Evergreen Health and Rehabilitation Center
For profit - Corporation
172 Beds
OPTALIS HEALTH & REHABILITATION
Data: November 2025
Trust Grade
5/100
#276 of 422 in MI
Last Inspection: August 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Evergreen Health and Rehabilitation Center has received a Trust Grade of F, indicating significant concerns and a poor overall reputation. Ranking #276 out of 422 facilities in Michigan places it in the bottom half, and #17 out of 43 in Oakland County signifies that only 16 local options are better. The facility is improving, having reduced serious issues from 27 in 2024 to just 5 in 2025. Staffing is average with a 2/5 rating and a turnover rate of 47%, which is similar to the state average. However, the center has incurred $71,130 in fines, which suggests some ongoing compliance issues. While the RN coverage is average, there have been serious incidents, including delays in diagnosing a resident's foot injury and failing to assess and treat pressure wounds properly, which could lead to serious harm. Overall, families should weigh these significant concerns against the facility's efforts to improve.
- Trust Score
- F
- In Michigan
- #276/422
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 47% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $71,130 in fines. Higher than 75% of Michigan facilities, suggesting repeated compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 32 minutes of Registered Nurse (RN) attention daily — about average for Michigan. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 76 deficiencies on record. Higher than average. Multiple issues found across inspections.
5/100
Bottom 35%
Review needed
27 → 5 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★★
5.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 27 issues
2025: 5 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Michigan average (3.1)
Below average - review inspection findings carefully
Staff Turnover: 47%
Near Michigan avg (46%)
Higher turnover may affect care consistency
Federal Fines: $71,130
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: OPTALIS HEALTH & REHABILITATION
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 76 deficiencies on record
7 actual harm
Aug 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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: 2581302. Based on interview and record reviews the facility failed to accurately assess, timel...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: 2581302. Based on interview and record reviews the facility failed to accurately assess, timely report a change in condition to the Physician and timely transfer to a higher level of care, for one (R404) of three residents reviewed for a change of condition/timely transfer to the hospital. Findings include:A review of a complaint submitted to the State Agency (SA) documented in part . resident fell out of his bed at 5am. the facility staff did not evaluate resident and stated that the doctor would see him on Monday. Complainant states it took her until 4 or 5pm Saturday to finally get staff to call the EMS (emergency medical services) and have him sent to (hospital name). Complainant states resident was put in the intensive care unit at hospital with a fractured neck and hematoma in the brain. Complainant states at the time of fall, resident was recovering from a seven hour back surgery.A review of the medical record revealed R404 was admitted to the facility with diagnoses that included: critical illness myopathy, intervertebral disc degeneration, spinal stenosis, wedge compression fracture of second lumbar vertebra and unspecified fall. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition and required staff assistance for all activities of daily living. Review of the progress notes documented the following:On 8/2/25 at 6:36 AM, a Incident Note documented . Nurse called to room after CNA (certified nursing assistant) observed resident laying on the floor on the side of the bed near the window. Call light on and still in the bed. Resident wearing CPAP (continuous positive airway pressure) mask disconnected from the tubing, Bed remote hanging at the side of the bed. CNA responded to call light to witness resident on the floor. Stated he was trying to reach for the bed remote after it kept going up, Stated he slipped out of the bed. Nurse in to observe resident laying on the floor, Vitals obtained, ROM (range of motion completed), Hoyer obtained along with 4 staff members to assist resident off floor. Noted to left ear small skin tear 0.5cm (centimeters) x 0.5cm) with surrounding redness. To left forehead noted redness from abrasion. Resident stated he had some pain to the ear. No increase pain to the rest of his body. Neuro checks initiated. Bed to lowest level. (Doctor name) and wife notified. This note was documented by Licensed Practical Nurse (LPN) A. A Nursing note created on 8/3/25 at 12:54 AM and back dated to 8/2/25 at 7:42 AM, documented . resident was sent out to the hospital per family request. Resident vitals were within resident normal limits. Resident A&O x3 (alert and oriented times three) resident was sitting in his wheelchair watching tv when his wife came in stating they wanted CT scans (computed axial tomography scan) and MRI (Magnetic Resonance Imaging) done on resident. Np (Nurse practitioner) aware, resident had no change of condition throughout the shift, then he stated he was having difficulty turning his head left to right writer assessed the resident no abnormal findings at the time of assessment, wife demanded resident to be sent out. Resident was picked up 8/2/2025 @ (at) 7:30 via transportation (transportation name) to (hospital name) accompany <sic> by wife. This note was documented by LPN B. A review of the hospital record revealed the following:A review of a Emergency Medicine consult date of service 8/2/25 at 5:11 PM, documented in part . thoracic and lumbar fracture s/p (status post) T9-L3 posterior laminectomy and fusion (back surgery) on 06/27/2025 who presents to the Emergency Center today with fall at 5 am, left ear bruising and head injury. Patient has <sic> at (nursing home facility name) since the surgery. Patient does not ambulate. Was found on the side of the bed this morning, nursing facility did not want to bring him in. Patient then started developing left ear bruising. Wife came to visit him, made them (facility staff) called EMS. Patient remembers entire incident, did not lose consciousness. Resp (respirations) 34. Interventions: Cervical collar in place. Cervical back: Spinous process tenderness present. Incision and Drainage. Type: Hematoma. Head. L (left) external ear. Local infiltration. Incision types: Single straight. Drainage: Bloody. Wound left open. Vaseline packing, bulky dressing, and coban (self-adherent wrap with latex). Called by radiology as. suggesting possible small subdural hematoma no other foci of intracranial hemorrhage. Also found to have Evidence of minimally displaced acute multidirectional predominantly oblique fracture through the mid to inferior portion of the odontoid process extending into the lateral mass with questionable involvement of the posterior cortex. will get repeat head CT in the AM (morning). Ortho (Orthopedic) evaluated the patient, patient placed in Aspen collar. Trauma surgery consulted who evaluated the patient. Awaiting recommendations. Chief Complaint: FALL. Working Differential Diagnosis: Odontoid fracture (fracture of the neck), subdural hematoma (a type of bleeding near the brain), hematoma of left auricular region (collection of blood to outer left ear, resulting in swelling, pain, bruising and puffy appearance). Awaiting trauma surgery admission.A review of a Trauma Surgery History and Physical Evaluation Note dated 8/2/25 at 10:08 PM, documented in part. Chief Complaint: Trauma, fall from bed. on Coumadin (blood thinner medication). Trauma Surgery being consulted for trauma evaluation. CT head demonstrated a small left SDH (subdural hematoma) and CT c-spine demonstrated an odontoid fracture. Admit to SICU (surgical intensive care unit). Q2H (every two hours) neuro (neurological) checks. MRI c-spine to further assess injury. NPO (nothing by mouth) for now.A review of a Emergency Medicine consult dated 8/3/25 at 12:08 AM, documented in part . presents with a fall out of bed. He is on warfarin (blood thinner) for antiphospholipid syndrome (a condition in which the immune system mistakenly creates antibodies that attack tissues in the body) and history of pulmonary embolism (blood clot that blocks and stops blood flow to an artery in the lung). Workup found an odontoid process fracture and a small subdural hematoma. Auricular hematoma has been incised and drained, and dressed appropriately. Trauma surgery has been consulted and pending admission.A review of a facility incident report dated 8/2/25 at 5:00 AM, completed by LPN A documented in part . Vitals obtained, ROM completed. Hoyer obtained along with 4 staff members to assist resident off floor. Noted to left ear small skin tear. with surrounding redness. To left forehead noted redness from abrasion. Resident stated he had some pain to the ear. No increase pain to the rest of his body. Injury Type- Abrasion. Top of Scalp. Skin Tear. Left ear. Level of Pain. 4. Injuries Report Post Incident. Injury Type- Other (Describe). Injury Location - Back of head (no description was documented of the injury type to the back of the head).A review of a facility policy titled Fall Management Guidelines dated 12/13/2023, documented in part . If a resident has just fallen or is observed on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities prior to moving the resident. Evaluate for sign and symptoms of pain. If there is evidence of injury, provide appropriate first aide and/or obtain medical treatment immediately. If after the evaluation it is deemed safe, use the full mechanical lift to assist the resident off the floor.On 8/6/25 at 9:14 AM, an interview was conducted with the complainant. The complainant stated in part . I blame that they (facility staff) didn't send him (R404) to the hospital timely. I had to fight for him to go. When I got there (at the facility) he couldn't move his neck, he was complaining of neck pain, his ear was twice the size and bruised all black and blue and it was painful for him. I talked to the nurse several times and I kept telling her that I wanted to talk to the doctor and she said well I paged him. I said I want him to go to the hospital. The complainant went on to say that the resident was transferred to the hospital hours later. The complainant stated they were really concerned considering R404 had a seven hour back surgery prior to admission to the facility. On 8/6/24 at 10:40 AM, LPN B was interviewed and asked about their note that was backdated to 8/2/25 at 7:42 AM, regarding R404 to have been transferred to the hospital per family's request. LPN B was asked if R404 was transferred out at 7:30 AM or PM (evening) and LPN B confirmed it was PM. LPN B was asked why there was such a delay in transferring the resident to the hospital. LPN B stated the resident did not have a change of condition on their shift and once the wife of R404 stated they wanted the resident sent to the hospital, they sent the resident to the hospital. LPN B' was asked to clarify how the resident did not have a change of condition on their shift, but it was immediately identified upon R404's wife arrival to the facility that R404 could not move their head and had a bruised and swollen left ear (this was also identified in the note documented by LPN B on 8/2/25). LPN B acknowledge they had identified that the resident could not move their head but was not sure of the time they had identified the change. LPN B stated they had notified the Physician on call and was awaiting a reply. LPN B stated they believe the wife was present all day at the facility and even accompanied the resident to the hospital. LPN B was asked about the statements made by R404's wife regarding to have asked LPN B initially when they got to the facility to send the resident out to the hospital due to R404 not being able to move their head and to have a swollen and black/blue left ear and to have requested multiple times throughout the day for the resident to be transferred to the hospital before they were actually transferred out. LPN B stated they had contacted the doctor earlier in the day to inform them of R404's wife request, however hours had passed before they received a reply. LPN B was asked to give an estimate of how many hours had passed while waiting for a reply from the Physician and LPN B stated an estimate of four hours. LPN B stated while they were on their break, another nurse had received an order for a scan to be done. LPN B stated they went to R404's room to inform the family that a scan will be ordered and R404's wife was adamant that the resident be sent to the hospital. LPN B stated they informed the Nursing supervisor of the wife request and began the transfer to the hospital. LPN B stated they had two residents that day that were having concerns and needed to be transferred to the hospital at the same time which made things a bit overwhelming for them. A review of a facility policy titled Change in Condition Notification dated 8/9/23, documented in part . The nurse will notify the resident's physician/practitioner. when there is. A significant change in the resident's physical. such as deterioration which includes life-threatening conditions or clinical complications. A need to transfer.On 8/7/25 at 3:32 PM, a follow-up phone call was conducted with the complainant. The complainant stated they arrived at the facility at around 11 AM on 8/2/25. The complainant stated at that time R404 was unable to move their neck and their ear was observed to be swollen and bruised. The complainant stated at that time they informed the nurse that they wanted R404 sent to the hospital. The complainant stated the nurse replied they would call the doctor to see if they wanted radiology done. The complainant stated they told the nurse they did not believe that would be adequate enough. The complainant confirmed they informed the nurse several times throughout the day that they wanted R404 transferred to the hospital, however it was not until the evening time that the resident was transferred out. The complainant stated they were unsure why it took hours to send the resident out when they had previously requested the resident to be transferred to the hospital multiple times.It was confirmed through multiple interviews conducted with the weekend nursing supervisors RN C and LPN D and confirmed by the complainant that a RN, Nurse Practitioner, Physician nor Physician Assistant had not come to assess the resident after their fall and before the transfer to the hospital. This indicated the concern of an accurate assessment of the resident to have been completed by a qualified personnel after the fall.On 8/6/25 at 12:49 PM, the Director of Nursing (DON) was interviewed and asked about the facility's RN weekend coverage. The DON stated that RN C worked the dayshift on 8/2/25. At this time the DON left the conference room to obtain RN C. At 12:54 PM, RN C (with the DON in attendance) was asked if they had assessed R404 on 8/2/25 and RN C stated they did not. RN C stated as they were getting ready to leave their shift on 8/2/25, they were approached by LPN B who stated the family of R404 wanted the resident sent to the hospital. RN C stated LPN B said the doctor was informed and said that the transfer to the hospital was not needed. RN C stated they instructed LPN B to document in their note that the resident was being transferred to the hospital per the family's request. RN C confirmed they were not aware of the fall or any concerns with R404 prior to LPN B approaching them at the end of their shift. The interview was concluded with RN C. At 1:07 PM, LPN D the weekend supervisor that worked 8/1/25 to 8/2/25 midnight shift was interviewed via telephone (with the DON in attendance). LPN D stated they were not informed of R404 to have had a fall on the morning of 8/2/25. LPN D stated they did not see the resident on 8/2/25. The interview was concluded with LPN D. At 1:03 PM, the interview with the DON resumed. The DON was asked how they were made aware of the fall with R404. The DON stated they were reviewing the electronic medical system from home and saw the documentation regarding R404's fall. The concern regarding the accurate assessment of R404 was discussed and the timely transfer to a higher level of care as requested by R404's family. The DON replied they believed the LPN's assessed the resident correctly. The DON stated it was their understanding that the resident did not exhibit a change of condition, however the family was requesting R404 to be sent to the hospital and the nurse sent the resident out. The DON was asked if they were aware that R404's family identified that the resident could not move their head, was complaining of pain and had a swollen/black/blue left ear when they initially observed the resident that morning. The DON was asked if they were aware that R404's family had requested the resident to be transferred to the hospital at that time. The DON stated they were not aware of the change in condition and was not aware that R404's family had requested the resident to be transferred to the hospital when they arrived at the facility. At 1:15 PM, Physician E (the Physician assigned to R404) was interviewed via telephone with the DON present. The Physician was asked about the fall with R404. Physician E stated they were informed by staff that the resident slid out of bed and there was no injury or pain. Physician E stated staff later called to inform them of the resident having ear and neck pain and the resident was being sent out to the hospital. The incident regarding the injury and pain noted on the incident report after the fall was discussed with Physician E and Physician E replied No, they didn't tell me about injury or pain. The concern of an accurate assessment, informing the physician of a change of condition and timely transfer to the hospital was again discussed with the DON. On 8/6/25 at 4:00 PM, a telephone interview was conducted with LPN A (the nurse assigned to R404 at the time of the fall on 8/2/25). LPN A was asked about the fall with R404 on 8/2/25. LPN A explained the fall incident as documented in their note on 8/2/25. LPN A stated two other CNA's joined them and the CNA in the room, a total of four staff members that . had to turn him (R404) back and forth to put the hoyer pad under him. LPN A' stated they couldn't do much ROM with the resident because the resident condition is normally stuck in one position. LPN A stated the resident is stiff in all areas and doesn't really move. LPN A stated they completed a full body check. LPN A stated the resident complained of . a little pain on his forehead. LPN A stated . He had a little abrasion on forehead and small skin tear to his ear. LPN A stated they called and informed Physician E . about the ear and forehead and that the wife was concerned that he might have re-fractured something on his back. LPN A stated Physician E stated they would see the resident on Monday and to continue to monitor and complete neuro checks. LPN A stated they called R404's wife and informed them of the Physician response and the wife told LPN A that they would be at the facility later. When asked about the documented injury to the back of the head noted on the incident report without a description, LPN A stated they did not remember identifying an injury to the back of the head. When clarified if they had R404 conduct ROM with their head and neck, LPN A state they had R404 . move his head as much as he could do. No further information or documentation was provided by the end of the survey.
