R1 and R2 appeared to be sleeping. R1 was still wearing the hospital gown with food spilled on it.
A review of R1's record revealed they were admitted to the facility on [DATE]. Further record review of R2's care plan revealed the following: I am incontinent of bowel and bladder. Check me frequenty and change my brief if needed. Keep me as clean and dry as possible. A record review of R1's toilet use task list and repositioning task list revealed long periods between care, sometimes greater than 18 hours.
A review of the record for R2 revealed they were admitted to the facility on [DATE]. Diagnoses included Arthritis and High Blood Pressure. The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition and the need for substantial to maximal assistance for toileting hygiene and personal hygiene.
On 07/02/24 at 11:30 AM, Certified Nursing Assistant (CNA) A reported there were three CNAs for the whole first floor and you can't make your co-workers come to work. There were four CNAs on the floor with one which was noted by the unit manager to have come in at 11 AM. CNA A commented the managers do not regularly help out when they are short staffed. CNA A also note they had one CNA that walked out and a lot of cnas quit recently. It was reported the care can depend on who the fourth CNA is but with four you are still running around and management doesn't catch our back like when I'm in a room and a light is on for 30 minutes.
On 07/02/24 at 1:30 PM, CNA B reported that they like working at the facility even though they are always short staffed and overworked as you can barely take your breaks. CNA B reported they can't always do their best because they are short staffed and with 19 to 23 residents one can't provide the proper care. CNA B further reported they often have residents in wet briefs on morning rounds and (R34) would have been changed sooner if they had more staff.
On 07/02/24 at 3:33 PM, staffing for nurse and CNAs was reviewed with the nursing staff Scheduler Staff F. Staffing challenges were reviewed and call offs and attrition were indicated as challenges. Staff F reported two call offs for the day one for the first floor and one for the second floor. It was noted that there were four CNAs on the fourth floor and three on the second floor for this day 07/02/2024. Staff F reported they schedule five CNAs for the first floor and four for the second floor. Staff F reported they went through the staff and were unable to obtain further assistance for the staff.
On 07/02/24 at 3:54 PM, the concerns for the survey were reviewed with the Director of Nursing (DON). The DON reported there was no set schedule or time frame to round on residents and complete incontinence care as it was based on the resident's preference and plan of care. The DON reported they will use the restorative CNA to cover some call offs and also managers are to help when needed. The DON reported weekly new staff orientation and on average three out of seven may make it onto the staff. The DON also noted a recent in-service on the requirement of staff to be available and cover for the staff member on break.
A review of the April 2024 Resident council meeting minutes documented concerns with timely medication pass on midnights, aides are not covering aides that go on break, nurses being rude and cell phone use while giving care.
A review of the May 2024 Resident Council meeting minutes documented concerns with medication passes on midnights, CNAs complaining about being short staffed in front of residents and not changing briefs in a timely manner, call lights not being answered timely, water pass becoming an issue again and cell phone use was still and issue.
A review of the June 2024 Resident Council meeting minutes documented concerns with CNAs identifying themselves to residents and cell phone use still an issue.
The sign in sheet for June 25, 2024 documented seven CNAs signed in on the day shift with 17 patients each. One midnight nurse signed in. On June 26, 2024, the schedule documented three CNAs on the first floor for the night shift with 23 residents each. On June 27, 2024 the schedule documented two of nine CNAs and four of five nurses signed in for the day shift. Notations on the assignment indicate: Answer call lights promptly. Please make rounds every two hours. The assignment sheet for July first documented two CNAs for the first floor on the midnight shift after nine PM. Three CNAs had been on seven PM to nine PM.
A review of the undated Brief and Underpads standard operating procedure policy revealed, Briefs are intended to provide incontinent residents with the support needed to maintain dignity .
A review of the undated Bowel and Bladder Incontinence standard operating procedure policy revealed, Preventative measures for controlling common infections are a critical component of the overall plan of care for incontinent residents .
Mar 2024
12 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
This citation pertains to Intake: MI00140563.
Based on interview and record review, the facility failed to honor a resident's right to smoke for one sampled resident (R211) of two residents reviewed f...
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This citation pertains to Intake: MI00140563.
Based on interview and record review, the facility failed to honor a resident's right to smoke for one sampled resident (R211) of two residents reviewed for smoking. Findings include:
A review of Intake MI00140563 revealed the following, The DON (Director of Nursing) lied to the physician and told the physician the resident was unsafe to go on an LOA (leave of absence) alone. This was not a true statement, resident was independent and was previously going on LOAs alone per PT (physical therapy) and physician. The DON was upset because the resident was smoking outside on the premises and took [their] rights away. When the resident tried to explain that [they] had an
appointment scheduled the DON forced [them] and documented it as being an AMA (against medical advice). No paperwork was signed, the resident called the facility multiple times trying to return and the DON would not let [them].
A review of R211's medical record revealed that they were admitted into the facility on 9/6/23 with diagnoses that include Heart Failure, Diabetes, Anxiety, Chronic Kidney Disease, and Acquired Absence of Left Leg Above Knee. Further review revealed that the resident was cognitively intact and was Independent with Activities of Daily Living .
Further review of the medical record revealed a Smoking Assessment dated for 9/7/23 indicating that the resident was safe to smoke without supervision.
Further review of the medical record revealed the following progress notes:
9/23/202316:42 (4:42pm) Health Status Note
Note Text: Nursing mgr. (manager) reported to writer observed resident alone self-propelling [their] wheelchair on a LOA from facility, resident attempt to enter facility unable to propel wheelchair without a struggle on the ramp/entrance. Resident made several attempts staff proceeded to assisted resident to enter building. Nursing mgr. Notified [physician] with above safety concerns. New order received resident unable to go on LOA alone must be accompanied by friend or family for safety concerns. Will continue POC (plan of care).
9/25/202316:15 (4:15pm) Nurses Note
Note Text: Writer received resident at 0700 (7:00am). Resident took all morning meds as order. At 0830 (8:30am) resident asked writer why [they] couldn't go on LOA's by [themselves] anymore. Writer stated that it was a safe concern with [them] and wheelchair. Writer attempted to reinforce teaching to resident about safely transferring self and proper usage of wheelchair going up ramps. Resident stated that [they] didn't want to hear that [expletive]. Resident demanded to talk to the administrator, stating that we can't keep [them] and [they're] going to leave.
At 11:37 resident was sitting at door demanded for writer to open door. Writer stated to resident [they're] unable to go on LOA's with out and (a) friend or family member accompanying [them]. Writer attempted to explain to resident the risk of leaving the facility agents (against) medical advice, and resident through (threw) hands up stating 'I don't want to hear that [expletive] man, and I ain't signing [expletive] Resident started making verbal threats to staff when staff wasn't putting door code in fast enough to let resident out. Resident left facility and refused to sign AMA documents. At 1340 (1:40pm) resident came back to building demanding to be let back in. Staff attempted to reeducate resident on AMA and direct resident that he had to leave premises. Doctor notified.
A review of the resident's medical record did not reveal a new smoking assessment indicating that the resident was an unsafe smoke, nor were there any other additional documentation or assessments indicating that they were unsafe to leave the facility for an LOA.
On 3/18/24 at 12:00 PM, an attempt to contact the resident to no avail, as the phone message indicated, services is restricted.
On 3/19/24 at 10:20 AM, and interview was completed with the DON regarding the circumstances of R211's discharge and smoking rights. The DON explained that R211 had some issues when they first arrived because they didn't like the smoking policy, and wanted to go smoke by themselves. She explained that they preferred to propel up and down the street however a nurse was concerned because they looked like they was going to flip out of their chair, and as a result, the doctor wanted them to have someone go out with them. The DON further explained that the date the resident left, they were demanding that they allow them to go out by themselves although they were attempting to accommodate them. The DON explained that the resident go upset and stated that they were leaving and refused to sign AMA paperwork. The DON admitted that two hours later, the resident returned to the facility and was not allowed back in. The DON acknowledged that the situation could have been handled differently.
On 3/19/24 at 1:30 PM, the Nursing Home Administrator, who was not in the position at the time of the incident, was asked facility expectation for resident's rights to smoke, and she acknowledged that she would have allowed the resident to leave the facility to smoke, and return.
A review of the facility's Resident Rights policy revealed the following, The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake M100141520 and MI00137527.
Based on interview and record review, the facility failed to prevent...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake M100141520 and MI00137527.
Based on interview and record review, the facility failed to prevent the misappropriation of resident funds by a staff member for one (R61) of six residents reviewed. Findings include:
Review of the facility record for R61 revealed an admission date of 04/03/23 with diagnoses that included Rheumatoid Arthritis, Chronic Obstructive Pulmonary Disease and Osteoarthritis. The Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 13/15 indicating intact cognition.
On 03/17/24 at 10:32 AM, R61 was interviewed in their room. R61 reported that on 12/02/23 they had given Certified Nurse Assistant (CNA) G their bank card and asked them to withdraw two hundred dollars from the ATM for them. R61 stated that CNA G had withdrawn money for them multiple times and that they trusted them and they would give CNA G a ten dollar tip for the assistance. R61 reported that after CNA G gave them the two hundred dollars they checked their bank account and the recorded amount of the withdrawal was four hundred dollars. R61 stated that they reported the situation to multiple staff who were working at that time. R61 reported that the additional two hundred dollars was returned to them either that evening or the next day. R61 reported that they have not seen CNA G since the incident. R61 stated that they were satisfied to have their money returned and they chose not to press charges or have the facility involve the police.
On 03/18/24 at 11:00 AM, review of the facility submitted incident report indicated that CNA G was terminated and their license was reported to the State agency following the reported incident. The facility investigation interview with Licensed Practical Nurse (LPN) H indicated that CNA G provided the missing two hundred dollars that was returned to R61 but stated that they did not take the money and that they were paying the money back in order to avoid confusion. The facility investigation indicated that after providing the missing two hundred dollars CNA G did not respond to facility requests for an interview regarding the incident.
On 03/18/24 at 11:26 AM, a call was placed to CNA G. A voice message was left requesting a return call.
On 03/18/24 at 11:51 AM, a call was placed to LPN H who received R61's initial report and reported the incident to the facility Director of Nursing (DON). A message was left requesting a return call.
As of 03/19/24 at 1:00 PM, no return calls were received from CNA G or LPN H.
On 03/19/24 at 1:12 PM, the DON reported that following the incident involving R61 and CNA G they completed in-servicing with all nursing staff regarding the abuse policy/procedure including misappropriation of resident funds however they were not sure if there was documentation of this in-servicing. The DON reported that they have advised the staff not to engage in exchange of money with residents and if they do so for simple situations such purchasing a drink or snack, to have another staff witness the situation in order to avoid any misunderstandings. The DON reported that their expectation is that staff follow the policies and procedures pertaining to abuse and misappropriation.
Review of the facility policy Abuse and Neglect Prohibition dated 02/17/20 revealed the policy statement Each resident has the right to be free from abuse, mistreatment, neglect, exploitation, involuntary seclusion, misappropriation of property and mental abuse facilitated or enabled through the use of technology. The Definitions portion of the policy includes the entry Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00137527.
Based on observation, interview and record review, the facility failed to report a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00137527.
Based on observation, interview and record review, the facility failed to report allegations of abuse to the State Agency (SA) within required regulatory timeframe's for one sampled resident (R3) of four residents reviewed for abuse. Findings include:
On 3/17/24 at 10:13 AM, R3 was observed lying in bed and asked about their stay in the facility. They explained that they had been punched in the stomach by a facility staff member approximately 5-6 weeks ago however, they had not seen that staff member since.
A review of R3's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that include Post-Traumatic Stress Disorder (PTSD), Depression, and Chronic Pain Syndrome. Further review of R3's medical record revealed that the resident was cognitively intact, and required extensive to total dependence with Activities of Daily Living.
Further review of the medical record revealed the following progress notes:
12/28/2023 16:56 (4:56pm) Social Services
Note Text: Writer, Unit Manager and Activity Director met with the resident for [their] scheduled care conference. During the conference [they] stated that a staff punched [them]. [R3] was asked did [they] know the staff's name. [R3] stated that [that] did not. [R3] stated that the incident took place this morning between 5:00am and 6:00am. Writer asked the roommate of the resident did [they] see or witness the incident. [They] stated that the staff grabbed [R3] and was very aggressive. In closing the Unit Manager stated that [they] will find out what staff worked during that shift. Writer, Unit Manager and Activity Director reported incident to Administrator immediately.
On 3/18/24 at 8:31 AM, a request for an investigation regarding R3 was requested from the facility, and was provided with a soft file which did not reveal that allegation of abuse had been submitted to the State Agency,
On 3/19/24 at 10:37 AM, the Director of Nursing (DON) was asked if she was aware why the allegation of abuse hadn't been reported to the SA, and she explained that the investigation was being handled by the previous Nursing Home Administrator, and may not have been reported based on their own internal investigation which did not substantiate abuse.
On 3/19/24 at 1:30 PM, the NHA was asked about the allegation of abuse not being submitted to the SA by the previous NHA, and she explained that it should have been.
A review of the facility's Abuse and Neglect Prohibition policy revealed the following, E. Investigation .3. The facility Administrator, or designee will report such allegations to the state, as per state regulation. 4. The facility Administrator, or designee with report all investigation findings to the state as per federal and state regulations
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00137527.
Based on observation, interview, and record review, the facility failed to operati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00137527.
Based on observation, interview, and record review, the facility failed to operationalize policies and procedures and thoroughly investigate an allegation of abuse for one resident (R3) of four residents reviewed for abuse. Findings include:
On 3/17/24 at 10:13 AM, R3 was observed lying in bed and asked about their stay in the facility. R3 explained that they had been punched in the stomach by a facility staff member approximately 5-6 weeks ago. R3 explained that they believed that there was another resident who also disclosed that the same staff member had become physical with them as well.
A review of R3's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that include Post-Traumatic Stress Disorder (PTSD), Depression, and Chronic Pain Syndrome. Further review of R3's medical record revealed that the resident was cognitively intact, and required extensive to total dependence with Activities of Daily Living.
Further review of the medical record revealed the following progress note:
12/28/2023 16:56 (4:56pm) Social Services
Note Text: Writer, Unit Manager and Activity Director met with the resident for [their] scheduled care conference. During the conference [they] stated that a staff punched [them]. [R3] was asked did [they] know the staff's name. [R3] stated that [they] did not. [R3] stated that the incident took place this morning between 5:00am and 6:00am. Writer asked the roommate of the resident did [they] see or witness the incident. [They] stated that the staff grabbed [R3] and was very aggressive. In closing the Unit Manager stated that [they] will find out what staff worked during that shift. Writer, Unit Manager and Activity Director reported incident to Administrator immediately.
On 3/18/24 at 9:35 AM, LPN I was interviewed regarding the allegations made against them by R3, and she explained that the resident was attempting to get out of bed, and she placed the resident's legs back in bed and left the room. Following the incident, she explained that she was reassigned to work on another unit, and hadn't worked on the same unit as R3 since the incident until last week.
On 3/18/24 at 8:31 AM, a request for an investigation regarding R3's was requested from the facility, and was provided with a soft file which revealed that the allegation of abuse occurred on 12/28/23 had not been submitted to the State Agency. In addition, the file did not reveal that the facility investigated any other incidents or trends related to abuse within the facility, or that the alleged perpetrator had been suspended pending investigation.
On 3/19/24 at 10:37 AM, the Director of Nursing was asked about the incident regarding R3 and facility staff, and she explained that the previous NHA completed the investigation and did not substantiate abuse based on discrepancies in the stories received regarding what allegedly occurred.
On 3/19/24 at 1:30 PM, the NHA was asked about the facility procedure for investigating allegations of abuse, and she explained that the incident should be reported to the State Agency, and the alleged perpetrator should have been suspended pending investigation.
A review of the facility's Abuse and Neglect Prohibition policy revealed the following, E. Investigation .5. The facility will investigate all patterns , trends or incidents that suggest the possible presence of abuse, neglect or misappropriation of property, identified through analysis conducted by the Quality Assurance & Process Improvement (QAPI) .6. The facility Administrator, or designee will conduct interviews with like residents to assess for patterns of abuse or collect witness statements .F. Protection. 1. The facility will protect resident from harm including investigations. Should the allegation allege a staff person, that individual will be suspended pending the outcome of the investigation .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes: MI00137973, MI00143112, MI00143340, MI00237527, and MI00139246.
Based on observation, intervi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes: MI00137973, MI00143112, MI00143340, MI00237527, and MI00139246.
