Regency at Shelby Township
For profit - Corporation
116 Beds
CIENA HEALTHCARE/LAUREL HEALTH CARE
Data: November 2025
Trust Grade
48/100
#223 of 422 in MI
Photo by Regency at Shelby Township
Photo by Regency at Shelby Township
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Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Regency at Shelby Township has a Trust Grade of D, indicating below-average performance with some concerns about resident care. They rank #223 out of 422 facilities in Michigan, placing them in the bottom half of the state, and #16 out of 30 in Macomb County, meaning there are better local options available. The facility is worsening, with issues increasing from 10 in 2023 to 11 in 2024. Staffing is a concern, with a 59% turnover rate, significantly higher than the state average of 44%, which may affect the continuity of care. They have $15,593 in fines, which is on par with other facilities, and average RN coverage, meaning they have enough registered nurses to catch potential problems. However, there are serious issues reported, such as a staff member verbally abusing a resident and failing to respond to call lights, leaving residents without necessary assistance. Additionally, there were concerns about food safety and hygiene in the kitchen, which could affect all residents. Overall, while the facility has some strengths, such as average staffing and RN coverage, the weaknesses in resident care and safety are significant factors for families to consider.
- Trust Score
- D
- In Michigan
- #223/422
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 59% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $15,593 in fines. Higher than 95% of Michigan facilities. Major compliance failures.
- Skilled Nurses ○ Average
- Each resident gets 36 minutes of Registered Nurse (RN) attention daily — about average for Michigan. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 39 deficiencies on record. Higher than average. Multiple issues found across inspections.
48/100
Bottom 48%
Needs review
10 → 11 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 10 issues
2024: 11 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
3-Star Overall Rating
Near Michigan average (3.1)
Meets federal standards, typical of most facilities
Staff Turnover: 59%
13pts above Michigan avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $15,593
Below median ($33,413)
Minor penalties assessed
Chain: CIENA HEALTHCARE/LAUREL HEALTH CARE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (59%)
11 points above Michigan average of 48%
The Ugly 39 deficiencies on record
1 actual harm
Sept 2024
11 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
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 one resident (R25) was catheterized (straight cathed-tube i...
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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 one resident (R25) was catheterized (straight cathed-tube inserted into the bladder to help drain urine) timely out of one reviewed for dignity, resulting in the potential for feelings of sadness. Findings include:
On 09/11/24 at 2:27 PM, an interview with R25 occurred and R25 stated Because I am one of the youngest ones here, I try not to cause trouble. I was up by 5:00 AM and cathed for my doctor's appointment. Upon returning from the appointment at 1:00 PM, I asked the nurse to cath me again because it was hurting. I had to wait until 3:00 PM. I was really upset and sad about waiting so long to be cathed. It made me feel sad like the nurses don't care about me or how I feel.
A review of R25 medical record revealed they were admitted into the facility on 7/23/24 with
diagnoses of Scoliosis, Insomnia, Hypertension, and Neuromuscular Dysfunction of Bladder. A review of R25's Minimum Data Set (MDS) assessment dated [DATE] revealed, R25's Brief Interview for Mental Status assessment score was a15 indicating intact cognition.
On 09/12/24 at 12:25 PM, an interview occurred with the Director of Nursing (DON) regarding the expectations of residents rights regarding dignity and care. The DON stated, It is my expectation the resident needs would be cared for once they asked for assistance
A review of the policy titled Resident Rights and Facility Responsibilities dated 9/01/13 and revised 5/14/24 revealed Dignity, Respect & Quality of Life. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.
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, interview, and record review, the facility failed to provide one resident (R56) of three residents reviewe...
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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 one resident (R56) of three residents reviewed for accommodation of needs with a comfortable bed, resulting in feelings of dissatisfaction and discomfort. Findings include:
On 9/10/24 at 2:58 PM, R56 was observed in bed with their feet on the end of the bed on the bed board, a pillow was underneath their feet. R56 was observed to be obese and their was very little room in the bed on either side of their body. R56 was interviewed about the comfort of their bed and indicated they were uncomfortable and dissatisfied with their bed. R56 stated, Can you talk to them about getting me a better bed.
On 9/10/24 at 3:05 PM, Certified Nurse Assistant (CNAG) entered R56's to provide them with fresh water and was asked about R56's bed. CNA G stated, We need better beds.
On 9/11/24 at 10:46 AM, R56 was observed in bed on their back with very little room in the bed on either side of their body. R56 stated, I cannot move in this bed. Once they put me in bed, I can't move. R56 again indicated they would like assistance with obtaining a more comfortable bed.
On 9/11/24 at 12:35 PM, an interview was conducted with Nurse/RN (Registered Nurse) H regarding R56's bed and R56's discomfort with their bed. Nurse H stated, I don't know why [R56] doesn't have a bariatric bed (Heavy-duty bed wider than a standard hospital bed).
On 9/11/24 at 2:20 PM, Unit Nurse Manager (UNM)/RN I was interviewed regarding R56's bed and the discomfort expressed by R56 regarding their bed. UNM I stated, I believe [R56] has a bariatric bed.
On 9/11/24 at 4:33 PM, R56 was again visited in their room and was observed in bed on their back with very little room in the bed on either side of their body. R56 was further interviewed about their bed and stated, I need a bigger bed.
On 9/11/24 at 4:44 PM, Environmental Services Director (ESD) J was interviewed about the bed in R56's room and indicated that R56's room was a bariatric room and should have a bariatric bed in it. EVS J and the surveyor then proceeded to go to R56's room and observed their bed. Upon observation of R56's bed, EVS J stated, That's not a bariatric bed. I'm going to have to look into that.
On 9/12/24 at 10:37 AM, the Administrator (NHA) was interviewed regarding their expectations for ensuring that obese residents have comfortable beds and are comfortable when in bed. The NHA indicated that all beds in the facility are considered to be bariatric, It's by weight, not by dimension. The NHA was asked specifically about R56's bed and R56's expressed discomfort when in their bed. The NHA stated, Rolling (moving side to side) was the issue, we discussed a positioning bar for [R56]. We don't have a bigger bed, but are not opposed to it if necessary.
A record review of R56's electronic medical record (EMR) revealed that R56 was admitted to the facility on [DATE] with diagnoses that included Morbid obesity and Muscle weakness. A review of R56's vitals revealed on 9/12/24 R56 was weighed and had a weight of 384 pounds. A review of R56's most recent minimum data set assessment (MDS) dated [DATE] revealed that R56 had an intact cognition and was dependent upon staff for all activities of daily living (ADLs).
A review of a facility policy titled, Bariatric bed use Revised: May 20, 2024 revealed the following, Introduction: .Various types of bariatric beds are available, ranging from [a] simple larger version of the standard bed to a bed with a low air mattress that provides pressure relief. A bariatric bed provides more comfort for a patient with obesity then a standard-sized hospital bed. A bariatric bed also preserves the self-esteem of a patient with obesity by fitting the patient's larger body size easily and providing special side rails that help the patient with turning and repositioning .
A review of the manufacture's product summary for Adjustable-width long-term care bed revealed the following, Product Description: The innovative [Product identification number] adjusts from 36 (Inches) to 39 to 42 .One bed can accommodate most residents in comfort safety, including many bariatric residents .
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develope a comprehensive care plan for one (R103) out ...
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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 develope a comprehensive care plan for one (R103) out of six residents reviewed for care plans. Findings include:
On 9/10/24 at 10:20 AM, 2:05 PM, and 4:22 PM, and on 9/11/24 at 8:29 AM, 9:52 AM, 12:05 PM, 1:23 PM, and at 4:22 PM, R103 was observed lying in bed and a back brace was observed in R103's room.
On 9/12/24 at 8:49 AM, R103 was observed standing in the hallway with their walker. Certified Nurse Assistant (CNA) C stated, Where is your back brace, you need to have it on at all times. CNA C was then observed applying R103's back brace.
A review of R103's medical record revealed they were admitted to the facility on [DATE] with a diagnosis of Wedge compression fracture of fifth lumbar vertebra, subsequent encounter for fracture with routine healing. A review of R103's Brief Interview for Mental Status revealed a score of four, indicating cognitive impairment.
A review of R103's physician orders revealed an active order which documented, Lumbar brace when OOB (out of bed). Check skin integrity under brace q (every) shift. Report any abnormal findings to MD/NP (medical doctor/nurse practitioner).
A review of R103's care plan and [NAME] (guide to resident care) revealed no documenteation of the back brace.
On 9/11/24 at 12:00 PM, during an interview, CNA C was asked how they ensure they have accurate information about a resident and confirmed they use the [NAME] which has information about their care.
On 9/12/24 at 9:30 AM, during an interview, Licensed Practical Nurse (LPN) D was asked if R103 is supposed to wear a back brace. LPN D replied No, (they) are not. LPN D was asked how would they knew if R103 was supposed to wear a back brace and said, I would look in the residents' careplan and if they are to wear a brace.
On 9/12/24 at 11:30 AM, during an interview, the Director of Nursing (DON) was asked to review R103's orders and careplan and was asked if R103 is supposed to be wearing a back brace. The DON stated (R103) does have an order for one so yes (they) should be wearing it. The DON was reviewing R103's care plans and confirmed the back brace should be included in the care plan.
A review of the facility's policy titled Care Planning stated the following: Every resident in the facility will have a person-centered plan of care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment that includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs identified in the comprehensive assessments and prepared by an interdisciplinary team who includes but not limited to; attending physician, a registered nurse who is responsible for the resident, a nurse aide, a member of food/nutrition services, the resident or resident representative, therapy staff as required and any other ancillary staff.
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 a care plan to reflect interventions for wandering behaviors for one resident (R76) out of one reviewed for behaviors....
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Based on observation, interview, and record review, the facility failed to revise a care plan to reflect interventions for wandering behaviors for one resident (R76) out of one reviewed for behaviors. Findings include:
On 9/10/24 at 10:13 AM, R76 was observed lying in bed sleeping soundly.
On 9/10/24 at 4:00 PM, R76 was observed sitting up in bed watching television.
On 9/10/24 during a confidential resident council, three residents discussed R76 wandering and behaviors at night. One resident stated, I have complained about (R76) coming into to room at all hours of the night. R76 doesnt pay attention to 'stop signs' on doors or if door is closed. I have to yell for the staff to come and help. R76 hits the staff and is difficult with them as well.
A review of the record revealed R76 was admitted into the facility 02/05/24 with following diagnoses: Alzheimer's Disease, Dementia, Hyperlipidemia, Catatonic Schizophrenia and Depressive disorder. A review of the Minimum Data Set (MDS) assessments on 8/14/24 revealed, Brief Inverview Mental Status assessment score was 00 indicating severely impaired cogntition.
Further review of the active care plans revealed:
-A care plan, (R76) is at risk for elopement and/or wandering R/T (related to) dementia initiated 02/05/24, revised 08/23/24 with no noted new interventions since 2/05/24.
-A care plan, (R76) is at risk for decline in cognition and has impaired cognitive function or impaired thought processes r/t Alzheimer's, impaired decision making, poor safety awareness, inability to follow directions and short term memory loss care plan initiated 2/07/24 and last revised 03/07/24 was noted with no new interventions since 2/07/24. The care plan did not represent the intrusive behaviors identified.
On 9/12/24 at 10:00 AM, along with Social Worker (SW) K a review of R76's care plans and interventions occured. SW K stated interventions are discussed and used to try to keep R76 from going into other residents rooms and areas.
On 9/12/24 at 12:26 PM, an interview with the Director of Nursing (DON) occurred and confirmed the interventions should be changed and be effective related to residents care plans.
A review of the policy titled, Care Planning implemented 9/01/11 and revised 6/24/21, revealed, Every resident inthe facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment that included measurable objectives and time framesto meet a residents medical, nursing, mental and psychosocial needs .The results of the interdisciplinary assessments will be used to develop, review and revise the residents care plans.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow up on physician's orders to scheduled an appoin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow up on physician's orders to scheduled an appointment for one resident (R30) of one resident reviewed for consultation.
Findings include:
On 09/10/24 at 9:30 AM, R30 was observed sitting on the side of his bed watching television. When asked about concerns with care, R30 stated Yes. I have not seen the wound doctor lately due to my old sore and I have a rash on my side that really itches and burns.
A review of R30's medical record revealed a physician's note dated 8/28/24 stating Resident was seen for the Chief Complaint: Requesting dermatology consult. Patient was seen today at their request for rash to the back of left hip and left groin. Resident also reports that it has been on the back for a long time, so this is not new for this patient. The areas appear round and raised, but no scaly or dry skin noted. Resident does report that they are itchy, sore and sometimes burns. They are very difficult to see. Resident states that the hydrocortisone cream did not help.
On 9/11/24 at 10:05 AM, Charge Nurse L was queried about the order and its follow up and revealed they were not aware of any follow up appointments.
On 9/11/24/at 12:55 PM, an interview occurred with Wound Care Nurse F who stated they did not know about the consult.
On 9/11/24 at 1:00 PM an observation of R30 affected area was observed with Nurse F. The observation revealed that R30's whole back, arms and lower back were covered with a rash and several scaly areas.
Further review of R30's medical record revealed they were admitted into the facility on 4/17/24 with
diagnoses of Orthopedic Aftercare, Type 2 Diabetes, Hypertension; Sleep Apnea. A review of R30's Minimum Data Set (MDS) assessment dated [DATE] revealed R30's Brief Interview for Mental Status (BIMS) assessment score was a 10 indicating mildly impaired cognition.
On 9/12/24 at 10:23 am, during an interview with the Director of Nursing (DON) stated, My expection would be that the appointment would be made by the appropriate party and the residents care would be followed up on.
A review of the policy titled Resident Rights and Facility Responsibilities dated 9/01/13 and revised 5/14/24 revealed A resident is entitled to recieve adequate and appropriate care, and to receive, from the appropriate individual within the health facility or agency, information about his or her medical condition, proposed course of treatment, and prospects for recovery in terms that the resident can understand .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services to maintain the functional abilities...
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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 services to maintain the functional abilities of one (R70) out of one resident reviewed. Findings include:
On 9/10/24 at 9:34 AM, R70 was observed lying in bed. R70 was asked if they had any concerns about their care. R70 explained they can no longer get out of bed as much as they used to and now need help with bathing. R70 explained they were previously getting therapy which was helping them perform their hygiene care and they were getting stronger but now they are on restorative care but haven't been getting it and cannot do anything without help now.
09/11/24 11:51 AM R70 was observed in the bathroom sitting in their wheelchair at the sink. R70 explained it takes them a long time to get washed up because they are much weaker since not receiving therapy.
A review of R70s electronic medical record (EMR) revealed they were admitted to the facility on [DATE] with the following diagnosis: Hypothyroidism unspecified. A review of R70's Brief Interview for Mental Status revealed a score of 15 indicating intact cognition.
A review of R70's physician orders dated 7/17/24 revealed the following: D/C (discontinue) skilled OT/PT (occupational therapy/physical therapy) tx (treatment) services and refer to RNP (restorative nursing program).
A review of R70's therapy restorative program plan revealed the following: Restorative Plan Detail 1. Restorative Plan BUE (bilateral lower extremeities)/LE (lower extremeities) AROM (active range of motion) all available planes 15 reps x2 sets, 1 - 3x weekly for 12 weeks. 2. Date of Plan 08/02/2024 3. Goal(s) To maintain mobility and ADL (activities of daily living) function. 4. Interventions BUE/LE AROM all available planes 15 reps x2 sets, 1 - 3x weekly for 12 weeks.
A review of R70's care plan revealed the following: (R70) is at risk for decline in function and requires Restorative Nursing r/t (related to) Impairment in range of motion. BLE AROM all available planes 15 repsx2 sets, 1-3x weekly for 12 weeks. BUE (bilateral upper extremity) AROM all available planes 15 reps x2 sets, 1-3 x weekly for 12 weeks.
A review of R70's EMR task list revealed no documentation of receipt of restorative treatment.
On 9/12/24 at 1:55 PM, during an interview with Physical Therapist (PT) E was asked if R70 was currently receiving therapy services. PT E explained R70 was not currently receiving physical or occupational therapy and R70 was discharged from physical and occupational therapy on 7/17/24 and was referred to the restorative nursing program to maintain contractures and limitations.
On 9/12/24 at 2:20 PM, during an interview, Restorative Nurse F was asked if R70 was currently receiving restorative nursing services. Nurse F explained there are two Certified Nurse Assistants (CNAs) that perform the restorative services and they divide the residents amongst themselves and R70 was scheduled to be seen on Tuesdays, Thursdays, and Saturdays. Nurse F confirmed R70 only received restorative services one time within the 12-week period saying, I'm going to look into it.
A review of the facility's policy titled Restorative Nursing revealed the following: Purpose: The facility strives to enable the resident to attain and maintain the highest practicable level of physical, mental, and psychosocial well-being .Nursing restorative is available up to 6-7 times per week and is provided for residents meeting restorative program criteria .If resident refuses to participate then care needs will be managed by nursing and other clinical staff as indicated. Document any refusal in the resident's medical record .Document the resident's daily participation and actual number of minutes participating in the resident electronic health 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
Based on observation, interview, and record review, the facility failed to properly store an oxygen tank for one resident (R221) out of five reviewed for respiratory care. Findings Include:
On 9/10/20...
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Based on observation, interview, and record review, the facility failed to properly store an oxygen tank for one resident (R221) out of five reviewed for respiratory care. Findings Include:
On 9/10/2024 at 10:20 AM, R221 was observed sitting in their room and was receiving oxygen via a nasal cannula. R221 stated they had recently arrived at the facility and needed oxygen continuously.
In the corner of the room an oxygen tank was observed freestanding. No stand or cart was noted in the room.
A review of the medical record revealed R22 admitted into the facility on 9/9/2024 with the following medical diagnoses, Lung Cancer and Chronic Obstructive Pulmonary Disease (COPD). A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition.
On 9/10/2024 at 10:31 AM, Certified Nursing Assistant (CNA) R was asked about the oxygen tank was in R221's room without a stand. CNA R stated they were going to get a stand immediately.
A review of a facility policy titled, Oxygen Storage and Assembly noted the following, Oxygen Tank Safety .Store each tank individually, by a chain, on a cart, or on a stand.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0691
(Tag F0691)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to obtain physician orders for colostomy (an opening through the skin) care for one resident (R11) out of one reviewed for colos...
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Based on observation, interview, and record review, the facility failed to obtain physician orders for colostomy (an opening through the skin) care for one resident (R11) out of one reviewed for colostomy care. Findings include:
On 9/10/2024 at 10:00 AM, R11 was observed laying in bed. R11 stated they were about to get up and get ready for lunch. R11 stated they needed their colostomy emptied. R11 stated they have had a colostomy for quite some time. R11 stated the staff does empty it, but they have to remind them.
A review of the medical record revealed that R11 admitted into the facility on 9/4/2024 with the following diagnoses, Chronic Respiratory Failure with Hypoxia and Major Depressive Disorder. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status score of 13/15 indicating an intact cognition. R11 also required staff assistance with bed mobility and transfers. The MDS assessment also noted R11 had an colostomy.
Further review of the physician's order and task guide did not reveal an order for colostomy care, including changing.
On 9/12/2024 at 12:13 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed R11 was admitted into the facility with a colostomy and stated R11 had been in and out of the hospital and their colostomy care orders must not have been reactivated.
A review of a facility policy titled, Colostomy and Ileostomy, appliance care, long-term care did not mention colostomy care orders and task.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
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 ongoing behavioral health services for one re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide ongoing behavioral health services for one resident (R27) out of eight reviewed for behavioral health. Findings include:
On 9/10/24 at 10:00 AM, R27 was observed in bed. R27 explained they used to get out of bed into their wheelchair but does not feel like getting out of bed anymore because they are worried about their son whom they have been supporting financially and is now running out of money to support.
On 9/11/24 at 11:24 AM, during an interview, Social Worker (SW) P was asked if they were aware of R27s mood and concerns regarding their son. SW P explained they were aware and they talked to accounts receivable and informed R27 of how much money was left over after they paid the facility. SW P also explained that they provided R27 with the name and phone number of a church and called R27s older son.
On 9/12/24 at 11:59 AM, R27 was observed in bed awake with the blinds closed and staring at the wall. R27 was observed to be wearing the same clothes as observed on the previous day. When asked if they had breakfast yet R27 stated they did not feel like eating. R27 stated I feel very bad. I wish to die. I have no money to help my son and he tells me he will be on the street. When asked if they had been eating, R27 stated I eat a little bit. I wish to die today but Jesus Christ told me it's not my time. I ask him to take me away. I don't want to eat. I have no appetite most of the time. This is not your problem, but I have to talk to someone. I wish to die so I don't have to worry anymore. I wish to die. I wish to die. I wish to die. Please Jesus take me away. I am so tired of this life.