Apr 2025
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00150988.
Based on interview and record review, the facility failed to thoroughly ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00150988.
Based on interview and record review, the facility failed to thoroughly evaluate and timely address a foot injury for one (R802) of one resident reviewed for a change in condition, resulting in a delay in diagnosing and treating a moderately comminuted avulsion fracture (bone broken in multiple places) to the resident's heel (calcaneus), increased pain, and the inability to fully participate in physical rehabilitation. Findings include:
A review of a complaint submitted to the State Agency revealed an allegation that the resident sustained an injury to her foot in the facility.
On 4/8/25, an unannounced onsite investigation was conducted.
A review of R802's clinical record revealed R802 was admitted into the facility on [DATE] and discharged on 10/25/24 with diagnoses that included: orthostatic hypotension and syncope and collapse. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R802 had intact cognition, received scheduled pain medication, no as needed (PRN) pain medication, and did not experience any pain during the assessment period.
A review of a Physical Therapy (PT) Treatment Encounter Note dated 10/21/24 revealed R802 complained of pain in the right foot after being assisted with transferring into bed which was new onset. According to the note, the nurse was notified and ice was applied.
A review of a Occupational Therapy (OT) Treatment Encounter Note dated 10/21/24 revealed, Upon returning patient to bed, patient sudden <sic> yelled out and grabbed her right ankle, stating that it suddenly started hurting. Not <sic> bruising identified .(Licensed Practical Nurse - LPN 'E') informed .Patient did not trip or kick any object and also did not appear to roll or twist her ankle during transfer. Unknown what exactly caused pain .
A review of a Nursing - Progress Note dated 10/21/24 at 12:00 PM, written by Licensed Practical Nurse (LPN) 'E' documented the following, Resident was working with therapy and when she stood up her foot buckled. Res (resident) right ankle is swelling res stated her pain is at a 9 (out of 10 with 10 being the worst level of pain). spoke with NP (Nurse Practitioner) she ordered a STAT (right away) xray.
A review of a Radiology Results Report dated 10/21/25 revealed R802 had an X-ray of the right ankle and there was no fracture or significant abnormality identified at that time.
A review of a Nursing - Progress Note dated 10/22/24 at 2:33 PM, revealed, R802 .complains of pain, ice pack given. NP spoke with resident regarding care, pt (Physical Therapy) and ot (Occupational Therapy) to continue.
A review of a Nursing - Progress Note dated 10/23/24 at 12:55 PM, written by LPN 'E', revealed, Resident (R802) is complaining of pain to the right foot spoke with NP she is aware. NP ordered 1 time Dose for Norco (opiate pain medication) .she ordered .Hydroxyzine .anxiety .
A review of a PT Treatment Encounter Note dated 10/23/24 revealed R802 declined PT on that date.
A review of an OT Treatment Encounter Note dated 10/23/24 revealed, .Pt (patient) c/o (complained of) ankle pain and states she doesn't think she sure <sic> do therapy today. Therapist educated pt on the need for consistent participation in therapy to reach goals .
A review of a progress note written by Physical Medicine and Rehabilitation (PM&R) Physician (Physician 'G') on 10/23/24 at 4:30 PM revealed, R802 .had no complaints today. She feels well. She continues to have some difficulties with blood pressure during therapy .Inspection of the .BLE (bilateral lower extremities) revealed no acute swelling .tenderness .gait not tested .Pain: Reasonably controlled. Continue gabapentin (a pain medication used to treat neuropathy - nerve pain) which she takes at home for some neuropathy . There was no mention in Physician 'G's note regarding R802's potential ankle injury and that R802's right foot was evaluated specifically for that reason as R802 had complained of pain that day and declined PT and OT due to the pain.
A review of an OT Treatment Encounter Note dated 10/24/24 revealed R802 refused to do any standing today. C/O right ankle pain.
A review of a PT Treatment Encounter Note dated 10/25/24 revealed, .Pt with NEW RT ANKLE swelling, X rays negative for any fractures, swelling present .
A review of an OT Treatment Encounter Note dated 10/25/24 revealed, .pt only able to take one-step this day as she is reporting Max ankle pain. Nurse and PMR Dr (doctor) aware of pt's c/o's .Pts fear of ankle pain impeding optimal performance. 'I know the doctor said the x-rays were fine, but still.
On 10/26/24 at 1:03 AM, it was documented in a Nursing - Progress Note that R802 .has edema to the rle (right lower extremity), cool to touch, pain to the heel, np notified new orders for rle venous arterial us (ultrasound).
A review of an OT Treatment Encounter Note dated 10/26/24 revealed, .Pt states she hurt her ankle stating that her leg collapsed when she was standing. 'It just collapsed suddenly'. Her leg is wrapped in ace wrap and she states it is painful. Xrays taken and negative .
It should be noted that upon further review of R802's complete clinical record, as of 10/26/24, five days after R802 first complained of pain to the right ankle/foot, there was no documentation that R802's right foot was evaluated by a medical provider after complaints of pain, swelling, and inability to participate in therapy, other than Physician 'G's note which did not address the potential injury and/or pain experienced that day.
A review of an OT Treatment Encounter Note dated 10/27/24 revealed R802 declined OT on that day.
On 10/27/24 at 1:09 PM, six days after R802 first complained of pain to the right ankle/foot, R802's attending physician, Physician 'H', documented, .CHIEF COMPLAINT: Right ankle injury .The patient stated that she inured her right ankle, moving inside of her room from the wheelchair to the bed. The patient had x-ray done secondary to significant amount of discomfort. It did not show the fracture, X-ray shows no significant abnormalities including soft tissue being intact. Arterial Doppler was also done reveals to abnormalities. At this point, the patient is complaining that she is unable to put pressure on the ankle. It is swollen with significant bloody bruising involving the inner side of the right ankle going down to the sole .Positive for inability to ambulate, significant pain in the right ankle, swelling and tenderness .Examination of the right ankle appears to be swollen in the outer area with significant amount of bruising and tenderness .ASSESSMENT AND PLAN: .Injury to the right ankle, no fracture of the bones. The patient definitely has some injury of the soft tissue involving swelling and bruising. At this point, I strongly encouraged the patient to be no weightbearing .I do not believe the patient should walk on these extremities .The patient is no weightbearing status on the right lower extremity until evaluated by podiatrist .
A review of a PT Treatment Encounter Note dated 10/27/24 revealed, Pt declined gait training today due to new R ankle swelling (it should be noted that R802 first injured her ankle on 10/21/24); stating 'they don't want me walking or standing on it'. Writer unable to find documentation on (electronic medical record) .Declined gait training today due to R ankle swelling .
On 10/28/24 at 7:30 PM, PM&R Physician 'G' documented, .Since last evaluation, she does complain of right ankle pain (It should be noted that R802 although she did not exhibit pain during the last evaluation by Physician 'G' on 10/23/24, she did exhibit pain during therapy and according to the nursing progress note at which time pain medication was administered). She stated this started when she stood up but does not remember any overt trauma. She had been placed NWB (non weightbearing) by the primary team. She had an x-ray, which did not show any acute process. She is pending a podiatry evaluation .Inspection of the .BLE revealed no acute swelling .tenderness .The patient does have ecchymosis (bruising) with increased swelling over the lateral right ankle. The patient does have tenderness to palpitation over the fibula (leg bone) as well as the fifth metatarsal (foot bone) .IMPRESSION/PLAN: .Right ankle pain: Anticipate that this is related to an ankle inversion injury (sprain) .Will obtain a CT (computed tomography) scan of the ankle and foot to rule out small fracture. The patient is currently NWB with pending podiatry evaluation. This will likely be a barrier to the patient's rehab .
Further review of R802's progress notes revealed R802 was transferred to the hospital for issues with orthostatic blood pressure on 10/29/24.
A review of a DR (Digital Radiography - X-ray) of the right ankle dated 10/21/24 revealed, There is a small ossific density which projects in the region of the superior calcaneus (heel bone). This is indeterminate, but could relate to an avulsion type injury. Recommend further dedicated radiographs of the calcaneus.
A review of a DR of the right foot dated 11/1/24 revealed, .Minimally displaced likely avulsion-type fracture of the posterosuperior calcaneus (heel bone) at the Achilles tendon (tendon on the back of the foot) insertion, correlating with torsion (torsion) included suspicious findings on the left <sic> ankle series one day earlier .
A review of R802's hospital records revealed an Orthopedic Foot and Ankle Surgery Consult Note dated 11/1/24 that read, .Reason for consultation/Indication: Right heel pain .reports having twisted her ankle 1 week ago which has been painful and difficult to bear weight on .She reports her ankle pain is worse with weightbearing, improved with rest .Assessment/Plan: .closed avulsion type fracture of the R (right) calcaneus (heel bone) after a twisting injury 1 week ago .Placed into a well padded bulky posterior mold splint .please no pressure is <sic> on the heel at any time .Maintain the RLE elevated .CT of the R hindfoot ordered for further evaluation .NWB RLE .
A review of a CT of R802's right lower extremity dated 11/2/24 revealed, .Moderately comminuted avulsion fracture at the posterior superior calcaneus at the attachment of the Achilles tendon with numerous avulsed and displaced bony fragments .
On 4/8/25 at 1:38 PM, a telephone interview was attempted with LPN 'E' to inquire about how R802's foot was assessed, which NP was contacted, and what information was given to the NP, as the progress notes did not address level of pain, a visual assessment of R802's right foot, or documentation that R802 had trouble with therapy due to the ankle pain. LPN 'E' was not available for interview prior to the end of the survey.
On 4/8/25 at 2:11 PM, an interview was conducted with the Director of Nursing (DON). When queried about whether R802's right foot should have been physically evaluated by a medical provider after continued pain, swelling, and the inability to participate in PT and OT, despite a negative X-ray, the DON reported the nurse notified the NP and therefore they did what they were supposed to do. At that time, the nursing notes related to R802's right ankle were reviewed with the DON and the DON was asked about the lack of documented assessment of R802's foot. The DON reported when the nurse called the NP (it was unknown which NP was contacted either time) the NP would ask more questions even if it was not documented. The DON reported a physical evaluation of R802's foot/ankle probably should have been done, but she would review the clinical record and follow up.
On 4/8/25 at 3:08 PM, the DON followed up and reported it was documented on 10/22/24 that the NP talked to R802 and on 10/23/24 R802 was seen by PM&R Physician 'G'. When queried about where it was documented that Physician 'G' documented an evaluation specifically of R802's injured ankle, the DON reported Physician 'G' documented R802's pain was reasonably controlled. However, it should be noted that the pain assessment was related to R802's chronic neuropathy and did not address the new and acute pain R802 had been experiencing, even if she did not experience it at that time (while at rest).