Based on observation, interview and record review the facility failed to ensure provide timely response to (activities of daily living) ADL needs was provided and or documented for three residents (R88, R91, R27) of three reviewed for services. Findings include:
R88
On 03/17/24 at 1:25 PM, R88 was observed to be in bed and dressed in a hospital style gown. The head of the bed was up around 45 degrees and R88 leaned toward the right side of the bed. Attempts to sit more up right were not observed. R88 reported they had a history of stroke and right sided weakness. R88 further reported along with their visitor they were not getting changed timely and at times it would be more than an hour once they asked to be changed. R88 also reported there had been times they received a bed bath instead of their preferred shower in the shower room and that it was due staffing.
On 03/17/24 at 4:37 PM, R88 was observed to bed, dressed in a hospital gown and leaned toward the right side of the bed. R88 reported they were wet and put their call light on. Staff entered, spoke with R88 and walked out. Staff were not observed to return prior to 5:30 PM.
On 03/18/24 at 1:48 PM, R88 reported they had put the call light on around 10 AM to be changed. Staff came in and told R88 they would get the staff to change them and around 11 AM another staff came but did not provide care. A half an hour later a third staff came and assisted R88 with care. R88 was not observed to be out of bed or dressed in clothes during the three days of the survey.
A review of the record for R88 revealed R88 was admitted into the facility on [DATE]. Diagnoses included Stroke affecting the right dominant side, Heart Disease and Diabetes. The Minimum Data Set MDS assessment dated [DATE] documented intact cognition with a 15/15 Brief Interview for Mental Status score (BIMS) and was dependent for toileting hygiene, bathing, transfer and lower body dressing. Substantial to maximal assistance was required for rolling left to right, sitting to lying and lying to sitting, and personal hygiene.
The nursing care plan I am incontinent of Bowel and Bladder Date Initiated: 02/07/2023 . indicated .keep me as clean and dry as possible . The nursing care plan I need maximum assistance with my (activities of daily living) ADLs Date Initiated: 02/07/2023 . indicated .Observe me and report any changes, any potential for improvement, reasons for self-care deficit, expected course and a decline in my function. Date Initiated: 04/07/2023.
R91
On 03/17/24 at 1:48 PM, R91 was observed to be in bed dressed in a hospital gown. R91 reported they had some foot pain and x-rays were done of the foot and neck and were wondering about the results. R 91 reported that they often wait for more than an hour for their brief to be changed when staff are asked and have gone unchanged or checked for three to four hours. R91 reported this was most often on nights. R88 reported this happened as recently at the Saturday prior to survey entry on Sunday. R91 was not observed to be out of bed or dressed in clothes during the first two days of the survey. R91 also reported they had been times they rececieved a bed bath instead of their preferred shower in the shower room and that staff commented it was due to time and staffing.
On 3/18/24 at 1:51 PM, R91 was observed to bed in bed dressed in a hospital style gown. R91 reported it takes a long time to get water when a staff is asked and on, nights they say they will and they never get back with the water.
A review of the record for R91 revealed R91 was admitted into the facility on [DATE]. Diagnoses included Ataxia (difficulty walking), Adjustment Disorder and Generalized Anxiety Disorder. The MDS dated [DATE] documented intact cognition with a 13/15 BIMS score and and was dependent for putting on footwear. Substantial to maximal assistance was required for toileting hygiene, bathing, transfer, lower body dressing, rolling left to right, sitting to lying and lying to sitting, and personal hygiene.
The nursing care plan documented, I am incontinent of bowel and/or bladder. Date initiated 05/17/23 . check me at least every two hours . keep me as clean and dry as possible . The Documentation Survey (task) report for February 2024 did not indicate if the bathing performed was a bed bath or shower. Bathing for a scheduled bath day on 02/02 was not documented as provided.
R27
On 03/17/24 at 10:41 AM, R27 was observed to be in bed dressed in a hospital gown. The head of the bed was up 30-45 degrees. R27 reported they can wait more than hour to be changes when staff are asked and has waited at times more than two hours. R27 was not observed to be out of bed or dressed in clothes during the three days of the survey.
A review of the facility record for R27 revealed R27 was admitted into the facility on [DATE]. Diagnoses included Chronic Pain Syndrome, Heart Disease and Diabetes. The MDS dated [DATE] documented intact cognition with a 13/15 BIMS score and and was dependent for toileting hygiene, personal hygiene, bathing, transfer and upper and lower body dressing. Substantial to maximal assistance was required for rolling left to right, sitting to lying and lying to sitting.
The nursing care plan documented, I am incontinent of bowel and/or bladder. Date initiated 09/29/23 . keep me as clean and dry as possible . The nursing care plan I need assistance with my (activities of daily living) ADLs Date Initiated: 09/29/2023 . indicated .Observe me and report any changes, any potential for improvement, reasons for self-care deficit, expected course and a decline in my function. Date Initiated: 09/29/2023.
On 03/18/24 at 1:28 PM, during the group meeting for resident it was reported that: Call light response time is often 30 minutes to an hour; Some staff are less respectful during incontinence
care; One resident stated staff indicated, Church has to come to you, I'm not getting you ready in time; Two residents indicated that they do feel like they will be retaliated against if they complain;
Staff have been observed sleeping in the dining room and on phone calls.
On 03/18/24 at 5:34 PM, Certified Nursing Assistant (CNA) M was asked about night shift concerns and reported about once or twice a week that they would go in to check on a resident during their initial rounds and the resident would be soaked or need a complete bed change due to incontinence. CNA M further noted this was at time, related to only one CNA being on the set the night before. CNA M also noted that they have had to work as the only aide with greater than 20 resident to care for.
On 03/19/24 at 10:14 AM, the Director of Nursing (DON) was asked about their knowledge of R27, R88 and R91. The DON was asked about nursing staffing and reported it was an ongoing challenge.
On 03/19/24 at 12:25 PM, CNA N reported they did have a period of time when staffing was a little rocky and they would have to change or had found residents that were soaked from the night shift.
A review of the Resident Council concerns revealed multiple months for concerns related to waiting extended periods of time for care to be provided.
A review of the staffing sign in sheet for 03/17/24 documented five CNAs were available to care for 115 residents on the 7 PM to 7 AM shift. A sixth CNA was handwritten in as on a one to one until 11PM-The CNA did not sign in.
On 03/19/24 at 1:15 PM, a policy for the documentation of care and incontinence care check and change protocol was requested. A policy was not provided prior to survey exit. Shower/bath documentation for R27 and R88 was also requested and not received prior to survey exit.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00137527 and MI00141187.
Based on observation, interview and record review, the facility fail...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00137527 and MI00141187.
Based on observation, interview and record review, the facility failed to provide and or document wound care treatment for two sampled residents (R72 and R160) of five residents reviewed for skin management. Findings include:
R72
On 3/17/24 at 8:49 AM, R72 was observed lying in bed and asked about their stay in the facility, and the care received for their pressure ulcers. R72 explained that they have a wound on their hip that isn't healing, and that wound care treatment is completed every other day.
A review of R72's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included with diagnoses that Hemiplegia and Hemiparesis following Cerebral Infarction, Diabetes, Anxiety, and Hypotension. Further review revealed the resident was cognitively intact and required extensive with Activities of Daily Living.
Further review of R72's medical record revealed the resident has a left hip chronic stage IV (four) pressure ulcer (Stage four pressure ulcers occur when the hypodermis (layer of skin) and underlying fascia are breached, exposing muscle and bone) which measures 2.0 x 2.0 x 0.1 cm (centimeters)
Further review of R72's medical record revealed that they had an active physician ordered dated for 2/16/24 indicating the following, Clean left hip with NS (normal saline), pat dry, then apply puracol (derivative of calcium) to area; cover with boarder gauze. Every day for wound
A review of R72's February and March Treatment Administration Record (TAR) revealed that the resident did not receive this treatment on the following dates: 2/23/24, 2/25/24, 3/1/24, 3/2/24, 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/12/24 and 3/17/24.
A review of R72's medical record revealed the following care plan, Focus: I am at risk for loss of skin integrity r/t (related to) my Dx (diagnosis) of Unspecified Protein-calorie malnutrition, Unspecified Cerebrovascular disease, Hemiplegia/Hemiparesis left dominant side, Type 2 Diabetes, Adjustment disorder with mixed Anxiety, Major Depressive Disorder, Hypotension and Hyperlipidemia
Date Initiated: 11/06/2021. Revision on: 10/16/2023 .Goal: By allowing staff allocated
interventions my risks for healing complications and further skin breakdown will be reduced. Date Initiated: 06/22/2023. Revision on: 07/09/2023 .
R160
A review of the record for R160 revealed, R160 was admitted into the facility on [DATE]. Diagnoses included Spinal Cord Dysfunction and Paraplegia. The Minimum Data Set (MDS) Assessment documented two pressure wounds present on admission. A stage III (Full-thickness skin and tissue loss) and a stage IV (through muscle, ligaments or to bone).
A review of the October 2023 Treatment Administration Record (TAR) revealed no documentation of care for the heel wound nor the ischial wound and missing documentation on 10/03, 10/09, 10/19, 10/25 and 10/26 for the sacral and coccyx wound. A review of the November 2023 TAR revealed the care every other day started on 11/09/23.
The wound progress note dated 10/25/23 revealed: .Wound #1 sacral stage IV pressure ulcer measuring 4.5 x 3 x 1.0 (centimeters) cm has undermining between 6 and 10:00 (on clock) measuring 0.5 cm. The wound base has 30% of slough (non-viable tissue) and 70% of granular (good) tissue with moderate moderate serous sanguinous drainage, borders are rolled and not attached to the base. There is no odor no erythema no edema around, there is low turgor of the skin around no signs of acute infection. Wound #2 right ischial stage IV pressure ulcer measuring 2 x 1.5 x 1 cm, there is granular tissue at the base, small moderate serous drainage no odor no erythema no edema around. There is rolled borders not attached to the base. No signs or symptoms of acute infection. Wound #3 left heel and unstageable pressure ulcer 3.0 x 1.5 cm x UTA 100% black necrotic tissue no odor no erythema (redness) no edema (swelling) at peri-wound there is a low turgor of the skin no signs of an acute infection .
The wound note dated 11/01/23 revealed, . Wound #1 sacral stage IV pressure ulcer measuring 8.0 x 3 x 0.5 cm has undermining between 6 and 10:00 measuring 0.5 cm. The wound base has 30% of slough and 70% of granular tissue with moderate moderate serous sanguinous drainage, borders are rolled and not attached to the base. Wound #2 right ischial stage IV pressure ulcer measuring 2 x 1.0 x 0.5 cm, there is granular tissue at the base, small moderate serous drainage no odor no erythema no edema around. There is rolled borders not attached to the base. No signs or symptoms of acute infection. Wound #3 left heel and (deep tissue injury) DTI pressure ulcer 3.0 x 1.5 cm x UTA 100% black necrotic (dead non-viable) tissue no odor no erythema no edema at peri-wound there is a low turgor of the skin no signs of an acute infection .
The wound note dated 11/08/23 revealed, .Wound #1 sacral stage IV pressure ulcer measuring 9.0 x 4.5 x 08 cm has undermining between 6 and 10:00 measuring 0.5 cm. The wound base has 100% of red tissue with moderate bloody drainage, with tendon/ligaments exposed wound borders are rolled and not attached to the base. There is considerable amount of edema and deep purple discoloration around wound There is no odor, there is low turgor of the skin around no signs of acute infection.
Wound #2 right ischial stage IV pressure ulcer resolved Wound #3 left heel and DTI pressure ulcer 1.8 x 2.7- cm x UTA 100% black necrotic tissue no odor no erythema no edema .
The wound note dated 11/15/23 revealed, .Wound #1 sacral stage IV pressure ulcer measuring 9.0 x 4.0 x 0.5 cm has undermining between 6 and 10:00 measuring 0.5 cm. The wound base has 100% of red tissue with scant serous drainage, with tendon/ligaments exposed wound borders are rolled and not attached to the base. There is considerable amount of edema and deep purple discoloration around wound There is no odor, there is low turgor of the skin around no signs of acute infection.
Wound #2 right ischial stage IV pressure ulcer Resolved Wound #3 left heel and DTI pressure ulcer 1.8 x 2.5 cm x UTA 100% black necrotic tissue no odor no erythema no edema at peri wound there is a low turgor of the skin no signs of an acute infection .
On 03/18/24 at 4:51 PM, the acting wound care nurse at the time R160 resided at the facility, Licensed Practical Nurse (LPN) I did not recall working with R160 more than once or twice.
On 03/19/24 at 9:15 AM, the Director of Nursing (DON) was asked about R160 and recalled the presence of wounds and was asked about the documentation of care and indicated there was a need for ongoing education related to this.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review, the facility failed to ensure restorative care was provided and documented for...
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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 restorative care was provided and documented for three residents (R88, R91, R27) of three reviewed for services. Findings include:
R88
On 03/17/24 at 1:25 PM, R88 was observed to be in bed and dressed in a hospital style gown. The head of the bed was up around 45 degrees and R88 leaned toward the right side of the bed. Attempts to sit more up right were not observed. R88 reported they had a history of stroke and right sided weakness and had some physical therapy but due to insurance it was discontinued and there had been subsequent delays in getting therapy started again. R88 was not observed to be out of bed or dressed in clothes during the three days of the survey.
On 03/18/24 at 11:26 AM, Physical Therapist (PT) J reported therapy had been waiting on authorization for a while and had just done an evaluation on 03/12/24. R88 was then referred to restorative pending authorization for more visits. The last documented physical therapy was 03/23/23. R88 was dependent or substantial maximal assistance for all goals except for sit to lying which was partial to moderate assistance. The last documented occupational therapy was 03/23/23. R88 was partial/moderate assistance or substantial/maximal assistance for all goals. The discharge summaries documented no restorative or functional maintenance program was indicated at the time of discharge. PT J reported R88 needed a bit of motivation. Insurance payer authorization requests were requested but not received prior to survey exit.
On 03/17/24 at A therapy screen dated 03/11/24, noted demonstrated decline in functional status and risk of decreased (range of motion) ROM in right, ankle. The last therapy screen documented on a paper Therapy Quarterly Screen was dated 05/29/23 nine months prior and reported resident was at baseline. No additional therapy screen were provided prior to survey exit.
A Therapy to Restorative Nursing Transfer form dated 03/13/24 documented the a physical therapy evaluation had been completed and authorization was pending. The referral was made for three times a week for six weeks and include exercise for the upper and lower extremities to maintain current ROM and functional status. It had not been signed by nursing and applicable restorative activity documentation was not found in the electronic record.
A review of the record for R88 revealed R88 was admitted into the facility on [DATE]. Diagnoses included Stroke affecting the right dominant side, Heart Disease and Diabetes. The Minimum Data Set MDS assessment dated [DATE] documented intact cognition with a 15/15 Brief Interview for Mental Status score (BIMS) and was dependent for toileting hygiene, bathing, transfer and lower body dressing. Substantial to maximal assistance was required for rolling left to right, sitting to lying and lying to sitting, and personal hygiene.
The nursing care plan I am incontinent of Bowel and Bladder Date Initiated: 02/07/2023 . indicated .keep me as clean and dry as possible . The nursing care pIan I am on a Restorative Nursing Program Date Initiated: 05/02/2023 . indicated R88 was to be on restorative three times a week for six weeks. The nursing care plan I need maximum assistance with my (activities of daily living) ADLs Date Initiated: 02/07/2023 . indicated .Observe me and report any changes, any potential for improvement, reasons for self-care deficit, expected course and a decline in my function. Date Initiated: 04/07/2023.
R91
On 03/17/24 at 1:48 PM, R91 was observed to be in bed dressed in a hospital gown. R91 reported they had requested therapy to restart but was wanting to talk with the doctor about their condition beforehand as they had some foot pain and x-rays were done of the foot and neck and were wondering about the results. R91 was not observed to be out of bed or dressed in clothes during the first two days of the survey.
On 03/18/24 at 11:42 AM, PT J was asked about R91 and reported R91 needed a little time to motivate and get up. PT J note R91 was on therapy 05/17/23 to 5/30/23 and then 6/27/23 to 9/14/23. PT J noted that the skilled stay ended with the first episode and was picked up a month later on supplemental insurance. The discharge summaries documented no restorative or functional maintenance program was indicated at the time of discharge from therapy. R91 was partial/moderate assistance for lying to sitting on the side of the bed and substantial/maximal assistance for all other goals. Documentation of any therapy screens prior to 03/2024 were requested but not received prior to survey exit.