A review of R27's record revealed they were admitted to the facility on [DATE] with the following diagnosis: pressure ulcer of sacral region; Anxiety disorder unspecified. A review of R27's Brief Interview for Mental Status revealed a score of 15 indicating intact cognition.
A review of R27's progress notes revealed a nurses note dated 9/1/24 stated: Guest refused lunch this shift, (R27) is worried about (R27) son and (R27's) sons financial situation, notified social work.
Further review of R27's record revealed a psychiatry note dated 7/5/24 stated He has obvious depression . demeanor: calm, pleasant, cooperative. Suicidal ideation: denies. Appetite: good. Notify of changes in mood or behaviors. Will follow. No other psychiatry notes or referrals were found.
On 9/12/24 at 11:30 AM, during an interview the Director of Nursing (DON) they explained they (residents) should be seen as needed and for any concerning behaviors or anything out of the ordinary.
A review of R27's care plan revealed the following: (R27) has the potential for fluctuation in mood r/t (related to) anxiety. Behavioral health/psych consults as needed and follow recommendations as indicated. Observed and report to SW and/or physician prn (as needed) acute changes in mood or behavior; feelings of sadness; increased anxiety/agitation, depression, withdrawal/loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills; how resident interacts with others.
On 9/12/24 at 12:12 PM, Certified Nurse Assistant (CNA C) was asked if they were aware of R27s mood and explained they thought R27 was upset and had gotten into a fight with their son. CNA C explained R27 doesn't always seem this way and the depressed mood was new.
A review of the facility's policy titled Behavior Management revealed the following: The facility will provide individualized care and services that promote the highest practicable level of function by providing activity/functional programs as appropriate and safety interventions to minimize behaviors .7. Resident may require a referral to psychiatric/psychological services or spiritual care. 9. A Behavior Management meeting will be conducted monthly and PRN or at the resident at risk at least monthly, as needed by the interdisciplinary team and document any changes in the care plan at the meeting. Residents will be reviewed during the meeting are as follows: Residents identified with new or worsening behaviors (including mood changes).
A review of the facility's policy titled Social Services Referral to Outside Providers revealed the following: Referrals to ancillary providers will be made to meet the psychosocial and or concrete needs of a resident while safeguarding protected health information .9. Follow up visits will be scheduled as needed. 10. The mood/behavior/psychosocial/trauma or substance abuse issues, that prompted the need for services, are to be monitored and the service provider is to be kept informed of the evaluation of progress.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to practice proper infection control practices in a contact isolation room and properly store nebulizer/C-Pap (non-rebreather) m...
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Based on observation, interview, and record review, the facility failed to practice proper infection control practices in a contact isolation room and properly store nebulizer/C-Pap (non-rebreather) mask for five residents (R36, R223, R221, R74, and R11) reviewed for infection control. Findings include:
R36
On 9/10/2024 at 12:06 PM, the call light for R36 was seen activated. R36 was noted to be on contact precautions. A sign, as well as personal protective equipment (PPE) was observed on the door.
On 9/10/2024 at 12:07 PM, Maintenance Assistant (MA) B was observed going into the room. MA B did not don/doff any PPE, nor perform hand hygiene upon exiting the room.
A review of the medical record revealed R11 admitted into the facility on 9/4/2024 with the following diagnoses, Chronic Respiratory Failure with Hypoxia and Major Depressive Disorder. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 13/15 indicating an intact cognition. R11 also required staff assistance with bed mobility and transfers.
On 9/12/2024 at 9:44 AM, an interview was conducted with the Director of Nursing (DON). The DON stated anyone who goes into a contact isolation room should be wearing all PPE, including gowns, gloves, and a mask. The DON also stated hand hygiene should occur upon exiting.
A review of a facility policy titled, Contact Precautions noted the following, Health care personnel caring for guests/residents on Contact Precautions should wear gloves and a gown for all interactions that may involve contact with the guest/resident or potentially contaminated areas in the guest's/resident's environment.
R223
On 9/10/2024 at 9:30 AM, R223 was observed in bed. R223 nebulizer mask was observed sitting n the nightstand. No barrier was observed between the mask and the nightstand. R223 stated they use the mask because they have lung cancer.
On 9/10/2024 at 2:42 PM, R223's nebulizer mask was observed still sitting on the nightstand with no barrier in between it.
R221
On 9/10/2024 at 10:20 AM, R221 was observed sitting up in their wheelchair. Their nebulizer mask was observed laying on the nightstand with no barrier in between them.
R74
On 9/10/2024 at 9:20 AM, R74 was observed sitting in a chair. R74's C-Pap mask was observed laying on the nightstand with no barrier in between them.
On 9/11/2024 at 10:20 AM and 11:52 AM, R74's C-Pap was observed laying on the nightstand with no barrier in between them.
R11
On 9/10/2024 at 10:00 PM, R11 was observed laying in bed. R11 stated they have been in and out of the hospital a few times for not wearing their C-pap mask. Their C-pap mask was observed on their bedside table with no barrier in between them.
On 9/11/2024 at 12:27 PM, R11's C-Pap mask was observed laying on the bedside table with no barrier in between them.
On 9/12/2024 at 8:42 AM, R11's C-Pap mask was observed laying on the bedside table with no barrier in between them.
On 9/12/2024 at 9:50 AM, an interview was conducted with the Director of Nursing (DON). The DON stated they have order sets for the nebulizer and c-pap mask for them to be cleaned. The DON stated they should be cleaned and set on a paper towel to dry and then put away once dry.
A review of a facility policy titled, Noninvasive positive-pressure ventilation, respiratory therapy id not mention storage practices.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R47
On 9/11/24 at 1:24 PM, call lights were observed to be on for rooms [ROOM NUMBER] (where R47 resided).
On 9/11/24 at 1:25 PM...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R47
On 9/11/24 at 1:24 PM, call lights were observed to be on for rooms [ROOM NUMBER] (where R47 resided).
On 9/11/24 at 1:25 PM, a therapy staff member, an activities staff member, a Certified nurse assistant (CNA), and a nurse all walked passed all 3 lights. A vendor was observed to leave room [ROOM NUMBER] and went to the nurses station to inform them the resident in room [ROOM NUMBER] needed help.
On 9/11/24 at 1:27 PM, the same nurse walked past all 3 call lights again.
On 9/11/24 at 1:28 PM, the activities staff member walked past all 3 lights again.
On 9/11/24 at 1:29 PM, the same nurse walked past again.
On 9/11/24 at 1:29 PM, the Director of Nursing (DON) walked in to room [ROOM NUMBER] and turned the call light off.
On 9/11/24 at 1:31 PM, a CNA turned off the light in room [ROOM NUMBER] and exited the room.
On 9/11/24 at 1:33 PM, R47 in room [ROOM NUMBER] was yelling out nurse!. When asked if anyone addressed their needs when they turned the call light off R47 stated no. they just turned it off and I gave up on it. R47 said they were yelling because they needed help and no one answered.
On 9/12/24 at 10:00 AM, during an interview, The Nursing Home Administrator (NHA) was asked about their expectations for staff when responding to resident needs and explained call lights should be answered within 15 to 30 minutes and explained that lengthy call light times and unanswered call lights is a known problem that has been brought to their attention in resident council repeatedly. The NHA explained the expectation is, all employees answer the lights.
On 9/12/24 at 11:30AM, during an interview, the Director of Nursing (DON) said they hope for a prompt answer of call lights and everything is taken care of at that time. The DON explained everybody should be answering call lights.
A review of the facility's policy titled Call Lights revealed the following: Call lights will be placed within the guests/residents reach and answered in a timely manner. 1. Identify the location and answer the guest/resident promptly. 2. Knock on the door, identify yourself and ask the guest/resident wat you can help them with. 3. Go to the location of the call light and turn off the light if you are able to meet the guest/resident request. 4. Do what the guest/resident requests of you, if permitted. If you are unsure go, ask the charge nurse. 5. When finished, turn the call light off an replace the call light within guests/resident's reach.
On 9/11/2024 at 9:50 AM, the call light for room [ROOM NUMBER] was observed activated.
At 10:00 AM, the light was still observed to be activated, the nurse for the hallway was observed at their cart.
At 10:06 AM, the light was still observed to be activated and therapy staff was observed walking past the light.
At 10:10 AM, the light was observed still activated and the nurse was noted to be in the hallway.
At 10:13 AM, the light was answered by a Certified Nursing Assistant (CNA) and care was rendered.
Based on observation, interview, and record review, the facility failed to respond to residents needs(call lights) in a timely manner for one resident (R81 and R47) and two resident rooms (rooms [ROOM NUMBERS]) fourteen reviewed for call light response. Findings include:
R81
On 9/10/24 at 9:59 AM, R81 was interviewed in their room with their daughter present and ask about the care and services they were receiving at the facility. Both R81 and their daughter indicated that call light wait times, Can be long, up to forty five minutes during the early morning and on weekends.
A review of R81's electronic medical record (EMR) revealed R81 was originally admitted to the facility on [DATE] with diagnoses that included, aftercare following knee joint prosthesis and weakness. R81's most recent minimum data set assessment (MDS) dated [DATE] revealed R81 had an intact cognition and required partial to moderate assistance with all activities of daily living (ADLs) other than eating and oral hygiene.
On 9/12/24 at 3:15 PM, CNA M was interviewed and asked about their ability to respond to and meet resident care needs. CNA M stated, It can be challanging.
09/12/24 03:25 PM, CNA O was interviewed about their ability to respond and meet resident care needs in a timely manner. CNA O stated, If we are fully staffed it's okay, if not then it's difficult. CNA O indicated they frequently work on units that are not fully staffed.
Jul 2023
10 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
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 Intakes: MI00135903 and MI00135359.
Based on observation, interview, and record review, the facility f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes: MI00135903 and MI00135359.
Based on observation, interview, and record review, the facility failed to provide an environment free from verbal abuse, physical abuse, and neglect from staff to resident for one of one sampled resident (R51) reviewed for abuse resulting in, abuse, neglect and the likelihood of mental anguish using the reasonable person concept. Findings include:
A review of Intake called into the State Agency: MI00135903 revealed the following, (R51) had called Certified Nursing Assistant (CNA L) an '[expletive]' and [they] replied, 'no you are an [expletive]' .(R51) and (CNA L) exchanged verbal remarks back and forth and then (CNA L) slapped (R51) on (their) bare bottom and said to (them), who is your daddy? .
On 7/24/23 at 10:00 AM, R51 was observed lying in bed and asked about the incident that took place on 3/13/23 between them and CNA L. R51 explained that they have problems with their memory, and did not remember the incident.
A review of R51's medical record revealed that they were admitted into the facility on 7/27/20 with diagnoses that included, Heart Failure, Dementia, Diabetes, and Fibromyalgia. Further review of R51's medical record revealed a quarterly Minimum Data Set assessment dated [DATE] revealing a Brief Interview for Mental Status score of 12/15 indicating an intact cognition. In addition, R51 required extensive assistance of 2 persons for bed mobility, transfers, dressing and toilet use.
Further review of R51's medical record revealed the following progress note:
3/16/2023 16:05 (4:05pm) Social Services Note. SW (social worker) checked on resident again r/t (related to) prior incident. When SW asked if resident is okay resident replied 'I am fine.' .Resident expressed to SW that [they were] in fear to tell someone about the prior incident. SW assured resident that they did the right thing .
On 7/25/23 at 10:18 AM, a phone call was attempted to CNA L to no avail. A message was left however, they did not return the surveyor's call by the end of survey.
A review of the local police departments police report regarding the incident between R51 and CNA L revealed the following interview of CNA L:
(Police officer) made contact with (CNA L) regarding this incident. He stated he has been doing nursing home care for 35 years and this incident was a big misunderstanding. He stated that he was
requested to come help with changing (R51). He stated that (R51) immediately started calling
him an a**hole. He says that (R51) scratched his arm while he was rolling (them) so he did call (R51)
an a**hole back .(CNA L) stated that while he was holding (R51) his grip slipped and he grabbed (their) hips. He stated (R51) called him a bastard at this time and he stated that he told (R51) I know who my daddy is. He said he never slapped (R51's buttocks) .I asked (CNA L) if he ever threatened to drop (R51) on the ground and he stated he did not. I asked him about how he moved (R51) back up on the bed and he stated that they did not have to. He stated he left the room and was called into the office and fired for swearing at (R51)
A review of CNA L's personnel file revealed that their effective date of separation from the facility was on 3/21/23 for Residential Abuse. Also noted on the separation notice was the following, Describe the reason(s) for disciplinary action towards patient. Employee interviewed and readily admitted that [they] used a**hole when speaking with a patient. Pt. (patient) called employee an a**hole and employee responded with You're the [expletive], I'm trying to help you.
On 7/25/23 at 10:32 AM, Registered Nurse (RN) M was interviewed regarding the incident they witnessed between R51 and CNA L. RN M explained that they needed to complete a skin assessment on R51 who was newly re-admission from the hospital. RN M explained that they asked CNA N to assist with turning R51 during the skin assessment however, upon entering the room at approximately 10:00 AM, R51 was covered in stool which was seeping out of their brief. RN M explained that the stool was a mess and had never seen and cleaned up so much stool before, as it had seeped up the resident's back and was all over the sheets. RN M explained that they asked CNA N to obtain assistance from R51's assigned CNA for the day, CNA L to assist with cleaning the resident up. RN M explained that as CNA L walked into the room, R51 stated, Oh, it's you, (to CNA L). RN M explained that at that time, CNA L took their hand and smacked R51's exposed skin near their buttocks area and stated, Who's your daddy?
RN M explained that during the process of cleaning the resident, they were yelling and afraid that they were going to fall off the bed, and stated, Don't drop me. RN M stated that CNA L grabbed and shook R51's shoulders stating, Don't make me drop you. RN M also explained that instead of CNA L using a drawsheet to reposition R51 along with their assistance, CNA L used R51's shoulders and roughly repositioned the resident. RN M explained that R51 is a larger resident, but CNA L threw [them] in the middle of the bed in which the resident screamed out. RN M explained that CNA N made a statement toward CNA L that she could have assisted him with repositioning. RN M also explained that CNA L told the resident, I didn't miss you while you were gone, I'm glad you were in the hospital. and that CNA L called the resident an expletive as least twice during their care.
On 7/25/23 at 11:05 AM, CNA N was interviewed via phone and asked about the incident regarding CNA L and R51. CNA N explained that she was in the resident's room with RN M who needed to complete a skin assessment on R51 however, upon rolling the resident over, they observed that the resident had a large bowel movement and needed to be cleaned up, so she went to get CNA L to assist with cleaning the resident. CNA N explained that when CNA L entered the resident's room and began to assist, he took his hand and slapped R51 on the bare buttocks and stated, Who's your daddy? CNA N stated that R51's response was, You're an [expletive] in which CNA L's response was, It takes one to know one, you're an [expletive]. CNA N explained that CNA L was pulling and tossing R51 around on the bed during care in which CNA L stated to the resident, You're lucky that I don't throw your [expletive] on the floor as he kept pulling and pushing R51 closer to the end of the bed. CNA N explained that R51 was screaming and stating that they were going to call the police on him.
On 7/26/23 at 9:21 AM, a phone call was made to R51's family member, Family Member Q and was asked if R51 had mentioned anything to them about the incident with CNA L, and they explained that due to R51's memory loss, they hadn't mentioned anything recently, but shortly after the incident, had concerns that CNA L was going to come back into the facility.
A review of the Facility Reported Incident documentation including their abuse investigation completed by the facility revealed the following regarding their interview with R51, .Resident was not able to fully describe events 90 minutes prior (date: 3/13/23). (R51) indicated that [they] did swear at the employee and that the employee did swear back at [them]. (R51) also indicates that at some point today (3/13/23) the same employee placed his hand over [their] mouth when [they] told [they were] going to report him. However, the patient was unable to accurately identify the employee other than that to say it was the same person .
Further review of the facility's abuse investigation revealed the following, .In conclusion, the facility completed a thorough investigation and did substantiate the employee did use profanity and called the resident an [expletive]. The termination of employment of this employee was processed due to violation of company policy .
On 7/26/23 at 11:09 AM, the Director of Nursing (DON) was asked about the incident regarding CNA L and R51, and why they had not substantiated that physical abuse occurred toward R51 based on the observation by RN M and CNA N . The DON explained that they did not substantiate physical abuse because CNA L denied that physical abuse took place, and the resident wasn't able tell them what occurred.
A review of the facility's Abuse Prohibition Policy revealed the following, .Each guest/resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include freedom from verbal, mental, sexual, physical abuse, corporal punishment .Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .Verbal Abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the guest/resident to experience humiliation, intimidation, fear, shame, agitation, or degradation .Physical Abuse include hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment .Neglect is the failure of the facility, its employees or services provides to provide goods and services to a guest/resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00137843.
Based upon interview and record review, the facility failed to provide timely notif...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00137843.
Based upon interview and record review, the facility failed to provide timely notification of a fall with injury to the family member/responsible party of one (R481) of five residents reviewed, resulting in family member/responsible party not knowing right away that the resident fell and causing a delay in the opportunity to participate in medical decisions regarding care and treatment. Findings include:
Review of the facility record for R481 revealed an admission date of 06/13/23 with diagnoses including Dementia, Hypoglycemia, Diabetes Mellitus and Acute Kidney Failure. The Minimum Data Set (MDS) assessment dated [DATE] indicated R481 required maximum/total assistance for self care.
Additional review of the facility record pertaining to R481's reported fall revealed a Certified Nurse Assistant (CNA) found the resident on the floor of their room on 06/16/23 and the resident was found to have a bump next the left eye and no further obvious injury upon further assessment. R481 was reported to be alert and orientated x 3 and indicating that they attempted to ambulate to the bathroom without calling for assistance and using a bedside table as an assistive walking device. Following initial assessment of the resident and assisting them back to bed, the incident/accident report and related progress note indicated the on-call provider (physician) was notified and requested that the resident's eye be iced, the resident continue to be monitored and not sent to hospital at that time. There is no indication or report of the responsible party being notified directly following the incident. The incident/accident report (dated 06/17/23) states that the responsible party was notified on 06/19/23.
Review of the facility policy titled Fall Management dated 07/14/21 includes the following Practice Guideline:
6. The licensed nurse will notify the attending physician and the responsible party of the fall, and document the notification in the medical record.
On 07/26/23 at 9:52 AM, the facility Director of Nursing (DON) reported that the expectation is that staff report a resident fall/accident to the responsible party in a timely manner and acknowledged that notification was not provided in this case until the responsible party inquired about the fall during a visit. The DON reported that upon discovery of this deficiency, the corrective action was initiated.
During the onsite survey, it was found that the facility identified and corrected their deficient practice prior to the survey team entry. The facility did the following to correct its deficiency:
Facility QAPI Plan / Past Non-compliance. Delay in Notification to Responsible Party.
Date of Report: 06-19-23
Date of Event: 06-16-23 discovered on 06-19-23.
Description of Deficient Practice (why and how did it happen): Family of resident alerted facility of failure to notify family after an incident. The facility nurse failed to notify the responsible party secondary to a lack of knowledge, despite having orientation within the building stating otherwise.
A Review of the facility Incident and Accidents policy was reviewed and was deemed appropriate.
The resident was noted on the floor near her bathroom, face down, presumably pushing an over bed table to use the restroom. Bump noted to right eyebrow area. Patient assessed and physician services notified. Order for ice and monitoring was received. The facility failed to notify the responsible party of the incident.
Plan of Correction:
The facility identified all residents with a current incident since 6-16-23 to ensure notification of responsible party had occurred. No deficient practice was noted.
Corrective action taken for resident affected.
Resident (481) continues to reside in the building, no other residents affected by this deficient practice. Facility nurses will be inserviced on the need to notify responsible parties after incidents occur.
The facility immediately provided education to facility nurse on the need to notify responsible parties after an incident occurs. The administrative nurses will audit every incident to ensure responsible parties are notified after an incident. Any deficiencies will be immediately addressed and parties will be notified. Said nurse involved in deficient practice will be offered additional education.
The administrative nurses will complete an audit all patients having an incident weekly x 4 weeks and then monthly x 2.
The Director of Nursing will review the audits concerns will be addressed. Results will be reported to QA monthly for 3 months, to ensure substantial compliance.
Director of Nursing will be responsible to sustain compliance.
Date of completion of plan of correction: 06-30-23.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00133827.
Based on observation, interview, and record review the facility failed to re-check ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00133827.