On 4/8/24 at 3:40 PM, a telephone interview was conducted with Physician 'G'. When queried about whether he evaluated R802's right ankle/foot on 10/23/24 specifically to address the potential injury and new onset pain that began on 10/21/24, Physician 'G' reported he did not recall R802 and said if he documented there was no pain, swelling or tenderness then that was going on at that time. Physician 'G' stated, Pain can come and go, if medicated, even with a small fracture. Physician 'G' clarified that he did not recall who R802 was or if he was notified by the therapy department of R802's pain and declination of therapy due to the pain.
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 #MI00150776.
Based on interview and record review, the facility failed to provide timely incont...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00150776.
Based on interview and record review, the facility failed to provide timely incontinence care for one (R801) of two residents reviewed for bowel and bladder.
Findings include:
Review of a complaint filed with the State Agency included allegations that they were not provided with timely incontinence care and were left wet and soiled for approximately 11 hours.
On 4/8/25 at 9:30 AM, R801 was observed in bed, asleep. Upon entry, the resident woke up and participated in an interview about their care. R801 reported concerns that they were left over eight hours before they got changed or repositioned. R801 further reported that unless they put their call light on, the staff on midnights don't come in to check or reposition them, they wait for the resident to put the call light on. R801 reported if they aren't changed on midnight shift, then they have to wait until after breakfast. The resident was asked if they had reported these concerns to anyone at the facility and they indicated they did, but concerns remained.
Review of the clinical record revealed R801 was initially admitted into the facility on 5/19/21 and readmitted on [DATE] with diagnoses that included: unilateral primary osteoarthritis, unspecified injury at unspecified level of cervical spinal cord, morbid obesity, scoliosis, bipolar disorder, and paraplegia.
According to the Minimum Data Set (MDS) assessment dated [DATE], R801 had a low Brief Interview for Mental Status (BIMS) score of 00/15 (which indicated severe cognitive impairment, however this was due to the resident not responding verbally to questions asked per the social service quarterly assessment on 2/20/25 - during the interview with this surveyor, they were alert and oriented to person, place and time and recalled staying up late last night to watch a championship game of the March Madness basketball). The resident was dependent for toileting, did not have a bowel and bladder program and was always incontinent of bowel and bladder.
Review of the care plan for ALTERATION IN ELIMINATION r/t (related to): incontinent bowel and bladder debility and generalized weakness RESIDENT MAY OFTEN REFUSE HYGIENE/INCONTINENCE CARE date initiated 5/19/21.
Interventions included: Incontinent care per facility policy. Keep resident clean and dry. Date initiated 7/15/24.
Review of the social work quarterly assessment dated [DATE] included, .Social Work (SW)completed a cognitive screening and current BIMS score is 0/15, resident did not respond verbally to questions, she stared and waved goodbye. SW asked if she wanted to participate in her quarterly assessment, resident waved goodbye again to SW .Previous BIMS score was 15/15 .
On 4/8/25 at 10:50 AM, the Director of Nursing (DON) provided a large binder of R801's concern forms and follow-up. Review of these concerns included one dated 2/27/25 initiated by the resident to the DON which read, in part: .CENA involved was educated & disciplined .On 2/28/25 attempt to discuss follow up with [R801]. Pt (patient) is not a good mood. Request writer to leave and don't come back .
Included with the facility concern form was the original email sent by R801 to the DON on 2/27/25 at 6:45 AM which read, in part: .On [DATE], I turned on the call light, at 9:45 AM, to ask for my brief to be changed & have my breakfast tray picked up & removed because I was finished with my breakfast. I DIDN'T get a responds <sic> to the call light until 10:15 AM, an <sic> half hour later. The receptionist from the Hickory Unit nurse's station was dressed in an aide's uniform. She responded to the call light. She removed my breakfast tray & said she'd tell the aides I needed to have my brief changed. I turned the call light on AGAIN at a quarter to noon (11:45AM) because I STILL HAVEN'T got my brief changed. The receptionist from the Hickory Unit nurse's station AGAIN answered/responded to the call light. I told her I'm STILL waiting to get my brief changed. I've been waiting almost 2 HOURS to have it changed. She said if the aides don't change my brief she'll come back & change it. The aides DIDN'T change my brief. She didn't come back to change my brief, either. The lunch tray came .I told the aide who brought by lunch tray to me that I had been waiting almost 3 HOURS to get my brief changed. All she said was wow. She made NO effort or attempt to change my brief. For the 3RD TIME today, I AGAIN turned on the call light. This time NOBODY responded to the call light until the shift changed with evening shift (3PM to 11PM) starting. Thank GOD & heaven! My evening shift aide & the Hickory Unit nurse's station receptionist dressed in an aide's uniform, FINALLY, changed by brief & my urine soaked bed linen. After waiting 5 HOURS to have my brief changed my bed linen was urine soaked. The last time I had by brief changed was 4AM earlier this morning. So I was in my brief for a total of 11 HOURS (4AM to 3PM) before it was changed. WHAT A DAMN DISGRACE!! .
The assignment sheets from 2/26/25 identified Certified Nursing Assistant (CNA 'A') had been assigned to R801.
The DON's interview with nursing staff from 2/26/25 revealed the room assignments had changed and CNA 'A' had been informed that R801's room was under their assignment around 9:00 AM on 2/26/25. The DON's interview with the Unit Clerk 'D' (who was also a CNA) denied being told by R801 they needed to be changes or that the call light was not answered for a long time (which conflicted with R801's recollection of events).
Review of an employee counseling and corrective action record dated 3/4/25 documented, in part:
.2nd Written Warning .CENA didn't provide care to [R801]on 2/26/25 7A-3P. Education given . the form was noted as refused to sign. The educational in-service by the DON to CNA 'A' read, OBJECTIVE/OUTLINE: CENAs reeducated on importance to check assignment at the beginning of the shift and freq (frequently). throughout the shift .TEACHING METHOD/EQUIPMENT: lecture .
A text message to all nurses included, ATTENTION ALL NURSES: When you make changes to the CNA assignment after start of shift you MUST let them know of the changes and update the assignment sheet, Thank you .
On 4/8/25 at 12:53 PM, a phone interview was conducted with CNA 'A'. When asked about R801 and what they could recall from 2/26/25, CNA 'A' reported that specific day they were not assigned to R801 and didn't know they swapped the assignment until the end of their shift (approximately 3:00 PM). CNA 'A' further reported they were familiar with R801 and when they are assigned to the resident they make them the first one to get done, and reported the resident tolerated them. When asked how they document when incontinence or toileting care is completed, CNA 'A' reported they document in [electronic system] and will do that at the end of the shift. That's when they told me about R801, they didn't tell me earlier.
On 4/8/25 at 2:10 PM, an interview was conducted with the DON. When asked when should staff be expected to check for incontinence care, or toileting needs, the DON reported the standard of care is every two hours. The DON was informed of the discrepancies between what R801 reported and what the facility's documentation reflected and the DON reported on that day, there was no documentation of refusals. When asked if they were able to provide a call-light report for that specific day, the DON reported they didn't think so, but would see as they periodically monitored call lights using an actual hard form (not electronic). (There was no additional documentation or follow-up regarding the call-lights provided by the end of the survey.) The DON was requested to provide the ADL documentation for the resident's bladder and bowel (B&B) elimination from 2/26/25 as this information was not available to the surveyor in the electronic medical record (EMR).
On 4/8/25 at 3:38 PM, the DON provided the ADL documentation which revealed the B&B - Bladder Elimination and Bowel Elimination for the Day shift (7:00 AM - 3:00 PM) were incomplete (blank). The DON was informed of the concern that incontinence care was not provided to R801 on 2/26/25.
According to the facility's policy titled, Incontinence Care - Urinary and Fecal dated 4/22/2024:
.Residents who are incontinent of bowel and/or bladder will be provided incontinent care assistance as needed based on resident request and/or check and change, or as per resident preference or need .
Feb 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0551
(Tag F0551)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00150187.
Based on interview and record review the facility failed to ensure a consent for p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00150187.
Based on interview and record review the facility failed to ensure a consent for psychotropic medications were obtained from a legally authorized resident representative for one resident (R303) of three residents reviewed for rights of legally authorized representatives. Findings include:
On [DATE], a concern submitted to the State Agency was reviewed with alleged R303 was provided psychotropic medications without the consent of their legally authorized representative (Durable Power of Attorney for healthcare-DPOA-H).
On [DATE] the medical record for R303 was reviewed and revealed the following: R303 was initially admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, Fall from bed and Cerebral Infarction and had expired on [DATE]. A review of R303's MDS (minimum data set) with an ARD (assessment reference date) of [DATE] revealed R303 needed assistance from facility staff with their activities of daily living. R303's BIMS score (brief interview of mental status) was 12 indicating moderately impaired cognition.
A Physician Certification of Capacity dated [DATE] that was signed by two Physicians revealed R303 was deemed Incompetent to participate in medical treatment, care and custody decision-making. The reason that the resident is unable to participate is Dementia and Visual Hallucinations .
A Durable Power of Attorney for Healthcare (DPOA-H) form signed by R303 on [DATE] was reviewed and revealed that R303's wife was their appointed DPOA-H.
A review of R303's Medication Orders revealed R303 was ordered Sertraline on multiple dates including the following:
(Anti-depressant) Zoloft Oral Tablet 25 MG (Sertraline HCl) Give 1 tablet by mouth in the morning for depression-Start date: [DATE] .
Sertraline HCl Tablet 50 MG Give 1 tablet by mouth one time a day for Depression-Start date [DATE] .
Sertraline HCl Oral Tablet 25 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for depression-Start date [DATE] .
Sertraline HCl Tablet 50 MG Give 1 tablet by mouth one time a day for Depression-Start date [DATE] .
Sertraline HCl Oral Tablet 25 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for Depression Give in addition to 50mg to equal 75mg Daily-Start date [DATE] .
Sertraline HCl Oral Tablet 25 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for Depression-Start date [DATE] .
Sertraline HCl Oral Tablet 25 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for
ANTIDEPRESSANTS, CHEMICALS-Start date [DATE] .
(Anti-Anxiety)LORazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet sublingually every 6 hours for anxiety crush tablet-Start date [DATE] .
A review of R303's UDA (User defined assessment) psychotropic consent and education forms was conducted and revealed the following: [DATE] was struck out XXX[DATE]-Consent and education provided to R303 [Note-deemed incapacitated on [DATE]] without the DPOA-H. [DATE]-Education/Consent field was blank. [DATE]-DPOA-H [declined consent for Sertraline.]
Further review of R303's psychotropic medication consent forms did not reveal R303's legally authorized representative- DPOA-H had provided consent for either the Sertraline or the Lorazepam.
On [DATE] at approximately 1:04 p.m., Social Worker C (SW C) was queried regarding the psychotropic medication consent forms for R303. SW C indicated that residents have to consent for their psychotropic medications. SW C was queried regarding R303's DPOA-H of not consenting for R303 to be provided Zoloft/Sertraline and they indicated that they were aware of R303's DOPA-H not consenting to the medication. At that time, a request for the psychotropic consent forms that R303's DPOA-H had provided consent for their psychotropic medications was requested.
On [DATE] at approximately 9:42 a.m., during a follow-up conversation with SW C, SW C indicated they did not have any documentation that R303's DPOA-H had provided consent for their psychotropic medications. SW C was queried as to why and they indicated nobody had brought it to their attention that it needed to be done.
On [DATE] a facility document titled Policy and Procedures-Psychotropic Medication Use was reviewed and revealed the following: It is the policy of the facility to only prescribe psychotropic medications when it is necessary to treat a specific diagnosed condition and the medication is deemed as beneficial to the resident. The facility will identify when a resident is prescribed a psychotropic medication and will obtain informed consent from the resident or authorized representative for each psychotropic medication ordered Informed Consent-For any resident taking a psychotropic medication, the Social Service employee or designee will obtain informed consent from the resident and/or authorized representative using the Psychotropic Medication Consent UDA in [electronic medical record] The Social Service employee, or designee, will review the medication prescribed, dosage, side effects, and risks versus benefits of the medication, which are outlined on the psychotropic informed consent evaluation. The Social Service employee, or designee, will discuss any Black Box Warnings associated with the psychotropic prescribed to the resident or authorized presentative <sic>so that they are aware of the potential risks. After review, the resident and/or authorized representative will either consent or refuse the psychotropic medication. The consent or refusal of the psychotropic medication may be obtained in person or verbally via a telephone conversation. If the resident and/or authorized representative refuses to consent to the psychotropic medication, the physician/medical practitioner will be notified so that the medication can be discontinued
On [DATE] the facility Administrator provided a copy of R303's UDA form dated [DATE] that indicated R303's DPOA-H had declined consent for sertraline.