A Therapy to Restorative Nursing Transfer Form dated 07/04/24 documented the reason for referral as pending for authorization and bilateral lower extremity exercises three times a week for six weeks were recommended to maintain R91's current range of motion. Documentation for completion of the restorative visits was requested on 03/18/24 but not received prior to survey exit.
A Therapy Screen assessment dated [DATE] documented R91 declined to have physical due to unresolved pain in their right foot.
A review of the record for R91 revealed R91 was admitted into the facility on [DATE]. Diagnoses included Ataxia (difficulty walking), Adjustment Disorder and Generalized Anxiety Disorder. The MDS dated [DATE] documented intact cognition with a 13/15 BIMS score and and was dependent for putting on foorwear. Substantial to maximal assistance was required for toileting hygiene, bathing, transfer, lower body dressing, rolling left to right, sitting to lying and lying to sitting, and personal hygiene.
The nursing care plan documented, I am incontinent of bowel and/or bladder. Date initiated 05/17/23 . check me at least every two hours . keep me as clean and dry as possible . The nursing care pIan I am on a Restorative Nursing Program Date Initiated: 07/04/2023 . indicated R91 was to be on restorative three times a week for six weeks. The care plan further documented R91 desired to return home when medically stable.
R27
On 03/17/24 at 10:41 AM, R27 was observed to be in bed dressed in a hospital gown. The head of the bed was up 30-45 degrees. R27 was not observed to be out of bed or dressed in clothes during the three days of the survey.
On 03/18/24 at 11:54 AM, PT J was asked about R27 and reported R27 takes some motivating but when down here (R27) will work. PT J reported therapy had been authorized for 06/28/23 to 7/27/23 and 10/24/23 to 11/24/23 and R27 was referred to restorative 11/29/23. The program was for bilateral upper and lower extremities, all plane three set of fifteen. Additional therapy screens were not found. Documentation of the recommended restorative program was not provided prior to survey exit.
A review of the facility record for R27 revealed R27 was admitted into the facility on [DATE]. Diagnoses included Chronic Pain Syndrome, Heart Disease and Diabetes. The MDS dated [DATE] documented intact cognition with a 13/15 BIMS score and and was dependent for toileting hygiene, personal hygiene, bathing, transfer and upper and lower body dressing. Substantial to maximal assistance was required for rolling left to right, sitting to lying and lying to sitting. The nursing care plan documented, I am incontinent of bowel and/or bladder. Date initiated 09/29/23 . keep me as clean and dry as possible .
The nursing care pIan I am on a Restorative Nursing Program Date Initiated: 02/02/2024 . indicated R27 was to be on restorative three times a week for six weeks. The nursing care plan I need assistance with my (activities of daily living) ADLs Date Initiated: 09/29/2023 . indicated .Observe me and report any changes, any potential for improvement, reasons for self-care deficit, expected course and a decline in my function. Date Initiated: 09/29/2023.
On 03/19/24 at 10:14 AM, the Director of Nursing (DON) was asked about their knowledge of R27, R88 and R91. The DON was asked about documentation and reported it was a work in progress and involved ongoing education with the staff.
On 03/19/24 at 2:04 PM, Restorative Aide L was asked about documentation of restorative services and reported it was done in the electronic medical record.
A review of the facility policy titled Resident Rights revealed, .The resident has the right to be informed of and participate in his or her treatment . A policy specific to documentation of care was requested on 03/19/24 at 1:15 PM, but not provided prior to survey exit.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to label and date tuberculin vials when opened in three of three medication rooms and inhalers in three of four medication carts. ...
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Based on observation, interview and record review the facility failed to label and date tuberculin vials when opened in three of three medication rooms and inhalers in three of four medication carts. FIndings include:
On 03/18/24 at 9:17 AM, in the south unit medication cart, a fluticasone/salmeterol inhaler for R63 was not dated when opened and did not have a resident identifier on the inhaler.
On 03/18/24 at 9:54 AM, in the north middle medication cart, an Incruse inhaler for R41 had no name or date on the actual inhaler and a fluticasone/salmeterol inhaler for R59 did not have a date opened on the actual inhaler.
On 03/18/24 at 10:24 AM, in the north front medication cart, a Trelegy inhaler for R49 did not have a resident identifier nor a date opened on the inhaler and a fluticasone/salmeterol inhaler for R19 was not dated when opened on the box nor the inhaler. A resident identifier was not on the acutal inhaler.
On 03/18/24 at 10:31 AM, the one north med room refrigerator was observed with the unit manager and two tuberculin vials were not dated when opened on the box nor the vial. The unit manager O reported the inhaler should be labled on the inhaler in case the boxes are mixed up and that the tubercilin vials should be dated when opened.
On 03/18/24 at 11:15 AM, in the north second floor, a tuberculin vial was not dated when opened on the box nor the vial. Licensed Practical Nurse (LPN) B reported the tuberculin should have been dated when opened.
On 03/18/24 at 11:20 AM, the first floor south medication room was observed with LPN I a tuberculin vial was dated on the box but not on the vial. The medication room floor had a lancet, a pen, bits of paper on the floor mixed with dust and debris along the walls and under the counter.
On 03/19/24 at 10:06 AM, the Director of Nursing reported that the pharmacy checks the medication carts for lables and dates and the actual inhaler and vial should have the date opened and a resident identifier should appear on the inhaler.
A review of the policy titiled, Storage and Expiration of Medications, Biologicals, Syringes and Needles with effective date of 12/01/07 revealed, .Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to experation dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened .
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
This citation pertains to Intake MI00137527.
Based on observation, interview and record review, the facility failed to provide resident food preferences for two (R96, R261) of six residents reviewed. ...
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This citation pertains to Intake MI00137527.
Based on observation, interview and record review, the facility failed to provide resident food preferences for two (R96, R261) of six residents reviewed. Findings include:
R96
Review of the facility record for R96 revealed an admission date of 09/01/23 with diagnoses that included Diabetes Mellitus with Diabetic Neuropathy, Morbid Obesity and Hypertension.
On 03/17/24 at 9:53 AM, R96 reported that they are diabetic and they receive large amounts of carbohydrates. The breakfast meal ticket was observed to indicate prefers sugar free condiments; large portions of protein, smaller portions of starches. The breakfast tray was observed to have oatmeal which was served with sugar already poured into it, three french toast sticks with powdered sugar and syrup which R96 indicated was not sugar-free. R96 stated that they often do not receive requested alternate menu items such as salads and instead receive grilled cheese sandwiches.
Review of R96's care plan dated 01/03/24 revealed a Focus area addressing nutritional risk which included the Interventions - Offer me my preferred choices of food and - Provide and serve me my diet as ordered. I receive NAS (No added sugar).
On 03/18/24 at 10:40 AM, R96 reported their breakfast included french toast sticks with powdered sugar and syrup which was not sugar-free.
R261
Review of the facility record for R261 revealed and admission date of 03/06/24 with diagnoses that included Prostate Cancer, Bone Cancer and Osteoarthritis.
On 03/17/24 at 10:51 AM, R261 reported that they were often not receiving what's on the food menu and that the meals are often brought without condiments.
Review of R261's care plan dated 3/11/24 revealed the focus area addressing nutritional risk which included the Intervention entry Offer me my preferred choices of food.
On 03/18/24 at 8:53 AM, R261's breakfast tray was tested and the meal ticket was observed. The ticket indicated cranberry juice but orange juice was provided. The ticket indicated two chocolate milks which were not present.
On 03/18/24 at 9:02 AM, Certified Nurse Assistant (CNA) E who served R261's breakfast tray reported that cartons of milk are put on the tray in the kitchen prior to arrival on the floor and that the juice is poured during tray service on the floor.
On 03/18/24 at 9:20 AM, R261's replacement breakfast tray (the original tray was obtained for testing with the resident's permission) was served with ham rather than sausage patties and toaster-style waffles rather than french toast sticks. R261 reported that he preferred to have the original menu items of french toast and sausage rather than waffles and ham. The replacement tray included cranberry juice and chocolate milk, which were available at the time of the original meal service.
On 03/18/24 at 10:25 AM, R261 reported that they requested sausage rather than ham for their replacement breakfast tray and staff told them there was no more sausage. R261 reported that they specifically prefer cranberry juice to orange juice and that they do not consider them to be interchangeable which was why it was specified on the ticket. R261 stated they feel the cranberry juice is important as they have an increased risk for urinary tract infection.
On 03/19/24 at 9:17 AM, R261 was interviewed as they were setting up and preparing to eat their breakfast. R261 reported no chocolate milk was provided and orange juice was brought again rather than cranberry juice. R261's meal ticket was viewed and it specified cranberry juice and two servings of chocolate milk which were not provided. R261 stated that they asked about the chocolate milk and staff told them none was available.
On 03/19/24 at 11:12 AM, the facility Dietary Manager (DM) reported that the breakfast syrup is not sugar-free but that they are able to order sugar-free syrup. The DM reported that sugar should not be pre-placed into the oatmeal and powdered sugar should not be added to the french toast for a no added sugar diet. The DM reported that juices are put in larger containers and the residents glasses are filled by floor staff and the juice served should match the stated ticket preference. The DM reported the expectation is that if preferences are stated on the meal ticket they should be met with the only exception being if an item is not available.
Review of the undated facility policy Food Preferences revealed the policy statement Food preferences will be obtained on residents to aid in meeting nutritional needs and satisfaction. The Procedure portion of the policy includes the entry 7. Food preferences will be identified on diet tickets to assure residents are provided with appropriate food items.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
This citation pertains to Intake MI00137527.
Based on observation and record review, the facility failed to clean multi-use equipment between resident use or perfrom hand hygeine during meal services ...
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This citation pertains to Intake MI00137527.
Based on observation and record review, the facility failed to clean multi-use equipment between resident use or perfrom hand hygeine during meal services for one resident (R106) of one reviewed for mutiuse equiment . Findings include:
On 3/18/24 at 9:00 AM, Nurse B did not clean the Electronic Wrist Blood Pressure/Pulse machine after use with R21.
On 3/18/24 at 9:35 AM, Nurse B did not clean the Electronic Wrist Blood Pressure/Pulse machine after use with R106. When it did not work, Nurse B obtained an upper arm Electronic Blood Pressure/Pulse machine from another medication cart. Nurse B did not clean the machine before or after use.
On 3/18/24 at 8:38 AM during a dining room observation, it observed that the CNA passing trays to residents, did not perform hand hygiene between providing trays to each resident.
During this same time, a different CNA was going from one resident to another, removing the cover and cutting resident's food without performing hand hygiene between residents.
On 3/20/24 at 1:00 PM, during a meeting with the Infection Control (IC) Nurse A, when asked what the standard of practice is for cleaning equipment, she stated that the blood pressure/machines should be cleaned after each use.
On 3/20/24, in a conversation with the Director of Nursing (DON) regarding the cleaning of multi-use equipment, they related that multi-use equipment should be cleaned after each use.
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** On 03/17/24 at 9:02 AM, during an initial tour of the facility the following was observed:
In room [ROOM NUMBER] paint marred a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 03/17/24 at 9:02 AM, during an initial tour of the facility the following was observed:
In room [ROOM NUMBER] paint marred along the walls and patches of missing paint above the head of the bed, the base was peeling away in an area along the entry;
In room [ROOM NUMBER] wall corners were rough patched but not painted, grates were missing form the top of the heater (this in multiple other rooms), the plastic covering on the entry door frame was torn and peeled away in places - a screw appeared to hold it on at the top, the base in the entry was peeling away from the wall in three areas;
In room [ROOM NUMBER], a tube feed pole had dried tan colored splashes of liquid on the feet of the pole and floor, electrical box covers/plates were missing and a tear was noted in the sheet for bed D;
In room [ROOM NUMBER] a single black shoe was observed against the wall in the area around bed A (it was visible there until 03/19);
In room [ROOM NUMBER] bed B, the cork bulletin board was on the floor, a loose disposable glove was on the window sill, sheet rock dust was on the window sill and floor, a tube of skin cream was on the floor, under the head of the bed (it was not picked up during the housekeeper's cleaning); The adjoining bathroom vent had caked on gray dust buildup, the ceiling tile had a water stain;
The hand rail outside room [ROOM NUMBER] was missing a return on the right side and an outside corner on the left side; In room [ROOM NUMBER] Bed B the electrical junction box was hanging off the wall just above the residents in the bed; The left hand half of the marble style window sill was missing;
In room [ROOM NUMBER] the visitor reported an open junction box had gone unrepaired for months; In room [ROOM NUMBER] multiple horizontal scrapes were observed along the wall;
Outside rooms 107, 119, 127, 133 the return for the hand rail was missing; The returns for the handrail at the left side of the Janitor's closets across from room [ROOM NUMBER] and 203, were missing.
On 03/19/24 at 09:35 AM, the Director of Nursing (DON) was asked about the reporting of maintenance concerns in resident rooms by nursing staff and reported they have access to the electronic reporting system and it is expected they would report an issue.
This citation pertains in part to Intakes MI00237527 and MI00139246.
Based on observation and interview, the facility failed to maintain a clean, safe environment, in multiple resident rooms and bathrooms. Findings include:
On 3/18/24 between 9:45 AM-10:30 AM, during a tour of the facility with Maintenance Supervisor K, the following items were observed:
room [ROOM NUMBER]- Bathroom ceiling vent cover dusty, toilet riser rusty, stained ceiling tiles, missing ceiling tiles
room [ROOM NUMBER]- The bathroom ventilation system was non functional. This was tested by placing a toilet tissue square against the ventilation grate. There was no suction observed, and the toilet tissue did not suction to the vent grate. Maintenance Supervisor K confirmed the vent was non-functional and stated he was unaware of any issues.
1 North Shower room- There were numerous missing and cracked floor tiles. Maintenance Supervisor K provided no explanation.
room [ROOM NUMBER]- There were large areas of torn wallpaper, and a dusty bathroom ceiling vent
1 South ice machine- The cove base molding was loose and torn away from wall behind ice machine. There was a black mold-like soil on the flooring and along wall edge behind ice machine. The drain tray at the front of the ice machine was full of standing water and was not draining.
The hand rail end caps were missing outside rooms [ROOM NUMBER]. There was a sharp, cracked end cap across from room [ROOM NUMBER].
room [ROOM NUMBER]- There was a dusty bathroom ceiling vent.
room [ROOM NUMBER]- Missing vent covers at the top of the heating unit, no pull cord on the call light in the bathroom
room [ROOM NUMBER]/205- The bathroom ceiling vent was non-functional.
room [ROOM NUMBER]- There was a dusty bathroom ceiling vent
room [ROOM NUMBER]- There was no pull string on the bathroom call light, a strong urine odor in the bathroom, and the floor in the bathroom was sticky.
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
On 03/17/24 at 9:21 AM, an observation of the main kitchen was conducted with the Dieatary Manager (DM). The following was observed: The towel dispenser for the hand wash sink was empty; The trash can...
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On 03/17/24 at 9:21 AM, an observation of the main kitchen was conducted with the Dieatary Manager (DM). The following was observed: The towel dispenser for the hand wash sink was empty; The trash can has a brown residue on the rim of the lid and on the front of the can; A ceiling vent above aisle area toward the three compartment sink was hanging down on the right side; A second vent was without a cover; Bits of dried food were noted on the meat slicer to the right of the blade area; A metal panel next to the bread rack had rust and scale along the edges and corners; The prep cooler had an approximate six by twelve inch area of puddled water inside; The toaster had a build up of one quarter to one half inch of crumbs in the slots; The scoop for the thickener was open side up on top of the lid and the lid had traces of thickener or other white substance on top; The blender had irregular cracks and longitudenal openings (about once inch wide and a few inches long) where pieces of the plastic housing were missing; The concentration for the sanitizer bucket tested high and the test strip was dark green; A puddle of water (around two to three feet long by six inches wide) was on the floor between the oven area and the prep/spice rack area; The panels of the vent hood appeared rusty in places; The faucet for the three compartment sink leaked and sprayed water when turned on by the DM; Serving size cups reported as cole slaw from the previous nights dinner and two serving size cups of pudding were uncovered in the refrigerator; The walk in freezer had a one and a half to two foot diameter area of frost and ice (frozen drips) on the ceiling over the food racks on the right side; An opaque cone of ice around three to four inches high and two inches wide had formed on top of the shelf near the light; An active drip was observed there; The globe had frozen puddles of ice in it; [NAME] discoloration or debris was visible along the inside edge at the floor to the left and right of the doorway; The freezer did not feel ice cold - The DM noted the fans wer not running; And two half pint chocolate milks on a tray for distribution had dried drips (possibly chocolate milk) on them.
This citation pertains to MI00137527.