Based on observation, interview, and record review the facility failed to re-check a blood glucose level (amount of sugar circulating in the blood) after an insulin administration for one resident R433 of two reviewed for change in condition, resulting in the potential for continued blood sugar instability and diabetic complication. Findings include:
On 7/25/23 at 9:23 AM, R433 was observed in bed and asked how the midnight shift care was. R433 stated that they had a really high blood sugar of 517 around 9:30 PM. R433 continued and stated that they were given 12 units of insulin. R433 was asked what their blood sugar read after the 12 units, R433 stated, The Nurse did not come back and check it. I didn't get checked again until this morning and it was 321.
A review of R433's medical record revealed, R433 was admitted to the facility on [DATE] with diagnosis of Type II Diabetes. A review of R433's Minimum Data Set (MDS) assessment noted, R433 with an intact cognition and required assistance with activities of daily living.
A review of R433's physician orders noted, Order: 7/21/2023 On Hand INSULIN LISPRO 100 UNIT/ML PEN{3 ML (milliliter)} Inject as per sliding scale: if 200 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units Call physician for BS (blood sugar) greater.
HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units Glucose levels less than 70 or greater than 300 notify M.D (medical doctor), subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS.
A review of R433's progress notes revealed, 7/24/2023 21:42 (9:42 PM) eMar - Medication Administration Note Text: BS: 517 mg (Milligram)/dL (deciliter). Notified the on- call provider ., and was instructed to administer 12 units of Insulin Lispro and to check in an hour or two and notify him with the result, for possible further instructions.
7/24/2023 16:00 (4 PM) eMar - Medication Administration Note Text: BS: 445 mg/dL Notified Dr . and was instructed to re-check in 2 hours and notify him for update.
A review of the policy titled, Diabetic Management dated 6/24/23, noted, Diabetic Management involves both preventative measures and treatment of complications. Upon admission, the interdisciplinary team works together to implement a plan of care to minimize complications . 1. If a guest/resident is observed with, or complains of any symptoms of hyperglycemia, report it to the nurse immediately. 2.Test the guest's/resident's blood glucose (BG). 3. Notify the physician of abnormal blood glucose test results and symptoms exhibited.
4. Follow physician's orders .
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 M100137843
Deficient Practice Statement #2.
Based on interview and record review, the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake M100137843
Deficient Practice Statement #2.
Based on interview and record review, the facility failed to ensure that medications were not left unattended at the bedside of one (R481) of five residents reviewed, resulting in the potential for accidental/improper medication consumption and overdosing. Findings include:
Review of the facility record for R481 revealed an admission date of 06/13/23 with diagnoses including Dementia, Hypoglycemia, Diabetes Mellitus and Acute Kidney Failure. The Minimum Data Set (MDS) assessment dated [DATE] indicated R481 required supervision/touching assistance for eating and primarily maximum/total assistance for self care otherwise.
On 07/26/23 at 9:40 AM, the facility's Director of Nursing (DON) was interviewed regarding an allegation called into the State Agency that medications had been left unattended on R481's lunch tray. The DON reported being aware of the incident and acknowledged that it did occur and that it was a deficient practice. The DON reported completing a subsequent investigation during which the person responsible for leaving the medication could not be identified as the resident's nurse reported having administered and witnessed the resident taking their medication and denying any knowledge of the source of the cup of pills. The DON reported that Unit Manager, Licensed Practical Nurse (LPN) C followed up after the incident was brought to the facility's attention.
On 07/26/23 at 9:45 AM, LPN C reported securing a cup of pills left in R481's room and removed them. When asked if they had identified/reconciled the cup of pills to compare them to R481's medication LPN C reported they did not.
On 07/26/23 at 9:53 AM, the DON reported that the expectation for medication administration is that medication be observed to be taken/administered and not left unattended with the resident.
This citation has two Deficient Practice Statements.
Deficient Practice #1.
This citation pertains to Intake MI00131868.
Based on interview and record review, the facility failed to assess, implement and ensure safe interventions were in place for one resident (R231) of five reviewed for accident/hazards, resulting in a fall. Findings include:
A review of an Intake called into the State Agency revealed, A few days after (R231's) arrival, the nurse helped (the resident) to a chair. Left. (R231) slid out of the chair and fell.
A review of R231's record revealed that the resident was admitted into the facility on 9/14/22 and discharged to the hospital on [DATE]. R231's medical diagnoses included Gas Gangrene (foot), Dysphonia (Hoarse Voice), Heart Failure, Kidney Disease, Peripheral Vascular Disease, Osteomyelitis (foot), Weakness, and Difficulty in Walking.
A review of R231's progress notes revealed:
-9/15/2022 .Physician - Plan of Care Review: .Ulcer to left heel .Assessment/Plan: .Rehab services for gait (walking) training; Fall Precautions; Gas Gangrene to left foot heel .
-9/15/2022 18:16 (6:16 PM) Nurses Note .(R231) .has a lift (sic - life) vest, a Foley Catheter and a wound vac to .left foot .
-9/16/22 .Physician Note Late Entry: Physical Medicine and Rehabilitation: .Impression and Plan: .Initiate subacute rehabilitation with safety and fall precautions highly recommended .
-9/16/2022 18:17 (6:17 PM) Nurses Notes . CENA (Certified Nursing Assistant or CNA) observed guest on floor in .room. Guest stated that (they were) sitting in (their) wheelchair and started to slide down .did attempt to keep pushing (themselves) back but eventually slid out of .chair .stated that (they) pushed the (call light) button when (they) fell. Guest states .not in any pain and vital signs are within normal limits. Upon assessment of the chair, the cusion (sic) was slidding (sic) easily along the chair. Guest is in need of a new dycem (non skid pad) for wheel chair. (Resident) has a skintear on .right arm from the fall. (Physician) was notified. Both emergency contacts were called but no answer, writer left a voicemail on (family) phone.
A review of R231's care plan revealed:
-Focus: (R231) is at risk for fall related injury and falls R/T (related to): decreased mobility skills, decreased WB (weight bearing) left foot from ulcer. Date Initiated: 09/15/2022.
-Intervention: Keep the resident's environment as safe as possible with: even floors free from spills and/or clutter; adequate lighting; call light within reach, commonly used items within reach, avoid repositioning furniture and keep the bed in the appropriate position. Date Initiated: 09/15/2022 .
-Intervention: Provide resident with activities that minimize the potential for falls while providing diversion and distraction Date Initiated: 09/15/2022.
-Will have therapy assess for appropriate body position. Date Initiated: 09/19/2022.
R231's care plan did not include an update to note the fall experienced on 9/16/22 nor the addition of a dycem mat to the wheelchair.
A review of the facility-provided incident/accident report for R231's fall on 9/16/22 noted, Equipment Malfunction, as a Predisposing Environmental Factor for the fall and Weakness/Fainted, as a Predisposing Physiological Factor.
On 7/26/23 at 1:03 PM, the Director of Nursing (DON) was interviewed and queried regarding R231's fall on 9/16/22. The DON stated she did not view the fall as an equipment malfunction, but contributed it to body habitus. The DON was queried if applying dycem to R231's wheelchair was added to their care plan but provided no response.
A review of the facility's policy/procedure titled, Fall Management, revised 7/14/2021, revealed, Policy: The facility will identify hazards and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls .A plan of care is developed and implemented based on this evaluation with ongoing review .If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00131868.
Based on interview and record review, the facility failed to document the replaceme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00131868.
Based on interview and record review, the facility failed to document the replacement of an indwelling urinary catheter and a nursing assessment after reported abnormal findings for one resident (R231) of one reviewed for catheters, resulting in a delay in the evaluation and treatment of urinary complications. Findings include:
A review of Intake called into the State Agency revealed, On 10/4/22 (R231) had (their) catheter changed and whoever changed it did not know what they were doing. (R231) bled and was in terrible pain for 4 hours until the staff decided to take (them to the hospital) to get it fixed.
A review of R231's record revealed that the resident was admitted into the facility on 9/14/22 and discharged to the hospital on [DATE]. R231's medical diagnoses included Gas Gangrene (foot), Obstructive and Reflux Uropathy, Dysphonia (Hoarse Voice), Heart Failure, Kidney Disease, Peripheral Vascular Disease, Osteomyelitis (foot), Weakness, and Difficulty in Walking. Further review revealed that the resident was admitted into the facility with a chronic indwelling urinary (Foley) catheter.
A review of R231's progress notes revealed the following, written by Licensed Practical Nurse (LPN) G:
-10/5/2022 03:39 (AM) Nurses Note Text: Guest was sent out via ambulance to (hospital) due to active bleeding from penis. Guest had Foley catheter changed on 10/3/22 during the day and was observed to have a blood tinge urine in the afternoon, reported to writer from outgoing nurse. Writer was assigned to guest at 2200 (10:00 PM) and observed Foley bag filled with blood, with no urine output. Writer irrigated foley, no flow observed over 30 minutes of monitoring. Guest c/o (complained of) of pain and pressure in bladder area. Writer bladder scanned guest and read 650 ml (milliliters). Writer removed foley catheter, in attempt to change foley to obtain urine. Upon removing the foley catheter guest immediately started to bleed from penis uncontrollably. Writer applied a bath towel and brief for monitoring. Supervisor notified, MD (Physician) phoned four times with no returned call. After 15 minutes of active bleeding, writer observed blood clots in brief. Supervisor directed for writer to 911 as guest is on blood thinners, obtaining urine, and passing blood clots. Phoned family, no answer will call in early morning, and also endorse to oncoming shift nurse.
On 7/26/23 at 9:52 AM, LPN G was called for interview and left a voicemail for call back. No call back was received prior to survey exit.
On 7/26/23 at 9:54 AM, LPN F was interviewed via phone. LPN F was noted to have cared for R231 on 10/3/22, however, LPN F was unable to recall anything specific about the resident or their catheter. LPN F stated that if a catheter is changed/replaced, it would at least be documented on the TAR (Treatment Administration Record). LPN F added that a progress note or nursing evaluation may be added into the record if a catheter is changed for a particular reason or for abnormalities.
A review of R231's Medication Administration Record (MAR) and TAR for September and October 2022 revealed an order, Change Foley catheter and bag PRN (as needed) for Foley maintenance -Start Date- 09/15/2022 -D/C Date- 10/07/2022. No documentation was found on the MAR/TARs indicating that this order was ever carried out prior to the resident's discharge.
A review of R231's October 2022 progress notes, and specifically notes and evaluations dated 10/3/22 and 10/4/22, did not reveal indication as to which staff member replaced R231's foley catheter and/or which nurse noted blood-tinged urine as documented in LPN G's progress note on 10/5/22. Documentation did not reveal clear indication as to when blood-tinged urine was first noted in R231's catheter bag and did not reveal on-going assessment throughout the afternoon and evening prior to when LPN G noted R231's catheter bag full of blood at 10:00 PM.
A review of R231's hospital After Visit Summary (AVS) dated 10/5/22 revealed that the resident was treated in the emergency room for Urinary Retention and was started on Bactrim (antibiotic for urinary tract infections).
On 7/26/23 at 10:12 AM, the Director of Nursing (DON) was interviewed. The DON was asked if she was able to determine who replaced R231's catheter per LPN G's documentation. The DON was unable to provide an answer. The DON indicated that she would not expect the Foley to have been changed unless something was wrong with it, and in that case, an assessment would be present. The DON stated she did not recall the resident or the situation and was unable to provide further information.
A review of R231's care plan with the DON revealed that the resident's catheter care plan was resolved on 9/27/22 and never re-initiated as an active care plan area prior to the resident's discharge.
The facility-provided document titled, Indwelling urinary catheter (Foley) care and management, reviewed 12/02/2022, included, Monitor intake and output, as ordered. Monitor for changes in urine output, including volume and color. Notify the practitioner of abnormal findings .(and) Document the procedure .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 07/24/23 at 10:23 AM, R100 was interviewed during initial resident screening and reported that the food is, in his opinion, p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 07/24/23 at 10:23 AM, R100 was interviewed during initial resident screening and reported that the food is, in his opinion, poor. R100 reported the quality of the food has declined since their original admission and that the facility seems to be buying cheaper food including the example that they used to have real cheeseburgers that people liked and now the burgers are baked in the oven. R100 reported that the hot food is consistently too cold.
Review of the facility record for R100 revealed an admission date of 09/27/22 with diagnoses that included Protein-Calorie Malnutrition, Muscle Weakness and Injury of the Superior Mesenteric Artery. The Minimum Data Set (MDS) assessment dated [DATE] indicated R100 required set up assistance for eating and primarily total/maximum self care assistance otherwise. The Brief Interview for Mental Status (BIMS) score of 15/15 indicated intact cognition.
On 07/24/23 at 11:40 AM, staff members serving lunch trays on the 130 hallway were observed to leave the tray cart door open while delivering trays until a member of the management team approached and closed the door.
On 07/25/23 at 9:13 AM, R100 was asked about their breakfast and stated I only had cereal this morning so it was ok but again, they use generic rice crispies now instead of the real thing.
On 07/26/23 at 10:06 AM, R100 reported that they were served fish for lunch the previous day and they demonstrated via the lunch ticket from that meal that fish is listed on the their ticket under dislikes. R100 also produced a picture of their dinner ticket dated Sunday 6/25/23 with tuna listed under dislikes along with the tuna salad sandwich they were served for the meal. R100 reported that this type of error has occurred regularly.
On 7/26/23 at 11:37 AM, a lunch test tray was obtained with the following temperatures measured:
Carrots- 121 Degrees Fahrenheit
Ground Meat- 125 Degrees Fahrenheit
Mashed Potatoes- 127 Degrees Fahrenheit
On 07/26/23 at 1:43 PM, the facility Dietary Manager reported that the expectation when an item is on a residents dislikes list on their meal ticket/plan is that it will not be served on a residents tray.
Review of the facility policy titled Food Preferences with revision date of 11/12/21 includes the Procedure entries:
- 6. The Dietary department will offer alternate meals for individuals who do not want to eat the primary meal.
-8. Food preferences will be identified on tray tickets to ensure guests/residents are provided with appropriate food items.
Note: The 2013 FDA Model Food Code section 3-501.16 states: Time/Temperature Control for Safety Food shall be maintained: (1) At 135 degrees Fahrenheit or above, or (2) At 41 degrees Fahrenheit or less.
Based on observation, interview, and record review the facility failed to serve food in a palatable manner and in an appetizing appearance for one sampled resident (R100) and seven confidential group residents, resulting in dissatisfaction during meals. Findings include:
On 7/25/23 at 2:02 PM, the residents that attended the resident council meeting were asked about the food served at the facility and explained, Kitchen doesn't have enough help, the food is cold a lot and doesn't look appetizing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
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, a facility staff person failed to don appropriate personal protective equipme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, a facility staff person failed to don appropriate personal protective equipment (PPE-items such as gloves, gowns, protective eye wear, etc.) when entering a room for one (R48) of two residents in transmission based precautions (TBP-precautions used for patients who may be infected with certain infectious diseases) reviewed for infection control compliance, resulting in the potential for the spread of infection. Findings include:
Review of the facility record for R48 revealed an original admission date of 09/20/18 with the most recent admission being 07/13/23 with diagnoses that included Diverticulitis of the Large Intestine, End Stage Renal Disease (requiring renal dialysis) and Polyneuropathy. The Minimum Data Set (MDS) assessment dated [DATE] indicated R48 required set up assistance for eating and maximum assistance with most daily care otherwise. The Brief Interview for Mental Status (BIMS) assessment score of 14/15 indicated intact cognition.
On 07/24/23 at 11:47 AM, Certified Nurse Assistant (CNA) K was observed entering R48's room with a lunch tray. It was noted that the entrance to R48's room included TBP signage and a PPE dispenser hanging on the door. CNA K was observed providing meal set up and assisting with R48's sitting position for eating in bed. CNA K exited the room without having donned/doffed any PPE during the interaction. CNA K was asked if they knew whether R48 remained on precautions and they stated yes. CNA K indicated that they were not aware that PPE had to be donned during service of a meal tray.
Further review of the facility record for R48 revealed a physician order dated 07/14/23 stating Contact isolation (Transmission Based Precautions) [related to] VRE and with an order
status of Active.
On 07/26/23 at 12:50 PM, the facility Director of Nursing (DON) reported that the expectation for staff entering a room with transmission based precautions including contact precautions is that PPE including gloves and gown be donned and that the only potential exception is in the case of an emergency such as a resident beginning to fall or being potentially harmed otherwise.
At 12:51 PM, the facility Registered Nurse Infection Preventionist (RN-IP) reported that the expectation for staff entering a room with transmission based precautions including contact precautions is that PPE always be donned.
Review of the Centers for Disease Control and Prevention (CDC) documented Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated 07/12/22 revealed the following entries:
- Examples of MDROs Targeted by CDC include: Vancomycin-resistant Enterococci (VRE).
- Contact Precautions are one type of Transmission-Based Precaution that are used when pathogen transmission is not completely interrupted by Standard Precautions alone. Contact Precautions are intended to prevent transmission of infectious agents, like MDROs, that are spread by direct or indirect contact with the resident or the resident's environment.
- Contact Precautions require the use of gown and gloves on every entry into a resident's room.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to transmit Minimum Data Set (MDS) assessments to the Centers for Medic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to transmit Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within 14 days after completion for four (R59, R95, R103, and R107) of four residents reviewed for resident assessment transmission, resulting in potential for inaccurate tracking of resident assessment, admission and discharges. Findings include:
A review of R59's MDS assessments noted, R59 was admitted on [DATE] and discharged on [DATE]. The list of assessments completed revealed, Entry [DATE] accepted, Admission/Medicare 5 day accepted [DATE]. R59 discharged home on [DATE]. R59's medical record did not reveal a completed and submitted discharged MDS assessment.
A review of R95's MDS assessments noted, R95 was admitted on [DATE] and discharge [DATE]. The list of MDS assessments complotted revealed, Entry [DATE] entry, Admission/Medicare 5-day [DATE]. R95 discharged to the hospital on [DATE]. R95's medical record did not reveal a completed and submitted discharged MDS assessment.
A review of R107's MDS assessments noted, R107 was admitted on [DATE] and discharge on [DATE]. The list of MDS assessments completed revealed, Entry [DATE] Accepted and Admission/Medicare 5 day [DATE] Accepted. R107 discharged to the hospital on [DATE]. R107's medical record did not reveal a completed and submitted discharged MDS assessment.
A review of R103's MDS assessments noted, R103 was admitted on [DATE] and discharge on [DATE]. The list of MDS assessments completed revealed, Entry [DATE] Accepted, admission [DATE], Medicare 5 day [DATE] completed, Discharge Return Anticipated [DATE] Accepted. The MDS Nurse explained that R103's assessment was completed late.
On [DATE] at 12:59 PM, the MDS Nurse D was ask when are the assessments due and stated, You have 14 days after discharge to complete the ARD (Assessment Reference Date).
A review of the facilty's policy titled, Submission of MDS dated, [DATE], noted, Long Term Care Facilities are required to submit MDS records for all residents in Medicare or Medicaid certified beds regardless of the pay source. Medicare Part A MDS's must be submitted prior to billing for Part A services Procedure 1. Once MDS's are completed and verified for accuracy they will be readied for transmission. 2. Completed MDS's are to be transmitted to CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (APAS) system in a timely manner in accordance with CMS policies a. Comprehensive assessments must be transmitted within 14 days of the V0200C (care plan completion date). b. All other MDS's must be transmitted within 14 days of the Z0500B (MDS Completion Date). c. Entry, re-entry and Death in facility tracking forms must be transmitted within 14 days of entry, re-entry or death date. d. Discharge tracking must be transmitted with 14 days of the Z0500B date .
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 Intake MI00133827.
Based on observation, interview and record review the facility failed to ensure ca...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00133827.
Based on observation, interview and record review the facility failed to ensure care needs were met timely for five sampled Residents (R24, R41, R65, R234, R236) of six reviewed for activities of daily living needs, resulting in dissatisfaction with the care provided, a delay in care needs being met and the potential for unmet care needs. Findings include:
R65
On 7/25/23 at 2:40 PM, the call light was observed to be activated for R65. R65 was observed lying on their back, and explained that they had decided to remain in bed today, as their stomach was uncomfortable due to constipation. R65 explained that their brief had not been changed all day and that this is the reason their call light was on. R65 was asked if the padding underneath them was wet, and they responded with, I think so. Along with Certified Nurse Assistant (CNA) R R65's brief was checked. Upon CNA R pulling R65's covers off them, a strong pungent smell of urine permeated the room. The brief was observed as extremely wet, and had saturated the padding and linen that was underneath the resident, as confirmed by CNA R.