No other documentation was provided by the end of the survey that indicated R303's DPOA-H had provided consent for R303's psychotropic medications including the multiple dose increases of sertraline or the lorazepam.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00150047
Based on interview, and record review, the facility failed to follow pest control p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00150047
Based on interview, and record review, the facility failed to follow pest control procedures for one resident (R305) of three residents reviewed for pest control. Findings include:
On 2/19/25 a concern submitted to the State Agency was reviewed which alleged staff were not utilizing effective procedures to maintain pest control resulting in an infection of bed bugs.
On 2/19/25 at 10:03 a.m., during a conservation with Maintenance Director A (MD A), MD A was queried regarding allegation of a bed bug infestation in the facility. MD A reported they did have multiple rooms in where bugs were found and that the facility pest control provider had been out multiple times to inspect and treat the rooms. MD A indicated that the rooms with alleged infestation were 414 and 409. A request for documentation of the bed bug procedures and treatments were requested.
On 2/19/25 a review of the facility's investigation into the bed bug infestation revealed the following: Bed Bug Investigation 2/6/2025 . On 2/5/25 sister of resident, [Name of resident] in (room) 414L visited resident. At that time, she brought in resident's clothing and belongings that were from her old apartment before admission to Evergreen. Bed bugs were noted on resident [Name of resident] in 414L after her sister [name of sister] had visited her. Before sister left, she hugged resident's roommate [R305]. Bed bug policy and procedures initiated. Both residents were showered. Resident's rooms were moved and orientated to their new bedrooms. Families notified. [Name of roommate] moved to 416 and [R305] moved to 409. All linen and clothing from bedroom [ROOM NUMBER] bagged and sent to laundry. Room cleaned, UV'd (ultra violet light) and exterminator contacted. Items that were unable to be thoroughly cleaned or washed were inspected by the exterminator and UV'd. Both resident's wheelchairs were also inspected and UV'd. On 2/6/25, bed bugs were noted in [R305's] hair. Resident voiced that CENA (Certified Nursing Assistant) showered her yesterday and put her old clothes back on her. Facial edema and lip swelling noted. Per UM (Unit Manager) EpiPen was administered. Facial edema occurred by an unknown reason. Provider notified. No new orders at this time. Bed bug policy and procedure started over. Resident showered and provided a gown. All clothing and linens were sent to laundry. Resident's room was cleaned and UV'd. CNA B was educated and disciplined regarding bed bug policies and procedures.
On 2/19/25 at approximately 12:48 p.m., CNA B was queried regarding being disciplined as result of R305 having bed bugs in their hair on 2/6/25 after being showered on 2/5/25. CNA B reported that they were unaware that putting on the same clothes that R305 was in previous to the shower was wrong and that they thought they were fresh clothes. CNA B reported they were disciplined and educated on the bed bug procedures after the incident.
On 2/19/25 at approximately 1:50 p.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding the bed bug investigation and CNA B placing the potentially infested clothing back on R305 after being showered. The DON indicated that they re-educated CNA B on the correct procedures when bed bugs are found on a resident and that all the education was completed as of 2/6/25 and they have not had any more bed bug occurrences.
A review of CNA B's re-education on the facility bed bug procedures was reviewed and revealed the following: Employee Counseling and Corrective Action Record Date: 2/6/25 .CENA assist resident with shower secondary to suspected bed bugs. After completing shower, CENA assisted patient with same clothes patient was wearing before shower
An education in-service attendance record for CNA B dated 2/6/25 revealed the following: Topic-Bed Bug Policy and Procedures .Objective/Outline-Resident to be fully showered with hair washed and new/clean outfit to be put on resident after shower .
On 2/19/25 the medical record for R305 was reviewed and revealed the following: R305 was initially admitted to the facility on [DATE] and had diagnoses including Bipolar disorder and Post traumatic stress disorder. A review of R305's MDS (minimum data set) with an ARD (assessment reference date) of 2/9/25 revealed R305 needed assistance from facility staff with their activities of daily living. R305's BIMS score (brief interview for mental status) was 15 indicating intact cognition.
A Physician progress note dated 2/6/25 revealed the following: .Pt (patient) alert and conversive upset as had to evacuate room d/t (due to) bedbugs. Reports bed bugs found in hair and few small bites observed on inner thighs. Pt was thoroughly showered. All belongings cleaned, clothes washed .
On 2/20/25 A review of the facility policy pertaining to bed bugs was reviewed and revealed the following: Policy-Bed Bug .Policy Overview: The purpose of this policy is to provide guidelines for the identification and treatment of bed bugs .The resident(s) should be thoroughly bathed and changed into a fresh gown. The resident(s) should be moved to a different room using a new wheelchair, walker, cane, etc. per their plan of care and given fresh clean linens and personal care products
During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included staff specific education, implementation of the current policy and follow through after interventions (showers, linen change, room treatments). The facility was able to demonstrate monitoring of the corrective action and maintained compliance.
Dec 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number MI00147674.
Based on interviews and record review, the facility failed to protect the re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number MI00147674.
Based on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for one (R803) of four residents reviewed for abuse, resulting in R804 pushing R803 out of their wheelchair. Findings include:
A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) revealed an allegation that R804 pushed R803's wheelchair and R803 fell.
On 12/10/24 at 12:40 PM, an interview was conducted with R803. R803 reported he used to be in another room and has had many roommates. R803 was difficult to understand, but said something about not trying to bother anyone. When queried about whether there had been any physical altercations with other residents, R803 reported there was, but did not give additional details and reported his memory was not good.
On 12/10/24 at approximately 12:50 PM, R804 was observed seated at the table in the dining room for lunch.
A review of R803's clinical record revealed R803 was admitted into the facility on 1/5/23 and readmitted on [DATE] with a diagnoses of Alzheimer's Disease with hallucinations. A review of a Minimum Data Set (MDS) assessment revealed R803 had moderately impaired cognition and no behaviors.
A review of R803's progress notes revealed the following:
A Nursing-Progress Note dated 10/15/24 and written by Licensed Practical Nurse (LPN) 'B', noted, Writer was alerted to (R804's room) after hearing screaming. Upon entering room, (R804) was standing near doorway irate and yelling towards (R803). (R804) stated he pushed (R803) and suggested (R803) was trying to take items. (R803) was on the L (left) side of (R804's) bed, on the floor sitting upright directly parallel to his wheelchair behind him. (R803) stated he was pushed when questioned by writer. (R803) is currently housed in (another room number). Occurrence happened in (R804's room number), where (R803) was previously housed. (R803) states slender black male rolled him into (R804's room number) and he thought it was his room. He was looking through the drawers when (R804) entered became upset and pushed him onto the floor from his w/c (wheelchair) .
A Social Work progress note dated 10/21/24 noted, .Resident stated he was taken to a room by mistake. The occupant of room became angry, shook my wheelchair and I fell out per resident. Resident stated he was spouting profanities at him. Resident also stated he feels he is being stalked by this resident because he keeps walking back and forth all day, I feel he's menacing per resident. Resident also stated the man yelled I don't like people touching my stuff. Per resident, when I see him coming, I look the other way .
A Physician Note dated 11/4/24 noted an altercation with R803's roommate and the roommate hit his left hand on 9/4/24 and the altercation on 10/15/24 when R803 was found in his old room .pushed on the floor and kicked in his back by other resident after going through his things .
A review of R804's clinical record revealed R804 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included: Metabolic encephalopathy. A review of a MDS assessment dated [DATE] revealed R804 had severely impaired cognition.
A review of R804's progress notes revealed the following:
A Nursing-Progress Note dated 9/5/24 noted, (R804) pushed roommate (determined to be R803) due to roommate touching his belongings .(R804) encouraged to notify staff for further concerns without touching roommate .
A Nursing -Progress Note dated 9/30/24 noted, Resident was visibly upset this morning and refused all medication. I tried to talk to the resident, and he cursed at me .Resident began to pace quickly/aggressively up and down the hall .I saw (R803) in the hallway sitting in his wheelchair. (R804) was pacing angrily and pushed the wheelchair of (R803) and telling him to get out of his way and accusing him of trying to trip him. I did not witness (R803) try and trip (R804) .
On 10/4/24, R804 asked staff if he could get a weapon to protect himself from a guy.
On 10/7/24, R804 was sent to the hospital.
There was no documentation in R804's record regarding the incident that occurred with R803 on 10/15/24.
A Social Work progress note dated 10/21/24 noted, .Resident remembered that a person was in his room going through his stuff which upset him. Per resident, I grabbed his w/c to take him out of my room and he fell onto the bed not the floor. Per resident, I did use profanity. SW (Social work) explained resident was taken by mistake to his room and that's why he was there .
On 12/10/24 at 12:28 PM, an interview was conducted with LPN 'B' regarding the incident between R803 and R804 on 10/15/24. LPN 'B' reported they returned to the unit from break, redirected a female resident away from R804's doorway and went to the medication cart. LPN 'B' reported R804 had the curtain closed and therefore they were unaware R803 was in R804's room at that time. When LPN 'B' was at the medication cart, they heard R804 yelling so they ran back to the room and R803 was on the floor near his wheelchair and next to R804's bed. Upon entrance to R804's room, LPN 'B' reported R804 was walking toward the door and yelling. R804 reported he pushed R803. When queried about how R803 got into R804's room, LPN 'B' reported there were only rumors that another staff member brought R803 into R804's room. LPN 'B' confirmed R803 previously resided in R804's room as his roommate and stated, (R804) is just aggressive, in general.
A review of an investigation conducted by the facility revealed the following:
A handwritten note by the Assistant Director of Nursing (ADON)/Inservice Director, Registered Nurse (RN) 'A'. that read, On 10/22/24, (RN 'A') had conversation with (Dietary Staff 'C') from kitchen. (Dietary Staff 'C') reported that on 10/15/24 he did assist (R803) to (R804's room) .
A summary of the facility's investigation that documented, Per interview with (R804's roommate), shortly before 5 pm 'young skinny male' assisted (R803) to (R804's) side of the room.
On 12/10/24 at 1:30 PM, a phone interview was attempted with Dietary Staff 'C' who was no longer employed at the facility. Dietary Staff 'C' was not available for interview prior to the end of the survey.
On 12/10/24 at 1:32 PM, an interview was conducted with RN 'A'. When queried about the education provided to Dietary Staff 'C', RN 'A' reported initially Dietary Staff 'C' denied that he brought R803 into R804's room, but RN 'A' talked to him again to try to figure out what happened. RN 'A' explained Dietary Staff 'C' was able to point out the resident (R803) but did not know his name and told RN 'A', R803 was in the doorway of R804's room, R803's wheelchair wheels were locked up. Dietary Staff 'C' was trying to be helpful, unlocked the wheels and R803 proceeded into R804's room, but Dietary Staff 'C' did not know that was not R803's room. RN 'A' provided education to ask the nursing staff when not sure of a resident's room.
A review of a facility policy titled, Abuse, updated on 5/24/23, revealed, in part, the following, Residents have the right to be free from abuse .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake # MI000148791
Based on interview and record review the facility failed to report allegations of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake # MI000148791
Based on interview and record review the facility failed to report allegations of neglect to the Administrator/Abuse Coordinator and to the State Agency (SA) for one (R806) out of four residents reviewed for Abuse/Neglect. Findings include:
A complaint was filed with the SA that alleged that on 12/5/24, R806 was observed covered in dry feces over an extended part of their body. The complainant noted that the allegation had been reported to Nurse F and the Director of Nursing (DON) on 12/5/24. The complainant noted that both the Nurse F and the DON indicated that incontinence care was not needed as the resident was dying and it was okay to leave them covered with hardened feces. The Complainant further reported that Unit Manager (UM) D, a family member of R806 was never informed on the incident until after the resident was discharged .
A review of R806's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: spontaneous bacterial peritonitis, cirrhosis of the liver and malnutrition. The resident was discharged from the facility to home on [DATE]. Review of the resident's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 14/15 (cognitively intact cognition).
Continued review of R806's clinical record revealed:
Care Plan: Focus: Risk for Pressure Injury .Incontinent of bowel and bladder Interventions: prevent skin care post incontinence care daily/prn . *There was no documentation in the resident care plan that documented they refused incontinence care.
On 12/10/24 at approximately 1:23 PM, an interview was conducted with Unit Manager (UM) D. UM D was queried as to the allegation that R806 was left in dried feces and staff members told CNA (certified nursing assistant) 'E not to worry about it as the resident was dying. UM D reported that they heard that had happened on Saturday (12/7/24) and had a discussion with the DON. UM D noted that R806 had discharge home on [DATE] with Hospice and had passed away at home.
On 12/10/24 at approximately 1:30 PM, an interview was conducted with Nurse F. Nurse F identified themselves as a Registered Nurse (RN) and had been employed by the facility for a year. When asked if they recalled CNA E reporting that that R806 was left covered in feces, Nurse F noted that they were not familiar with R806. Further, they had never been assigned to work with the resident. They noted they had never had a conversation with CNA E, never responded that the resident should be left alone as they were dying and further never had a conversation with the DON.