Based on observation, interview, and record review, the facility failed to maintain the kitchen, equipment, and the first floor resident refrigerator in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include:
On 3/18/24 at 10:00 AM, in the 1 South resident refrigerator, there was an undated food container of corned beef, an undated bag with tuna salad and 2 foil wrapped sandwiches, an undated chef salad, and an orange liquid pooled at the bottom surface of the refrigerator.
According to the facility's policy Food From Outside Sources dated 12/28/17, 2. All food brought in must be .labeled with the resident's name and date the food was processed/cooked and the date it is to be discarded .
On 3/18/24 at 11:30 AM, the 2nd floor ice machine was observed with a black mold-like substance along the bottom edge of the ice chute.
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.
On 3/18/24 at 11:50 AM, there was a dusty wall mounted fan in use in the dish machine room.
According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean.
On 3/18/24 at 12:05 PM, the juice machine was observed with a buildup of thick, sticky syrup near the nozzles. The stainless steel backsplash of the juice machine was soiled with sticky juice drippings, and the drip tray was full with juice overflow.
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.
On 3/18/24 at 12:15 PM, the sugar bin was observed with the scoop inside the bin, and the scoop handle was buried in the sugar. Dietary Manager F confirmed the scoop was not to be stored inside the bin.
On 3/18/24 at 3:30 PM 1st floor ice machine observed with ice scooper stored resting on top of the ice inside the ice bin, with the handle touching the ice.
According to the 2017 FDA Food Code section 3-304.12 In-Use Utensils, Between-Use Storage, During pauses in FOOD preparation or dispensing, FOOD preparation and dispensing UTENSILS shall be stored: (A) Except as specified under ¶ (B) of this section, in the FOOD with their handles above the top of the FOOD and the container; (B) In FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD with their handles above the top of the FOOD within containers or EQUIPMENT that can be closed, such as bins of sugar, flour, or cinnamon;.
Nov 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00138028.
Based on observation, interview and record review, the facility failed to ensure t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00138028.
Based on observation, interview and record review, the facility failed to ensure that one (R905) of one residents end of life wishes were followed, resulting in a transfer to a local hospital for a change in condition. Findings Include:
A review of the Intake noted, [R905] resided at (name of) nursing home for 7 years until [R905's] death . [R905] had been under hospice care for weeks. [R905's] grandson . was [R905's] medical POA (Power of Attorney). There was a DNR (Do Not Resuscitate ) put in place due to [R905's] declining health. A copy of it was provided to the nursing home. On [DATE], [R905] began to make [their] transition. The facility wanted to provide CPR (Cardiopulmonary Resuscitation) to [R905] . Hospice care advised the staff at the facility not to provide CPR to [R905]. The staff at the facility advised that they could not find their copy of the POA and they were sending [R905] to the hospital
On [DATE] at 2:31 PM, Licensed Practical Nurse (LPN) A was asked about the day R905 was sent out to the hospital and stated, It was something with the paperwork and that [R905] wasn't a DNR. The family was here and there was a debate about [R905] going out to the hospital.
A review of R905's medical record noted, Hospice notes: admitted New admission [DATE] Code Status/Do Not Resuscitate (DNR) Directive dated [DATE], completed by the patient advocate, signed by the Physician and two witnesses. DNR dated [DATE]. R905 was declared incapacitated 2018 and 2021. Patient Advocate Designation form completed that noted, .4. Life-sustaining treatment. I understand that I do not have to choose any of the instructions regarding life-sustaining treatment listed below. If I choose one, I will circle my choice number and sign below my choice. If I sign one of the choices listed below, I direct that reasonable measures be taken to keep me comfortable and to relieve pain . The form did not have a choice circled. The form was dated [DATE], signed by R905, Witness, and the two DPOAs.
A review of the Physician's order noted, DNR dated, [DATE]. Order: dated [DATE] No labs or test only if approved by hospice, Do not send to hospital call hospice.
A review of R905's care plan noted, Focus: My Power Of Attorney has reviewed my advanced directives with the social worker/physician and wishes for me to be a DNR. My power of attorney has consented for all other physician recommended medical or surgical treatments. Date Initiated: [DATE].
Further review noted, R905 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Unspecified Cerebrovascular Disease.
On [DATE] at 3:36 PM, the former Social Service staff (FSS B) was called and asked about R905. The FSS B explained that the facility's corporate Social Services staff instructed that R905 was a full code, due to the DPOA paperwork not having a choice selected for life sustaining treatment.
On [DATE] at 3:48 PM, the Director of Nursing (DON) was asked about R905 and stated, I'm not sure if the corporate social worker was doing an audit or how this came about. [R905's] code status came up that [R905] was a full code. The DON explained because of the confusion the facility sent the resident out so that they could honor the residents DNR wishes.
A reivew of the federal regulations notes, DEFINITIONS §483.24(a)(3) Advance directive is defined as a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. 42 C.F.R. §489.100. Some States also recognize a documented oral instruction .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes MI00136068 and MI00138028.
Based on observation, interview and record review, the facility fai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes MI00136068 and MI00138028.
Based on observation, interview and record review, the facility failed to ensure a safe, clean and sanitary environment was maintained on the north unit and for the north exit door potentially affecting the 52 residents who reside on the north unit. Findings include:
On 11/07/23 at 1:00 PM, a resident who asked to remain anonymous (R X) reported to the surveyor that the first floor north shower room does not drain well and has mildew or mold growing in it.
On 11/07/23 at 1:11 PM, observation of the first floor north shower room revealed: the metal drain cap in the shower was loose and not secured to the floor. The four inch drain pipe was therefore open and could allow a shower chair wheel to slip into the hole. The were nine 2 x 2 inch tiles missing around the drain hole. The ridge for water retention in the shower had missing or cracked tiles. A black mildew like substance covered an area of 12 tiles at the left side of the retention ridge. Approximately 58 tiles around the water retention ridge were cracked or chipped and 11 tiles were missing in one spot along the ridge. The grout in the tiles for the shower area appeared a brownish gray as compared to the tile with a gray grout away from the shower area. A build up of dust and dirt was noted behind door at the jamb. The grab bar for the shower was not continuous and had two (around four feet total) sections missing. One piece was on the floor of the shower pan and the second was in the bathtub on the opposite side of the room. A shower chair and other items were stored in the sink area. The mesh back on the shower chair was worn/torn on left upper edge and at right side seam as when sitting in the chair. The sharps container was closed and could not accept sharps. Three razors were left on top of the sharps container. Three hangers were missing from the left hand side of the shower curtain. Two base trim tiles were cracked or missing pieces. In the tub along with the grab bar was a bottle of soap, a shard of tile and the sprayer for the tub. The drain area of the tub had a dried orange/yellow splatter around it. The caulk around the tub base pulled away from the edges in places. The cover for the middle fluorescent light was hanging down on right side. The plastic guards for the outside door frame were damaged or missing toward the bottom and up a few inches on the right side.
On 11/07/23 at 1:44 PM, the first floor north shower room was observed with the Maintenance Supervisor. The Maintenance Supervisor reported they had been at the facility around a year and were not aware of the condition of the shower room. The maintenance supervisor further reported that none of the items had been entered into the electronic reporting system (TELS) nor the paper maintenance log kept at the nurse's station. The maintenance supervisor reported that environmental did the floor and shower cleaning. The outside egress door from the stairwell was also noted to the maintenance supervisor at this time who did not appear aware of the extent of deterioration. On the inside of the door: The internal paint on the door had rusted spots along the bottom and up the door jamb side. Light was showing through at the threshold and the lower right side where the door meets the wall. The paint was peeling on the cinder blocks on both sides of the door two rows up. Bits of the cinder blocks had crumbled onto the floor and mixed with the dirt and dead grass on the floor in front of the door. When viewed from the outside the lower portion of the door was rusted out almost the entire width of the door and easily visible from the front sidewalk when walking into the buildings front door. Shingles were missing and hanging down from the roof area above the door. The egress door and damage had been observed two months prior.
On 11/07/23 at 2:00 PM, the Environmental Director was shown the first floor north shower room and reported that housekeeping cleans and sanitizes it daily and it is top scrubbed once a week using a powered side by side scrubber. The Environmental Director reported when asked that they were sure it was getting done because they check. The Environmental Director acknowledged the soiled appearance of the floor in the shower area as compared to the tub area and reported the grout may need replacement and that would be a maintenance issue.
Also observed was a missing return on the handrail outside room [ROOM NUMBER].
On 11/07/23 at 3:49 PM, an information request was sent via email to the Administrator which included: Please provide: A policy on facility maintenance and any TELS (the electronic reporting system) or Logs related to facility maintenance, shower rooms. No logs or TELS reports were provided prior to exit.
On 11/07/23 at 3:58 PM, an information request was sent via email to the Administrator which read, Please also provide shower cleaning and maintenance schedule and documentation and any Pending capital improvements related to the shower rooms/facility. The shower cleaning schedule was received but no indication/documentation of any pre-planned maintenance on the shower room or egress door was provided prior to exit.
On 11/07/23 at 4:00 PM, the Director of Nursing (DON) reported that the expectation was for staff to report maintenance issues when found.
On 11/07/23 at 4:20 PM, the bathroom between rooms [ROOM NUMBERS] was observed to have unpatched holes where the toilet paper dispenser had been. The dispenser had been moved higher up the wall.
On 11/07/2023 at 4:52 PM, a response from the administrator via email to the prior requests indicated, Maintenance schedule varies through TELS, morning meeting and telling to (Maintenance Supervisor name). Pertaining to the bathroom on north we just fixed, tile replacement, drain cover, grab bar, and in process of replacing corner guards.
On 11/07/23 at 5:05 PM, the Administrator was notified to send the requested documents and specifically the requested shower documentation and Activities of Daily Living policy. No additional documents were received as of this writing.
A review of the facility Deep Clean Calendar documented the first floor north shower room was to be deep cleaned weekly on Wednesdays.
Apr 2023
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00135614
Based on observation, interview and record review, the facility failed to provide a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00135614
Based on observation, interview and record review, the facility failed to provide adequate supervision and implement interventions to prevent an elopement from the facility for a severely cognitively impaired resident (R906), who was a known wanderer and at risk of elopement.
On 3/26/23, the R906 exited the facility building through an alarmed door, and then through a second unalarmed door at approximately 12:00am.The resident was located at a local gas station which was .8 miles away, and a 15-minute walk in a high traffic, busy vehicular area. The resident was transported back to the facility by the local police, after responding to a call by the gas station security, approximately 30-40 minutes after the resident was identified as missing. This deficient practice resulted in the likelihood of serious injury, serious harm, serious impairment, or death.
Immediate Jeopardy:
The Immediate Jeopardy (IJ) started on 3/26/23 and the immediacy was removed 3/26/23 per review of the facility's responding interventions as verified on 4/18/2023.
The IJ was identified on 4/18/23 during an abbreviated survey. The facility's Nursing Home Administrator (NHA) was notified of the IJ on 4/18/23 at 1:24 PM and was asked for an abatement plan.
The IJ was removed on 3/26/23, based on the facility's implementation of the abatement plan as verified onsite on 4/18/23.
Findings include:
A review of Intake MI00135614 revealed the following, Incident Summary dated 3/26/23: Administrator received a phone call at approximately 12:15 a.m. that [R906] was not in the facility. [R906]
was observed in [their] room at approximately 11:00 p.m. At approximately 11:40 the alarm sounded, and the staff went to check where the alarm was sounding. When they went to the door where the alarm was sounding, they did not see anyone at the door nor outside. The staff immediately did a head count and could not account for [R906]. The staff
contacted the [local police department] at 12:08 (am) and discovered that [R906] had walked over to the police department. [R906] was returned to the facility at 12:25 (am) by [local police]. The [local police department] is located right next door to the facility .[R906] did have a wander guard on at the time [they] left the facility but upon return it was gone .
On 4/18/23 at 9:23 AM, R906 was observed sitting in their room eating breakfast. Attempts to interview R906 were made to no avail, as they were pleasantly confused and speaking in a non-sensical manner.
A review of R906's medical record was reviewed and revealed that they were admitted into the facility on 2/3/21 with diagnoses that included Vascular Dementia, Other Ulcerative Colitis without complication, Sick Sinus Syndrome, and Bipolar Disorder. Further review of R906's medical record revealed a Minimum Data Set (MDS) assessment dated [DATE] revealing a Brief Interview for Mental Status (BIMS) score of 3/15 indicating a severely impaired cognition, and required supervision with Activities of Daily Living.
Further review of R906's medical record revealed an Elopement assessment dated [DATE] revealing that the resident was at risk of wandering. A review of R906's Care Plan revealed the following, Focus: ELOPEMENT: I am at risk for elopement r/t (related to) Dx (diagnosis) Vascular dementia, cognitive impairment, hx (history of) of eloping from previous group home, and making statements about wanting to leave the facility, I also decline to wear a wander guard and if one is put on me, I will take it off. I chose to take my wander guard off at times. Date Initiated: 03/10/2022. Revision on: 10/03/2022 .Interventions: At times you may have to monitor my location every 15/30/60 (minutes) If this occurs, document my wandering behavior and attempted diversional interventions in behavior log. Date Initiated: 07/26/2022. Revision on: 07/26/2022 .
On 4/18/23 at 10:49 AM, an interview was completed with the Director of Nursing (DON) regarding R906 and the timeline of events of their elopement. The DON explained that the length of time R906 was missing was less than 30 minutes as the alarm sounded at midnight, in which a head count was completed, and the police was notified that R906 was missing. She further explained that the police department contacted the facility at 12:18am indicating that they located R906, and the police brought R906 back to the facility at 12:25am. The DON explained that R906 went out of the door located on the 100-unit, North hallway, and was located inside a local gas station.
A review of the local police department's police report revealed the following, On 3/26/2023 at approximately 0008 (12:08 am) hours, I was dispatched to the listed address [facility] for an elderly [resident] that staff was unable to locate. Staff believed [R906] left the building. As I arrived on scene, dispatch updated that a call came in from [local gas station security]. An elderly [resident] matching the description of [R906] had walked into the gas station. I made contact with [R906] inside the gas station. [R906] appeared to be in good health and was speaking with security. [R906] stated [they] did not need medical treatment. [R906] advised [they do not] stay at [nursing facility], and stays at [their] home every night. [R906] could not say where [their] home was, stated [they do not] have any family, and could not remember [their spouse's] name .[R906] agreed to come with officers, which I had [them] sit in the backseat of patrol [vehicle number] .I transported [R906] to [facility] .
On 4/18/23 at 11:30 AM, an interview was completed with Licensed Practical Nurse A (LPN A), assigned nurse for R906 the night of their elopement. She explained that R906 had to be redirected back to their room that night by their assigned certified nursing assistant (CNA B), took the resident to their room. LPN A explained that 5-7 minutes later, the door alarm went off and when they checked for R906, they were gone. LPN A explained that she executed the elopement policy and explained that R906 was gone from the facility between 30-40 minutes. LPN A was asked if R906 had on a Wander Guard that evening, and she indicated that she confirmed that it was in place at the start of her shift, and that it was located on their ankle.
On 4/18/23 at 12:20 PM, CNA B was interviewed via phone and explained that she observed R906 in bed asleep at 10:00 pm. She explained that at shift change (11:00 pm) they heard the alarm, completed a room count, and realized that R906 was missing. CNA B explained that she drove around in her car looking for R906, and did not see them, and that R906 was missing for approximately 20-30 minutes.
On 4/18/23 at 12:43 PM, CNA C was interviewed via phone regarding R906's elopement from the facility. She explained that she was assigned to R906 for the afternoon shift and that anytime she is assigned to R906, the resident lies in bed and stays in their room. CNA C explained that she last saw R906 in their room at 10:15 pm, and that she eventually left at the end of her shift at 11:00 pm. She reports that upon leaving, she did not hear any alarms.
On 4/18/23 at 1:25 PM, the current Nursing Home Administrator (NHA) admitted that the resident did elope from the facility, however, he explained that the staff handled the elopement protocol appropriately by responding to the alarm and completing room checks.
A review of R906's medical record revealed the following progress notes:
8/18/2022 10:56 (10:56 am) Nurses Note: Writer spoke with physician regarding wander guard placement for resident. Based on elopement assessment, resident is triggering high. However currently, resident is not actively seeking exit. Physician gave orders that wander guard placement is not warranted at the time and resident will be reapproached for wander guard daily and as needed.
8/18/2022 12:08 (12:08 pm) Physician Progress Notes: Discussed earlier today with the nursing and other staff regarding elopement risk for [R906]. [R906] has dementia and has not shown any behavior of elopement and currently is refusing to wear the wander guard. Will keep the wander guard off and regularly reassess [their] behaviors and make necessary changes.