Review of R65's medical record (post 2:40 PM observation) the following progress note was entered and revealed the following:
7/25/2023 15:10 (3:10pm) Nurses Notes. Pt (patient) pressed call light to alert staff [they] needed incontinent care at 2:45pm. Brief and linens saturated with high volume urine output. Pt choosing to remain in bed all day. This AM when CNA offered AM care, pt declined. CNA told pt to press call light when she wanted brief to be changed. Writer asked pt why [they] didn't call staff earlier (pt A&Ox3, verbalizes toileting/incontinent care needs) Pt stated she just called now because she needs it now. Writer educated pt to request incontinent care more frequently to prevent skin breakdown. Pt agreed .
A review of R65's care plan revealed the following, Focus: [R65] is at risk for impaired skin
integrity/pressure injury R/T (related to) : Incontinence bowel and bladder, weakness Date Initiated: 12/08/2022 .Interventions: Provide incontinence care with each incontinent episode and as needed and apply moisture barrier cream/ointment per facility policy/orders Focus: [R65] is at risk for decline in cognition and has impaired cognitive function or impaired thought processes r/t BIMS (mental score) score of 9. Date Initiated: 12/09/2022 .Interventions: Anticipate needs from non-verbal indicators and past preferences as known. Date Initiated: 12/09/2022 .Assist resident with decision making as needed. Date Initiated: 12/09/2022 .
A review of R65's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included, Cerebrovascular Disease, Diabetes and Hypertension. Further review of the medical record revealed that the resident has a moderately impaired cognition, and required extensive assistance for toilet use.
R234
On 7/24/23 at 10:27 AM, Confidential Witness I was observed to be very frustrated and going in and out of R234's room, at times approaching various staff members out in the hallway. Witness I was approached and agreed to be interviewed at the bedside of R234. An attempt was made to interview R234, however, the resident did not respond to inquiry. Witness I indicated that R234 has Alzheimer's disease and would not be able to answer any questions. Witness I lifted the lid on R234's breakfast tray, which was observed to be untouched. Witness I stated that R234 needs to be fed and expressed frustration that no one had come to feed the resident. Witness I commented that the resident's food is now cold. Witness I stated they brought a banana and grapes from home that they provided to the resident, but emphasized that no staff had come in all morning to assist the resident with eating/drinking or other care. R234 was observed lying in bed, with their bare shoulders exposed. R234 had on a hospital type gown but it was noted to have come undone. Witness I continued to express their frustration that the resident was not up and out of bed and continuously pulled up R234's covers/gown so that their chest was not exposed. Witness I explained that R234 was normally able to ambulate and be taken to the bathroom as long as they have assistance. Witness I stated that they have visited the facility multiple times (staying for hours at a time) since the resident's admission on [DATE] (Saturday) and claimed that the resident has not been moved up and out of bed since arriving. Witness I continued to be express their frustration and was asked at 10:34 AM to activate the resident's call button. Certified Nurse Assistant (CNA) J entered the room at 10:36 AM but stated that she was not R234's assigned aide for the shift. CNA J left and came back with Unit Manager Licensed Practical Nurse (LPN) C. CNA J and LPN C then provided morning care and incontinence care to R234 as Witness I went to retrieve clothing for the resident to change into. When queried, LPN C was unsure of where R234's assigned CNA was, but indicated that the assigned aide (CNA O) had come in a little late today.
A review of R234's record revealed the following:
-7/22/2023 17:11 (5:11 PM) Nursing Summary Note Text: Guest arrived around 1530 (3:30 PM) .Guest is alert and orient to self (confused). No denture, glasses, assisted 2 person with ADLs (activities of daily living), toileting, transfer. Guest is a 1:1 feeder .
R41
On 7/24/23 at 10:56 AM, during the initial tour, R41's call light was observed to be activated. R41 was observed lying in bed wearing a hospital type gown and was interviewed at this time. R41 was queried regarding concerns at the facility. R41 expressed frustration that they have been waiting for 2 hours to get up and dressed and stated, I would do it myself but I don't want to hurt myself. R41 pulled out their cell phone and showed this surveyor that they had called a number for the facility six times this morning. Certified Nursing Assistant (CNA) P entered the room without knocking on the door and informed R41 that she would help them. When queried, CNA P did not know who R41's assigned aide was for the day.
A review of R41's record revealed that the resident was most recently admitted into the facility on 7/15/23 and is cognitively intact. Further review revealed that the resident requires the assistance of one staff member for dressing, transfers, and mobility.
R236
On 7/24/23 at 11:26 AM, R236 was observed slowly propelling themselves in their wheelchair into their bathroom. R236 indicated that they were taking themselves to the toilet. A raised toilet seat with handles was observed in the resident's bathroom. When queried regarding concerns at the facility, R236 stated they had pressed their call button this morning for help getting dressed, but no one came, so they had to do it themselves. R236 added that they also requested that their bed be made this morning. R236's bed was observed with disheveled sheets and was not made. R236 indicated that they do require some assistance to use the bathroom, but they usually just take themselves because staff doesn't come when they call. R236 added that approximately two days ago, they, messed their pants, while waiting for bathroom assistance.
At 4:11 PM, R236 was observed in their room and had a visitor. R236's bed remained disheveled and un-made.
A review of R236's record revealed that the resident was most recently admitted into the facility on 7/18/23 and is moderately cognitively impaired. Further review revealed that the resident requires the assistance of one staff member for dressing, transfers, and toileting.
R24
On 7/26/23 at 9:05 AM, R24 was observed lying in bed. This surveyor entered R24's room with Licensed Practical Nurse (LPN) E and LPN H. R24 informed the nurses that their incontinence brief needed to be changed. R24 stated that their brief had not been changed since last night and no staff had been in yet this morning to check their brief or provide morning care. R24 added that yesterday (7/25/23), their brief was, Loaded with urine .I sat in it for 3 hours. R24 stated that they had hit their call button to be changed, but care was not provided upon their request. R24 stated, They don't have the help they need.
At 9:13 AM, LPN E and LPN H provided incontinence care to R24. R24's green incontinence brief was observed to be completely saturated with urine. The bottom edge of the resident's gown, back of their bare legs, and cloth pad (chux) underneath their bottom were also observed to be wet. R24's skin on their buttocks was observed to be moisture-laden but intact, and reddened with white indentations/wrinkles - indicative of being in the same position for an extended period. This observation was also confirmed by LPN E.
A review of R24's record revealed that the resident was recently re-admitted into the facility on 7/21/23 and is cognitively intact with medical diagnoses of Fracture of Shaft of Right Ulna (Broken Arm), Acute Osteomyelitis, Olecranon (Elbow) Bursitis, Weakness, Anxiety, and Depression.
A review of R24's [NAME] (pulled from the care plan) revealed the following:
-Brief usage: Resident uses disposable briefs. Change prn (as needed).
-Check q 2 hr (every 2 hours) and prn for incontinence .
-Provide incontinence care with each incontinent episode and as needed .
- .Resident requires 1 person assistance to reposition and turn in bed.
-Keep skin clean and dry .
On 7/26/23 at 1:14 PM, the Director of Nursing (DON) was interviewed. When queried regarding resident ADL care observations and concerns, the DON indicated she would not expect to see residents with outstanding ADL care concerns unless there is an acute/urgent event happening on the unit. The DON stated the facility is fully staffed and ADL's are brought up in daily quality rounds.
A review of the facility's policy/procedure titled, Routine Resident Care, Last Revised 3/7/2023, revealed, Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene .Residents are encourages or assisted to dress in appropriate clothing and footwear daily .Residents are provided assistance to the restroom or with the bedpan, urinal, or bedside commode as needed .Incontinence care is provided timely according to each resident's needs .Resident's call lights are answered timely and resident's requests are addressed, if permitted. Call lights should be placed within easy reach of the resident.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure food items were labeled and stored at the appropriate temperature, failed to maintain sanitary conditions, failed to e...
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Based on observation, interview, and record review, the facility failed to ensure food items were labeled and stored at the appropriate temperature, failed to maintain sanitary conditions, failed to ensure staff donned a beard restraint, and failed to ensure handwashing to prevent cross contamination. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include:
On 7/24/23 between 8:45 AM-9:15 AM, during an initial tour of the kitchen with Culinary Manager A, the following items were observed:
In the dry storage room, the flour, sugar, bread crumbs and oatmeal bins were all observed to be unlabeled with the contents inside. Culinary Manager A confirmed the bins should be labeled.
According to the 2017 FDA Food Code section 3-302.12 Food Storage Containers, Identified with Common Name of Food, Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD.
Dietary Staff B was observed serving breakfast from the steam table. Dietary Staff B was observed with a beard, but was not wearing a beard restraint. When queried, Culinary Manager A stated Dietary Staff B should be wearing a beard restraint.
According to the 2017 FDA Food Code section 2-402.11 Effectiveness, (A) Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.
The clean dishware rack located adjacent to the steam table was observed with cobwebs along the bottom rack and along the side of the top shelf. When queried about the cobwebs, Culinary Manager A provided no explanation.
According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.
On 7/24/23 at approximately 8:45 AM, numerous boxes were observed stacked outside the walk-in cooler and freezer. Culinary Manager A stated stock had just been delivered. On 7/24/23 at 11:55 AM, most of the boxes remained outside the walk-in coolers, and Dietary Staff B was observed putting stock away into the freezer. 4 boxes each containing 1 pound containers of chicken salad were observed in the stack of boxes waiting to be put into the cooler. The internal temperature of the chicken salad was measured to be 53 degrees Fahrenheit. Culinary Manger A stated staff needed to move quicker when getting the stock put away into the cooler.
According to the 2017 FDA Food Code section 3-501.16 Potentially Hazardous Food (Time/Temperature Control for Safety Food), Hot and Cold Holding, 1. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C ) of this section, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be maintained: 1. (1) At 57ºC (135ºF) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54ºC (130ºF) or above; P or 2. (2) At 5ºC (41ºF) or less.
On 7/24/23 at 12:05 PM, Culinary Manager A was observed helping to put stock away. Culinary Manager A carried a box into the oven/grill area, and placed the box inside the reach-in cooler. Culinary Manager A then went directly to the grill, and began placing slices of bread onto the grilled cheese sandwiches that were cooking on the flat top grill. Culinary Manager A did not wash her hands after handling the boxes of stock before changing tasks and handling food items.
According to the 2017 FDA Food Code section 2-301.14 When to Wash, Food employees shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles P and: .(F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (H) Before donning gloves for working with food; P and (I) After engaging in other activities that contaminate the hands.
May 2022
18 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement consistent and effective forms of communicati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement consistent and effective forms of communication, translator services for daily communication and to obtain accurate assessments in a language that could be understood for one (R27) of three residents reviewed for communication. Findings include:
On 5/16/22 at 10:01 AM, R27 was observed in bed. An interview was attempted, however the resident started speaking a foreign language. Further observation of the room revealed no communication device visible to use.
Review of the medical record revealed R27 was admitted to the facility on [DATE] with a readmission date of 4/7/2022 and diagnoses that included: acute on chronic systolic (congestive) heart failure, acute and chronic respiratory failure, unstable angina, chronic diastolic heart failure and history of pulmonary embolism. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5 indicating severely impaired cognition and required staff assistance for all ADLs.
Review of a care plan titled (R27) has impaired communication r/t (related to) speaking English as a second language. (R27) primary language is Arabic (implemented on 11/27/20), documented in part . (Goal) Will be able to make basic needs known on a daily basis . (Interventions) . Anticipate and meet needs as needed . Ensure availability, functioning and effectiveness of adaptive communication equipment which is a communication board . Observed for non-verbal indicators of attempts to express self-such as tears, furrowing of the brow, pursing of the lips, yelling, grabbing, reaching, gestures etc. Use communication techniques to enhance interaction: Allow adequate time to respond, Repeat as necessary, Do not rush, Request feedback, clarification from (R27), to ensure understanding, Face when speaking and make eye contact, Turn off TV/radio as needed to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed, such as communication book/board, writing pad, gestures, signs and pictures .
On 5/17/22 at 1:33 PM, Unit Manager (UM) B was asked to accompany the surveyor into R27's room. UM B was asked to complete an assessment on the resident without using yes or no questions. R27 was asked how they were doing and R27 begin to speak in Arabic. UM B was asked to translate what R27 was saying, however UM B was unable to understand the resident. UM B was asked what services or devices the staff can utilize to effectively communicate with R27 and UM B stated if needed they would call the family to translate.
On 5/17/22 at 1:38 PM, Licensed Practical Nurse (LPN) D (the nurse assigned to R27) was asked to accompany the surveyor in the room to help conduct an interview with R27. LPN D asked R27 if they were in pain. R27 stated yes. When asked where, R27 touched the left side of their chest. LPN D then asked R27 what their pain level was on a scale of 1 to 10 and the resident started speaking in Arabic. LPN D was asked what the resident was saying and LPN D as unable to understand or translate. The surveyor then asked the resident how they felt today and the resident stated yes. LPN D was asked what methods of communication the staff used to effectively communicate with R27 and LPN D stated if it's something important they will call the family to translate. Concerns of being able to effectively communicate with the resident to obtain accurate assessments was discussed with LPN D and LPN D agreed that it was a concern.
Review of a facility policy titled Communicating with Limited English Proficient Persons revised 11/1/2017, documented in part . It is Facility policy to ensure that persons with limited English Proficiency are identified and that the Facility is capable of communicating information to such persons efficiently . Accurate and effective communication between the Facility and limited English-proficient (LEP) persons, including current and prospective residents and family, is necessary to ensure that LEP residents have meaningful access to services . This includes adequate communication involving the resident's medical conditions and treatment . Language assistance may be provided through use of qualified bilingual staff, contracts or other formal arrangements with local organizations providing interpretation or translation services, technology, and telephonic interpretations services. All interpreters/translators and communication services will be provided without cost to the person being served .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a timely and accurate advance directive in acco...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a timely and accurate advance directive in accordance with the facility policy and conditions of a legal guardianship for one R58 of two residents reviewed for advance directives. Findings include:
On 5/16/22 at 11:21 AM, R58 was observed sitting in the common area on a chair with their wheelchair in front of them. An interview was attempted however R58 did not respond to the interview questions appropriately.
Review of the clinical record revealed R58 was admitted to the facility on [DATE] with a readmission date of 7/6/20 and diagnoses that included: cerebral infarction and dementia. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3 indicating severely impaired cognition and required staff assistance for all Activities of Daily Living (ADLs).
Review of a Resident Code Status dated 6/29/2020, checked off the option of Full Code - Full Resuscitation and life sustaining treatment (includes all treatment items outlined below under Selective Code Selective Resuscitation) as designated by resident or healthcare legal decision maker. This was initialed and signed by R58.
Review of a Do-Not-Resuscitate Order signed by the legal guardian on 1/20/21, documented in part . I authorize that in the event the ward's heart and breathing should stop, no person shall attempt to resuscitate the ward. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law . The physician signature was dated as 1/21/21.
Review of the facility's policy titled Code Status revised 11/1/17, documented in part . A fully appointed Guardian can authorize medical treatment for the ward (resident) . A Guardian can designate a ward a DNR (Do Not Resuscitate) status only when (MI- Michigan Only) . It does not conflict with the prior wishes of the resident/patient or Patient Advocate . The Guardian must meet with the ward within 14 days of executing the DNR and if possible, have meaningful communication about executing the DNR order . The Guardian must consult directly with the wards attending physician as to specific medical indications that warrant a DNR order. This must be completed annually to reaffirm the order .
According to state law regarding [NAME] and duties of guardian effective 3/28/19, .A guardian shall not execute a do-not-resuscitate order unless the guardian does all of the following .Not more than 14 days before executing the do-not-resuscitate order .Consults directly with the ward's attending physician as to the specific medical indications that warrant the do-not-resuscitate order .
Review of the clinical record revealed no documentation from the physician regarding consultation and/or discussion with the legal guardian regarding going from a Full Code to DNR status and the specific medical indications that warrant the need of a DNR.
On 5/18/22 at 9:12 AM, Social Worker (SW) K was interviewed and asked if the facility could provide documentation of a discussion or consultation between R58's legal guardian, R58 and the physician regarding the change of code status from a Full Code to a DNR.
SW K stated they were not employed with the facility at that time however would look into it. Shortly after, SW K stated they consulted with the facility's Director Of Nursing (DON) and they were unable to provide documentation of the required consultation between the guardian and physician occurred when the resident's code status was changed to DNR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
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 privacy was provided during toileting/brief chan...
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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 privacy was provided during toileting/brief changing for one resident (R19) of one resident reviewed for privacy. Findings include:
On 5/16/22 at approximately 11:17 a.m., R19 was observed in their room having their brief changed by Certified Nursing Assistant M (CNA M). R19 was observed to not have their privacy curtain being used while the CNA M was providing the brief changing and had no clothes on. R19's roommate was observed in the room standing and watching the care being provided to R19.
On 5/16/22 at approximately 11:22 a.m., CNA M was queried regarding the use of R19's privacy curtain to prevent R19's roommate from watching the brief change and they indicated that they usually use the privacy curtain but had forgotten to use it that time.
On 5/16/22 at approximately 11:24 a.m., R19 was queried if they had preferred the use of their privacy curtain while being changed and they indicated they did. R19 reported that it has happened multiple times where their roommate has been in the room, saw them being changed and the CNA did not pull the curtain.
On 5/17/22 The medical record for R19 was reviewed and revealed the following: R19 was initially admitted on [DATE] and had diagnoses including Obesity and Muscle Weakness. A review of R19's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/23/22 revealed R19 Needed extensive assistance from facility staff with their activities of daily living.
A review of R19's careplan revealed the following: Focus-[R19] is incontinent of bladder &/or
bowel R/T (related to): impaired mobility and weakness .Interventions-BRIEF USAGE: Resident uses disposable briefs. Change prn (as needed).
On 5/18/22 at approximately 9:19 a.m., Nurse Manager B (NM B) was queried regarding the observation of CNA M not using the privacy curtain while doing the brief change for R19. NM B indicated that staff should always use the privacy curtain when completing brief changes and that staff have been inserviced multiple times on how to provide privacy for the residents.
A facility document titled Guidelines for Clinical Procedures was reviewed and revealed the following: Appropriate care is taken to ensure the guest's/resident's right to privacy and dignity, as well as the guest/ resident's health and safety are protected during the performance of any clinical procedure .1. Before the initiation of any clinical procedure: .h. Position the guest/resident in a manner to maintain dignity and privacy. Allow the procedure to be performed. Consider the use of pillow, rolled towels or blankets as necessary, to provide positioning support .2. During the clinical procedure: c.
Maintain the guest's/resident's privacy and dignity during the procedure .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect for one resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect for one resident, (R49) of four residents reviewed for abuse. Findings include:
A review of a facility policy titled, Abuse Prohibition Policy with a revision date of 7/2019 was conducted and read, Each resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property .To assure residents are free from abuse, neglect, exploitation, or mistreatment, the facility shall monitor resident care and treatments on an on-going basis .Definitions .Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment .This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being .
On 5/17/22 at 2:15 PM, a review of facility provided document titled, Resident, Family, Employee, and Visitor Assistance Form for R49 was conducted and read, INFORMATION ABOUT YOUR CONCERN: See attached letter of concerns . A review of a letter hand written by R49 attached to the form was reviewed and read:
On 11/10/21 I put my light on about 0130 (1:30 AM). I had fallen asleep on my chair and wanted to go to the bathroom to use it and wanting to get in my pajamas. (Certified Nurse Aide (CNA) 'A') thought I would go to bed at that time and I explained to her that I would get back in my chair to get ready fro my appointment. She complained of how tired she was and that her back was in pain. I was curious why her back hurt her so much and why she wore the back brace. She said said <sic> 2 years ago she was shot. I immediately <sic> thought why is she doing this kind of work. At 0345 (3:45 AM) (CNA 'A') was in the hall back in the corner by the door sitting in a lounge chair covered by the blanket listening to music and talking on the phone. I told her I was ready to get into bed. She continued to stay sitted <sic> in the chair listening to music and talking on the phone. I asked her the second time to come help me, by then it was 0415 (4:15 AM). She was very irritated and said she had to check and change all of this hall and had to leave by 0600 (6:00 AM) to take her daughter to the hospital. She refused to put me in bed and on the bedpan .She put me on the sit/stand (mechanical lift), pulled my pajama pants down and sat me in the middle of the bed. I begged to remove my pull up (adult incontinence brief) and use the bed pan .By then it was 0430 (4:30 AM) she insisted in putting me in bed and my feet were over the foot rest. She ripped off my pull up with me lying down, grabbed the bedpan put it underneath me incorrectly and said I have to wait until she finishes all the residents check/change and left me in bed on top of the bed pan with no call light and bed control and I became desperate thinking I was not going to be put to bed until the morning shift arrive <sic> at 0630 (6:30 AM) so I began to yell for HELP. (R45) heard me so he came into my room to hand me my call light and with all the comotion <sic> (CNA 'A') came back with (Licensed Practical Nurse (LPN) 'C') and another agency CNA. I was frantic and the other CNA and (LPN 'C') assisted me. (LPN 'C') knew I was very upset. I have never experience <sic> anything like that in the 4 years I have lived at (Facility Name). Only to find out that (CNA 'A') did not change any of the residents .