On 12/10/24 at approximately 2:00 PM, an interview was conducted with the DON. The DON was queried as to the facility's protocol when allegations of abuse/neglect are observed by a CNA. The DON noted that all allegations of abuse/neglect should be reported to their supervisor and/or to her as the DON and/or the Administrator. When asked if they were made aware of any neglect concerns pertaining to R806, the DON noted that they believe someone had mentioned an incident where the resident was left soiled, however they were not aware of anyone stating that the resident should not be cared for as they were dying. The DON was asked if they remembered who reported the concern and the date and time. The DON could not recall the name of the person who reported the concern. The DON was asked if they discussed any concerns pertaining to R806 with UM 'D. The DON reported that they did not. The DON did note that towards the end of their stay at the facility, R806 refused care and was combative at times when being changed. The DON was asked to provide any documentation that noted the resident refused to be cleaned following a bowel movement. *It should be noted that no documentation was provided prior to the end of the Survey. Further, no documentation reviewed in R806's clinical record noted the resident's refusal of incontinent care.
On 12/10/24 at approximately, 2:10 PM, an interview was conducted with the Administrator/Abuse coordinator. The Administrator was asked if they had received any indication that R806 had been lying in dried feces and that nursing staff indicated that the resident did not need to be changed as they were dying. The Administrator reported that they did not receive any allegations of abuse by any staff on 12/5/24. The Administrator reported that today they received notice from the DON that the resident may have been left in feces but refused care.
On 12/10/24 at approximately 2:50 PM, the DON reported that they believe the staff person who noted the resident was left sold was most likely CNA E. Again, they were not able to recall the date/time they reported the allegation. The DON noted that they had written up the CNA on two occasions and believed they were upset and might have alleged that R806 was neglected. *It should be noted that that prior to the interview, Human Resource (HR) staff provided staff personnel records for four employees, including CNA E, there was no indication in CNA E's personnel record that they had received any disciplinary actions. HR G was able to confirm that all disciplinary actions should be in the staff's record.
On 12/10/24 at approximately 4:15 PM, the DON presented a typed document, not dated that documented, in part: Investigation report re: R806 .On 12/5/24 at around 4:30 PM CENA (*No name was noted) reported to writer that R806 was found in bed covered in dry feces .Per interview with CENA (hereinafter CNA H) who was assigned to R806 7 AM to 3 PM At time resident removed his incontinent briefs and at time did not like to be changed. The last round was completed at around 2 PM .resting in bed clean and dry .per interview with Nurse F who was assigned to R806 on 12/5/24, 7 AM to 11 PM; no concerns or issues were reported (*It should be noted that Nurse F when interviewed on 12/20/24 reported that they were not familiar with R806 and was never assigned to the resident or interviewed regarding concerns) .Per interview with UM D .R806 was presented with worsening confusion .at 10 am resident demonstrated aggressive behavior .staff kept the resident safe and wait till resident calm down to continue with care . *It should be noted that during an initial interview with the DON on 12/10/24 at approximately 2:00 PM, there was no mention that the incident as noted above occurred on 12/5/24 and further that any staff were interviewed as to the alleged incident.
The facility policy titled, Abuse (5/24/23) was reviewed and documented, in part, the following: .Resident have the right to be free from abuse, neglect .mistreatment .the facility will develop and implement written policies and procedures that include: training new and existing staff on prohibiting, preventing and identifying abuse .The facility will ensure that all allegations involving abuse, neglect .mistreatment .are reported immediately to the Administrator and Reported to the State Agency immediately but not later that two hours after the allegation is made if the allegation involves abuse .Definitions: .Abuse: the willful infliction of injury .Abuse 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 .Neglect: Failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .
Aug 2024
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0555
(Tag F0555)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure choice of an attending physician was honored for one (R288) of three residents reviewed for choices. Findings include:
...
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Based on observation, interview and record review, the facility failed to ensure choice of an attending physician was honored for one (R288) of three residents reviewed for choices. Findings include:
On 8/5/24 at 10:30 AM, R288 was observed lying in bed. A sign announcing Contact Precautions was posted on the door and a isolation cart was observed in the hallway immediately outside R288's room which contained personal protection equipment (PPE) including isolation gowns and gloves. R288 was asked about care at the facility. R288 explained their doctor, Dr. F, had come in the day before, but was touching their PICC (peripherally inserted central catheter) line and the dressing over the wound on their foot without gloves . when they told Dr. F to put on gloves, Dr. F got an attitude about wearing gloves. R288 also explained they had told Dr. F they did not want them as their doctor anymore.
Review of the clinical record revealed R288 was admitted into the facility on 7/29/24 with diagnoses that included: diabetes, cellulitis and acute kidney failure. According to a Brief Interview for Mental Status (BIMS) exam dated 7/30/24, R288 scored 14/15 indicating intact cognition.
Review of R288's progress notes revealed a Physician Team - H&P (health and physical) note dated 8/4/24 at 4:08 PM that read, Patient refused exam.
On 8/7/24 at 9:13 AM, Dr. F was interviewed by phone and asked about R288. Dr. F explained they were not wearing gloves, they wanted to see the PICC line, but R288 would not let them touch it, then they noticed a bandage on R288's foot, so they tried to move the blanket, but R288 yelled at them for not wearing gloves. Dr. F was asked if they were aware R288 was in Contact Precautions. Dr. F explained they normally enter the room and does an evaluation of what supplies they would need, then exits the room to gather the supplies, then they would put on a gown and gloves to do the examination and look at the wound. Dr. F was asked if R288 had said they did not want them as their doctor. Dr. F explained R288 was upset and had fired them, but that they were going to see them that day to see if they had calmed down.
On 8/7/24 at 9:32 AM, the Director of Nursing (DON) was interviewed and asked if a resident did not want to see their doctor again, could they get a different doctor. The DON explained they had several doctors at the facility and a resident could change doctors at any time. The DON was informed R288 had told Dr. F they did not want them as their doctor, and Dr. F had agreed R288 had told them, but they had said they were going to see them anyway. The DON explained she would talk to R288 and facilitate a different doctor if that was what they wanted. When asked if Dr. F should have informed the facility that R288 had fired them, the DON agreed Dr. F should have informed them.
Review of the facility's admission Contract dated 11/2017 read in part, .The resident has the right to choose his or her attending physician . If the resident subsequently selects another attending physician who meets the requirements specified in this part, the facility shall honor that choice .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0559
(Tag F0559)
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 appropriate notice in a dignified manner of a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide appropriate notice in a dignified manner of a room change for one (R289) of one resident reviewed for room changes. Findings include:
On 8/5/24 at 11:11 AM, R289 was observed lying in a bed different than the room census provided by the facility. R289 was asked about being in that particular room. R289 explained their room had been changed that morning, it was the third room they had been in, and they had only been there four days.
Review of the clinical record revealed R289 had been admitted into the facility on 8/1/24 with diagnoses that included: open wound of abdominal wall, prostate cancer and chronic kidney disease. According to a Brief Interview for Mental Status (BIMS) exam dated 8/2/24, R289 scored 13/15 indicating intact cognition.
Review of R289's census revealed upon admission, R289 was in room [ROOM NUMBER]. On 8/3/24, R289 was moved to room [ROOM NUMBER], then on 8/5/24 R289 was moved to room [ROOM NUMBER], their current room.
On 8/6/24 at 1:05 PM, R289 was observed lying in bed and asked about their room changes. R289 explained they had been admitted (8/1/24) into one room, then was moved to a different room on Saturday (8/3/24) then at 2 o'clock in the morning that night (8/4/24) staff came and told them they had to change rooms, but did not say why .R289 asked why they had to change rooms, but staff told R289 they did not have to tell them the reason, they were a guest .R289 said even if they were a guest, they knew they had basic rights, but staff told them the room change was not part of their rights .R289 asked the staff if they had to call their lawyer because they knew they had rights. R289 was asked when they had moved to their current room. R289 explained staff came again that morning (8/5/24) and told them the reason for the room change, so they agreed to it. R289 was asked if staff had told them the reason for the room change at 2:00 AM, would they have agreed to the room change. R289 explained they definitely would have moved as it was explained to them that it had been a mistake to be put in that room, and it was for health reasons to be moved. When asked if they knew the name of the staff that wanted to move them at 2:00 AM on 8/4/24, R289 explained there had been four staff members, and they did not know their names.
On 8/6/24 at 4:21 PM, the Director of Nursing (DON) was interviewed and informed of the conversation with R289. The DON explained she had been told R289 had refused to be moved on 8/4/24, but then agreed to be moved on 8/5/24, but did not know the specifics. When asked if R289 should have been told the reason for the move, especially at 2:00 AM, the DON agreed R289 should have been told the reason.
On 8/6/24 at 4:47 PM, Licensed Practical Nurse (LPN) D was interviewed and asked about the attempting to change R289's room at 2:00 AM on 8/4/24. LPN D explained she did tell R289 the reason for the room change, but R289 wanted specific information about the reasons, and were told they could not give specifics, R289 threatened to call their attorney.
Review of a facility policy titled, Notification of Room/Roommate Change dated 4/18/23 read in part, .The right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed .Discuss possible room or roommate changes with the Interdisciplinary Team. Ensure room or roommate changes meet the CMS (Centers for Medicare & Medicaid Services) guidelines prior to proceeding with the change .Discuss the change with the resident and/or the resident's representative including the reason for the change. Provide the resident or representative with the printed notification form .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to execute a Do-Not-Resuscitate (DNR) Advance Directive order for one resident (R128) reviewed of two residents reviewed for Advance Directive...
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Based on interview and record review, the facility failed to execute a Do-Not-Resuscitate (DNR) Advance Directive order for one resident (R128) reviewed of two residents reviewed for Advance Directives.
Findings include:
Clinical record review revealed R128 was admitted from the hospital to the facility on 7/23/24. R128 required rehabilitation from right toe gangrene (death of body tissue due to lack of blood flow or infection). R128's medical history included diabetes, hypertension, end stage renal disease and required peritoneal dialysis (removal of waste products via the lining inside the belly as a natural filter for blood). A Brief Interview of Mental Status (BIMS) score totaled 14/15 indicating R128 was cognitively intact.
On 7/29/24, a review of the health care conference summary held on 7/29/24 at 2:00 PM documented Advance Directives were reviewed and R128 expressed their choice of DNR code status. The facility documented the DNR form was completed by R128 and awaiting physician signature and order.
On 8/6/24 at 12:49 PM, an interview with Corporate Social Services B confirmed the facility failed to implement R128's wishes of a DNR code status and remained a full code for the duration of R128's residency at the facility.
On 8/6/24 at 1:12 PM, Social Services B provided the DNR form signed by R128, dated 7/29/24, stated the physician signed and dated the form 8/6/24. Social Services B was aware R128 was discharged from the facility at the time the physician signed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0624
(Tag F0624)
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 safe and collaborated discharge for one (R29)...
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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 safe and collaborated discharge for one (R29) of three residents reviewed for discharge. Findings include:
On 8/5/24 at 9:40 AM, R29 was observed in the bathroom unassisted. R29's spouse was in the room waiting for them to return from the bathroom. R29 stated that they would like a surveyor to return once they were finished getting ready for the day. At 10:00 AM, this surveyor returned to the room, R29 was sitting in the wheel chair with their left leg elevated on the bed. Their spouse was sitting in a chair across the room. R29 was interviewed and asked how was their current stay at the facility, and stated, It has not been good and explained that they were getting discharged today (8/5/24). R29's spouse interjected and stated, Well, we don't know because social work came in and stated that we might not be getting discharged due to a fall (that R29 had that morning around 9:05 AM). R29's spouse explained that the facility called them on Friday 8/2/24 to state that R29 would be discharged on Monday 8/5/24. R29's spouse stated, Hence, why I have packed up her room and have her all ready to go, and now they are saying we are not leaving. So, we do not know what is going on but either way if they are making [R29] stay, we will stay but if they are discharging her then we will leave. R29 stated that it (their discharge) had just been an unorganized mess and that they just wanted to go home and stated, If they are not going to render any services, then I can sit at home and do the same thing. R29 and their spouse was then asked did the facility hold a care conference (a conference updating the resident and resident's representative of the plan of care for the resident)with them and they both said, No. R29's spouse asked this surveyor what a care conference consisted of. R29 stated that the only person who had talked to her from the facility was the social worker on the day after admission and that Friday (8/2/24).
A record review revealed that R29 was admitted to the facility on [DATE] with a diagnosis of type two diabetes, repeated falls, and generalized anxiety disorder. R29 had a brief interview for mental status score of 15, indicating an intact cognition.
On 8/6/24 at 9:00 AM, R29 was observed in bed resting. R29 was asked how they were. R29 explained that they were still in pain from the fall and that they had been vomiting since yesterday and that their head and their hip were still hurting.
On 8/7/24 at 10:13 AM, R29 and their spouse were interviewed. R29's spouse explained that they had received a call from the facility and was told that R29 was ready to be discharged . R29's spouse continued to explain that they were already on the way to the facility so that was okay (to discharge her then). The spouse stated that when they arrived to the facility around 9:30 AM, another lady came into the room and told them that we were not being discharged .