Further review of the R906's medical record revealed the following physician's order dated for 8/18/22: Offer and place wander guard if resident is agreeable every shift.
A review of R906's progress notes and Medication Administration Records (MAR) did not reveal if or when a wander guard had been placed on the resident between the order date, and the date of their elopement on 3/26/23. In addition, on 3/26/23, the MAR was observed as blank on the shift that R906 eloped.
A review of the facility's Missing Resident Hazard revealed the following, Policy: It is the policy of this facility to reasonably protect the residents form harm through the prevention of elopements. A missing resident is one that cannot be located within the facility and has not been signed out.
Facility Abatement Plan:
Element 1
R689 currently lives in the facility. R689 was reassessed for elopement immediately upon return on March 26, 2023m with a score of 13 indicating high risk for elopement. A complete head to toe assessment and pain assessment was completed, and no issues were identified. A UA lab work was ordered and completed with no issues identified. A new Wander Guard was also placed on resident immediately upon return on March 26, 2023. MD and guardian were made aware immediately. Ordered were revised to check for placement and functionality daily. The provider saw R689 and there were no immediate issues identified. Plan of care was reviewed and revised as needed. R689 was seen by Social Services and there was no decrease or effects on their psychosocial wellbeing and quality of life. R 689 was immediately placed on 15-minutes checks on March 26, 2023.
Exit doors remained activated with no concerns.
Element 2
Residents residing in the facility can be affected in an equivalent manner. Remaining residents are accounted for at 100%. 11 (eleven) residents were identified.
Doors and alarms were checked immediately by staff, to ensure the safety of other residents.
The 11 (eleven) residents at high risk for elopement care plans were reviewed by the DON (Director of Nursing) on March 26, 2023, and revised as needed.
Elopement Books located at each nurse's station were reviewed/revised as needed by the Director of Nursing on March 26, 2023.
The Maintenance Director did a check on the door alarms , the battery was changed, and the door was sounds appropriate and not automatically disable without the use of a key. The Maintenance Director implemented daily battery checks on all the door alarms.
Element 3
The Elopement Policy was reviewed and deemed appropriate. Staff were re-education on the elopement policy immediately. The Maintenance Dept. has been reeducated on continued battery checks of alarmed doors. The Maintenance Director implemented daily battery checks on all the door alarms. The remained staff will be reeducated upon return to work.
Element 4
The Maintenance Director implement a daily battery check on all the door alarms for one week then three tome a week for 1 month, then monthly thereafter. The Maintenance Director will report any findings to the QA committee monthly for 3 months and then as directed by the committee.
Facility will conduct elopement drills 1x monthly to ensure facility complaint. All results of audits will be brought to QAPI.
The Nursing Home Administrator will be responsible for sustaining overall compliance with this plan.
Date of Compliance: 3/26/23
Mar 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00135002.
Based on interview and record review the facility failed to report an allegation of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00135002.
Based on interview and record review the facility failed to report an allegation of sexual abuse to the State Agency for one (R700) of three residents reviewed for abuse, resulting in an allegation of sexual abuse to go unreported, and the potential for an allegation of sexual abuse to fail to be investigated. Findings include:
On 3/20/23 at 8:30 AM, a review of a complaint called into the State Agency revealed the following: Today, [R700] was admitted to the hospital due to being sexually assaulted. [R700] reported an African American female worker assaulted [R700] at the nursing home. They penetrated [R700's] anus with their fingers .
On 3/20/23 at 11:10 AM, progress notes located in R700's electronic medical record (EMR) were reviewed and revealed the following: 2/19/23 1430 (2:30 PM) Discharge Information: Sent to [Hospital] Sent From: [Nursing Home] Reason(s) for Transfer: Altered Mental Status .2/19/23 2:30 PM: [City] fire department EMT's [Emergency medical technicians] arrived at facility around 2:20pm, paramedic arrival to facility per resident request, they stated they were aware of resident previous encounter with [City] police department from this morning. Resident transferred to [Hospital] at this time, report given ER [Emergency room] nurse .
On 3/20/23 at 11:20 AM, further review of R700's EMR revealed that R700 was most recently admitted to the facility on [DATE] with diagnoses that included Cerebral infraction (Stroke) and Bi-polar disorder, current episode manic severe with psychotic features. R700's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R700 had an intact cognition and required supervision with all activities of daily living (ADLs).
On 3/20/23 at 11:25 AM, Nurse Unit Manager/ Licensed Practical Nurse (LPN) C was interviewed regarding the sexual abuse allegations made by R700. LPN C stated, [R700] never said anything to me and then the next thing I knew, the police arrived, at first R700 indicated that someone stole their purse, then they changed it and [R700] said someone stuck their finger up [R700's] butt. LPN C was asked if they reported the allegations to the facility's Abuse Coordinator. LPN C stated, Yes, I immediately reported the allegations to the Administrator (NHA) and Director of Nursing (DON).
On 3/20/23 at 1:30 PM, the DON was interviewed regarding the allegations of sexual abuse made by R700. The DON stated, I started an investigation immediately, the police were contacted, investigated, and found nothing. I contacted R700's daughter who indicated that R700 had a history of accusing others of sexual abuse. The DON was asked if they and/or anyone else at the facility reported R700's allegations to the State Agency. The DON stated, No.
The NHA was unable to be interviewed regarding the reporting of the allegations made by R700 due to being off and not present at the facility on 3/20/23.
On 3/20/23 at 1:43 PM, the Assistant Administrator (ANHA) was interviewed regarding the sexual abuse allegations made by R700 and asked if R700's allegations were reported to the State Agency. ANHA stated, It's hard when the resident has behaviors and it's care planned. The ANHA was asked about their expectations regarding reporting allegations related to abuse to the State Agency. The ANHA stated, Every allegation has to be looked at and investigated. The ANHA further indicated that R700's abuse allegations were not reported to the State Agency based upon R700's behavior being care planned and the police investigation which found Inconsistencies in R700's story.
On 3/20/23 at 2:00 PM, a facility policy titled Abuse and Neglect Prohibition Policy Reviewed and/or Revised 2/17/20 was reviewed and stated the following, Procedure: E. Investigation 3. The facility Administrator or designee will report such allegations to the state, per state regulation. 4. The facility Administrator or designee will report (see reporting) all investigation findings to the state as per federal and state regulations. G. Reporting and Response 3. The Administrator or designee is responsible for reporting to the State Agency all alleged violations involving abuse .a. Immediately but no later than 2 hours after the allegation is made if the allegation involves abuse .5. The results of the investigation must be reported to the State Survey Agency ([NAME]) within 5 working days of the incident.
Jan 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00133133.
Based on interview and record review, the facility failed to protect the resident's...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00133133.
Based on interview and record review, the facility failed to protect the resident's (R904) right to be free from physical abuse by another resident (R903), resulting in R904 being repeatedly punched in the head, transfer to the hospital for diagnostic evaluation of injury, hematoma (bruise) and redness, and continued fear. Findings include:
A facility reported incident (FRI) was submitted to the State Agency alleging a resident to resident physical abuse incident involving R903 (perpetrator) and R904 (victim) that occurred on 11/16/2022.
On 1/23/23 at 3:47 PM, R904 was interviewed at the facility. R904 was observed to be short in stature and petite in size. R904 used a wheelchair but was observed to be able to stand up without assistance. R904 was asked to recall the incident involving herself and R903 that occurred in November 2022. R904 stated, I was sitting at the table, she (R903) just came in and started pounding on me. She's not going to come back here is she? She told me she wasn't done with me, that I'd be getting more. R904 explained that days prior to the physical altercation, there had been a birthday party at the facility. R904 indicated that there was one piece of cake left that R903 tried to take, but it was intended for a different resident. R904 admitted that she loudly told R903 that the piece of cake wasn't hers but that R903 ignored her at the time. R904 added that she ended up with a bump on the head, from being hit by R903 and needed to get a scan. R904 stated, I would be very scared if she came back .She wasn't a friend or anything but we would talk occasionally .I feel safer without her here. When queried if R903 hitting her was accidental or intentional, R904 replied, I think [R903] knew what she was doing .She told me I deserved more.
A review of R904's Minimum Data Set (MDS) assessment dated [DATE] and medical record revealed that the resident was admitted into the facility on 6/22/22 with medical diagnoses of Bipolar Disorder, Asthma, Failure to Thrive, Hypertension, and History of Falling. Further review revealed that the resident is cognitively intact and requires supervision to extensive assistance from staff for activities of daily living (ADLs).
A review of R904's progress notes revealed:
-11/16/2022 20:07 (8:07 PM) Nurses Note Note Text: Writer was made aware by staff that the residents had an altercation with another resident. Writer approached the resident and ensured she was safe. Assessment was completed, resident did not have any c/o (complaints of) pain, writer observed a hematoma apx (approximately) the size quarter on the left side of resident's forehead with some redness noted [Physician] .ordered for the resident to be transported to the emergency room for a cat (CT-computerized tomography test) scan .
-11/16/2022 21:39 (9:39 PM) .[Ambulance] arrived to transport resident to hospital via stretcher .no c/o pain. Swelling noted to right eye, hematoma noted to right temple no new changes .
-11/17/2022 12:44 (PM) .Writer followed up with resident after her return from the hospital. Writer asked if she feels safe in the facility resident stated as long as I don't have to see her (R903) I will be fine. Resident stated she is not in pain and safety is maintained. Writer assessed resident psycho-social needs and resident appears to be fine talking and laughing with others in dinning (sic) room at this time.
-(Psych Services Note) 11/22/2022 15:56 (3:56 PM) .Patient (pt-R903) .noted to have been involved in altercation with peer .pt with noted ongoing irritability, symptoms of anxiety mild to moderate, sporadically occurring, exacerbated by ongoing placement and difficulty coping at times. Appetite/sleep are fair. Cognition at baseline .
On 1/23/23 at 4:09 PM, the Nursing Home Administrator (NHA) was queried regarding R903. The NHA indicated that R903 was sent to the hospital for a psychiatric evaluation after the incident that occurred with R904. When queried if R903 had been involved in other incidents with staff or residents in the past, the NHA stated that R903 had been involved in past facility-reported incidents. The NHA was asked to provide the facility's behavior plan that was in place for R903 that was a result of past incidents.
A review of R903's MDS dated [DATE] and medical record revealed that the resident was initially admitted into the facility on 6/2/22 and discharged on 11/16/22. R903's medical diagnoses included Hip and Nasal Fractures, Falls, Seizures, Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder, Traumatic Brain Injury, Major Depressive Disorder, and Dementia. Further review revealed that the resident was moderately cognitively impaired and was mostly independent/required some supervision from staff for ADLs.
A review of R903's progress notes revealed the following:
-5/28/2022 07:18 (AM) admission Note Note Text: Resident arrived to facility .Resident very aggressive and has impaired hearing .Resident was kicked out of group home for aggressive behavior. Resident alert with slight confusion .
-(Psych Services Note) 6/21/2022 16:51 (4:51 PM) .Pt noted to have long-standing hx (history) of mental illness/schizoaffective disorder; managed on multiple psychotropic medications, pt noted to have hx of progressive cognitive impairment and long-standing mood fluctuations and symptoms of psychosis. Noted to have symptoms of paranoia since admission on [DATE]. Pt with symptoms moderate in intensity and at times severe, associated with accusing others of talking about her, stealing her belongings, as a result pt with difficulty adjusting and sleep disrupted .
-9/26/2022 18:28 (6:28 PM) Incident Note Note Text: Resident stated she is stealing my clothes the lady with the grocery basket! Writer went to look to see if any of her clothing was with her and noted no clothing in room. As writer was coming out of room, writer observed both residents hitting each other. No observable injuries noted .
-(Psych Services Note) 10/6/2022 14:43 (2:43 PM) .Today, facility staff requested [R903] be seen due to a recent physical encounter with a fellow female resident. On 9/26 she was observed in an altercation with a female resident where they were both hitting each other .Today on exam resident was again calm but severely cognitively impaired and hard of hearing .Apparently, she has remained fixated for months with various staff here on the idea that people here are stealing her clothes .[R903] has severe cognitive impairment and delusional beliefs. Today she was unable to provide any meaningful account of the incident. Her behavior was likely triggered by something that occurred in her environment at the time, as (to my knowledge) she does not have a pattern of being spontaneously aggressive here. Recommend staff provide her with increased monitoring when she is nearby other residents who are prone to be confused/aggressive .
-(Psych Services Note) 10/18/2022 23:39 (11:39 PM) .Pt with noted ongoing symptoms of mood swings, associated with severe, sporadic epsiodes (sic) of impulsivity, resistance to care, ambulating unsafely; at times agitated; continues on noted Rx (prescriptions) with no side effects, appetite/sleep vary; pt with noted cognitive decline and impairment, interval BIMS 6/15 (moderate/severe impairment) .
-11/16/2022 18:18 (6:18 PM) Nurses Note Note Text: Resident in a physical altercation with another resident in the dining room. Resident was arguing with another resident. Resident redirected to room.
A review of R903's care plan included the following:
-Focus: I have a behavior problem, at times I may choose to lower myself to the floor and remove my soft cast .Sometimes I falsely accuse other residents, and staff for stealing my clothes or my belongings I never possessed .I may confabulate, and perseverate and make up stories/statements that never happened and change them over time. Date Initiated: 10/03/2022, Revision on: 11/01/2022.
-Interventions: Approach me and speak in a calm manner. Divert my attention and remove me from a situation as needed. Date Initiated: 10/03/2022.
-Praise any indication of my progress/improvement in behavior. Date Initiated: 10/03/2022.
Information regarding R903's previous resident to resident incident and noted aggressive behavior was not found upon review of their care plan.
On 1/24/23 at 8:09 AM, Witness A (former employee of the facility) was interviewed via phone regarding the incident involving R903 and R904. Witness A explained that he was talking with R904 at a table in the dining room, when R903, came from nowhere and just started throwing hands on this old lady [R904]. Witness A claimed that R903 hit R904, at least four times .and swung about six times. Witness A stated that nearby staff separated the residents.
On 1/24/23 at 8:22 AM, Witness B (former employee of the facility) was interviewed via phone regarding the incident involving R903 and R904. Witness B stated that R904 was sitting at a front table in the dining room with Witness D. Witness B stated, [R903] came storming in there, she walked past me but I didn't know what she was going to do .no one had told me the two residents had had a conflict days prior .She walked past the table and started hitting [R904]. Witness B stated that R903 did not say anything to indicate she was about to start hitting R904. When queried regarding any past aggressive behavior exhibited by R903, Witness B stated she was unsure of any because she had been new to the facility when the incident occurred.
On 1/24/23 at 8:30 AM, the Social Work Director (SWD) was interviewed and queried regarding if R903 had exhibited any behaviors at the facility prior to the incident with R904. The SWD indicated that R903 had shown behaviors of insistence that her clothing was being stolen and fixation on alleged missing clothing. The SWD stated that R903 had lashed out at other people at her prior living arrangement (group home setting) and would go into other residents' rooms here at the facility and state others' clothes were hers. The SWD explained that she had attempted to find alternate/more suitable placement for R903. Upon reviewing R903's record, no information was found regarding referrals sent to alternate settings after June 2022. When queried regarding her assessment of how R904 felt after the incident happened, the SWD stated that R904 had indicated she felt safe in the facility but didn't understand why the incident had occurred. The SWD indicated she thought R903 may have felt like she was being teased by other residents, causing her to lash out.
On 1/24/23 at 8:52 AM, Witness D (current resident) was interviewed regarding the incident involving R903 and R904. Witness D described a birthday party for another resident that occurred days prior to the physical altercation. Witness D explained that R904 hollered at [R903], about taking a piece of cake that was not intended for her, but added that R904's voice is very loud. Witness D also admitted that they, R904, and others may have made comments about some of R903's behaviors in the past. Witness D stated that on the day the altercation occurred, [R903] came frantically over here with no warning and started pounding on [R904]. They broke it up and took [R903] away and she said, 'I'm going to get her again, she deserves more.' I couldn't believe what I was seeing. It was scary when [R903] said she wasn't done with [R904] when she was being taken out of the facility. When queried regarding R903's past behaviors in the facility, Witness D stated that R903 seemed, very agitated all the time .Yelled things out that didn't make sense . and added, I do think [R903] knew what she was doing when she hit [R904] .[R903] was aggressive in nature. Witness D stated that R904 ended up with a lump on her head.