Continued review of the Resident, Family, Employee, and Visitor Assistance Form revealed a section titled FACILITY RESPONSE and the hand-written response read, DON (Director of Nursing) investigated situation being reported and found allegations to be substantiated .poor treatment & poor customer services was identified .
On 5/17/22 at 2:30 PM, the Administrator/Abuse Coordinator was asked about R49's concern form. They were asked if they investigated R49's allegations, had any other investigation documentation, or reported the incident to the State Agency. They said they did not because it was determined to be, poor customer service, not abuse.
On 5/17/22 at 3:45 PM, a review of R49's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: multiple sclerosis, anemia, weakness, muscle wasting, osteoporosis, breast cancer, and adjustment disorder. R49's most recent Minimum Data Set assessment dated [DATE] indicated they had intact cognition, was non-ambulatory, but independent with wheelchair mobility, and required total assistance from two staff members for transferring, bed mobility, and toilet use.
On 5/17/22 at 3:25 PM, an interview was conducted with R49. They were asked if they recalled the incident with CNA 'A' and said they did. R49 said CNA 'A' was an agency nurse and she was, Very insulting, and what she did, was very wrong. R49 was asked if the facility followed-up with them regarding the incident and said they were told CNA 'A' wouldn't be back to the facility. R49 further expressed concerns of fear that other residents suffered because of CNA 'A's behavior.
CONCERN
(D)
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** Resident 49
On 5/17/22 at 2:15 PM, a review of facility provided document titled, Resident, Family, Employee, and Visitor Assist...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 49
On 5/17/22 at 2:15 PM, a review of facility provided document titled, Resident, Family, Employee, and Visitor Assistance Form for R49 was conducted and read, INFORMATION ABOUT YOUR CONCERN: See attached letter of concerns . A review of a letter hand written by R49 attached to the form was reviewed and read:
On 11/10/21 I put my light on about 0130 (1:30 AM). I had fallen asleep on my chair and wanted to go to the bathroom to use it and wanting to get in my pajamas. (Certified Nurse Aide (CNA) 'A') thought I would go to bed at that time .She complained of how tired she was and that her back was in pain. I was curious why her back hurt her so much and why she wore the back brace. She said said <sic> 2 years ago she was shot. I immediately <sic> thought why is she doing this kind of work. At 0345 (3:45 AM) (CNA 'A') was in the hall back in the corner by the door sitting in a lounge chair covered by the blanket listening to music and talking on the phone. I told her I was ready to get into bed. She continued to stay sitted <sic> in the chair listening to music and talking on the phone. I asked her the second time to come help me, by then it was 0415 (4:15 AM). She was very irritated and said she had to check and change all of this hall and had to leave by 0600 (6:00 AM) .She refused to put me in bed and on the bedpan .She put me on the sit/stand (mechanical lift), pulled my pajama pants down and sat me in the middle of the bed. I begged to remove my pull up (adult incontinence brief) and use the bed pan .By then it was 0430 (4:30 AM) she insisted in putting me in bed and my feet were over the foot rest. She ripped off my pull up with me lying down, grabbed the bedpan put it underneath me incorrectly and said I have to wait until she finishes all the residents check/change and left me in bed on top of the bed pan with no call light and bed control and I became desperate thinking I was not going to be put to bed until the morning shift arrive <sic> at 0630 (6:30 AM) so I began to yell for HELP. (R45) heard me so he came into my room to hand me my call light and with all the comotion <sic> (CNA 'A') came back with (Licensed Practical Nurse (LPN) 'C') and another agency CNA. I was frantic and the other CNA and (LPN 'C') assisted me. (LPN 'C') knew I was very upset. I have never experience <sic> anything like that in the 4 years I have lived at (Facility Name).
Continued review of the Resident, Family, Employee, and Visitor Assistance Form revealed a section titled FACILITY RESPONSE and the hand-written response read, DON (Director of Nursing) investigated situation being reported and found allegations to be substantiated .poor treatment & poor customer services was identified .
On 5/17/22 at 2:30 PM, the Administrator/Abuse Coordinator was asked about R49's concern form. They were asked if they reported the allegations to the State Agency and said they did not. They were asked why, and said it was, poor customer service, not abuse.
On 5/17/22 at 3:45 PM, a review of R49's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: multiple sclerosis, anemia, weakness, muscle wasting, osteoporosis, breast cancer, and adjustment disorder. R49's most recent Minimum Data Set assessment dated [DATE] indicated they had intact cognition, was non-ambulatory, but independent with wheelchair mobility, and required total assistance from two staff members for transferring, bed mobility, and toilet use.
On 5/17/22 at 3:25 PM, an interview was conducted with R49. They were asked if they recalled the incident with CNA 'A' and said they did. R49 said CNA 'A' was an agency nurse and she was, Very insulting, and what she did, was very wrong. R49 was asked if the facility followed-up with them regarding the incident and said they were told CNA 'A' wouldn't be back to the facility. R49 further expressed concerns of fear that other residents suffered because of CNA 'A's behavior.
Based on interview and record review, the facility failed to identify and report allegations of abuse/neglect and injury of unknown origin to the State Agency (SA) for three (R49, R60 and R66) of four residents reviewed for abuse/neglect.
Findings include:
According to the facility's policy titled, Abuse Prohibition Policy dated 4/28/22:
.Neglect is the failure of the facility, its employees .to provide goods and services to a guest/resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .An injury should be classified as an injury of unknown source when both of the following criteria are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the guest/resident; and the injury is suspicious because of the extent of the injury .The Administrator or designee will notify .any State or Federal agencies of allegations per state guidelines (2 hours if abuse allegation .) .
On 5/17/22 at 11:01 AM, the Administrator and Director of Nursing/DON were requested to provide documentation of any grievance/concern forms for R49, R60 and R66.
Resident #60:
Review of a grievance form provided by the facility dated 3/2/22 (no time noted) revealed documentation initiated by R60's family which read, .What is your concern about? About the safety of my Aunt She was vebally <sic> threaten to be punched when asked if she made a report on this nurse by the name of (name of Certified Nursing Assistant/CNA 'E') .How can we address your issues? To make sure my Aunt is properly cared for and not to be Harmed .Is this an ongoing problem? Yes .Was told they have a Love/Hate relationship .Have you contacted us in the past about this issue? Yes .My mom has to admitting I believe her name is . The facility's response included documentation from the Director of Nursing/DON, Immediate interview with pt (patient) - pt indicated that her and CENA were joking around .Facility Follow-Up called to speak with niece - niece would like CENA to no longer joke with pt . This form was completed by the DON.
Review of the clinical record revealed R60 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: cerebral infarction, visual hallucinations, altered mental status, insomnia, anxiety disorder, major depressive disorder recurrent, adjustment disorder with anxiety, multiple sclerosis, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, functional quadriplegia, legal blindness, ulcerative colitis, chronic pain syndrome, and vascular dementia with behavioral disturbance.
According to the Minimum Data Set (MDS) assessment dated [DATE], R60 had moderately impaired cognition and required extensive assistance of two or more people for bed mobility and was totally dependent upon two or more people for transfers.
On 5/17/22 at 4:21 PM, an interview was conducted with the Administrator (who was also identified as the facility's Abuse Coordinator). When asked about the alleged abuse reported by R60's family on 3/4/22 and whether that had been reported to the State Agency, or whether there was any additional documentation of an investigation in accordance with their policy, the Administrator reported the DON immediately investigated and determined it was a joke as that's how the resident and staff member were with one another.
The Administrator further reported this was not reported to the State Agency as it was determined it was not abuse in less than two hours. When asked to review their process for identifying and reporting allegations of abuse, the Administrator confirmed their policy in accordance with regulations included reporting of any abuse allegation within two hours. Additionally, the Administrator acknowledged they had mis-interpreted the reporting guidance and thought if abuse was ruled out within two hours, that did not need to be reported.
Resident #66:
Review of the clinical record revealed R66 was admitted into the facility on 8/23/21 and readmitted on [DATE] with diagnoses that included: dementia in other diseases classified elsewhere with behavioral disturbance, restlessness and agitation, generalized anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder single episodes, and acute post-hemorrhagic anemia.
According to the MDS dated [DATE], R66 had severely impaired cognition, had communication limitations, and was independent with ambulation without any assistive device.
Review of the progress notes included an entry on 1/30/22 at 6:38 PM by Nurse 'F' (who no longer employed with facility) which read:
.Dark scab observed to pt's (patient's) rt (right) lateral knee. Redness surrounding and Pt states its painful to touch. Pt unable to communicate how it was acquired. x2 sutures preset <sic> in center of scab. (Physician 'H') informed and treatment in place .
Review of the incident/accident documentation provided by the facility for R66 revealed there was no documentation of any investigation into the resident's knee injury identified on 1/30/22.
Review of the treatment orders included a treatment started on 1/31/22 through 2/26/22 for Rt knee scab: apply betadine moist 2x2 and cover w (with) bordered gauze QD (every day). Notify WCT (Wound Care Team) if scab becomes loose or falls off.
On 5/17/22 at 2:48 PM, an interview was conducted with the Administrator. When asked about whether R66's injury of unknown origin had been reported to the state agency, the Administrator reported that was not and they were not aware of the injury from 1/30/22 for R66.
On 5/17/22 at 3:31 PM, an interview was conducted with Nurse 'B' (Unit Manager for the unit R66 resided). When asked about R66's injury of unknown origin for the right knee with sutures, they reported they were only in the current role for about 90 days and was unable to offer any further details.
On 5/18/22 at 11:32 AM, an interview was conducted with the DON who reported they began working at the facility in that role since January 2022. When asked to review the progress note on 1/30/22, the DON reported they were unable to offer any information at this time, but would follow up. When asked if this injury of unknown origin had been reported to the State Agency, the DON reported it had not. There was no additional documentation or explanation provided by the end of the survey.
CONCERN
(D)
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** R49
On 5/17/22 at 2:15 PM, a review of facility provided document titled, Resident, Family, Employee, and Visitor Assistance For...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R49
On 5/17/22 at 2:15 PM, a review of facility provided document titled, Resident, Family, Employee, and Visitor Assistance Form for R49 was conducted and read, INFORMATION ABOUT YOUR CONCERN: See attached letter of concerns . A review of a letter hand written by R49 attached to the form was reviewed and read:
On 11/10/21 I put my light on about 0130 (1:30 AM). I had fallen asleep on my chair and wanted to go to the bathroom to use it and wanting to get in my pajamas. (Certified Nurse Aide (CNA) 'A') thought I would go to bed at that time .She complained of how tired she was and that her back was in pain. I was curious why her back hurt her so much and why she wore the back brace. She said said <sic> 2 years ago she was shot. I immediately <sic> thought why is she doing this kind of work. At 0345 (3:45 AM) (CNA 'A') was in the hall back in the corner by the door sitting in a lounge chair covered by the blanket listening to music and talking on the phone. I told her I was ready to get into bed. She continued to stay sitted <sic> in the chair listening to music and talking on the phone. I asked her the second time to come help me, by then it was 0415 (4:15 AM). She was very irritated and said she had to check and change all of this hall and had to leave by 0600 (6:00 AM) .She refused to put me in bed and on the bedpan .She put me on the sit/stand (mechanical lift), pulled my pajama pants down and sat me in the middle of the bed. I begged to remove my pull up (adult incontinence brief) and use the bed pan .By then it was 0430 (4:30 AM) she insisted in putting me in bed and my feet were over the foot rest. She ripped off my pull up with me lying down, grabbed the bedpan put it underneath me incorrectly and said I have to wait until she finishes all the residents check/change and left me in bed on top of the bed pan with no call light and bed control and I became desperate thinking I was not going to be put to bed until the morning shift arrive <sic> at 0630 (6:30 AM) so I began to yell for HELP. (R45) heard me so he came into my room to hand me my call light and with all the comotion <sic> (CNA 'A') came back with (Licensed Practical Nurse (LPN) 'C') and another agency CNA. I was frantic and the other CNA and (LPN 'C') assisted me. (LPN 'C') knew I was very upset. I have never experience <sic> anything like that in the 4 years I have lived at (Facility Name).
Continued review of the Resident, Family, Employee, and Visitor Assistance Form revealed a section titled FACILITY RESPONSE and the hand-written response read, DON (Director of Nursing) investigated situation being reported and found allegations to be substantiated .poor treatment & poor customer services was identified .
On 5/17/22 at 2:30 PM, the Administrator/Abuse Coordinator was asked about R49's concern form. They were asked if they had any additional investigation documentation and said they did not, they only had the Resident, Family, Employee, and Visitor Assistance Form. It was noted the facility did not interview CNA 'A', LPN 'C', or any other staff members at the time of the incident. It was further noted they did not reach out to any other residents regarding CNA 'A's behavior, or followed up with R49 after the incident.
On 5/17/22 at 3:45 PM, a review of R49's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: multiple sclerosis, anemia, weakness, muscle wasting, osteoporosis, breast cancer, and adjustment disorder. R49's most recent Minimum Data Set assessment dated [DATE] indicated they had intact cognition, was non-ambulatory, but independent with wheelchair mobility, and required total assistance from two staff members for transferring, bed mobility, and toilet use.
On 5/17/22 at 3:25 PM, an interview was conducted with R49. They were asked if they recalled the incident with CNA 'A' and said they did. R49 said CNA 'A' was an agency nurse and she was, Very insulting, and what she did, was very wrong. R49 was asked if the facility followed-up with them regarding the incident and said they were told CNA 'A' wouldn't be back to the facility. R49 further expressed concerns of fear that other residents suffered because of CNA 'A's behavior.
Based on interview and record review, the facility failed to conduct thorough investigations of injury of unknown origin and abuse/neglect allegations for three (R49, R60 and R66) of four residents reviewed for abuse/neglect, resulting in incomplete investigations and the increased potential for unidentified and/or inaccurate investigation results, unidentified abuse, and inappropriate corrective measure to prevent reoccurrences.
According to the facility's policy titled, Abuse Prohibition Policy dated 4/28/22:
.Neglect is the failure of the facility, its employees .to provide goods and services to a guest/resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .An injury should be classified as an injury of unknown source when both of the following criteria are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the guest/resident; and the injury is suspicious because of the extent of the injury .The Director of Nursing and Administrator review all incident reports to identify and further investigate any suspicious incidents .f the incident has resulted in an injury (requiring acute intervention) .the guest/resident will be transferred to a hospital emergency room .The investigation may consist (as appropriate) of .A review of the completed Incident Report .An interview with the person(s) reporting the incident .Interviews with any witnesses to the incident .An interview with the guest/resident, if possible .An interview with staff members having contact with the guest/resident during the period/shift of the alleged incident .Interviews with the guest's/resident's roommate, family members, and visitors .A review of all circumstances surrounding the incident .At the conclusion of the investigation, and no later than 5 working days of the incident, the facility must report the results of the investigation .
On 5/17/22 at 11:01 AM, the Administrator and Director of Nursing/DON were requested to provide documentation of any grievance/concern forms for R49, R60 and R66.
Resident #60:
Review of a grievance form provided by the facility dated 3/2/22 (no time noted) revealed documentation initiated by R60's family which read, .What is your concern about? About the safety of my Aunt She was vebally <sic> threaten to be punched when asked if she made a report on this nurse by the name of (name of Certified Nursing Assistant/CNA 'E') .How can we address your issues? To make sure my Aunt is properly cared for and not to be Harmed .Is this an ongoing problem? Yes .Was told they have a Love/Hate relationship .Have you contacted us in the past about this issue? Yes .My mom has to admitting I believe her name is . The facility's response included documentation from the Director of Nursing/DON, Immediate interview with pt (patient) - pt indicated that her and CENA were joking around .Facility Follow-Up called to speak with niece - niece would like CENA to no longer joke with pt . This form was completed by the DON.
Review of the clinical record revealed R60 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: cerebral infarction, visual hallucinations, altered mental status, insomnia, anxiety disorder, major depressive disorder recurrent, adjustment disorder with anxiety, multiple sclerosis, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, functional quadriplegia, legal blindness, ulcerative colitis, chronic pain syndrome, and vascular dementia with behavioral disturbance.
According to the Minimum Data Set (MDS) assessment dated [DATE], R60 had moderately impaired cognition and required extensive assistance of two or more people for bed mobility and was totally dependent upon two or more people for transfers.
On 5/17/22 at 4:21 PM, an interview was conducted with the Administrator (who was also identified as the facility's Abuse Coordinator). When asked about the alleged abuse reported by R60's family on 3/4/22 and whether there was any additional documentation of an investigation in accordance with their policy, the Administrator reported the DON immediately investigated and determined it was a joke as that's how the resident and staff member were with one another and referred back to the grievance documentation provided. When asked if any other staff or residents had been interviewed to determine if there were any witnesses or others with similar concerns, the Administrator reported they did not.
Resident #66:
Review of the clinical record revealed R66 was admitted into the facility on 8/23/21 and readmitted on [DATE] with diagnoses that included: dementia in other diseases classified elsewhere with behavioral disturbance, restlessness and agitation, generalized anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder single episodes, and acute post-hemorrhagic anemia.
According to the MDS dated [DATE], R66 had severely impaired cognition, had communication limitations, and was independent with ambulation without any assistive device.
Review of the progress notes included an entry on 1/30/22 at 6:38 PM by Nurse 'F' (who no longer employed with facility) which read:
.Dark scab observed to pt's (patient's) rt (right) lateral knee. Redness surrounding and Pt states its painful to touch. Pt unable to communicate how it was acquired. x2 sutures preset <sic> in center of scab. (Physician 'H') informed and treatment in place .
Review of the incident/accident documentation provided by the facility for R66 revealed there was no documentation of any investigation into the resident's knee injury identified on 1/30/22.
Review of the treatment orders included a treatment started on 1/31/22 through 2/26/22 for Rt knee scab: apply betadine moist 2x2 and cover w (with) bordered gauze QD (every day). Notify WCT (Wound Care Team) if scab becomes loose or falls off.
On 5/17/22 at 2:48 PM, an interview was conducted with the Administrator. When asked about whether R66's injury of unknown origin had been reported to the state agency, the Administrator reported that was not and they were not aware of the injury from 1/30/22 for R66.
On 5/17/22 at 3:31 PM, an interview was conducted with Nurse 'B' (Unit Manager for the unit R66 resided). When asked about R66's injury of unknown origin for the right knee with sutures, they reported they were only in the current role for about 90 days and was unable to offer any further details.
On 5/18/22 at 11:32 AM, an interview was conducted with the DON who reported they began working at the facility in that role since January 2022. When asked to review the progress note on 1/30/22, the DON reported they were unable to offer any information at this time, but would follow up. When asked if this injury of unknown origin had been reported to the State Agency, the DON reported it had not. There was no additional documentation or explanation into the injury of unknown origin provided by the end of the survey.
On 5/18/22 at 12:12 PM, a phone interview was conducted with Physician 'H' (Medical Director). When asked about what they could recall regarding R66's knee injury which was identified as having two sutures on 1/30/22 and a treatment order from Physician 'H', they reported they were not able to recall. When asked about whether sutures would be completed at the facility, or if that would require transfer to the hospital, Physician 'H' reported the facility would not have done any sutures, the resident might have fallen, gone out for stitches and came back to the facility and they would've followed up. When informed of the lack of documentation of any follow up following this injury of unknown origin, Physician 'H' apologized and reported they were not able to recall any specific details.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to consistently assess and follow up on skin conditions...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to consistently assess and follow up on skin conditions for (R14 and R66) and apply consistent treatments for (R14) of two residents reviewed for non-pressure skin conditions.
Findings include:
Resident #14:
On 5/17/22 at 1:23 PM, an interview was conducted with R14, who was observed sitting in their wheelchair next to their bed. When asked about their skin issue on their abdomen, R14 raised their shirt and revealed a irregular circular shaped ring worm observed to be similar to the size of a half dollar coin. It was dark maroon in color with raised outer edges.
Review of the clinical record revealed R14 was admitted to the facility on [DATE] with diagnoses that included: seizures, dementia, legal blindness and chronic kidney disease, stage 3. A MDS assessment dated [DATE], documented a BIMS score of 10 indicating moderately impaired cognition and requiring staff assistance for all ADLs.