On 8/7/24 at 11:33 AM, R29 and their spouse were observed going towards the exit with items in their hands. R29 waved this surveyor over to walk towards door with them where R29 then stated, This place is a crap show. A nurse just came in the room and said we were discharged so we are leaving. But it is so unorganized! R29 stated that there was no continuous care and no one knows what's going on in each department. The Director of nursing (DON) saw R29 and their spouse talking to this surveyor and came into the conversation and asked R29 if she knew who she was. R29 replied Yes, you are the DON but what did you want? The DON asked them where they were going and R29 stated, I have been discharged . The DON replied, No, you have not. There was no homecare set, no follow up appointments or anything, you need to go back to your room so we can set this up for you. R29 stated, You all need to get your shit together because this is unacceptable, and if you are going to send me to my room I do not need a psychiatrist! I am competent, you all are just not collaborating with each other and it has confused me!
On 8/7/24 at 11:47 AM, an interview was conducted with the social worker (SW). They were asked what role they play in their discharge plan? The SW explained that she just took over R29's case and she was not 100 percent sure what happened (with the discharge). The SW explained that she was trying to fix it from this point on. The SW was asked who informed the family of the discharge. The SW explained that she was not sure, that the social work director had resigned on 8/5/24. The SW stated, I'm just trying to do what I can.
On 8/7/24 at 1:00 PM, the facility had the resident petitioned to hospital for psychiatric behaviors that stated the resident was trying to self harm.
There was no additional information provided by the exit of survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to implement a baseline care plan for tube feeding was provided to one (R287) of one resident reviewed for tube feeding. Findings...
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Based on observation, interview and record review, the facility failed to implement a baseline care plan for tube feeding was provided to one (R287) of one resident reviewed for tube feeding. Findings include:
Review of a facility policy titled, Care Plan - Baseline dated 8/25/23 read in part, .It is the policy of the facility to develop a baseline plan of care to meet the resident's immediate health and safety needs for each resident within forty-eight (48) hours of admission . The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident .
On 8/5/24 at 9:54 AM, R287 was observed sleeping in bed. Enteral nutrition (tube feeding) was being delivered via pump.
Review of the clinical record revealed R287 was admitted into the facility on 8/3/24 with diagnoses that included: stroke, major depressive disorder and malnutrition. According to a Brief Interview for Mental Status (BIMS) exam dated 8/4/24, R287 scored 3/15 indicating severely impaired cognition.
Review of R287's baseline care plan revealed no care plan for tube feeding.
On 8/6/24 at 2:39 PM, the Director of Nursing (DON) was interviewed and asked if a resident receiving tube feeding should have a care plan for tube feeding. The DON explained there should be a care plan. When informed R287 had no care plan for tube feeding, the DON explained there should have been one from admission.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure medications were accurately documented and orders written according to professional standards of practice for two (R27 ...
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Based on observation, interview and record review, the facility failed to ensure medications were accurately documented and orders written according to professional standards of practice for two (R27 and R287) residents. Findings include:
R27
On 8/6/24 at 8:25 AM, as part of the Medication Administration task, Licensed Practical Nurse (LPN) E was observed to prepare seven medications for R27. LPN E crushed the medications and mixed them with applesauce. LPN E was observed to enter R27's room to give the seven crushed medications to R27. R27 refused to take the medications. LPN E was then observed to leave R27's room with the medications R27 had refused.
On 8/6/24 at 9:05 AM, the medications LPN E had prepared were reconciled with R27's physician orders. All seven medications were marked as given by LPN E.
On 8/6/24 at 9:15 AM, LPN E was asked if she had gone back and given R27 their medications. LPN E explained she had not. When informed all the medications had been marked as given, LPN E explained she had marked them as done before R27 had refused them. LPN E was asked when should medications be marked as given. LPN E explained they should not be marked until after they have been given.
On 8/7/24 at 8:24 AM, the Director of Nursing (DON) was interviewed and asked when medications should be marked as given. The DON explained medications should only be marked as given after the resident takes the medication.
R287
On 8/5/24 at 9:54 AM, R287 was observed sleeping in bed. Jevity 1.5 Cal (calorie) Enteral nutrition (tube feeding) was being delivered via pump at 65 ml/hr (milliliters per hour).
Review of the clinical record revealed R287 was admitted into the facility on 8/3/24 with diagnoses that included: stroke, major depressive disorder and malnutrition. According to a Brief Interview for Mental Status (BIMS) exam dated 8/4/24, R287 scored 3/15 indicating severely impaired cognition.
Review of R287's physician orders revealed an Enteral Feed order with a start date of 8/4/24 that read, in the evening Up at 1800 (6:00 PM); down at 1400 (2:00 PM); 20 hours total. There was no specific type of tube feed formula or rate the tube feed was to be infused in the order.
On 8/6/24 at 8:49 AM, R287 was observed sleeping in bed. No tube feed was being delivered to R287.
On 8/6/24 at 10:51 AM, Registered Dietician (RD) G was interviewed and asked about R287's tube feed orders. RD G explained when a resident is admitted at night or on the weekends like R287 was, the nurse would call him and he would give a standard order or use what the resident had been receiving in the hospital until he could come and evaluate the resident's nutritional needs. RD G was asked if an order should be put in reflecting the specific type of tube feed formula and the infusion rate. RD G explained the order should be complete with all the required elements including the type of formula and the rate. RD G also explained the tube feed formula and rate were in a progress note. When asked if a progress note was sufficient for tube feed orders, RN G explained there needed to be an order for tube feed.
Review of R287's progress notes revealed a Nursing note written by Registered Nurse (RN) H dated 8/3/24 at 8:17 PM that read in part, Pt (patient) admitted .Jevity 1.5 to run at 65 ml/hr .
On 8/6/24 at 11:36 AM, RN H was interviewed by phone and asked about R287's tube feed orders. RN H explained she was the Midnight Manager and had been assisting with R287's admission and had written the admission progress note. RN H was asked if the type of tube feed and infusion rate should just be in a progress note. RN H explained the physician orders should be complete with the type of formula and infusion rate.
Review of the facility's Unit Charge Nurse (RN/LPN) job description undated read in part, .As a member of the interdisciplinary team, the unit Charge Nurse assumes responsibility and accountability for nursing services delivered to all residents of a designated unit for one shift .
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** Deficient Practice Statement #2
Based on interview and record review, the facility failed to follow up on a Physician consult ap...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice Statement #2
Based on interview and record review, the facility failed to follow up on a Physician consult appointment for one resident (R128) of one reviewed for physician consults, resulting in the potential for missed or delayed new orders and treatments.
Findings include:
Clinical record review revealed R128 was admitted from the hospital to the facility on 7/23/24. R128 required rehabilitation from right toe gangrene (death of body tissue due to lack of blood flow or infection). R128's medical history included diabetes, hypertension, end stage renal disease and required peritoneal dialysis (removal of waste products via the lining inside the belly as a natural filter for blood). A Brief Interview of Mental Status (BIMS) score totaled 14/15 indicating R128 was cognitively intact.
On 8/6/24 at 4:38 PM, The Director of Nursing (DON) was questioned of a progress note dated 7/30/24 that the daughter took R128 to a doctor's appointment and no documentation of an after-visit summary was identified. The DON acknowledged the process for outside appointment was not done correctly and acknowledged the facility did not follow up on the physician consult.
On 8/6/24 at 4:45 PM, The facility's policy on coordination of care for outside appointments was requested and not received by end of the survey.
This citation has 2 Deficient Practice Statements.
Deficient Practice Statement #1
Based on observation, interview and record review, the facility failed to provide wound care for two (R337 and R120) of two residents reviewed for nonpressure related wound care. Findings include:
R337
On 8/5/24 at 9:15 AM, R337 was observed lying in bed resting. R337 was asked how their stay at the facility had been. R337 stated that they were in pain and that someone needed to change their wound dressings but they (the facility) had not done so. R337 stated, There is an area on my butt that they have not changed yet. R337 stated that the abdominal wound had started to stink and proceeded to show this surveyor the abdominal wound. There was blood and drainage from the wound that had a mild odor.
A record review revealed that R337 was admitted to the facility on [DATE] with the diagnosis of hyperlipidemia, type two diabetes and mild protein deficit. R337 had a brief interview for mental status score of 15, indicating an intact cognition. A further review of the record revealed that R337 received orders for treatment for surgical wound to gallbladder in the hospital paper work.
On 8/6/24 at 12:00 PM, the wound care (WC) nurse was interviewed and asked about the process of new admissions who come in with surgical wounds. The WC explained that there is supposed to be orders in once the admission is completed and the nurses would call the doctors for treatment orders if they were unable to speak to the doctor and the orders would remain until wound care rounds on the resident. The WC explained that they would normally follow orders from the hospital paper work. WC nurse was asked if R337 should have wound care orders. The WC clarified that there were no orders for wound care currently and there should have been some.
R120
On 8/5/24 R120 was observed sitting in a wheel chair in their room. R120 had a wound vac in place as well as a hand dressing dated 7/31/24. When R120 was asked about the care they received while at the facility, R120 stated its pretty decent but anywhere you go you would be able to tell the people who love doing what they do and the ones who love to get a pay check. R120 was asked when was the last time the facility changed their hand dressing. R120 stated it was changed on the date that was written on the bandage (07/31/2024). R120 stated, It's supposed to be completed 3 times a week.
A record review revealed that R120 was admitted to the facility on [DATE] with the diagnosis of sepsis, pressure ulcers stage 3, and hyperlipidemia. R120 had a brief interview for mental status of score of 15, indicating an intact cognition. A further review of the record revealed that in the medication administration record (MAR) the hand dressing was marked off as being completed on 08/02/2024.
On 8/6/24 at 12:00 PM, the WC nurse was asked how the treatment was marked off as being completed on 8/2/24, when the bandage on R120's hand was dated for 7/31/24 and that R120 confirmed that was the last time it was completed. The WC nurse stated, I am not for sure as I did not do that wound. The floor nurses are responsible for (R120) wounds outside of the wound vac. The Director of Nursing interjected and stated that the nurse (Nurse R) who clicked off on the treatment was in the facility today would have them come and speak with this surveyor. Nurse R was why did she sign off on a treatment that had not been completed, Nurse R stated, It must have been a miscommunication (between her and WC) and explained that she did not complete the treatment.
No addition information was provided by the exit of survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to ensure there were wound care orders placed 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 there were wound care orders placed for one resident (R337) of two residents reviewed for pressure ulcers. Findings include:
On 8/5/24 at 9:15 AM, R337 was observed lying in bed rest. R337 was asked how their stay at the facility had been. R337 stated that they were in pain and that someone needed to change their wound dressings but they had not done so yet. R337 stated, There is an area on my butt that they have not changed yet. R337 explained that the abdominal wound had started to stink. R337 proceeded to show the abdominal wound area to this surveyor. There was blood and drainage on the bancage with a mild odor that came from the site.
On 8/5/24 at 9:20 AM, the certified nurse aid performed incontinence care for R337. At that time R337's coccyx area was observed. The wound presented with a reddened border and a greenish yellow slough base. There were two dime sized stage two pressure sores on the left gluteal cheek.
A record review revealed that R337 was admitted to the facility on [DATE] with the diagnosis of hyperlipidemia, type two diabetes and mild protein deficit. R337 had a brief interview for mental status score of 15, indicating an intact cognition.
A review of the medical record revealed further that there were no admission wound care orders placed for R337 on the day of admission on [DATE].
On 8/6/24 at 12:00 PM, the wound care (WC) nurse was interviewed and asked who is responsible for putting in orders upon admission and shoud there be treatment orders in place until wound care rounds on patients? The WC explained that there are supposed to be orders in place on admission that is completed by the nurses if the WC nurse was not able to assess the resident. The WC nurse also explained that the admitting nurses are responsible for calling the doctors and getting a treatment order put in place until wound care can round on the residents. WC nurse was then asked was R337 supposed to have wound care orders, WC confirmed that there was not orders put in place but should there have been orders put in place.
There was no additional information provided by the exit of survey
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the facility failed assess promptly after a fall for one (R29) resident of re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the facility failed assess promptly after a fall for one (R29) resident of reviewed for accidents. Findings include:
On 8/5/24 at 9:40 AM, R29 was observed in the bathroom unassisted. R29's spouse was in the room waiting for them to return from the bathroom. R29 stated that they would like this surveyor to return once they were finished getting ready for the day. At 10:00 AM, this surveyor returned to the room, R29 was sitting in the wheel chair with their left leg elevated on the bed and the spouse sitting in a chair across the room. R29 was asked about their stay at the facility and explained that they had fallen that morning (8/5/24). R29 stated that they hurt their leg and they hit their head a little bit because when they fell, they landed on their left side.
A record review revealed that R29 was admitted to the facility on [DATE] with diagnoses of type two diabetes, repeated falls, and generalized anxiety disorder. R29 had a brief interview for mental status score of 15, indicating and intact cognition. A further review of the record revealed that R29 was supposed to get assisted when using the restroom.
On 8/6/24 at 9:00 AM, R29 was observed lying in bed. R29 was asked how they were feeling. R29 stated that there were sick to their stomach, they had been vomiting, and leg was in pain. R29 stated they were exhausted. R29 was then asked did they tell anyone about the vomiting and pain? R29 stated that they did tell the facility. R29 explained that she started having those symptoms yesterday, while visiting with her spouse.