A review of the facility's policy/procedure titled, Abuse and Neglect Prohibition Policy, reviewed/revised 2/17/20, revealed, Policy: Each resident has the right to be free from abuse .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Physical abuse includes hitting, slapping, punching, and kicking .Procedure: .When known, the facility will accommodate the needs of residents and staff who have been involved in incidents (recent or past) of abuse to minimize risk .
Dec 2022
15 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain dignified chair position and safely transport...
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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 dignified chair position and safely transport one resident (R64) of three residents sampled for positioning and mobility, resulting in the potential for injury, and embarrassment utilizing the reasonable person concept. Findings include:
On 12/07/2022 at 08:53 AM, R64 was observed in a tan colored, custom high back wheelchair in the busy hallway in front of the lobby. R64 was sitting with their back on the seat portion of the chair, and their legs extended up resting above and over the seat back of the wheelchair. R64's head was upside down resting on the foot pedals of the wheelchair. The resident was being transported down the hallway in that position with an unknown staff member pulling the wheelchair behind them. There were several staff members and residents in the hallway.
On 12/09/2022 at 08:13 AM, R64 was observed in the dining room in their wheelchair with their head resting at the foot of the wheelchair and their feet resting passed the seat back of the wheelchair. R64 was fidgeting in the wheelchair and had a pillow beneath their head. Unknown staff members were observed to be randomly entering and exiting the dining room.
On 12/09/2022 at 08:55 AM, R64 was observed to be upside down in the wheelchair, grinding their teeth very loudly with their eyes closed. When approached, the resident did not answer questions. There was no staff present in the dining room.
On 12/09/2022 at 10:52 AM, R64 was observed to be in the wheelchair upside down, there was a pillow under the resident's head. At this time, a staff member transported the resident (upside down) in their wheelchair back to their room.
On 12/09/2022 at 10:56 AM, R64 was brought out of their room and was upright in the wheelchair and brought back to the dining room.
A review of the Progress Notes for R64 revealed the following:
10/27/2022 12:27 (PM) Physical Medicine Rehabilitation Note Text: Assessment of current positioning and seating per nursing request. Resident with Huntington's disease (condition in which nerve cells in the brain breakdown over time) and associated ataxic (spastic) and involuntary movement of UE's (upper extremities) and trunk. Resident would most benefit from a Broda style tilt, recline and padded W/C (wheelchair) to minimize risk of falls, provide comfort and maintain functional positioning when out of bed. Care plan, [NAME] and orders updated to reflex change.
A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that R64 was admitted to the facility on [DATE] with the diagnoses of Huntington's Disease and Anxiety. R64 had a severely impaired cognition, and needed extensive assistance with bed mobility, transfers and wheelchair locomotion.
A record review of the care plan for R64 revealed the following:
Focus-I like to sit in my chair with my knees positioned in my chest, I may tend to hit my face on my knees as a result of my random movements from my Huntington's Disease. I prefer to be placed on a Geri-chair or Broda-chair for comfort. I sometimes like to reposition myself in my chair. Goal-I will remain free of injury .Interventions- Assist me with repositioning as needed .Date Initiated: 08/23/2022.
On 12/13/2022 at 09:39 AM, the Director of Nursing (DON) was interviewed in regard to the positioning and transportation of R64 while in the wheelchair. The DON explained that staff ambulate with the resident. The DON stated, (R64)'s movements are involuntary. I try to have someone in the main dining room at all times, (R64) is focus patient all the time. The DON was queried in regard to staff transporting the resident while upside down in the wheelchair and stated, No, they are not supposed to do that!
On 12/13/2022 at 09:59 AM, the Nursing Home Administrator (NHA) was interviewed in regard to the transporting and positioning of R64 while in the wheelchair. The NHA stated, (R64) needs a lot of attention. Staff should have repositioned (R64). (R64) does that (flips self upside down) while in the chair. We have told them (staff) that when (R64) starts to get fidgety, that usually means (R64) needs something. They need to pay attention to that, it is not a behavior. The older staff, know that, the newer ones need education.
A policy for wheelchair positioning/transporting was requested. The NHA reported that the facility did not have a policy regarding positioning or transporting residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0577
(Tag F0577)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to inform residents, families, and visitors of the location of the survey results (Statement of Deficiencies (Form CMS-2567) and...
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Based on observation, interview, and record review, the facility failed to inform residents, families, and visitors of the location of the survey results (Statement of Deficiencies (Form CMS-2567) and the Statement of Isolated Deficiencies generated by the most recent standard survey and any subsequent surveys) for nine confidential residents who attended a confidential group meeting, resulting in the potential for residents, families, and visitors to be uninformed of the facility's deficient practices. Findings include:
During a group meeting that was conducted in the facility on 12/9/22 at 11:13 AM, all nine residents who attended the meeting verbalized that they were unaware of the location of the most recent and past survey results.
On 12/8/22 at 4:45 PM, a tour of the facility resulted in the survey binder/survey results unable to be located.
On 12/9/22 at 8:30 AM, the Administrator (NHA) was interviewed regarding the location of survey results at the facility and stated, It's in the first floor south dinning room. Other places I've worked at, it's been located up front.
On 12/9/22 at 9:26 AM, the survey binder/survey results were attempted to be located in the first floor south dinning room. The survey binder/results were not observed in the dinning room and were unable to be located.
On 12/9/22 at 3:03 PM, the survey binder/survey results were presented to the survey team and it was indicated that the Assistant Administrator (ANHA) had been organizing it.
On 12/13/22 at 9:40 AM, the NHA was interviewed about the expectations on where the survey results should be placed so was readily accessible to residents, families and visitors, which they responded, It should be located in the front lobby.
On 12/13/22 at 10:00 AM, a facility policy titled, Resident Rights & Responsibilities with no date was reviewed and stated the following, 7. Information and Communication. K. You have the right to 1. Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to follow-up and bring resolution to a concern/grievance for one resident (R26) out of one reviewed for grievances, resulting in dissatisfacti...
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Based on interview and record review, the facility failed to follow-up and bring resolution to a concern/grievance for one resident (R26) out of one reviewed for grievances, resulting in dissatisfaction and unresolved claim of missing personal items. Findings Include:
On 12/07/2022 at 9:57 AM, an interview was conducted with Family Member (FM) C regarding R26's care in the facility. FM C stated that R26 is constantly missing clothes and that they have spent thousands of dollars replacing them. FM C stated that there is a huge sign on the closet that read family will do laundry, yet R26 is constantly missing clothes. FM C stated that they have written out inventory sheets, grievance, forms, and worked with facility staff, but they have never been reimbursed or no resolution to the problem.
On 12/08/2022 at 1:52 PM, an interview was conducted with Social Worker (SW) F regarding R26's missing items. The SW F stated that R26's family member filled out the inventory sheet so they could create a baseline list of items in inventory. SW F stated that the family member wrote up a new concern form just to start the whole process over.
On 12/13/2022 at 9:49 AM, an interview was conducted with the Nursing Home Administrator (NHA) regarding R26's missing items. The NHA stated that R26 has not received any of the items that FM C stated were missing. The NHA stated that it has been a while and they still can not locate the items. The NHA stated that prior to them starting in the position things such as inventory sheets were not being completed. The NHA stated that they have started a process to ensure that this does not continue to happen.
A review of a facility policy titled, Concern/Grievance Policy noted the following, .f. The Grievance Official will issue a written decision, on the concern form and send a copy of the entire form with the resolution to the resident or representative at the conclusion of the investigation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to revise and/or update the plan of care related to falls for one sampled resident (R83) out of one reviewed for falls, resultin...
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Based on observation, interview, and record review, the facility failed to revise and/or update the plan of care related to falls for one sampled resident (R83) out of one reviewed for falls, resulting in the potential for continued falls and injury. Findings include:
On 12/07/2022 at 9:30 AM, R83 was observed received an x ray of the right shoulder. An unidentified nurse stated that R83 was receiving a x ray due to having a recent fall.
A review of six months of incident and accident reports for R83 revealed that they had falls on the following dates, 8/25/22,9/26/22,9/30/22,10/18/22,10/21/22, 11/20/22, 12/5/22, and 12/6/22.
Further review of the care plan revealed that the interventions were not updated or revised following each fall.
On 12/13/2022 at 9:28 AM, an interview was completed with the Director of Nursing (DON) regarding falls in the facility. The DON stated that interventions should be implemented immediately following a fall and the care plan should be updated to reflect those falls. The DON stated that R83's care plan should have been updated with an intervention following their falls.
On 12/13/2022 at 9:49 AM, an interview was conducted with the Nursing Home Administrator (NHA) regarding falls in the facility. The NHA stated that they put falls through Quality Assurance and Performance Improvement (QAPI) because when the NHA first started working at the facility, falls were out of control. The NHA stated that although they have gotten better, it is a work in progress.
A review of the facility's undated policy titled, Fall management Guidelines noted, Overview: Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk of falls. Residents will be evaluated by the interdisciplinary team for their risk for falls. A plan of care is developed and implemented based on this evaluation with ongoing 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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
This citation pertains to inttake MI00130598.
Based on interview and record review, the facility failed to complete weekly skin assessments for one resident (36) out of two reviewed for skin assessmen...
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This citation pertains to inttake MI00130598.
Based on interview and record review, the facility failed to complete weekly skin assessments for one resident (36) out of two reviewed for skin assessments, resulting in the potential for missed skin alterations. Findings Include:
On 12/07/2022 at 9:37 AM, an interview was conducted with R36 regarding their care in the facility. R36 stated that they thought that they were developing bedsores, but no one will tell them anything. R36 was queried as to if the staff checks their skin weekly. R36 stated that this does not happen.
A review of the medical record revealed that R36 had skin assessments completed on the following dates in 2022, 3/2, 3/23,7/4, 7/6,9/23, and 11/1.
On 12/09/2022 at 12:31 PM, an interview was conducted with the Wound Care Nurse (WCN) H regarding skin assessments being completed in the facility. WCN H stated that floor nurses are responsible for completing skin assessments. WCN H stated that skin assessments should be completed weekly, and that it has been identified as a problem in the facility. WCN H stated that they started an education and will be implementing a new process to ensure that they are completed weekly.
On 12/13/2022 at 9:28 AM, an interview was conducted with the Director of Nursing (DON) regarding weekly skin assessments. The DON stated that they just had the Wound Care Nurse complete a skin sweep of the entire facility to establish skin integrity baseline. The DON stated that they have identified the problem and moving forward a weekly skin assessment will be completed on all residents.
A review of a facility policy titled, Pressure Ulcer and Skin Care Management noted the following, .1. A licensed nurse checks the residents body for the presence of pressure ulcers, wounds, and other skin conditions .Weekly on resident,.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete weekly skin assessments and/or apply a heel b...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete weekly skin assessments and/or apply a heel boot consistently for two residents (R97 and R23) of three reviewed for pressure ulcers, resulting in the potential for unassessed, worsened, or new wounds. Findings include:
Resident 97 (R97)
On 12/07/2022 at 09:29 AM, R97 was observed awake in bed. The resident had clear speech and answered questions appropriately. R97 was asked about the condition of their skin and explained that they had a wound on their left hip. The resident further explained that the wound had been there for awhile and that it caused pain occasionally.
A record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed R97 was independent with decision making and needed extensive assistance with bed mobility and transfers. R97 was most recently admitted to the facility on [DATE] with the diagnoses of Anxiety and Depression.
A record review of the Physician Orders for R97 revealed the following:
Apply Maxorb Ag Daily to left hip with border gauze one time a day every Mon (Monday), Tue (Tuesday), Thu (Thursday), Fri (Friday), Sun (Sunday) for wound.
A record review of the weekly skin assessments revealed a skin assessment on 11/03/2022, 11/07/2022 and 11/14/2022. There were no skin assessments in the Electronic Medical Record (EMR) beyond 11/14/2022.
A record review of the Physician's note on 11/09/2022 revealed a left hip wound measuring 1.5 centimeters (cm) x 0.6 cm x 0.2 cm.
On 12/13/2022 at 09:29 AM, the Director of Nursing (DON) was interviewed and asked about the skin management process and explained that she was new to the position and had the Wound Nurse do a complete skin sweep (assessed every residents skin condition) across the whole building to see where they stood with skin issues. The DON explained that she was becoming aware of what the problems were in the facility and stated that weekly skin assessments were important.
On 12/13/2022 at 12:03 PM, a wound observation was made with R97. The resident was lying in bed and lifted their gown to reveal their uncovered wound to their left hip. The resident explained that the wound was healing. The wound had a pink, dry wound base that was less than the size of a dime. There was no drainage or odor. There was pink scar tissue all around the wound.
Resident 23
On 12/07/22 at 12:16 PM, R23 was observed in bed and asked about the care at the facility and stated, they need more help. Observed in the chair against the wall was a green and blue pressure relieving heel protector boot. R23 was asked if they wear the boot while in bed and stated, Yes. It's not on. My heel hurts. The sheets were lifted to reveal R23's heels without a heel protector.
On 12/08/22 at 12:18 PM, the Wound Care Nurse was asked about R23's heel wound and stated, Right heel wound is improving. The Wound Care Nurse was asked if R23 was to have the heel protector on while in bed and stated, Yes. The Wound Care Nurse was asked if R23 refused to wear the heel protector and stated, No [R23] doesn't refuse.
On 12/13/22 at 9:48 AM, R23 was observed in bed without a heel protector on their right foot.
A review of R23's medical record noted, R23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Cerebral Infarction Significant change in status. A review of Minimum Data Set (MDS) dated , 11/07/22 noted, R23 with an moderately impaired and required assistance with activities of daily living.
A review of R23's [NAME] noted, Bilateral Heel off Boot when Patient in bed only.
R23's care plan did mention the heel protectors.
On 12/13/22 at 2:41 PM, the Director of Nursing (DON) was asked the facility's expectations regarding ensuring heel protectors were on as ordered. The DON explained, staff are to make sure that it is linked to the [NAME] so that they will know to put them on.
A review of the facility policy titled Pressure Ulcer & Skin Care Management (undated) revealed the following: .Procedure 1. A licensed nurse checks the resident' s body for the presence of pressure ulcers, wounds and other skin conditions:
·
At admission or readmission to the facility,
·
Whenever the resident arrives by medical transport,
·
Weekly on residents, and
·
Prior to discharge.
2. The licensed nurse documents that the body check was completed on the resident ' s weekly head to toe skin record .
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 maintain safety during care, for two sampled residents...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain safety during care, for two sampled residents (R23 and R83) of four reviewed for accidents, resulting in a fall from bed and shoulder pain. Findings include:
On 12/07/22 at 12:19 PM, R23 reported that they fell out the bed about 3 weeks ago. R23 was asked if they were alone when the fall happened and R23 stated, No I was with a CNA(Certified Nursing Assistant). R23 asked how the fall happened and stated, I fell off the bed. [CNA ] was washing me up. R23 explained that they hit their head.
A review of R23's incident report revealed, Date: 11/10/22. Type: Fall. Incident Description: CNA said resident rolled out of bed during care. Resident observed on floor on left side facing window. Did not hit head. c/o (complaint of) left arm pain and left humorous pain rates, a 6 on scale 1-10. Moves all extremities, no neur deficits. [Physician] notified of fall and ordered x rays. Resident Description: I rolled out of bed. my left arm and shoulder hurts.
A review of R23's medical record revealed, Progress Notes: 11/10/22. Per [CNA] resident rolled out of bed on to floor. Resident observed on floor side of bed lying on left side facing window . rates pain to left shoulder and arm a 6 on scale of 1-10. tylenol given. ROM (range of motion) intact. no neuro deficits no skin injury or bruising. [CNA] states she did not hit her head. resident has been placed back into bed, 2 person assist.
On 12/13/22 at 11:55 AM, Nurse I was asked about the fall and what CNA it was and stated, It was CNA J. According to the CNA she told [R23] to roll one way and R23 rolled the wrong way and fell out of bed. Nurse I was asked the results of the xray and explained, the results was no acute fracture dated 11/11/22.
A review of R23's medical record revealed, R23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Cerebral Infarction Significant change in status. A review of R23's Minimum Data Set assessment dated [DATE], noted R23 required extensive assistance by two staff for physical assist with bed mobility, transfer, and dressing.
On 12/13/22 at 2:07 PM, the facility provided a one on one education with CNA J that noted, One on One in-service Record Educational Opportunity. Date 11/10/22. Employee CNA J Department Nursing. Title: CNA. Description of Occurrence Post Fall Assessment. Date of Occurrences: 11/10/22 Employee will follow plan of care according to resident [NAME]. Employee signature 11/10/22.