Review of a Nursing note dated 3/27/22 at 4:56 PM, documented in part . Pt (patient) has a circular rash to abdomen that pt states is itchy. Antifungal lotion ordered x7days.
Review of a March 2022 Treatment Administration Record (TAR) documented Clotrimazole Cream 1 %, Apply to abdomen and back rash topically two times a day fungal rash for 7 days (start date 3/27/22). This order stopped on 4/3/22.
Review of the progress notes revealed no documentation if the abdomen rash had resolved, worsened, or if the prescribed treatment was effective.
Review of a Nursing note dated 4/29/22 at 2:06 PM, documented in part . Pt. seen by (physician name) for podiatry services. X10 nails cut. Rash also assessed and dx (diagnosed) as ringworm. Lotrisone ordered BID (twice a day) . The resident went from 4/3/22 until 4/29/22 without treatment to the ringworm on the abdomen and no follow up from the facility staff to ensure the area had resolved prior to the completion of the Clotrimazole cream treatment.
Review of the April 2022 TAR revealed an order for Lotrisone Cream 1-0.05%, Apply to rt (right) abd (abdomen) rash topically two times a day for ringworm fungal rash for 10 days (start date 4/29/22). This order stopped on 5/9/22.
Review of Nursing notes dated 5/10/22 at 12:28 and 4:43 PM, document the identification of the ring worm still present on the abdomen, however failed to follow up with the physician to implement treatment for the ring worm.
Review of a Nursing note dated 5/13/22 (4 days after the last treatment to the ringworm), documented in part . Pt fungal infection to RLQ (Right Lower Quadrant) unresolved after treating with lotrisone. (Doctor name) consulted and order changed to Naftin bidx7d (twice a day for 7 days). Orders updated .
Review of the May 2022 TAR revealed the nurses signed for the Naftin cream on 5/13 and 5/14, however review of the nursing progress notes revealed the cream was not delivered to the facility until the evening of 5/16/22 as documented in the Nursing note dated 5/15/22 at 1:29 PM, . called pharmacy to see when the Naftifine cream 2% would be delivered: Operator stated the medication is on back order, and it will not be available until Monday evening . The start date was changed to 5/17/22 (4 days after the implementation of the order).
Review of R14's care plans revealed no care plan or interventions implemented for the ringworm identified on the resident's abdomen.
On 5/18/22 at 2:14 PM, the Director Of Nursing (DON) was interviewed and asked why there was no consistent follow up assessments to ensure the effectiveness of treatment to the resident's ringworm that was identified two months ago, why the nurses signed on 5/13 and 5/14 when the treatment had not been delivered from the pharmacy yet and why there was no care plan implemented regarding R14's abdomen ringworm. The DON stated they would follow up. Shortly after the DON returned and stated a care plan is now implemented (dated 5/18/22) and that the resident was seen by the wound doctor on 4/29/22 and 5/6/22.
No further information or documentation was provided by the end of survey.
Resident #66:
Review of the clinical record revealed R66 was admitted into the facility on 8/23/21 and readmitted on [DATE] with diagnoses that included: dementia in other diseases classified elsewhere with behavioral disturbance, restlessness and agitation, generalized anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder single episodes, and acute post-hemorrhagic anemia.
According to the MDS dated [DATE] documented R66 had severely impaired cognition, had communication limitations, and was independent with ambulation without an assistive device.
Review of the progress notes included an entry on 1/30/22 at 6:38 PM by Nurse 'F' (who no longer employed with facility) read:
.Dark scab observed to pt's (patient's) rt (right) lateral knee. Redness surrounding and Pt states its painful to touch. Pt unable to communicate how it was acquired. x2 sutures preset <sic> in center of scab. (Physician 'H') informed and treatment in place .
Review of the physician and extender progress notes and consultations revealed there was no documentation that identified R66's right knee had been assessed, or that there had been a transfer for placement of sutures, or any indication of what may have contributed to the injury of unknown origin. The first available progress note following 1/30/22 was on 2/11/22 and did not identify anything about the resident's knee injury, only that they were consulted for complaints of nausea, vomiting and diarrhea. There was no follow up to ensure that the sutures were removed, or any further assessment.
Review of the skin assessments did not indicate any change in skin condition or identify concerns.
Although the treatment orders were initiated on 1/31/22 through 2/26/22 for Rt knee scab: apply betadine moist 2x2 and cover w (with) bordered gauze QD (every day). Notify WCT (Wound Care Team) if scab becomes loose or falls off. there was no further documentation about the monitoring or care of the sutures.
On 5/17/22 at 2:48 PM, an interview was conducted with the Administrator. When asked about R66's right knee injury, the Administrator reported they were not aware.
On 5/17/22 at 3:31 PM, an interview was conducted with Nurse 'B' (Unit Manager for the unit R66 resided). When asked about R66's injury of unknown origin for the right knee with sutures, they reported they were only in the current role for about 90 days and that had occurred prior to them working in that role and was unable to offer any further details.
On 5/18/22 at 11:32 AM, an interview was conducted with the DON who reported they began working at the facility in that role since January 2022. When asked to review the progress note on 1/30/22, the DON reported they were unable to offer any information at this time, but would follow up. When asked if the facility would perform sutures on-site, or if the residents would go out for that if needed, the DON reported they were not aware of any of the medication rooms having suture kits. The DON was asked about the lack of physician follow up and reported they would follow up. There was no additional documentation or explanation provided by the end of the survey.
On 5/18/22 at 12:12 PM, a phone interview was conducted with Physician 'H' (Medical Director). When asked about what they could recall regarding R66's knee injury which was identified as having two sutures on 1/30/22 and a treatment order from Physician 'H', they reported they were not able to recall. When asked about whether sutures would be completed at the facility, or if that would require transfer to the hospital, Physician 'H' reported the facility would not have done any sutures, the resident might have fallen, gone out for stitches and came back to the facility and they would've followed up. When informed of the lack of documentation of any follow up following this injury of unknown origin, Physician 'H' apologized and reported they were not able to recall any specific details.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation has two deficient practices.
Deficient Practice Statement #1
Based on observation, interview and record review, th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation has two deficient practices.
Deficient Practice Statement #1
Based on observation, interview and record review, the facility failed to ensure an appropriate assistance level was provided during care for one resident (R#19) of six residents reviewed for accidents/hazards. Findings include:
On 5/16/22 at approximately 11:17 a.m., R19 was observed in their room, laying in their bed while having their brief changed by Certified Nursing Assistant M (CNA M). CNA M was observed attempting to move R19 away from them to the other side of the bed with one hand while trying to remove a soiled brief with the other hand. R19 was observed to be moaning and CNA M appeared to be having difficulty holding R19 away from them on their side while trying to remove the brief. CNA M then managed to remove the brief and let R19 come back down in supine position. CNA M was queried if R19 required another staff member to assist while proving care and they indicated they thought he might. CNA M then indicated that they would go find help to attempt to safely complete the rest of the brief change and left the room.
On 5/16/22 at approximately 11:24 a.m., R19 was queried if staff usually have two staff members present while providing care to them and they indicated they should but many times they do not.
On 5/17/22 The medical record for R19 was reviewed and revealed the following: R19 was initially admitted on [DATE] and had diagnoses including Obesity and Muscle Weakness. A review of R19's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/23/22 revealed R19 Needed extensive assistance from facility staff with their activities of daily living. Further review of the MDS indicated that R19 had two staff members providing assistance for bed mobility.
A review of R19's careplan revealed the following: [R19[ has an ADL (activity of daily living) Self Care
Performance Deficit and requires assistance with ADL's and mobility r/t (related to): debility/weakness obstructive nephropathy .Interventions-BED MOBILITY: [R19] is two person to reposition and turn in bed .
On 5/18/22 at approximately 9:19 a.m., Nurse Manager B (NM B) was queried regarding the observation of CNA M attempting to complete R19's brief change by themselves and turning R19 away from them towards the other side of the bed. NM B reviewed R19's medical record and indicated that it requires to staff members to safely provide care. NM B indicated that CNA M should have waited until some help arrived. NM B indicated that they have seen other residents have accidents when not using the right about of staff to provide care. NM B indicated that CNA M has access to the medical record and can review how each resident is safely handled in the bed.
A facility document titled Guest/Resident Care was reviewed and revealed the following: Guests/residents receive the necessary assistance to maintain good grooming and personal/oral hygiene. Steps are taken to ensure that a guest's/resident's capacity for self-performance of these activities does not diminish unless circumstances of the guest's/resident's clinical condition demonstrate the decline is unavoidable. Care is taken to ensure guest/resident safety at all times .
Deficient Practice Statement #2:
This citation pertains to intake# MI00127996.
Based on observation, interview and record review, the facility failed to provide adequate supervision for residents with known wandering behaviors for one (R66) of six residents reviewed for accidents.
Findings include:
On 5/16/22 at 10:38 AM, R66 was observed ambulating up and down the hallway with a two wheeled walker going from room to room and at times entering the rooms of other residents.
On 5/16/22 at 12:57 PM, R66 was observed to enter the conference room used by the survey team (which was located beyond the closed fire doors from the far end of the unit on which R66 resided). When redirected out of the room by the surveyor, there was no other staff present in the hallways and it was unknown how long R66 had been outside of the fire doors to their unit. At that time, the Director of Social Services was approached and asked to escort the resident back to their area. (It should be noted that signage on the fire doors indicated these were to remain closed to prevent residents from moving throughout the facility due to COVID-19 outbreak.)
Review of the clinical record revealed R66 was admitted into the facility on 8/23/21 and readmitted on [DATE] with diagnoses that included: dementia in other diseases classified elsewhere with behavioral disturbance, restlessness and agitation, generalized anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, and major depressive disorder single episode.
According to the Minimum Data Set (MDS) assessment dated [DATE], R66 had severely impaired cognition, had communication limitations, had physical and verbal behavioral symptoms directed towards others, and was independent with ambulation without an assistive device.
Review of the progress notes included:
An entry on 12/7/21 at 9:22 PM, read Guest observed entering other guests rooms without being invited. Guest is calm and cooperative when being removed from the rooms but re-enters the rooms 10-20 min (minutes) later again. Especially when room doors are closed she will enter and walk around. She is not touching other people or taking items that don't belong to her. Staff will continue to attempt to convey that this is not okay. May have to contact family if behavior persists.
An entry on 12/27/21 at 5:54 PM read, .Resident screaming at staff, attempting to push other residents to her room, redirected by staff but resident continues to yell at staff, also observed spitting on floor. Grand daughter contacted and spoke with resident redirecting her but unsuccessful.
An entry on 3/21/22 at 10:19 PM read, Writer notified by another staff nurse that nurse witnessed resident (R66) standing over resident 002739 when 002739 scratched resident which led to a skin tear on her right lower arm .R (right) lower arm cleansed with wc (wound cleanser), steri-strip applied, foam dressing .
An entry on 3/28/22 at 4:50 PM read, .Guest observed blocking meal carts not allowing staff to access trays. Yelling at staff loud and closely and refusing to move. Guest almost knocking food trays over. Follow staff down the halls ding <sic> this and is unable to be redirected. Becomes more angry when attempted to stop guest from touching cart.
An entry on 4/10/22 at 9:17 AM, read Guest was observed on the roommates side of the bed pulling her covers and talking very loudly to her roommate and waving her hands. Guest roommate was stating please stop, leave me alone. Writer attempted to re-direct guest to her side of the room, ineffective, attempted to give guest 1 on 1 time - ineffective d/t (due to) language barrier. Guest still on other roommate side .
On 5/17/22 at 2:48 PM, an interview was conducted with the Administrator. When asked about R66's observations of ambulating throughout the unit and close proximity with other residents in the common area, hallways and observations of entering other resident rooms, the Administrator reported those were common behaviors for R66 and prior to the COVID-19 outbreak and closing the fire doors, R66's usual behavior and routine was to walk throughout the facility. When informed of the observation of R66 entering the conference room during survey without any other staff aware, they indicated they were not aware that had occurred, but that was also a normal routine for the resident to enter the conference room when they were in there to say hello. The Administrator was asked if there had been consideration for need for increased supervision due to the multiple incidents noted in the clinical record and observations during survey and they reported they did not and felt the nursing staff tried to redirect and provide supervision. When asked about what happens when management leave and staffing levels go down in the evenings, the Administrator reported there was front desk staff here till 9:00 PM and this had been a challenge for the past week and a half with the COVID-19 outbreak. The Administrator was informed of the observations made of R66 during survey and concerns regarding lack of adequate supervision.
On 5/17/22 at 3:31 PM, an interview was conducted with Nurse 'B' (Unit Manager for the area R66 resided). When asked about how staff were able to provide supervision to R66 in addition to making sure other assignments and care needs were done, Nurse 'B' reported R66 normally walks all day and family is available as well. (There was no family observed visiting at any of the observations during survey.) Nurse 'B' further reported staffing was a challenge when staff called in. When asked how increased supervision was able to be provided to residents that wander like R66, Nurse 'B' reported R66 is the one (resident) that wanders the most and takes the most time from the staff down there (on the unit). She would be the busiest one.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #29:
On 5/16/22 at 10:13 AM, R29 was observed sitting in their wheelchair next to their bed. When asked R29 stated they...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #29:
On 5/16/22 at 10:13 AM, R29 was observed sitting in their wheelchair next to their bed. When asked R29 stated they had no concerns and whatever past concerns they had was already addressed by the facility.
Review of the clinical record revealed R29 was admitted to the facility on [DATE] with a readmission date of 12/14/20 and diagnoses that included: Parkinson's disease, enterocolitis due to clostridium difficile, chronic kidney disease and dementia. A MDS assessment dated [DATE] documented a BIMS score of 13 indicating intact cognition and required staff assistance for all ADLs.
Review of a pharmacist medication review for R29 dated 12/15/21 identified irregularities noted.
On 5/17/21 at 11:35 AM, a copy of the pharmacist report that noted the irregularities and recommendations was requested from the DON. At 1:04 PM a second request was made to the DON and a third request at 2:17 PM.
Review of a pharmacy Consultation Report dated 12/15/21 documented in part, . REPEATED RECOMMENDATION from 10/12/2021: Please respond to promptly to assure facility compliance with Federal regulations . (R29) has received loperamide 4 mg (milligram) QD (everyday) since 9/17/21 (in addition to PRN (as needed) order) . Recommendation: Please consider discontinuing routine use of loperamide. If therapy is to continue without a stop date, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual; and b) the facility interdisciplinary team ensures ongoing monitoring for effectiveness and potential adverse consequences . The Physician's Response, physician signature and DON signature spaces were all blank. This indicated the consultation report was not reviewed by the physician or DON.
Review of the clinical record revealed no documentation by the physician of the review of the loperamide medication or assessment of risk versus benefits documented.
Review of May 2022 Medication Administration Record (MAR) documented the following: Loperamide HCl 2 MG, Give 2 tablets by mouth one time a day for diarrhea. This indicated the resident was currently (at the time of survey) being administered the daily dose, despite the recommendations from the pharmacist.
Review of a facility policy titled Timeliness of Medication Regimen Review (MRR) Reports revised 9/30/21 documented in part, . The pharmacist will review and report any medication irregularities at least once a month . The consultant will provide monthly MRR reports addressed to the Medical Director, Director of Nursing and Attending Physician within 3-5 days of completion . The attending physician is expected to review the guest's/residents individual MRR and document and sign that he/she has reviewed the pharmacist's identified recommendations within 14 days of receipt . If the attending Physician does not respond to the guest's/resident's MRR report within 14 days, the Director of Nursing will notify the physician of pending MRR reports . If by the 21st day , the attending physician had not yet responded to the guest's/resident's individual MRR report, the Director of Nursing will notify the Medical Director to review and respond to the pending MRR reports .
On 5/18/22 at 9:31 AM, the DON was interviewed and asked why the pharmacist recommendation was not reviewed and implemented. The DON stated they were not employed with the facility at the time of the recommendation but reviewed the record and seen that the PRN order was discontinued. The DON was again asked why the repeated recommendation by the pharmacist was not reviewed and addressed and could not provide any further explanation or documentation by the end of survey.
Based on observations, interview and record review, the facility failed to review and report monthly pharmacist medication recommendations for three (R29, R38 and R44) of five resident's reviewed for unnecessary medications.
Findings include:
According to the facility's policy titled, Timeliness of Medication Regimen Review (MRR) Reports dated 9/30/21:
.The pharmacist will review and report any medication irregularities at least once a month .The consultant will provide monthly MRR reports addressed to the Medical Director, Director of Nursing, and Attending Physician within 3-5 days of completion via secure e-mail or hard copy .The attending physician is expected to review the guest's/resident's individual MRR and document and sign that he/she has reviewed the pharmacist's identified recommendations within 14 days of receipt .If the attending Physician does not respond to the guest's/resident's MRR report within 14 days, the Director of Nursing will notify the physician of pending MRR reports .If by the 21st day, the attending physician has not yet responded to the guest's/resident's individual MRR report, the Director of Nursing will notify the Medical Director to review and respond to the pending MRR reports .If the Medical Director is also the attending physician, the Director of Nursing will escalate the issue to the facility Administrator .
Resident #38:
Review of the clinical record revealed R38 was admitted into the facility on 6/28/21 and readmitted on [DATE] with diagnoses that included: acute polynephritis, end stage renal disease, pneumonia, anorexia, adjustment disorder with mixed anxiety and depressed mood, insomnia, major depressive disorder recurrent moderate, type 2 diabetes mellitus, chronic respiratory failure with hypoxia, unspecified dementia without behavioral disturbance, anxiety disorder, and dependence on renal dialysis.
Review of the pharmacy medication regimen reviews (MRR) revealed there were identified irregularities on 10/12/21 and 12/15/21. However, there was no documentation of what the specific irregularities were, or if the physician had followed up to agree/disagree with recommendations.
Resident #44:
Review of the clinical record revealed R44 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: congestive heart failure, dysphagia, dyspnea, COVID-19 (1/18/22), peptic ulcer, acute kidney failure, hypokalemia, chronic kidney disease stage 3, anemia, anxiety disorder, Parkinson's disease, irritable bowel syndrome without diarrhea, and type 2 diabetes mellitus.
Review of the pharmacy MRRs revealed there were no pharmacy recommendations for August 2021 or January 2022. Additional review of the census information revealed resident was at the facility during these months.
On 5/18/22 at 8:55 AM, an interview was conducted with the Director of Nursing (DON). When asked to review their process to ensure MRRs were completed and addressed timely, the DON reported the pharmacy recommendations were emailed to the DON, then they are given to the individual physician, then those are returned to the DON, then given to medical records to be scanned into the miscellaneous tab in the resident's electronic clinical record. The DON was asked if they had previously identified any concerns with MRRs not being completed, or followed up by physicians timely and they reported they had not. When asked where the monthly pharmacy MRRs were kept, the DON reported those were under the assessments tab of the electronic clinical record. The DON was informed of the above missing recommendations and identified irregularities that were not available for review, and was asked to provide any additional documentation.
On 5/18/22 at 9:25 AM, Pharmacy Consultant (Staff 'I') was attempted to be contacted by phone at the number provided by the DON. There was no response, or returned call before the end of the survey.
On 5/18/22 at 12:53 PM, the DON provided some additional documentation, and reported there was no further documentation available to provide for the above MRRs for R38 and R44. The DON also reported that Staff 'I' had contacted them and reported they would not be able to discuss information with this surveyor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who was prescribed as needed (PRN) psychotropic m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who was prescribed as needed (PRN) psychotropic medication had adequate indication for continued use beyond 14 days, had adequate behavior monitoring and identification of the resident specific targeted behaviors and non-pharmacological approaches at the time of medication administration for one (R38) of five residents reviewed for unnecessary medication use.
Findings include:
According to their policy titled, Psychoactive Medication Management dated 8/3/21:
.Non-pharmacologic interventions are the first choice in management of behavioral symptoms .PRN orders for psychotropic medications .which are not antipsychotic medications are limited to 14 days. The attending physician/prescriber may extend the order beyond 14 days if he or she believes it is appropriate. If the attending physician extends the PRN for the psychotropic medication, the medical record must contain a documented rationale and determined duration .
Review of the clinical record revealed R38 was admitted into the facility on 6/28/21 and readmitted on [DATE] with diagnoses that included: anorexia, adjustment disorder with mixed anxiety and depressed mood, insomnia, major depressive disorder recurrent moderate, unspecified dementia without behavioral disturbance, anxiety disorder, and dependence on renal dialysis.
According to the Minimum Data Set (MDS) assessment dated [DATE], R38 had intact cognition, and received anti-anxiety medication for three of the seven days during this assessment period.