A review of the medical record revealed with a progress note dated for 8/5/24 at 2:44 PM written by the nurse who cared for R29 during the shift stated Resident was observed lying on their left side around 9:05 AM. R29 stated that they was trying to get out the chair and fell on their bottom. Resident was quickly assessed and the team lifted to the chair then to the bed. Resident stated they had no pain at this time. Vital signs were 94/51 pulse 72, temperature 98.1 pulse oximetry 100 on room air. Spoke with the Nurse Practitioner(NP) she was in the building to assess the patient and she ordered 500cc (cubic centimeters) bolus for hypotension. And she ordered Neurochecks, waiting assess for peripheral IV (intravenous) placement .
On 8/6/24 at 9:05 AM, the Unit Manager (UM) was interviewed and asked how does the facility follow up with residents after a fall. The UM stated they use a neuro check sheet, but R29 did not complain of anything yesterday (warranting the neuro check sheet). This surveyor explained that R29 had stated that they were in pain yesterday as well as this morning but added that they feel sick to their stomach and had started to vomit yesterday. The UM explained that R29 never complained of anything. The UM was then asked to asses R29 with the surveyor and once in the room, R29 stated that they were in pain , felt sick to stomach and explained when the pain started after the fall and the nausea and vomiting after lunch on 8/5/24. The UM asked R29 were they still sick to stomach and R29 stated, Yes. After we left the room the UM stated that she would call the doctor to let them know that R29 was in pain to order x-rays, labs and to order Zofran for the nausea.
On 8/7/24 at 10:13 AM R29 and their spouse were interviewed about the fall that resident had experienced on the morning of 8/5/24 asked how they were feeling. R29 stated that they felt better and that the facility finally took an Xray of their leg, but did not understand why they did not take one of their head. Spouse stated that no one from the facility even called them to let them know R29 had a fall and no one mentioned the fall to them. The spouse stated, I was at the facility all day no one ever mentioned the incident.
No additional information was provided at the exit of survey.
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** R288
On 8/5/24 at 10:30 AM, R288 was observed lying in bed. A sign announcing Contact Precautions was posted on the door and a i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R288
On 8/5/24 at 10:30 AM, R288 was observed lying in bed. A sign announcing Contact Precautions was posted on the door and a isolation cart was observed in the hallway immediately outside R288's room which contained personal protection equipment (PPE) including isolation gowns and gloves. R288 was asked about care at the facility. R288 explained their doctor, Dr. F, had come in the day before, but was touching their PICC (peripherally inserted central catheter) line and the dressing over the wound on their foot without gloves .when they told Dr. F to put on gloves, Dr. F got an attitude about wearing gloves. R288 also explained they had told Dr. F they did not want them as their doctor anymore because they would not put on glove before touching them.
Review of the clinical record revealed R288 was admitted into the facility on 7/29/24 with diagnoses that included: diabetes, cellulitis and acute kidney failure. According to a Brief Interview for Mental Status (BIMS) exam dated 7/30/24, R288 scored 14/15 indicating intact cognition.
Review of R288's progress notes revealed a Physician Team - H&P (health and physical) note written by Dr. F dated 8/4/24 at 4:08 PM that read, Patient refused exam.
On 8/7/24 at 9:13 AM, Dr. F was interviewed by phone and asked about R288. Dr. F explained they were not wearing gloves, they wanted to see the PICC line, but R288 would not let them touch it, then they noticed a bandage on R288's foot, so they tried to move the blanket, but R288 yelled at them for not wearing gloves. Dr. F was asked if they were aware R288 was in Contact Precautions. Dr. F explained they normally enters the room and does an evaluation of what supplies they would need, then exits the room to gather the supplies and then they would put on a gown and gloves to do the examination and look at the wound, otherwise they would have to put on the PPE just to take it off again to go get the supplies they would need and then put on PPE again when going back into the room. Dr F was asked in a Contact Precaution situation, could R288's gown over the PICC line and the blanket over their wound potentially have the infectious organism on them. Dr. F did not answer.
On 8/7/24 at 9:28 AM, Registered Nurse (RN) B, who served as the Infection Control Nurse, was interviewed and asked about going into a Contact Precaution room. RN B explained everyone who entered the room and would have contact with R288 or objects in the room must wear a gown and gloves at all times.
On 8/7/24 at 9:32 AM, the Director of Nursing (DON) was interviewed and asked if physicians were required to wear PPE in a Contact Precaution room. The DON explained all staff, including physicians must wear PPE for any contact with a resident or objects in a Contact Precaution room.
R289
On 8/5/24 at 11:11 AM, R289 was observed lying in a bed different than the room census provided by the facility. R289 was asked about being in that particular room. R289 explained their room had been changed that morning.
Review of the clinical record revealed R289 had been admitted into the facility on 8/1/24 with diagnoses that included: open wound of abdominal wall, prostate cancer and chronic kidney disease. According to a BIMS exam dated 8/2/24, R289 scored 13/15 indicating intact cognition.
Review of R289's census revealed upon admission, R289 was in room [ROOM NUMBER]. On 8/3/24, R289 was moved to room [ROOM NUMBER], then on 8/5/24 R289 was moved to room [ROOM NUMBER], their current room.
Observation of room [ROOM NUMBER] revealed a Contact Precautions sign on the door and an isolation cart with PPE in the hallway directly outside the room. Review of the census revealed the resident in room [ROOM NUMBER] had been admitted [DATE] and had been on Contact Precautions from admission.
On 8/6/24 at 11:14 AM, Registered Nurse (RN) B, who served as the Infection Control Nurse, was interviewed and asked about R289 being put in room [ROOM NUMBER], a Contact Precaution room. RN B explained R287 should not have been put in the Contact Precaution room.
On 8/6/24 at 11:36 AM, RN H, who served as the Midnight Manager, was interviewed by phone and asked why R287 was put into a Contact Precaution room. RN H explained R287 requested to change rooms and there was not a Contact Precaution sign on the door to room [ROOM NUMBER], so they moved R287 into that room.
On 8/6/24 at 11:46 AM, the DON was interviewed and asked about R287 being moved into a Contact Precaution room. The DON explained R287 should not have been moved into that room, but they had been moved out again to another room and they would monitor them closely.
Review of a facility policy titled, Infection Control - Standard and Transmission-Based Precautions revised 3/4/24 read in part, .Transmission based precautions are used for residents who are known or suspected to be infected with infectious agents that require additional control measures above standard precautions to effectively prevent transmission which included: Contact precautions (direct or indirect contact with infectious agent) .Employees, residents, and visitors are responsible for complying with precautions .Contact transmission is the most frequent mode of transmission of healthcare associated infections. It includes direct contact transmission (where there is a person-to-person physical transfer of microorganisms between an infected person to another person) and indirect contact transmission (where there is a transfer of microorganisms between a contaminated object and a person) .Resident placement - Provide a private room with a dedicated bathroom or cohort residents who have the same infection from the same microorganism .
Based on observation, interview and record review the facility failed to ensure proper infection control protocols and practices including hand hygiene during meals, transmission-based precautions (TBP) regarding use of personal protective equipment (PPE) and room placement for four (R42, R73, R288, and R289) of four residents reviewed for infection control.
Findings include:
Dining Observation:
On 8/5/24 at 1:00 PM, the family member of R42 was observed standing at the end of the table and feeding the R42 by the spoonful. This family member was then observed to state to R73, You look like you haven't had a crumb of food in years, right?.
During this time, the family member was observed to touch their clothing, hair, and table multiple times. This family member was then observed to assist R73 and R42 at the same time. There was no use of hand sanitizer or washing of hands by this family member in between assisting the two residents with their lunch meal. Additionally, although nursing staff were present, no one was observed to intervene or address this family member's actions.
On 8/7/24 at 8:45 AM, an interview was conducted with Nurse Manager (NM 'N'). When asked about the observations during the lunch meal on 8/5/24, NM 'N' reported they had observed the same, and had spoken to that family member as well that day. When asked why no one intervened if they observed continued actions, they were unable to offer any further explanation.
R42
Review of the clinical record revealed R42 was admitted into the facility on 7/1/20, readmitted on [DATE], signed onto hospice on 11/21/23 with diagnoses that included: Alzheimer's disease with late onset, adult failure to thrive, unspecified severe protein-calorie malnutrition, and anorexia.
According to the Minimum Data Set(MDS) assessment dated [DATE], R42 had severe cognitive impairment.
Review of the resident's plan of care included, .Announce self when entering room and explain all procedures .Assistance needed with feeding, may fluctuate day to day .EATING: 1 person assist as needed .
R73
Review of the clinical record revealed R73 was admitted into the facility on 2/10/21 and readmitted on [DATE] with diagnoses that included: cerebral palsy, bipolar disorder, metabolic encephalopathy, unspecified severe protein-calorie malnutrition, and unspecified intellectual disabilities.
According to the facility's MDS assessment dated [DATE], R73 had severe cognitive impairment.
Review of the resident's plan of care included, .EATING: 1 person assist .Encourage resident to join small dining for meals .
According to the facility's policy titled, Hand Hygiene dated 4/14/2023:
.SITUATIONS IN WHICH USING SOAP AND WATER OR ALCOHOL BASED HAND RUB CAN BE USED .Between direct contact with residents .After handling contaminated objects, equipment, dressings, etc .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
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 provide an environment that promoted and enhanced resi...
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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 an environment that promoted and enhanced residents' dignity for multiple residents, including three (R42, R73, and R85) of residents reviewed for dignity.
Findings include:
According to the facility's policy titled, Dignity dated 9/21/23:
.Residents will be treated with dignity and respect at all times .Residents' private space and property are respected at all time .Staff are expected to knock and identify themselves before entering residents' rooms .Demeaning practices and standards of care that compromise dignity are prohibited .Staff are expected to treat cognitively impaired residents with dignity and sensitivity .
On 8/5/24 from 9:00 AM to 11:30 AM, multiple observations included nursing staff entering the rooms of residents on Anna's Place (a secured unit) without knocking, announcing themselves prior to entering the room, or waiting of acknowledgment from the residents to enter.
Additional dignity concerns were observed during the lunch meal on 8/5/24 which included:
At 12:56 PM, Nurse 'K' was observed standing while providing feeding assistance to R85 who was seated in a gerichair recliner in the dining room. There were several empty chairs nearby that were available to use.
At approximately 1:00 PM, the family member of R42 was observed standing while at the end of the table and feeding the R42. This family member was then observed to state to R73 (who was directly across from R42 at the end of the table), You look like you haven't had a crumb of food in years, right?.
During this time, the family member was observed to touch their clothing, hair, and table multiple times. This family member was then observed to begin to feed both R73 and R42 at the same time. There was no use of hand sanitizer or washing of hands by this family member in between assisting the two residents with their lunch meal. Additionally, although nursing staff were present, no one was observed to intervene or address this family member's actions.
On 8/7/24 at 8:45 AM, an interview was conducted with Nurse Manager (NM 'N'). When asked about the observations during the lunch meal on 8/5/24, NM 'N' reported they had been made aware and also observed the same in regard to Nurse 'K' standing while feeding. They were also informed of the multiple observations of nursing staff entering the rooms without knocking, acknowledging prior to entering and they reported staff should absolutely be knocking and announcing before entering the rooms.
R42
Review of the clinical record revealed R42 was admitted into the facility on 7/1/20, readmitted on [DATE], signed onto hospice on 11/21/23 with diagnoses that included: Alzheimer's disease with late onset, adult failure to thrive, unspecified severe protein-calorie malnutrition, and anorexia.
According to the Minimum Data Set(MDS) assessment dated [DATE], R42 had severe cognitive impairment.
Review of the resident's plan of care included, .Announce self when entering room and explain all procedures .Assistance needed with feeding, may fluctuate day to day .EATING: 1 person assist as needed .
R73
Review of the clinical record revealed R73 was admitted into the facility on 2/10/21 and readmitted on [DATE] with diagnoses that included: cerebral palsy, bipolar disorder, metabolic encephalopathy, unspecified severe protein-calorie malnutrition, and unspecified intellectual disabilities.
According to the facility's MDS assessment dated [DATE], R73 had severe cognitive impairment.
Review of the resident's plan of care included, .EATING: 1 person assist .Encourage resident to join small dining for meals .
R85
Review of the clinical record revealed R85 was admitted into the facility on 1/3/22 and readmitted on [DATE] with diagnoses that included: Alzheimer's disease, dementia with other behavioral disturbance, legal blindness, and adult failure to thrive.
According to the MDS assessment dated [DATE] documented R85 had severe cognitive impairment.
Review of the resident's plan of care included, .assist w (with)/feeding as indicated .EATING: 1 person assist .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0563
(Tag F0563)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure unrestricted, 24-hour visitation for residents. This deficient practice had the ability to affect all 143 residents in the facility....
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Based on interview and record review, the facility failed to ensure unrestricted, 24-hour visitation for residents. This deficient practice had the ability to affect all 143 residents in the facility. Findings include:
On 8/6/24 at 10:30 AM, during a resident council meeting with the State Agency, several anonymous residents reported that the facility's visitor hours ended each night at 8:00 PM with the front door being locked at that time, and were announced overhead. Twelve residents were present and each resident reported not knowing that they were allowed to have visitors outside of the hours of 8:00 AM and 8:00 PM.