On 12/13/22 at 2:10 PM, an attempt was made to interview CNA J via phone. A voice mail was left. CNA J did not return the call by the end of this survey.
On 12/13/22 at 2:39 PM, the Director of Nursing (DON) was asked about the incident and stated, I wasn't here at that time, but trying to figure out what happened.
A review of the facility's undated policy titled, Fall management Guidelines noted, Overview: Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk of falls. Residents will be evaluated by the interdisciplinary team for their risk for falls. A plan of care is developed and implemented based on this evaluation with ongoing review .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide one resident (R26) with their ordered therapeutic diet out of one reviewed for nutrition, resulting in the potential f...
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Based on observation, interview and record review, the facility failed to provide one resident (R26) with their ordered therapeutic diet out of one reviewed for nutrition, resulting in the potential for aspiration. Findings include:
On 12/07/2022 at 1:31 PM, R26 lunch was observed. A review of their meal ticket noted that R26 was on a mechinal soft diet and had been served a piece of ham that was cut into pieces by the certified nursing assistant.
On 12/8/2022 at 12:42 PM, an interview was conducted with Dietary Manager G who stated that R26's ham should have been ground up when it came up from the kitchen and would look into it.
A review of a facility policy titled; Nutritional Care did not address therapeutic diets.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to maintain an nebulizer mask in a sanitary manner, for one Resident (R69), resulting in the likelihood for infection. Findings i...
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Based on observation, interview and record review, the facility failed to maintain an nebulizer mask in a sanitary manner, for one Resident (R69), resulting in the likelihood for infection. Findings include:
On 12/07/22 at 9:21 AM, R69 was observed in bed and on the overbed table was a nebulizer and tubing next to the breakfast tray.
On 12/07/22 at 12:41 PM, R69's overbed table was on the side of the bed with the nebulizer mask not in a bag laying on the table.
On 12/08/22 at 9:40 AM, R69's nebulizer mask was on the overbed table, in the same position.
On 12/13/22 at 2:36 PM, the Director of Nursing was asked the facility's process for nebulizer mask not in use and stated, Should be in a bag.
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 F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #MI00131359.
Based on observation, interview and record review, the facility failed to administ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #MI00131359.
Based on observation, interview and record review, the facility failed to administer available pain medication as ordered to two residents (R321 and R97) of two residents reviewed for pain management, resulting in unnecessary prolonged pain. Findings include:
Resident 321 (R321)
A record review of the Electronic Medical Record (EMR) for R321 revealed the resident was admitted to the facility following a motor vehicle accident (MVA) on 09/15/2022 with the diagnoses of Right Pubis Fracture, Fracture of the 5th Metacarpal Bone of the Right Hand, Left Fibula Fracture and Multiple Right Rib Fracture.
R321 discharged from the facility (per their initiation) on 09/19/2022. The Minimum Data Set (MDS) assessment dated [DATE] revealed that R321 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognition and needed minimal assistance with activities of daily living.
A record review of the hospital discharge record prior to R321's admission to the facility revealed the following pain medication orders to be continued after discharge from the hospital: Motrin, Gabapentin and Oxycodone.
A record review of the Physician Orders for R321 revealed the following orders for pain medication:
Oxycodone 10 mg (milligrams) PRN (as needed) Q (every) 6 hrs (hours), ordered 09/16/2022.
Lidoderm patch 5% daily, ordered 09/16/2022.
Methocarbamol 500 mg Q 8 hrs.
Tylenol 650 mg po (by mouth) Q 4 hrs PRN.
Gabapentin 200 mg Q 8 hrs, ordered 09/16/2022.
A record review of the September 2022 Medication Administration Record (MAR) for R321 revealed the following:
Oxycodone-first dose administered on 09/17/2022.
Lidoderm patch, administered 09/17/2022.
Gabapentin, administered first on 09/17/2022.
Tylenol-not administered.
A record review of the Statsafe inventory sheet from the electronic back up medication machine supplied by pharmacy revealed the following medications available from back up:
Gabapentin 100 mg (30 tablets)
Oxycodone 5 mg (15 tablets)
On 12/09/2022 at 02:15 PM, an interview was completed with the Infection Control Preventionist (ICP) at the Statsafe electronic back up medication machine. According to the ICP, nurses are able to pull medications from the back up machine in case the residents medications had not arrived back from pharmacy. The ICP further demonstrated the removal of Oxycodone 5 mg from the machine, but stopped the procedure once the machine asked for a second nurse verification (a second nurse witness used to reduce drug diversion). The ICP was asked how the machine gets filled and explained that the Director of Nursing (DON) receives the back up medication from pharmacy and loads the machine up with as needed inventory.
On 12/13/2022 at 09:35 AM, the DON was interviewed regarding the process of pulling medication out of back up when medications are not available from pharmacy yet. The DON stated, We should be making sure we send the prescription over to pharmacy right away and make sure it is in the back machine to give. I reviewed (R321's) chart, they came in on Gabapentin and a muscle relaxant. If it is available from the back up machine then the nurse should pull it.
At 09:58 AM, the Nursing Home Administrator (NHA) was interviewed in regard to removing medications from back up when they are not available from pharmacy. The NHA explained that the nurses are supposed to pull medications from back up if it is not available. The NHA stated, I can't speak to the staff at the time. Everyone should know by now that there is a back up with medications available (around the clock).
R97
On 12/08/22 at 12:07 PM, R97 asked the nurse behind the station if their pain medication was in, the nurse replied Meds are not in. R97 said My Morphine is not in and I'm not getting any Norco. The nurse stated, Let me see if I can get you a one time order. R97 said, I'm in a lot of pain. the nurse explained that the pharmacy got the order because she herself called the pharmacy to confirm.
On 12/08/22 on 3:34 PM, R97 was asked about the pain medication and stated, They changed my medication. They took the Norco away and put me on Morphine. R97 was asked if they got anything for pain yet and stated, They gave me a Norco, but my Morphine is still not in.
On 12/09/22 at 12:48 PM, R97 was asked if they got there Morphine today and explained, No, they said they have it on the cart, but they already gave me a Norco today. I can't get the Morphine yet.
On 12/09/22 at 2:15 PM, an observation of the backup inventory was completed and noted, that original quantity 15 tablets and current quantity 13 tablets of Morphine 15 mg was available on site, which is the current order for R97.
A record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed R97 was independent with decision making and needed extensive assistance with bed mobility and transfers. R97 was most recently admitted to the facility on [DATE] with the diagnoses of Anxiety and Depression.
A review of R97's care plan noted, Focus: I have the potential for pain/discomfort r/t (related to) CVA (Cerebrovascular accident) Date Initiated: 11/06/2021. Goal: I hope to not have an
interruption in my normal activities due to discomfort through next review. Date Initiated: 11/08/2021. Interventions: Administer my analgesic per orders. Give approx (approximately). 1/2 hour - 45 min. before treatments or care when needed. Date Initiated: 11/26/2021. Anticipate my need for pain relief and respond as soon as possible to any complaint/signs of pain.
A review of the facility policy titled PCU005-Emergency Medication Kit-LTC (Long Term Care) Facilities Only (2022) revealed no procedure for the utilization of the medication back up inventory.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure that two confidential group residents were offered bedtime snacks of nine residents reviewed for snacks, resulting in resident dissat...
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Based on interview and record review the facility failed to ensure that two confidential group residents were offered bedtime snacks of nine residents reviewed for snacks, resulting in resident dissatisfaction and the potential for nighttime hunger. Findings include:
On 12/8/22 at 11:13 AM, a group meeting was held with nine confidential group residents and the group was asked about being offered bedtime snacks. The group indicated that bedtime snacks were typically brought to the unit, placed on the counter and Residents who are able to get to the counter get snacks, residents who are in bed and unable to get out of bed do not. All group members expressed dissatisfaction with this arrangement regarding the distribution of bedtime snacks.
On 12/9/22 at 9:15 AM, all nine confidential group residents' electronic medical records (EMR) were reviewed over the past thirty days for documentation of bedtime snacks being offered to them. Results of the EMR review revealed that two confidential group residents had no documentation in their EMR of having been offered bedtime snacks.
On 12/9/22 at 11:23 AM, Dietary Manager (DM) E was interviewed about the process for distributing bedtime snacks to residents. DM E stated, The kitchen brings a tray up to the unit and staff is responsible for passing them out. What usually happens is residents roll up to the counter and take three or four snacks.
On 12/13/22 at 9:40 AM, the Administrator (NHA) was interviewed about their expectation for the offering of bedtime snacks to residents. The NHA stated, The kitchen brings snacks up to the units and staff is expected to offer them to residents and pass them out.
At 11:00 AM a facility policy regarding bedtime snacks was requested and the NHA indicated that the facility did not have a policy related to this issue.
/
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document and/or offer the pneumonia vaccine for three residents (R9...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document and/or offer the pneumonia vaccine for three residents (R97, R39, R34) of five residents reviewed for vaccinations, resulting in the potential for infection. Findings include:
Resident 39 (R39)
On 12/07/2022 at 10:19 AM, R39 was observed awake in bed with their eyes open wearing a shirt. The resident had clear speech and was able to answer questions appropriately. R39 was asked about the care received in the facility and explained that they were waiting to get out of bed for the day, but needed help from staff first.
A record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed R39 was most recently admitted to the facility on [DATE] with the diagnoses Anemia and Hypertension. R39 needed extensive assistance with bed mobility and transfers. R39's Brief Interview for Mental Status (BIMS) score was not assessed.
A review of the immunizations for R39, revealed no pneumonia vaccination record.
Resident 97 (R97)
On 12/07/2022 at 09:19 AM, R97 was observed in bed awake. The Resident answered questions appropriately with clear speech.
A record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed R97 was independent with decision making and needed extensive assistance with bed mobility and transfers. R97 was most recently admitted to the facility on [DATE] with the diagnoses of Anxiety and Depression.
A review of the immunization records revealed no pneumonia vaccine information for R97.
Resident 34 (R34)
On 12/09/2022 at 12:10 PM, R34 was observed walking around in their room. The resident was hard of hearing but was able to communicate via writing. When asked about the care received in the facility, the resident had no concerns.
A review of the immunization records for R34 revealed no information on the pneumonia vaccine.
A record review of the MDS dated [DATE] revealed that R34 was most recently admitted to the facility on [DATE] with the diagnoses of Hypertension, Dementia and Diabetes Mellitus. R34 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognition, and needed supervision assist with bed mobility and transfers.
On 12/09/2022 at 11:06 AM, the Infection Control Preventionist (ICP) was interviewed in regard to the offering of the pneumonia vaccination. According to the ICP, the immunizations are usually offered upon admission.
On 12/13/2022 at 09:38 AM, the Director of Nursing (DON) was interviewed in regard to pneumonia vaccines being offered to residents and stated, They should offer pneumonia vaccines upon admission to the facility.
A second request was made on 12/09/2022 at 10:12 AM for information regarding the offering of the Pneumonia vaccine for R97, R34 and R39. A refusal for the pneumonia vaccine was provided on 12/12/2022 for R97 (dated 12/12/2022-during the survey) and R34 (dated 12/09/2022-during the survey). There was none provided for R39.
A review of the facility policy titled Resident Health Program (undated) revealed the following: .6. Each resident is offered a pneumococcal immunization .8. The resident's medical record includes documentation that indicates, at minimum, the following: a That the resident or resident's legal representative was provided education regarding the benefits and potential side effects of the pneumococcal and influenza vaccine. b. That the resident either did or did not receive the pneumococcal and influenza immunization due to medical contraindication or refusal.
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 MI00131345.
Based on observation, interview, and record review, the facility failed to provide ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00131345.
Based on observation, interview, and record review, the facility failed to provide a safe, clean, homelike environment, in eight resident rooms (Room #'s 106, 200, 204A, 207, 210, 212, 214, and 216), resulting in the potential for dissatisfaction in living conditions. Finding include:
On 12/07/2022 at 9:21 AM, a tour of the facility was completed.
In room [ROOM NUMBER], crumbs were observed on the floor. There were multiple used gloves on the floor and a brown dried substance on the walls.
In room [ROOM NUMBER]A, the sheets were observed to be stained with a red substance on them. The wall had a brown dried substance on it as well.
In room [ROOM NUMBER], multiple gloves were observed on the floor. Napkins and a cup were observed on the floor.
In room [ROOM NUMBER] a pile of dust was observed in the middle of the room. There were multiple used gloves on the floor and the nightstands.
In room [ROOM NUMBER], an unknown sticky substance was on the floor. Crumbs were observed on the floor.
In room [ROOM NUMBER], a strong urine smell was noticed in the room. The bed by the window had a flat sheet that appeared to be stained with urine. Tissue paper was observed on the floor, as well as paper and gloves. A brown substance was observed dried up on the floor.
In room [ROOM NUMBER], crumbs were observed on the floor. There were forks on the floor and nightstands, as well as gloves.
At 9:20 AM, room [ROOM NUMBER]A bed was observed against the wall. The wallpaper was observed to hang off the wall. The resident in the bed explained that the wallpaper needed to come off the wall.
At 12:49 PM, room [ROOM NUMBER] was observed with multiple plaster patches on wall. The resident in the room was asked how long have the patches been on the wall. The resident stated, they have been in the room for about three months and the wall has been like that the entire time.
At 9:57 AM, an interview was conducted with Family Member (FM) C regarding the facility. FM C stated that the facility is filthy, and no one ever cleans. FM C stated that their loved one never lived in a filthy place like the facility and that is one of the reasons they were moving them to another facility.
On 12/9/2022 at 8:56 AM an interview was conducted with Housekeeping Manger (HM) D. HM D stated that they were the district manager and has been in the facility to correct some previously identified issues with housekeeping. HM D stated that they had a new house keeping manager starting and created a check list for the housekeepers. HM D stated that things were not being followed up on as they should have been, but more supervision is being given to the housekeepers and they are seeing positive results.
On 12/13/22 at 11:00 AM, the ice machine was observed with white towels under it do to it leaking.
Across from the ice machine the wall was observed with scotch tape attached to the door frame and the wallpaper.
On 12/13/22 at 11:13 AM, the Maintenance Director was asked about the above observations and explained that he was not aware of the concerns with room [ROOM NUMBER] or the wallpaper. The Maintenance Director was observed to push the ice machine in line to prevent the water to leak on the floor.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 36 (R36)
On 12/07/2022 at 9:30 AM, an interview was conducted with R36 regarding their stay in the facility. R36 stated...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 36 (R36)
On 12/07/2022 at 9:30 AM, an interview was conducted with R36 regarding their stay in the facility. R36 stated that they hated living in the facility and that they feel as though they are being ignored at time by staff. R36 stated that one example of this is showers. R36 stated that they can go weeks without even being offered a shower.
A review of shower sheets provided by the facility revealed that for the months of November and December 2022, R36 received a shower on 12/2/2022.
No other shower documentation was provided prior to end of survey.
Resident 30 (R30)
On 12/7/2022 at 9:25 AM, R30 was observed in the bed with a head bandage on. A strong smell was coming from R30. R30 was unable to state the last time that they had a shower.
A review of shower sheets provided by the facility revealed that for the months of November and December R30 received care on the following days, 11/9/22-bed bath, 12/3/22, and 12/7/22.
No other shower documentation was provided prior to the end of survey.
Resident 26 (R26)
On 12/7/2022 at 9:57 AM, an interview was conducted with Family Member (FM) C regarding the care in the facility for R26. FM C stated that the care in the facility is terrible. FM C stated that R26 was supposed to have a shower the previous day, but still has a chin full of hair. Upon observation of R26, hair was noted on their upper lip and chin areas.
A review of shower sheets provided by the facility revealed that for the months of November and December R26 received care on the following days, 11/1/22-refused, 11/3/22, 11/8/22-bed bath, 11/10/22, 11/17/22, 11/22/22-refused, 12/1/22-bed bath, and 12/6/22 (there was no documentation that R26 refused to be shaven).
No other shower documentation was provided prior to the end of survey.
Resident 83 (R83)
On 12/07/2022 at 9:40 AM, R83 was observed in their room with striped pajama pants on, a navy-blue shirt, and black and red socks. R83 hair appeared to be greasy, and their nails were long. R83 was unable to state the last time they had a shower.
A review of shower sheets provided by the facility revealed that for the months of November and December R83 received care on the following days, 11/9/22-Bed Bath, 11/19/22,11/23/22-Refused nails and toes, and 12/3.
No other shower documentation was provided prior to the end of survey.
Resident 2 (R2)
On 12/07/2022 at 12:14 PM, R2 was observed in the bed. R2 nails were long with dirt under them. R2 was unable to state the last time they had a shower.