Review of the care plans included:
(R38) has the potential for fluctuations in mood R/T (related to): Dementia, Anxiety Disorder, Major Depressive Disorder, Insomnia. This was initiated on 9/13/21 and reviewed on 12/2/21.
Interventions included:
Attempt non-pharmacological interventions to decrease mood exacerbation's such as: assist to reposition, provide reassurance, offer food/beverage, attend to toileting needs, encourage to talk about issues, attempt diversional activities, attempt to change environment/decrease stimulation, provide consistent routines as able, and orient to environment as needed
Review of the Medication Administration Records (MARs) revealed R38 had been prescribed the prn Xanax (Alprazolam) medication since 11/16/21. The most recent order written on 5/17/22 had no end date and read indefinite, however there was no physician/clinical rationale available in the clinical record to justify an indefinite prn order for the xanax medication.
According to the May 2022 MAR, R38 received six prn doses of Xanax on:
5/3 at 8:10 AM; 5/5 at 8:06 AM; 5/7 at 2:54 AM; 5/9 at 8:53 AM; 5/10 at 9:34 AM; 5/11 at 8:14 AM; 5/16 at 11:43 AM; 5/17 at 7:58 AM; and 5/18 at 8:34 AM.
Review of the MARs included a section for nurses to document the non-pharmacological approaches, however these were incomplete and left blank.
Review of the progress notes, including the electronic eMAR notes (section of the clinical record for nurses to document behaviors, interventions, etc) revealed most indicated the reason was R38 requested the medication, and some were left blank with no indication noted.
On 5/18/22 at 8:55 AM, an interview was conducted with the Director of Nursing (DON). When asked about what the facility's process was for administering and documenting as needed psychotropic medication such as what the specific targeted symptoms were and what non-pharmacological approaches were done at the time of medication administration, the DON reported that should be on the MAR. When asked to review R38's MAR, the DON confirmed the section to document non-pharmacological approaches was left incomplete and left blank. The DON reported they would see if there was additional documentation and would follow-up.
On 5/18/22 at 9:32 AM, the DON reported the nursing staff would document resident behaviors and non-pharmacological interventions in the eMAR progress notes. When asked about the direct care staff, the DON reported the CNAs (Certified Nursing Assistants) would document on the CNA task and tell the nurse. There was no further documentation provided by the end of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the 2021-2022 influenza (flu) vaccine and recommended pneumo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the 2021-2022 influenza (flu) vaccine and recommended pneumococcal (pneumonia) vaccines were offered and administered for two residents (R#'s 2 and 38), of five residents reviewed for influenza and pneumococcal vaccines, resulting in the potential for complications from influenza and pneumococcal infections.
5/17/22 at 10:40 AM, the facility's Director of Nursing (DON) was asked about the facility's vaccination program and said that upon admission, residents were assessed for COVID-19, influenza and pneumococcal vaccination status, and they could accept or decline the vaccinations at that time. They were then asked where in the record evidence of vaccination administration and vaccination consents or declinations could be reviewed. They reported the administration of the vaccines were documented in the Immunization tab of the electronic medical record and the consent/declination forms were scanned into the Miscellaneous tab of the electronic medical record. They also reported they used the State's online database to verify vaccination status and reported to the database if they administered any vaccinations to any residents in their facility.
On 5/17/22 at 11:33 AM, R2's clinical record was conducted and revealed they most recently admitted to the facility on [DATE]. Continued review of R2's clinical record was reviewed for evidence of having been offered or having received the 2021-2022 influenza vaccine. The Immunization tab of the electronic medical record indicated R2 received an influenza vaccine in 2019, and 2020, but there was not a documented administration for 2021. A review of R2's Miscellaneous tab was conducted and did not reveal any consents or declinations for the influenza vaccine for the 2021-2022 flu season. A review of a facility provided document printed from the State's database summarizing R2's vaccination status was reviewed, but did not indicate they received a 2021-2022 influenza vaccine.
On 5/17/22 at 2:01 PM and 4:20 PM, a review of R38's clinical record revealed they admitted to the facility on [DATE] and re-admitted on [DATE]. R38's Miscellaneous tab in the electronic medical record was reviewed for evidence of consent or declination of the 2021-2022 influenza vaccine and it was discovered the resident declined the vaccine after their admission on [DATE], but there was no evidence the vaccine was offered at the beginning (October 2021, per the Center of Disease Control) of the 2021-2022 influenza season. Continued review of documents in R38's Miscellaneous tab in the electronic medical record revealed an undated consent signed by R38 that indicated they wished to receive both of the pneumococcal vaccines. A review of the Immunization tab in R38's electronic medical record documented the R38 had refused the pneumococcal vaccines. A review of a facility provided document printed from the State's database summarizing R38's vaccination status was reviewed, but did not indicate they received any pneumococcal vaccines.
On 5/18/22 at 3:00 PM, concerns regarding R2 and R38's influenza and pneumococcal vaccine status was brought to the attention of the DON. They were requested to provide any additional evidence regarding whether the residents had been offered or received the vaccines, however; nothing additional was received by the end of the survey.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to respond and resolve concerns/grievances brought fourth by the resident council in a timely manner for two (R#'s 29 and 73) of four resident...
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Based on interview and record review, the facility failed to respond and resolve concerns/grievances brought fourth by the resident council in a timely manner for two (R#'s 29 and 73) of four residents reviewed for resident council concerns in a current facility census of 97 residents. Findings include:
On 5/17/22 at approximately 3:19 p.m., R29 was queried regarding the facility resident council meetings and subsequent concerns follow-up. R29 indicated that the council has had ongoing concerns about the food including not getting what they want to eat and requesting more soup and salad. R29 also reported the they have brought up the call lights not being answered and the issue with not enough staff. R29 indicated the facility has very few people and not enough help on the night or weekend shifts. R29 indicated they have had to wait 30 minutes to an hour many times to get assistance. R29 stated I've been told by other aides that its because they don't have enough help. Regarding food, R29 further reported they (the facility) used to have a nice big salad a year ago but no longer have salad enough. R29 also stated I like soup. It doesn't take much to put it in the microwave. They should always serve it as a side. R29 was queried regarding the facility follow up pertaining the issues brought fourth by the resident council and they indicated that nobody does anything and it is still a problem every month.
On 5/17/22 at approximately 3:23 p.m., R73 was queried regarding the staffing in the facility. R73 stated, they have s*** for staff. Not enough ever. R73 reported they needed two staff members to help them and they always have to wait because one aide cannot help them. R73 indicated they have had multiple nights were they just laid in my bed wet, waiting for a bed pan that never came. R73 indicated that when staff do come to assist it's too late. R73 was queried regarding the food in the facility and they indicated that their dog ate food. R73 indicated they have brought up the food and staff multiple times in resident council and it is never fixed. R73 indicated that it goes in one ear and out the other. R73 was queried regarding follow-up pertaining to the concerns brought fourth in resident council and they indicated that nobody follows up with anyone and nobody can communicate.
On 5/18/22 the monthly resident council minutes (documentation) were reviewed from December 2021 until April 2022 and revealed the following issues brought fourth by the resident council: December 13th 2021-Old business-Culinary: Reports wanting to have more soup options and suggest having the availability of pre-made soup on hand for meals. Council would like to see a bigger portion of fruits given with meals .January 14th 2022-Nursing: Council is reporting long call light wait times .Culinary: Council is requesting to have soup and salad offered more frequently .Culinary: Council is requesting the kitchen install an answering machine or get voicemail so they may leave a message for kitchen staff regarding their meal trays .February 16th 2022-Culinary: Council reports not noticing an increase in soups and salads being offered .Nursing: Council reported that newer staff are not familiar with guest's plan of care i.e.: transfer status, toilet/brief usage .March 31st 2022-Culinary: Council would like to be informed on meal substitutions .Nursing: Council reported that nursing staff are not removing trash and soiled linens from room .April 13th 2022-Nursing: staffing appears to be challenged again especially in the afternoons. Residents mentioned that during the weekends call wait light times are longer .
On 5/18/22 at approximately 12:56 p.m., A review of the facility responses to the resident council's concerns were reviewed with Activities Director L (AD L). AD L was queried regarding the facility response for the January 14th, 2022 concern that indicated the facility had long call light wait times and requesting to have soup and salad offered more frequently. AD L indicated they were unable to provide a facility response for the call light wait times but did provide a facility response on a Resident, Family, Employee and Visitor Assistance form that was signed by the dietary manager on 2/3/22 that revealed the following: Facility Response [Blank] .Action to be taken: CDM (certified dietary manager) aware of request added to dinner. Council educated on calling request <sic> in to kitchen. preference added to meal ticket .Facility Follow-Up: [Blank] .Signed/Title: [BLANK]. Date: [Blank]. A second assistance form signed on 2/3/22 by the CDM pertaining to the request for the kitchen to get an answering machine installed on their phone revealed the following: Facility Response: [Blank] .Action to be Taken: Unfortunately our system cannot <sic> this feature. Culinary will do a better job of answering phone .Facility Follow-Up: [Blank] .Signature/Title (facility): [Blank] .Date: [Blank} .AD L was queried why the rest of both forms were blank with the exception of the Action to be Taken section and why the date that the CDM signed the form was 2/3 when the concern was noted on the minutes for January and AD L indicated they just give the forms out and it was a delay on their part for getting the assistance form out to the CDM weeks later. AD L was queried regarding the facility response to the concerns on the February 2022 meeting minutes that indicated there were long call light wait times for Nursing assistance and the continued concern regarding increased soup and salad being offered more. AD L provided a facility response that was on another assistance form dated 3/24/22 by the CDM which revealed the following: How can we address your issues? Salad and soup is on the menu sometimes 2x a week or the resident request to add to to their ticket daily, or salad to their diet ticket daily .Facility Response: [Blank] .Action to be taken: [Blank] .Facility follow-up: [Blank] .Signature/Title: [Blank] .Date: [Blank] . AD L was queried why it was over a month since the February meeting to have the CDM indicate a response to the food concern and why the form was incomplete as well as to why no response for the Nursing concern was provided and AD L again indicated they had a delay in getting the form to the CDM for the food concern and did not have a response for the Nursing concern. The March 2022 concerns identified by the resident council and the facility responses were reviewed with AD L. AD L provided an assistance form dated 3/31/22 which revealed the following: What is your concern about? Culinary: Council is reporting they would like to be informed when the meal being offered is different than on the posted menu .Further review of the assistance form indicated the rest of the form was blank. A second assistance form dated 3/31/22 was reviewed and reveled the following: Nursing staff are not removing trash and soiled linen from room. Further review of that assistance from was blank. AD L was queried regarding the responses for these concerns identified by the resident council and AD L indicated they had not received a response/follow-up. A review of the concerns from resident council on the April 2022 meeting were reviewed with AD L which had indicated a concern with long call light wait times on the weekends and staffing challenges in the afternoons. AD L provided an assistance form dated 4/13/22 that revealed the following: What is your concern about: Nursing: Council reported long call wait times on the weekends . Further review of the assistance form revealed the rest of it to be blank and no facility action/follow-up indicated. A second assistance form dated 4/13/22 was reviewed and revealed the following: What is your concern about: Nursing staffing appears to be challenged again especially in the afternoons. Further review of that assistance form revealed no facility action or follow-up on it.
At that time, AD L was queried why there were no follow-up or actions taken from the facility on the assistance forms pertaining to the April concerns and they indicated they did not know. AD L was queried regarding the lack of facility responses, follow-up and incomplete assistance forms in response to the identified concerns of the resident council meetings and they indicated that they would let the departments head know about it and see that the concerns are follow up and documented appropriately.
No other assistance forms were received by the end of the survey regarding the facility responses to the resident council concerns.
CONCERN
(E)
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** Resident #29
On 5/17/22 at approximatley 3:19 p.m., R29 was queried regarding residnet council meetings and concern followup. R2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #29
On 5/17/22 at approximatley 3:19 p.m., R29 was queried regarding residnet council meetings and concern followup. R29 reported the they have brought up the call lights not bieng answered and the issue with there not being enough staff. R29 indicated the facilty has very few people and not enough help on the night or weekened shifts. R29 indciated they have had to wait 30 minutes to an hour many times to get assistance. R29 stated I've been told by other aides that its because they don't have enough help.
Resident #73
On 5/17/22 at approiamtley 3:23 p.m., R73 was queried regarding the staffing levels in the facilty. R73 stated, they have s*** for staff. Not enough ever. R73 reported they needed two staff members to help them and they always have to wait because one aide cannot help them. R73 indicated they have had multple nights were they just layed in their bed wet, waiting for a bed pan that never came. R73 indcaited that when staff do come to assit it's too late. R73 indicated they have brought up the staff issue multiple times in resdient council and it is never fixed. R73 indicated that it goes in one ear and out the other.
On 5/18/22 the monthly resident council minutes were reviewed from December 2021 until April 2022 and revealed the following staffing issues brought fourth by the resident council: Januay 14th 2022-Nursing: Council is reporting long call light wait times .February 16th 2022-Nursing: Council reported that newer staff are not familiar with guest's plan of care i.e.: transfer status, toilet/brief usage .March 31st 2022-Nursing: Council reported that nursing staff are not removing trash and soiled linens from room.
Resident R275
On 5/16/22 at 11:13 AM, an interview with R275 was conducted regarding their stay in the facility. R275 expressed concerns with staffing saying that on Saturday's and Sunday's the halls are empty, and staff take a long time to answer their call light. R275 said they require two people for assistance but they can't get two people to provide the help. They said when they ask staff for assistance the staff say, It's not their job.
Resident R49
On 5/16/22 at 12:07 PM, R49 was interviewed about their stay in the facility. They said they had been in the facility a long time and moved rooms. R49 said they noticed a lack of staff. They said Graduate Nurses were working as CNA's and said they don't work. R49 continued to say they witnessed the staff taking long breaks and sleeping and had reported it to management.
This citation pertains to intake# MI00127996.
Based on observation, interview and record review the facility failed to ensure sufficient nursing staff were provided to meet resident needs including timely care and supervision for five (R#s 29, 49, 66, 73 and 275) residents reviewed for sufficient staffing.
Findings include:
Resident #66:
On 5/16/22 at 10:38 AM, R66 was observed ambulating up and down the hallway with a two wheeled walker going from room to room and at times entering the rooms of other residents.
On 5/16/22 at 12:57 PM, R66 was observed to enter the conference room used by the survey team (which was located beyond the closed fire doors from the far end of the unit on which R66 resided). When redirected out of the room by the surveyor, there was no other staff present in the hallways and it was unknown how long R66 had been outside of the fire doors to their unit. At that time, the Director of Social Services was approached and asked to escort the resident back to their area. (It should be noted that signage on the fire doors indicated these were to remain closed to prevent residents from moving throughout the facility due to COVID-19 outbreak.)
Review of the clinical record revealed R66 was admitted into the facility on 8/23/21 and readmitted on [DATE] with diagnoses that included: dementia in other diseases classified elsewhere with behavioral disturbance, restlessness and agitation, generalized anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, and major depressive disorder single episode.
According to the Minimum Data Set (MDS) assessment dated [DATE], R66 had severely impaired cognition, had communication limitations, had physical and verbal behavioral symptoms directed towards others, and was independent with ambulation without an assistive device.
Review of the progress notes included:
An entry on 12/7/21 at 9:22 PM, read Guest observed entering other guests rooms without being invited. Guest is calm and cooperative when being removed from the rooms but re-enters the rooms 10-20 min (minutes) later again. Especially when room doors are closed she will enter and walk around. She is not touching other people or taking items that don't belong to her. Staff will continue to attempt to convey that this is not okay. May have to contact family if behavior persists.
An entry on 12/27/21 at 5:54 PM read, .Resident screaming at staff, attempting to push other residents to her room, redirected by staff but resident continues to yell at staff, also observed spitting on floor. Grand daughter contacted and spoke with resident redirecting her but unsuccessful.
An entry on 3/21/22 at 10:19 PM read, Writer notified by another staff nurse that nurse witnessed resident (R66) standing over resident 002739 when 002739 scratched resident which led to a skin tear on her right lower arm .R (right) lower arm cleansed with wc (wound cleanser), steri-strip applied, foam dressing .
An entry on 3/28/22 at 4:50 PM read, .Guest observed blocking meal carts not allowing staff to access trays. Yelling at staff loud and closely and refusing to move. Guest almost knocking food trays over. Follow staff down the halls ding <sic> this and is unable to be redirected. Becomes more angry when attempted to stop guest from touching cart.
An entry on 4/10/22 at 9:17 AM, read Guest was observed on the roommates side of the bed pulling her covers and talking very loudly to her roommate and waving her hands. Guest roommate was stating please stop, leave me alone. Writer attempted to re-direct guest to her side of the room, ineffective, attempted to give guest 1 on 1 time - ineffective d/t (due to) language barrier. Guest still on other roommate side .
On 5/17/22 at 2:48 PM, an interview was conducted with the Administrator. When asked about R66's observations of ambulating throughout the unit and close proximity with other residents in the common area, hallways and observations of entering other resident rooms, the Administrator reported those were common behaviors for R66 and prior to the COVID-19 outbreak and closing the fire doors, R66's usual behavior and routine was to walk throughout the facility. When informed of the observation of R66 entering the conference room during survey without any other staff aware, they indicated they were not aware that had occurred, but that was also a normal routine for the resident to enter the conference room when they were in there to say hello. The Administrator was asked if there had been consideration for need for increased supervision due to the multiple incidents noted in the clinical record and observations during survey and they reported they did not and felt the nursing staff tried to redirect and provide supervision. When asked about what happens when management leave and staffing levels go down in the evenings, the Administrator reported there was front desk staff here till 9:00 PM and this had been a challenge for the past week and a half with the COVID-19 outbreak. The Administrator was informed of the observations made of R66 during survey and concerns regarding lack of adequate supervision.
On 5/17/22 at 3:31 PM, an interview was conducted with Nurse 'B' (Unit Manager for the area R66 resided). When asked about how staff were able to provide supervision to R66 in addition to making sure other assignments and care needs were done, Nurse 'B' reported R66 normally walks all day and family is available as well. (There was no family observed visiting at any of the observations during survey.) Nurse 'B' further reported staffing was a challenge when staff called in. When asked how increased supervision was able to be provided to residents that wander like R66, Nurse 'B' reported R66 is the one (resident) that wanders the most and takes the most time from the staff down there (on the unit). She would be the busiest one.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medications were appropriately stored and secur...
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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 medications were appropriately stored and secured for one resident (R37), and in one medication treatment cart and in three medication carts. Findings include:
On 5/16/22 at approximately 9:59 a.m., A medication cart located next to room [ROOM NUMBER] was observed to be unlocked and unattended by any Nursing staff. Upon return to the cart, Nurse Q was queried regarding the unlocked cart and unattended cart and they indicated that they thought they had locked it.
On 5/16/22 at approximately 10:05 a.m., A medication cart next to room [ROOM NUMBER] was observed to be unlocked and unattended by any Nursing staff. Nurse Q was observed walking by the cart and was queried regarding the unlocked cart and unattended cart and indicated that it was not their cart but was observed having to lock it.
On 05/16/22 at approximately 11:24 a.m., A medication cart containing wound treatments was observed next to be unlocked and unattended by any Nursing staff. After a few minutes, Nurse D was shown the unlocked cart and queried if it should be unlocked while unattended and they indicated that it should be locked when nobody is at it.
On 5/16/22 at approximately 11:37 a.m., A medication cart next to room [ROOM NUMBER] was observed to be open and unattended by any Nursing staff. A few minutes later, Nurse EE was queried if the medication cart could be unlocked and unattended and they indicated that it should be locked.
Resident #37
On 5/17/22 at approximately 11:11 a.m., R37 was observed to have a medication titled Vicks Vapor Rub on their nightstand next to their bed.
On 5/18/22 at approximately 9:00 a.m., R37 was observed to have a medication titled Vicks Vapor Rub on their nightstand next to their bed. R37 was queried why they had the medication on their nightstand and they indicated it was for their chest.
On 5/18/22 at approximately 2:35 p.m., Nurse Manager B (NM B) was queried regarding Vicks vapor rub on R37's nightstand. Nurse B indicated that they had to confiscate it and call the family. NM B was queried regarding the observations of it being in room, the last few days and indicated that the Nurses should be more observant when in the residents rooms. NM B was queried if R37 had a Physicians order for the Vapor Rub and they indicated they did not.
On 5/17/22 The medical record for R37 was reviewed and revealed the following: R37 was initially admitted to the facility on [DATE] and had diagnoses including Sick Sinus Syndrome, Nausea and Chest pain. Further review of the record did not indicate an order for the Vicks Vapor Rub medication.