A review of shower sheets provided by the facility revealed that for the months of November and December R2 received care on the following days, 11/1/22-bed bath, 11/8/22-refused, 11/24/22-bed bath, and 12/6/22-bed bath.
On 12/13/2022 at 9:28 AM, an interview was conducted with the Director of Nursing (DON) regarding showers in the facility. The DON stated that they have been speaking with the nurses and certified nursing assistants regarding showers and bed baths. The DON stated that no bed baths should be given unless requested and the care plan updated with their preference. The DON stated that if someone refuses a shower, they should attempt to educate them, reapproach, and document the refusal.
On 12/13/2022 at 9:49 AM, an interview was conducted with the Nursing Home Administrator (NHA) regarding showers in the facility. The NHA stated that they have put showers through Quality Assurance and Performance Improvement (QAPI) and have implemented a process for showers. The NHA stated through QAPI they found areas of concern, such as showers in the computer not matching the room schedule, which they have fixed. The NHA stated that bed baths are not acceptable and that they residents should receive showers unless otherwise noted.
A review of the facility's policy packet titled, Personal Care Needs dated 9/2/22 noted multiple polices Toileting, noted, Purpose: to help the resident maintain and adequate bowel and bladder habits as indicated by his or her condition. Procedure: 1. When a resident indicates either verbally or non-verbally a need to use the bathroom, staff should promptly assist the resident . Tub Bath or Shower, noted, Purpose: Tub baths and/or showers are used to cleanse the body, stimulate circulation, and condition & assist debriding skin. Bed linen is changed at lease weekly and PRN (as needed) . Fingernail Care. Purpose: Care of the fingernails promotes circulation to the hands and helps prevent small tears around the nails that could lead to infection. Finger nails are checked on shower days and trimmed as needed . Hair Care, noted Purpose: Hair care is given maintain or improve personal appearance, to clean hair and scalp, to stimulate circulation to the scalp, and/to apply for a bed bound resident .
This citation pertains to intake MI00130961 and MI00131345.
Based on observation, interview and record review, the facility failed to complete and/or document the completion of showers and/or nail care for 12 residents (Resident #'s 39, 85, 97, 23, 24, 36, 87, 30, 26, 115, 83, 2) of 24 reviewed for hygiene, resulting in poor hygiene, and an overall dissatisfaction with care. Findings include:
Resident 39 (R39)
On 12/07/2022 at 10:19 AM, R39 was observed awake in bed with their eyes open wearing a shirt. The resident had a U-shaped pillow around their neck that was soiled with dry food. The resident had clear speech and was able to answer questions appropriately. R39 was asked if they received showers regularly and stated, (I get showers) When they (staff) feel like it.
A record review of the shower/bathing tasks for the last 30 days revealed that R39 is supposed to get a shower every Monday and Thursday. According to the documentation, R39 received one shower for the month of December (12/08/2022).
On 12/13/2022 at 09:34 AM, the Director of Nursing (DON) was interviewed in regard to residents receiving their scheduled showers and stated that residents do refuse to have their showers completed, but that should be documented. The DON further explained that by documenting why showers were not done, the facility could identify a pattern and care plan it.
A record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed R39 was most recently admitted to the facility on [DATE] with the diagnoses Anemia and Hypertension. R39 required extensive assistance with bed mobility and transfers. R39's Brief Interview for Mental Status (BIMS) score was not assessed.
Resident 85 (R85)
On 12/07/2022 at 11:07 AM, R85 was observed resting in bed watching television. R85 was interviewed in regard to the care received within the facility and stated, I have had no showers since I have been here. I am big, they (the staff) say it takes two persons to shower me so they do a bed bath (with one person assist) instead because they don't have the staff.
A record review of the bathing task for 30 days revealed that R85 received a bed bath on 11/23/2022, 11/28/2022 and 12/07/2022.
A record review of the Activities of Daily Living care plan revealed the following bathing intervention for R85:
BATHING/SHOWERING: I require (Extensive assistance) by staff with (bathing/showering) at least weekly and whenever I prefer. Date Initiated: 11/03/2022.
A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that R85 was admitted to the facility on [DATE] with the diagnoses of Acute Respiratory Failure and Osteoporosis. R85 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognition, and needed extensive assistance with dressing and bed mobility. According to the MDS, bathing had not occurred during the observation period of the assessment.
On 12/13/2022 at 09:32 AM, the DON was interviewed in regard to offering showers verses just bed baths. The DON stated, They are to get bed baths if that is their preference, otherwise they are supposed to be doing showers.
On 12/13/2022 at 09:55 AM, the Nursing Home Administrator (NHA) was interviewed in regard to residents receiving showers per the schedule and personal preferences. The NHA explained that not offering showers was not acceptable and explained that the shower process was placed on QAPI (Quality Assurance Process Improvement) back in August. According to the NHA, the showers were not correct in the computer system and did match the care plans/tasks. The NHA stated, The showers didn't match the current schedule so we went through the whole building and made sure they all matched, then we found out when we do room moves, the showers don't get updated. So we identified that as well. Then we found out they were not documenting refusals. We found out they weren't charting that. They are supposed to do skin assessments with the showers.
Resident 97 (R97)
On 12/07/2022 at 09:19 AM, R97 was observed in bed awake. The resident answered questions appropriately with clear speech. R97 was interviewed in regard to receiving showers in the facility and stated, I get one shower a month, I am supposed to get one twice per week.
A review of the bathing task x 30 days for R97 revealed the resident received a shower on 11/22/2022,11/29/2022 and 12/06/2022.
A record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed R97 was independent with decision making and needed extensive assistance with bed mobility and transfers. R97 was most recently admitted to the facility on [DATE] with the diagnoses of Anxiety and Depression.
Resident 87 (R87)
On 12/07/22 at 10:15 AM, R87 was asked about their stay at the facility and explained, the facility needs more help. R87 stated, Yesterday I went to an appointment and when I came back, I was in the wheelchair for a long time. I use a mechanical lift and it took over an hour because they said there was not enough qualified Hoyer staff to help. R87 explained that this has happened before and that they have wounds that are painful if they sit in the chair for long periods of time.
On 12/09/22 at 10:31 AM, R87 was asked about their night and stated, It's just so hard to get help from an aide. I waited an hour and 20 minutes. My night did not go well.
On 12/09/22 at 12:34 PM, R87's call light was observed to be activated, the HRD (human resources director) was observed to go into R87's room [room [ROOM NUMBER]] at 12:35pm. R87 stated, Tell someone I need to be changed. The staff exited out of the room and the call light was now observed off.
At 12:37 PM, medical records staff was overheard talking to Certified Nurse Assistant (CNA) J about R87 needing help. CNA J said I don't have [R87's room] (not assigned to render care). I stop at room [ROOM NUMBER].
On 12/09/22 at 1:19 PM, R87 was observed in bed and explained that they were still waiting for assistance. R87 stated, I hate when they come in and say they are going to tell someone, I don't know if they tell anyone. R87 activated the call light button again during the interview.
On 12/09/22 at 1:22 PM, an unidentified CNA went into R87's room to deliver a lunch tray, during that time R87 told the CNA that they needed to be changed, the light went off and the CNA left out of the room. The CNA was asked if they knew who R87's assigned CNA was and stated, CNA J.
On 12/09/22 at 1:30 PM, HRD was asked if they had told a CNA about R87 needing assistance and stated, Yes, I told someone.
On 12/09/22 at 1:32 PM, a review of one assignment sheet revealed that CNA J did not have R87, but on a edited assignment sheet noted, CNA J assigned to R87. A conversation between the HRD and CNA J was heard, CNA J stated, I have to room [ROOM NUMBER]. The HRD stated, The assignment changed. CNA J stated, No one ever told me. These residents have been not cared for because I stopped at room [ROOM NUMBER].
A review of R87's medical record revealed that R87 was admitted to the facility on [DATE]. A review of R87's Minimum Data Set (MDS) assessment dated [DATE] noted, R87 with an intact cognition and required extensive assistance from two or more staff for activities of daily living.
A review of R87's Care plan noted, Focus I am at risk for incontinent of Bowel and/or Bladder r/t (related to) hx (history) of ileus, GERD (Gastroesophageal reflux disease ), depression, COPD (Chronic obstructive pulmonary disease). Date Initiated: 09/01/2022. Goal: I will be free of odor while maintaining my dignity Date Initiated: 12/10/2020. Interventions: Keep me as clean and dry as possible. Apply protective barrier cream prn (as needed). Date Initiated: 11/04/2020. Check me at least every two hours during the day and change my brief if needed. Date Initiated: 11/04/2020. BED MOBILITY: I require extensive assistance Date Initiated: 10/17/2022.
Resident 115 (R115)
On 12/08/22 at 11:20 AM, R115 was observed in bed with nails that appeared long and brown in color. R115 was asked about their nails and stated, They are long. I would like to get them cut. They said they would two weeks ago, but they never came back.
On 12/09/22 at 1:16 PM, R115 was observed in the hallway, R115 nails were observed to be in the same condition.
On 12/13/22 at 2:30 PM, R115 was observed sitting in bed with their nails in the same condition. R115 was asked if the staff came in the cut their nails and stated, No and they hurt.
On 12/13/22 at 2:40 PM, the Director of Nursing (DON) was asked about R115's nail care and stated, That should be done as routine care and monitored routinely.
A review of R115's medical record revealed that R115 was admitted to the facility on [DATE]. A review of R115's (MDS) assessment noted, R115 with an moderately impaired cognition and required supervision assistance for activities of daily living.
Resident 24 (R24)
On 12/07/22 at 9:30 AM, R24 stated, They are not washing or combing my hair. I will get a bed bath once per week, but that is not enough. Not removing chin hairs, I'm a woman, common sense says I want it remove. R24 continued and explained that the staff is not changing their brief in a timely manner and that they are afraid that they will get an infection.
A review of R24's medical record revealed that R24 was admitted to the facility on [DATE]. A review of R24's (MDS) assessment noted, R24 with an intact impaired cognition and required assistance for activities of daily living.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00130598.
Based on observation, interview, and record review, the facility failed to ensure s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00130598.
Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff were available, affecting three residents (R24, R87 and R23) from a total sample of 39, nine confidential group residents, and potentially all residents residing in the facility, resulting in, unmet care needs, dissatisfaction with the care provided, and lack of resident monitoring with the potential to affect resident safety. Findings include:
On 12/7/22 at 3:15 PM, resident council meeting notes for the months of August 2022 through November 2022 were reviewed and revealed the following, October 19, 2022, call lights are not being answered in a timely manner (when they answer the lights they come back 2hrs (hours) later). November 22, 2022, still not answering call lights, if they do they just turn the light off and come back 2 hrs later to assist.
On 12/8/22 at 11:13 AM, a confidential group meeting was held with nine confidential group residents at the facility. The group was asked about staffing at the facility and all group members indicated that lack of staff was their biggest concern. The group indicated that staff do not monitor them or other residents in the first and second floor dinning rooms and that there have been residents who have fallen due to the lack of monitoring. A few of the group residents stated, We have to monitor the residents. That's not our responsibility. The group indicated that at times when the asked staff to assist them to bed, staff indicated that they could not, due to being busy, due to short staffing.
On 12/08/22 at 9:42 AM, Nurse K was asked how many residents she had assigned to her and stated, About 22 or 23.
On 12/08/22 at 2:36 PM, during medication observation Nurse K was asked if the morning medications were given and stated, I didn't get to the cart until 9:00 am. When I started, I had to do the vitals and blood sugars. This is my first time working here so that slowed me down as well.
R24 was asked about staffing at the facility and stated, There is no one here to give the meds. A review of R24 medication administration record revealed multiple medication documented more than two hours after the scheduled time.
Percocet tablet (pain medication)10-325 MG (milligram) Give 1 table by mouth every 8 hours for pain management. Schedule Date: 12/10/22 14:00 (2:00 PM). Administration Record: 12/10/22 18:09 (6:09 PM).
Diclofenac Sodium Gel 1% Apply to affected areas topically every shift for pain. Schedule Date 12/11/22 07:00 (7:00 AM). Administration Record: 12/11/22 15:10 (3:10 PM).
Rivaroxban Tablet 20 MG Give 1 tablet by mouth one time a day related to Cerebellar Stroke Syndrome. Schedule Date: 12/10/22 06:00 AM. Administration Record: 12/10/22 11:42 AM.
Duloxetine HCI Capsule Delayed Release Particles 30 MG. Give 1 capsule by mouth one time a day related to Major Depressive Disorder, Recurrent Mild. Administration Record: 12/10/22 11:44 (11:44 AM).
Fenofibrate Tablet 48 MG Give 1 tablet by mouth one time a day related to Hemiplegia. Schedule Date: 12/10/22 06:00. Administration Record: 12/10/22 11:40 (11:40 AM).
Resident #87 (R87)
12/07/22 at 10:15 AM, R87 was asked about the care at the facility and stated, They need more staff. Meds are late and I wait a long time for someone to come and change me. A review of R87's medication administration record revealed multiple medication documented more than two hours after the scheduled time.
Ipratroplum Solutions 0.5-25 MG/3ML (milliliter). 3ml inhale orally four times a day for SOB (shortness of Breath)/wheezing via nebulizer. Schedule Date: 12/10/22 09:00 (9:00 AM). Administration Record: 12/10/22 15:58 (3:00 PM).
Other medication that was documented as late on 12/10/22 were: Bumex, Albuterol. 12/11/22 9:00 AM medications were documented as administered after 3:00 PM.
12/13/22 at 1:30 PM, the scheduler was asked about staffing for the weekend and explained, that over the weekend (12/10/22 and 12/11/22) there were eight call off's and the facility had to call a staffing agency for CNA (Certified Nurse Aide) coverage.
Resident #23 (R23)
On 12/07/22 at 12:06 PM, R23 was asked about the care at the facility and stated, I been waiting about 30 minutes for someone to come in change me. R23 was asked to press the call light at that time. At 12:09 PM, staff from medical records came into R23's room and turned the light off and said they would go get the person to help. At 12:14 PM, the medical records staff came into R23's room and reported that the aide had one person in front of R23. At 12:40 PM, aide was observed to enter R23's room.
A review of R23's medical record revealed, R23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Cerebral Infarction Significant change in status. A review of R23's Minimum Data Set assessment dated [DATE], noted R23 required extensive assistance by two staff for physical assist with bed mobility, transfer, and dressing.
On 12/13/22 at 2:38 PM, the Director of Nursing (DON) was asked about late medication administration and reported, that she found that the nurses were giving them on time, but charting late. The DON was told the observations of late medication administration with Nurse K and the reports from the residents. The DON reported that she would look into the concern.
On 12/13/22 at 10:08 AM, during an interview with the DON regarding staffing, she reported the facility lost the staff scheduler with in the last month and staffing had been crazy, but the facility had hired a new scheduling staff member.
A facility policy regarding staffing was requested and never received by survey exit.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s), $101,905 in fines. Review inspection reports carefully.
- • 47 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $101,905 in fines. Extremely high, among the most fined facilities in Michigan. Major compliance failures.
- • Grade F (13/100). Below average facility with significant concerns.
Bottom line: Trust Score of 13/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is The Orchards At Roseville's CMS Rating?
CMS assigns The Orchards at Roseville 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 Roseville Staffed?
CMS rates The Orchards at Roseville's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 68%, which is 22 percentage points above the Michigan average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 67%, 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 Roseville?
State health inspectors documented 47 deficiencies at The Orchards at Roseville during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 45 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates The Orchards At Roseville?
The Orchards at Roseville 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 169 certified beds and approximately 115 residents (about 68% occupancy), it is a mid-sized facility located in Roseville, Michigan.
How Does The Orchards At Roseville Compare to Other Michigan Nursing Homes?
Compared to the 100 nursing homes in Michigan, The Orchards at Roseville's overall rating (2 stars) is below the state average of 3.1, staff turnover (68%) is significantly higher than 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 Roseville?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is The Orchards At Roseville Safe?
Based on CMS inspection data, The Orchards at Roseville has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Michigan. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at The Orchards At Roseville Stick Around?
Staff turnover at The Orchards at Roseville is high. At 68%, the facility is 22 percentage points above the Michigan average of 46%. Registered Nurse turnover is particularly concerning at 67%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was The Orchards At Roseville Ever Fined?
The Orchards at Roseville has been fined $101,905 across 2 penalty actions. This is 3.0x the Michigan average of $34,098. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is The Orchards At Roseville on Any Federal Watch List?
The Orchards at Roseville 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.