A facility document titled Medication Management was reviewed and revealed the following: Medications are stored, dispensed and destroyed in a manner to ensure safety and conformance with state and federal laws .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Resident #29
On 5/17/22 at approximatley 3:19 p.m., R29 was queried regarding residnet council meetings and concern followup. R29 indicated that the council has had ongoing concnerns about the food in...
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Resident #29
On 5/17/22 at approximatley 3:19 p.m., R29 was queried regarding residnet council meetings and concern followup. R29 indicated that the council has had ongoing concnerns about the food including Not getting what they want and requesting more soup and salad. Further inquiry regarding food, R29 reported they (the facilty) used to have a nice big salad a year ago but no longer have salad enough. R29 also stated I like soup. It doesnt take much to put it in the microwave. They should always serve it as a side. R29 was queired how the food in the facilty tasted and they indicated that even when they do get something that they like it is not made well. R29 indicated the facilty needed new cooks.
Resident #73
On 5/17/22 at approiamtley 3:23 p.m., R73 was queried regarding the food in the facilty and they indciated that their dog ate better food. R73 indicated they have brought up the food multiple times in resdient council and it is never fixed. R73 indicated that it goes in one ear and out the other.
On 5/18/22 the monthly resident council minutes were reviewed from December 2021 until April 2022 and revealed the following issues brought fourth by the resident council: December 13th 2021-Old business-Culinary: Reports wanting to have more soup options and suggest having the availability of pre-made soup on hand for meals. Council would like to see a bigger portion of fruits given with meals .Januay 14th 2022-Culinary: Council is requesting to have soup and salad offered more frequently .Culinary: Council is requesting the kitchen install an answering machine or get voicemail so they may leave a message for kitchen staff regarding their meal trays .February 16th 2022-Culinary: Council reports not noticing an increase in soups and salads being offered .March 31st 2022-Culinary: Council would like to be informed on meal substitutions .
Based on observation, interview, and record review, the facility failed to ensure food was palatable for seven residents (R#'s 245, 275, 276, 31, 274, 29 and 73) of twelve residents reviewed for food palatablity, resulting in verbalized complaints and frustration. Findings include:
A review of a facility provided policy titled, Food Preferences with a revision date of 11/12/21 was conducted and read, Policy: It is the policy of the facility to obtain food preferences for all guests/residents .5 The Nursing staff will inform the kitchen about guest/resident requests .
On 5/16/22 at 10:55 AM, an interview was conducted with R246 about their stay in the facility. R246 verbalized complaints about the food saying they were served too much turkey and everything came with gravy. They were asked if they could get an alternative meal and said they could, but went on to explain the alternate meal was always similar to the scheduled meal.
On 5/16/22 at 11:13 AM, an interview was conducted with R275. R275 was asked about the food in the facility and said they did not like it, and when they tried to call down to the kitchen to order something else, nobody answered the phone. R275 said their last Sunday's dinner was a tuna fish sandwich and said they did not like the turkey with gravy. R275 said it was too salty and stated, It's a turkey loaf and it tastes like it came from a can.
On 5/16/22 at 11:27 AM, an interview was conducted with R276. They said they were served too many spaghetti/pasta with meat sauce meals and too often they received cooked carrots and canned peaches.
On 5/16/22 at 11:35 AM, R31 was asked about their stay in the facility. They said they had been there for several years and said the food was getting worse. R31 said they used to be able to order salads and soup if they didn't like what was on the menu. R31 said they frequently ordered take-out food. They were asked specifically if they felt they got too many meals of turkey and gravy and said they did. R31 said, There's not much diversity with the food.
On 5/16/22 at 12:31 PM, R274's meal was observed. Their tray contained peas, mashed potatoes, turkey with gravy, canned peaches, and a glass of cola. R274's meal ticket was reviewed and indicated they had a standing order for coffee. R274 said they did not like or drink coffee or cola. R274 was asked if they had seen a dieitician or if anyone had assessed them for their food likes/dislikes, and said, I don't think so.
A review of the facility's 4 week menu cycleswas conducted and revealed the following:
Soup was never offered for a lunch meal, and only seven times with a dinner meal in the four-week menu cycle.
Fresh Fruit was never offered for a lunch meal and only twice for a dinner meal in the four-week menu cycle.
Salad was only offered twice in a four-week cycle.
Continued review of the menu was conducted and the following meals were noted:
5/8/22 Lunch-Turkey with gravy
5/10/22 Dinner-Pulled Pork
5/11/22 Breakfast-Bacon
5/11/22 Lunch-Pork Fritter
5/11/22 Dinner-BLT
5/12/22 Lunch-Turkey with gravy
5/25/22 Dinner-Chicken Enchilada
5/26/22 Dinner-Sliced turkey with gravy
5/27/22 Dinner-Chicken fried Steak
5/28/22 Lunch-Chicken stir fry
5/29/22 Lunch-Crispy chicken
5/29/22 Dinner-Chicken patty sandwich
6/1/22 Lunch-Turkey with gravy
6/2/22 Lunch-Turkey burger
On 5/17/22 at 1:22 PM, a review of resident council meeting minutes was conducted and revealed the following:
December2021- .Culinary: Reports wanting to have more soup options and suggest having the availabity of pre-made soup on hand for meals. Council would like to see a bigger portion of fruits given with meals . It was noted there were no grievence forms that addressed this concern with resolution or follow-up.
January 2022- .new business .Culinary: .Council is requesting to have soup and salad offered more frequntly .Culinary: Council is requesting the kitchen install an answering machine or get voicemail so they may leave a message for kitchen staff regarding their meal trays . It was noted there were no grievance forms that addressed these concerns with resolution or follow-up.
February 2022- .Old Business .Culinary Council is requesting to have soup and salad offered more frequently .Culinary: Coucil is requesting the kitchen install an answering machine or get a voicemail so they may leave a message for kitchen staff regarding their meal trays .New Business .Culinary Council reports no noticeced increase in soups and salads being offered .Attached are Resident, Family, Employee, and Visitor Assistance Form(s), .INFORMATION ABOUT YOUR CONCERN: Council reports not seeing an increase in soup and salad being offered . It was noted the rest of the form that addressed follow-up and resolution were left blank.
March 2022- .Old Business .Culinary: Council reports not noticing an increase in soups and salads being offered .New Business .Culinary .Couuncil would like to be informed on meal substitutions . It was noticed an assistance form that outlined the grievance was with the minutes, but it was left blank in the areas that addressed follow-up and resolution.
On 5/17/22 at 2:45 PM, an interview was conducted with the facility's Registered Dietician regarding the food. They said the corporate dietician made the menus and as the Dietician they were required to see new admissions within five days of admission. They were asked if any other staff members assisted with assessing for food preferences so it may be completed in less than five days and they indicated there were no other staff members who assisted.
On 5/18/22 at approximately 2:30 PM, an interview was conducted with the facility's Certified Dietary Manager 'J' and they were asked if they were aware of any concerns with the food and said they were, and had addressed some grievance forms given to them. They were also asked if they were aware of resident's frustration reaching the kitchen via the phone, and said they were not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 29
On 5/16/22 at 10:13 AM, R29 was observed sitting in their wheelchair next to their bed. When asked R29 stated they h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 29
On 5/16/22 at 10:13 AM, R29 was observed sitting in their wheelchair next to their bed. When asked R29 stated they had no concerns or issues with their care at the facility.
Review of the clinical record revealed R29 was admitted to the facility on [DATE] with a readmission date of 12/14/20 and diagnoses that included: Parkinson's disease, enterocolitis due to clostridium difficile, chronic kidney disease and dementia. A MDS assessment dated [DATE] documented a BIMS score of 13 indicating intact cognition and required staff assistance for all ADLs.
Review of a Temperature Summary documented the following:
5/16/22 at 8:33 AM, 99.7 F (Fahrenheit)
5/16/22 at 2:29 PM, 99.0 F
5/11/22 at 4:20 PM, 99.0 F
Review of Centers for Disease Control and Prevention (CDC) guidance titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes updated 2/2/22, documented in part . Older adults with SARS-CoV-2 infection may not show common symptoms such as fever or respiratory symptoms . Additionally, more than two temperatures >99.0 F might also be a sign of fever in this population. Identification of these symptoms should prompt isolation and further evaluation for SARS-CoV-2 infection .
Review of R29's May 2022 Medication Administration Record and Treatment Administration Record (MAR and TAR) documented the following:
Respiratory Screen one time a day, Document Yes or No for symptoms of COVID-19.
Further review of the May 2022 MAR and TAR revealed a n (No) documented for 5/11/22 and 5/16/22, indicating the nurses did not identify the low-grade temperature of the resident. Upon further review of the May 2022 MAR and TAR an order for Tylenol 650 mg (milligram) was noted to be administered to the resident three times a day. The administration of this medication three times a day would significantly reduce an elevated body temperature potentially masking the accurate temperature of the body.
Review of the clinical record revealed no documentation by the facility staff identifying the low-grade temperatures.
Review of a facility policy titled Coronavirus (COVID 19) revised 4/18/22, documented in part . Guests/Residents will be screened, at a minimum of daily, for signs and symptoms of COVID-19. If any symptoms are exhibited, regardless of known or unknown exposure, the guest/resident will be placed on transmission-based precautions, have increased monitoring, and testing completed . If symptoms are identified: notify physician .
On 5/17/22 at 4:41 PM, the facility's Infection Preventionist (IP) T, unit manager (UM) U and DON was interviewed and asked about the low-grade temperatures for R29 not being identified by the floor nurses, the daily assessments for COVID not completed correctly and the possible masking of the residents elevated temperature by the administration of Tylenol 650 mg three times daily. IP T, UM U and the DON stated they would follow up.
No additional information or documentation was provided by the end of survey.
Based on observation, interview, and record review, the facility failed to ensure appropriate use of personal protective equipment (PPE) in transmission-based (TBP) precaution rooms, and appropriate hand hygiene, resulting in the potential for the spread of infection. This deficient practice had the potential to affect all residents who reside in the facility. Findings include:
A review of a facility provided policy titled, Hand Hygiene revised 7/2021 was conducted and read, .I. HANDWASHING When hands are visibly dirty or contaminated with proteinaceous material, are visibly soiled with blood or other body fluids .use soap and water. Alcohol based hand sanitizer may be used before and after: touch a guest/resident, before performing an aseptic task or handling invasive medical devices, after glove removal .and after contact with contaminated surfaces.
A review of a second facility provided policy titled, 'Multi route Transmission Based Precautions revised 8/2021 was conducted and read, .Droplet Precautions: Use droplet precautions for guests/residents with known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a guest/resident who is coughing, sneezing or talking. This can include, but is not limited to: .COVID-19 .Ensure PPE appropriately, [NAME] mask upon entry into the guests/resident's room .
On 5/16/22 at approximately 9:15 AM, the facility's Administrator and Director of Nursing (DON) informed the survey team there were rooms on the 100 hallway that were transmission-based precaution for residents recently admitted from an acute care setting who were being monitored for signs and symptoms of COVID-19. They said staff entering those rooms were to don an isolation gown, gloves, N95 mask, and eye protection. They further explained that upon exiting the rooms, all PPE (including the N95 mask) were doffed and discarded, (with the exception of the eye protection which was to be sanitized) and new PPE was donned for entry into the next room.
On 5/16/22 at 9:45 AM, room [ROOM NUMBER] was observed to have signs that indicated the room was a TBP room and required an N95 mask, gown, gloves, and eye protection. At that time, Housekeeping Supervisor 'N' was observed from the hallway in room [ROOM NUMBER] wearing an isolation gown, gloves, and eye protection, however; they were not observed to be wearing an N95 mask, rather they were wearing a black surgical mask. Upon exiting the room, Housekeeping Supervisor 'S' was asked what PPE was required in the TBP room. They reported they were supposed to wear an N95 mask, gown, gloves, and eye protection. They were asked why they were not observed to have an N95 mask on and said I messed up.
On 5/16/22 at 9:50 AM, an interview was conducted with Licensed Practical Nurse (LPN) 'P' regarding their room assignment. They said they were assigned the even numbered TBP rooms on the left side of the hall and LPN 'Q' was assigned the odd numbered TBP rooms on the right side of the hallway. They were then asked what their process was for donning and doffing PPE in the TBP rooms and said they donned an isolation gown, N95 mask, gloves, and eye protection prior to entry. When they exited, the discarded the gown and gloves, sanitized the eye protection and placed the N95 mask in a paper bag. They were asked why the mask would be placed in a paper bag and said it was because it could be re-used.
On 5/16/22 at 10:09 AM, LPN 'Q' was observed in the 100 unit hallway near the TBP rooms. LPN 'Q' was observed to have a surgical mask that did not cover their nose, and a face shield that was pulled up on their forehead, not covering their nose.
On 5/16/22 at 10:20 AM, Nurse Aide 'R' was observed preparing to enter TBP room [ROOM NUMBER]. Nurse Aide 'R' was observed to be wearing a face shield and a black surgical mask. Nurse Aide 'R' donned an isolation gown and entered the room. Nurse Aide 'R' was not observed to change to an N95 mask or don gloves prior to entering room [ROOM NUMBER].
On 5/16/22 at 10:38 AM, Staff Member 'O' was observed wearing a black surgical mask with an N95 mask over top of the surgical mask and a face shield. They were observed to don an isolation gown and gloves and enter TBP room [ROOM NUMBER]. Approximately one minute later Staff 'O' exited the room, they were not observed to sanitize their face shield after exiting the room. They were then observed to go across the hall to room [ROOM NUMBER] where they donned another isolation gown and pair of gloves. Upon exiting room [ROOM NUMBER], Staff 'O' was observed to doff their gown in the hallway and place it into the garbage inside the door of room [ROOM NUMBER]. They were not observed to sanitize their face shield. Staff 'O' then doffed the N95 mask that was over top of the surgical mask and the gloves and crumple them up and place them in their uniform pocket as they exited the unit toward the lobby. Staff 'O' was not observed to perform hand hygiene after contact with their used PPE.
On 5/18/22 at 3:12 PM, an interview was conducted with the facility's DON regarding the observations of the TBP rooms and staff use of PPE. They said staff entering TBP rooms should don a new N95 mask each time the enter a room, doff the PPE in the room and discard it, and perform hand hygiene upon exiting the room. They were also asked if it was appropriate to wear a surgical mask under an N95 mask, and they said it was not.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to maintain a refrigerator gasket in good repair, failed to maintain kitchen flooring and equipment in a sanitary manner, and fa...
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Based on observation, interview, and record review, the facility failed to maintain a refrigerator gasket in good repair, failed to maintain kitchen flooring and equipment in a sanitary manner, and failed to ensure the Riverbend nutrition room was free from pests. This deficient practice had the potential to affect all residents in the facility. Findings include:
On 5/16/22 between 8:45 AM-9:15 AM, during an initial tour of the kitchen with Dietary Manager (DM) J, the following items were observed:
The gasket on the door of the Delfield reach-in cooler was observed to be torn and loose. DM J confirmed the torn gasket and stated it would be replaced.
According to the 2013 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment, (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) Equipment components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications.
The flooring under the Delfield reach-in cooler and the ice machine was observed with a heavy buildup of a black substance. In addition, there was a heavy accumulation of food debris and crumbs on the floor near the True Freezer. DM J confirmed the buildup of debris on the floor, and stated it would get cleaned up right away.
According to the 2013 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.
The ice scoop holder located on the side of the ice machine, was observed with pooled, stagnant water at the bottom. The tip of the ice scoop was observed to be resting inside the stagnant water.
In the Riverbend nutrition room, the floor underneath the ice machine was observed with piles of a sand-like substance surrounding the floor drain, with numerous ants observed. In addition, the microwave located in the nourishment room was observed with a rusty surface on the top interior. DM J confirmed the the rusty surface inside the microwave, and stated it would be replaced.
According to the 2013 FDA Food Code section 6-501.111 Controlling Pests, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: .(B) Routinely inspecting the PREMISES for evidence of pests; .and (D) Eliminating harborage conditions.
According to the 2013 FDA Food Code section 4-101.19 Nonfood-Contact Surfaces, Non-FOOD-CONTACT SURFACES of EQUIPMENT that are exposed to splash, spillage, or other FOOD soiling or that require frequent cleaning shall be constructed of a CORROSION-RESISTANT, nonabsorbent, and SMOOTH material.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to accurately track and document the COVID-19 vaccination status for facility staff, resulting in the potential for inaccurate reporting of sta...
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Based on interview and record review the facility failed to accurately track and document the COVID-19 vaccination status for facility staff, resulting in the potential for inaccurate reporting of staff vaccination staus. Findings include:
On 5/18/22 at 9:20 AM, a review of a facility provided document that listed staff and their COVID-19 vaccination status was reviewed. During the review, the document indicated the following:
Nurse Unit Manager 'B', Receptionist 'V', Dietary Staff 'W' and Social Work Director 'K' were on the roster as, NOT VACCINATED. The document did not indicate those individuals had a granted exemption (medical or non-medical) from receiving the vaccine.
CNA 'X', LPN 'AA' LPN 'Z', Activity Staff 'Y', and Maintenance Staff 'CC' were partially vaccinated.
CNA 'BB' had been granted a non-medical exemption from the COVID-19 vaccine.
On 5/18/22 at 10:50 AM, an interview with unit Manager B' was conducted regarding their COVID-19 vaccination status. Unit Manager 'B' said they were fully vaccinated and had received the booster. They said they had transferred employment from a sister facility and maybe their vaccination card did not transfer to the current facility.
On 5/18/22 at 10:55 AM, an interview was conducted with Social Work Director 'K' regarding their COVID-19 vaccination status. Social Work Director 'K' said they were fully vaccinated, plus had two booster vaccinations.
On 5/18/22 at 11:20 AM, an interview was conducted with the facility's Administrator regarding the provided Staff COVID-19 Vaccination Matrix. They indicated Receptionist 'V', Dietary Staff 'W' and Social Work Director 'K' were fully vaccinated, but appeared on the roster twice because their names had been misspelled. They said they had tried to remove the misspelled names and thought those individuals had been removed, but due to a glitch in the software, they kept appearing on the list.
On 5/18/22 at 3:12 PM, the facility's Director of Nursing (DON) was asked about the partial vaccination status of CNA 'X', LPN 'AA' LPN 'Z', Activity Staff 'Y', and Maintenance Staff 'CC'. They said they believed those individuals were fully vaccinated, but would check into it.
On 5/18/22 at approximately 4:00 PM the DON provided proofs of vaccination status from the State's online vaccination database and the following was revealed:
CNA 'X' received two doses of a multi-dose vaccine, second dose in February 2022.
LPN 'AA' received two doses of a multi-dose vaccine, second dose March 2022.
LPN 'Z' received two doses of a multi-dose vaccine, second dose December 2021.
CNA 'BB' received two doses of a multi-dose vaccine, second dose December 2021.
Activity Staff 'Y' received two doses of a multi-dose vaccine, second dose August 2021.
Documentation for Maintenance Staff 'CC' was not provided by the end of the survey.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "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
- • 39 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $15,593 in fines. Above average for Michigan. Some compliance problems on record.
- • Grade D (48/100). Below average facility with significant concerns.
- • 59% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 48/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Regency At Shelby Township's CMS Rating?
CMS assigns Regency at Shelby Township an overall rating of 3 out of 5 stars, which is considered average nationally. Within Michigan, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Regency At Shelby Township Staffed?
CMS rates Regency at Shelby Township's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 59%, which is 13 percentage points above the Michigan average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Regency At Shelby Township?
State health inspectors documented 39 deficiencies at Regency at Shelby Township during 2022 to 2024. These included: 1 that caused actual resident harm and 38 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Regency At Shelby Township?
Regency at Shelby Township is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CIENA HEALTHCARE/LAUREL HEALTH CARE, a chain that manages multiple nursing homes. With 116 certified beds and approximately 111 residents (about 96% occupancy), it is a mid-sized facility located in Shelby Township, Michigan.
How Does Regency At Shelby Township Compare to Other Michigan Nursing Homes?
Compared to the 100 nursing homes in Michigan, Regency at Shelby Township's overall rating (3 stars) is below the state average of 3.1, staff turnover (59%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Regency At Shelby Township?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.
Is Regency At Shelby Township Safe?
Based on CMS inspection data, Regency at Shelby Township has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Michigan. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Regency At Shelby Township Stick Around?
Staff turnover at Regency at Shelby Township is high. At 59%, the facility is 13 percentage points above the Michigan average of 46%. 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 Regency At Shelby Township Ever Fined?
Regency at Shelby Township has been fined $15,593 across 1 penalty action. This is below the Michigan average of $33,235. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Regency At Shelby Township on Any Federal Watch List?
Regency at Shelby Township 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.