On 8/7/24 at 1:10 PM, an interview was conducted with the Administrator. When queried what the facility's visitor hours were, they responded 8:00 AM to 8:00 PM with the front door locking at 8:00 PM each day, which is announced overhead. When queried if the residents were aware that they had the right to have visitors outside of the 8:00 AM to 8:00 PM timeframe, the Administrator chose not to speak for what the residents were aware of. The Administrator mentioned there may be visitor hours listed in the facilities admission packet. When asked if there was a script that was followed each night when announcing the end of visitor hours, the Administrator deferred to the Business Office Manager (BOM).
When the BOM was queried about the overhead announcements, they reported that beginning at 7:45 PM each night, there is a series of announcements made announcing the end of visitor hours and informing residents and visitors that visiting hours end at 8:00 PM and the front door will be locked at that time.
A visitor policy was requested from the facility, however the Administrator responded that they did not have a formal visitor policy.
Review of the first page of the admission packet provided by the facility revealed, in large bold print and in all capital letters VISITATION 10 AM TO 7:45 PM DAILY. LOBBY DOOR LOCKS AT 8PM.
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 the ventilation hood filters in a sanitary manner, failed to ensure the dish machine was sanitizing, and failed to m...
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Based on observation, interview, and record review, the facility failed to maintain the ventilation hood filters in a sanitary manner, failed to ensure the dish machine was sanitizing, and failed to maintain the dish machine in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include:
On 8/5/24 at 9:30 AM, the cookline hood ventilation filters were observed with a buildup of grease. Certified Dietary Manager (CDM) O stated kitchen staff were responsible for cleaning the hood vent.
According to the 2017 FDA (Food and Drug Administration) 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 8/5/24 at 9:40 AM, a plate simulating dishwasher tester was sent through the dish machine to check the sanitizing properties of the facility's high temperature dish machine. The maximum temperature recorded on the plate simulator was noted to be 152 degrees Fahrenheit. At 9:50 AM, the plate simulator was again sent through the dish machine, and the maximum temperature noted on the plate simulator was 153 degrees Fahrenheit. At that same time, the digital temperature display unit on the dish machine noted the final rinse temperature to be 146 degrees Fahrenheit. When queried about what temperature the rinse temperature should be to ensure sanitization, CDM O stated 150-160.
On 8/5/24 at 9:45 AM, the Temperature Log for the dish machine was reviewed and noted the following:
8/1 AM 165/147
8/2 AM 175/139
8/2 PM 173/140
8/3 AM 175/139
8/4 AM 122/139
8/4 PM 122/139
When queried about the low temperatures documented on the dish machine temperature log, CDM O stated he was not made aware of the low temperatures for the dish machine. CDM O was unable to provide an explanation as to why staff continued to use the dish machine after logging inadequate temperatures.
On 8/5/24 at 10:00 AM, kitchen staff was observed using the dish machine to clean soiled dishware. The plate simulating dishwasher tester was again sent through the machine, and recorded the maximum temperature of 147 degrees Fahrenheit. The final rinse temperature on the machine's digital display unit was noted to be 155 degrees Fahrenheit. At that time, dietary staff noted the dishwasher temperature on the temperature log as 151/155.
On 8/5/24 at 11:10 AM, Maintenance Supervisor P was observed working on the dish machine. When queried, Maintenance Supervisor P stated there were forks inside that were blocking the sensor and that the machine needed cleaning inside. At that time, the inside of the dish machine as well as the coils, were observed with a thick, slime buildup.
According to the 2017 FDA Food Code section 4-703.11 Hot Water and Chemical, After being cleaned, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED in: (B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under §§ 4-501.15, 4-501.112, and 4-501.113 and achieving a UTENSIL surface temperature of 71°C (160°F) as measured by an irreversible registering temperature indicator; P
According to the 2017 FDA Food Code section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures, (A) Except as specified in ¶ (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90°C (194°F), or less than: Pf (1) For a stationary rack, single temperature machine, 74°C (165°F); Pf or (2) For all other machines, 82°C (180°F). Pf.
Jul 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00144802.
Based on interview and record review, the facility failed to ensure safe transfer ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00144802.
Based on interview and record review, the facility failed to ensure safe transfer per plan of care (use of a mechanical hoyer lift) and facility policy for one (R901) of three residents reviewed for accidents.
Findings include:
Review of a complaint filed with the State Agency included allegations that the resident was not transferred with the correct assistance required.
On 7/8/24 at 1:28 PM, the facility was requested to provide any incident reports and investigations since R901's admission.
Review of the clinical record revealed R901 was admitted into the facility on 5/2/24, discharged on 5/27/24 and had not returned to the facility. Diagnoses included: other specified fracture of right pubis (5/2/24) and morbid obesity due to excess calories (severe).
According to R901's care plans and [NAME] since admission, the resident's transfer status was TRANSFER: Resident requires Mechanical Lift with 2 PA (Person Assist).
Review of the progress notes included:
An entry on: 5/27/24 at 11:22 PM read, .Incident Note Note Text : Late entry approx (approximately) 1800 (6:00 PM) Note Text: Res c/o (complains of) pain after transfer from w/c (wheelchair) to bed by staff. Res (Resident) states her left knee twisted during transfer and pain has not resolved after being given PRN (as needed) norcox2 (narcotic pain medication) tabs and scheduled Gabapentin. Daughter is at bedside and adamant that res be sent to hospital for further evaluation .
On 7/8/24 at 2:00 PM, an interview was conducted with the Director of Nursing (DON). The DON reported they had identified a Past Non-Compliance (PNC) regarding improper transfer for R901 and provided documentation. When asked to confirm their compliance date, they reported it would be 6/11/24.
Documentation included:
Investigation re [name of R901] 5.27.24
Concern:
ON 5/28/24 resident daughter [name redacted] contacted administrator.
1. Daugther <sic> believed that on 5/27/24 resident was transferred by CENA [name of Certified Nursing Assistant/CNA 'A']. During transfer CENA dropped resident to the floor, then picked resident up and put in bed. After that incident resident c/o knee pain . Background: [name of R901] was admitted to our facility on 5/2/24 with hx (history) of anemia, arthritis, asthma, depression, DM2 (Diabetes Mellitus Type 2), Factor 5 . admitted to hospital d/t (due to) fall at home with right hip/groin pain, right nondisplaced pubic ramus fracture. Resident is alert and able to make needs known. BIMS (Brief Interview for Mental Status Exam) 12/15 (score indicated moderately impaired cognition) on 5/8/24. Resident was admitted to facility for skilled therapy medical and nursing care. Since admission resident attended skilled PT/PT (Physical Therapy) <sic>. Needs Hoyer lift with transfers. Resident tolerates therapy with moderate verbal cuing <sic> and guidance . A:
Investigation:
Per interview with [name of CNA 'A'], CENA was scheduled on different unit on 5/27/24. Did not entered <sic> [name of R901] room on 5/27/24.
Per interview with [name of CNA 'D'], CENA who was assigned to resident on 5/27/24: CENA respond to call light. Resident was up in w/c and asked to go to bed. [name of CNA 'D'] went in hallway and asked [name of CNA 'E'], another CENA to help with transfer. CENAs positioned self at right and left side of w/c. W/c was locked. CENAs assisted resident to standing position. Attempted to assist resident with pivot to the right. Resident was unable to move and asked to sit back in w/c. Resident was assisted back in w/c. Shortly after, CENAs assisted the resident to stand up again. The resident stand <sic> up and was able slowly pivot to left side. When the resident was positioned in front of bed, CENAs assist resident to sitting position. One CENA was holding legs, another upper body and resident was positioned in bed. At no time during the above transfer resident demonstrated verbal/nonverbal S/S (Signs/Symptoms) of pain. Very shortly after CENAs left the resident room, resident started to yell out. CENA immediately returns to the room. Resident stated that her knee hurts and he did it. [Name of CNA 'D'] was the last one leaving the room. No one entered resident room between time [Name of CNA 'D'] left the room and come back. [Name of R901] did not say that she fell. Stated that she twisted her leg. Cen <sic> did not see the resident on the floor. Did not hear anyone talking that resident was on the floor.
Per interview with [Name of CNA 'E'], CENA who worked on Oakridge unit 5/27/24: [Name of CNA 'D'] asked for help. He entered [Name of R901] room. Assist with other CENA to stand up resident from w/c. Pt (patient) was not able to pivot to right side. (resident stated that she cannot move). Resident asked to sit back in w/c. CENAs assisted resident back to w/c. Shortly after two CENAs assisted back to stand up. Resident was able to pivot to left side. After that resident was assisted to sit down at edge of bed. Two CENAs positioned the resident to bed. At no time during transfer or bed positioning resident complained of pain: verbal or nonverbal. After the resident was in bed, [Name of CNA 'E'] left the room. Did not see the resident on the floor. Did not hear anyone was talking that resident was on the floor.
Per interview with [Name of CNA 'F'], CENA who work Oakridge 5/27/24: did not assist resident. Did not hear that resident was on the floor. Did not witness resident on the floor.
Per interview with [Name of Nurse 'G'] who was assigned to resident on 5/27/24: [Name of R901] reported to LPN [Licensed Practical Nurse] that her leg got twisted during transfer with staff assist from w/c to bed. At no time resident reported to LPN that she was dropped to the floor during transfer.
During the interview with resident daughter [Name redacted]: daughter admitted that she did not witness transfer. Did not witness resident been <sic> dropped to the floor or been on the floor. [Name of daughter] stated that she believed what he <sic> mother told her.
Conclusion:
Based on resident functional mobility and staff interviews, resident was notdropped <sic> to the floor during 5/27/24 transfer.
B. Investigation:
During interview with [Name of daughter]: [Name of Nurse 'G'] went to pt room with haist <sic>. Nurse was talking without compassion. Was given dry data. [Name of daughter] claimed that nurse did not want to send resident to hospital. Told daughter that insurance will not cover it and if you want to take her, call yourself. [Name of daughter] said that she did call 911. Few minutes later, [Name of Nurse 'G'] enter room and said that she canceled 911 and scheduled ambulance. Daughter [Name redacted] stated during interview that therapist [Name of Therapist 'H'] witnessed [Name of Nurse 'G'] behavior.
Per interview with therapist [Name of Therapist 'H']: resident had skilled therapy earlier on 5/27/24. Later on 5/27/24 [Name of Therapist 'H'] was on Oakridge unit when [Name of daughter] ask her to go back to [Name of R901] room. [Name of Therapist 'H'] observed resident in bed. Resident was c/o knee pain. [Name of Therapist 'H'] explained to reisdnet <sic>and resident daughter that nursing is aware about resident pain and addressing it. If [Name of daughter] wants he <sic> mother to go to ER (Emergency Room), she can request it from nursing. [Name of Therapist 'H'] also briefly discussed d/c (discharge) plan to resident daughter [Name redacted]. [Name of Therapist 'H'] stated during interview that [Nurse 'G'] was doing her job and was handling situation correctly.
Per interview with [Name of Physician 'C'], LPN never mentioned to he <sic> that there is a therapist who is trying to playing <sic> nurse.
Per interview with [Name of Nurse 'G']: at no time ever she told resident daughter [Name redacted] that insurance will not cover it and if you want to take her, call yourself.
Conclusion:
Nurse [Name of Nurse 'G'] was re-educated on how to provide excellent customer service; how to be more compassion <sic> and attentive .KNEE LEFT COMPLETE 4 OR MORE VIEWS Addendum: 5/27/2024 Please note that impression point #3 should read: Moderate to large LEFT knee joint effusion. The findings portion of the exam should also state: Moderate to large LEFT knee joint effusion .IMPRESSION: .Moderate to large right knee joint effusion .
ELEMENT1: [Name of R901] is no longer at the facility.
ELEMENT2: All residents at the facility who receive assistance with transfers have the potential to be affected. Those residents have been assessed and reviewed to make sure that they have proper transferring assistance and matching happy feet in the room. Any deficiencies were corrected immediately.
ELEMENT3: All staff re-educated on importance to follow [NAME] instructions and happy feet instruction when assisting resident with transfers. All transfers are to be completed with use of gait belt unless instructed differently. Re-educated on facility policies: gait belt use; transfer with staff assist; transfer with use a mechanical lift machine.
ELEMENT4: The DON or designee will audit 5 residents on each unit to make sure staff follows [NAME] instructions and happy feet instructions with transfers.
Review of the facility's policy titled, Transferring - Using a Mechanical Lift Machine dated 9/28/23 documented:
.Mechanical lifts may be used for tasks that require .Transferring a resident from bed to chair (or vice versa) .Lateral transfers .Repositioning .
Review of the PNC documentation included ongoing audits, which identified instances of areas that needed to be completed and updated. These audits were reviewed during the facility's Quality Assurance meetings on 6/13/4 and 6/27/24.
Further review of the documentation provided of the facility's investigation and audits, revealed no further concerns. Discussion with the survey team acknowledged this deficient practice as an accepted Past Non-Compliance.
May 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a medication cart was locked and secured, resulting in the pot...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a medication cart was locked and secured, resulting in the potential for unauthorized access and diversion of narcotic medications. Findings include:
On 5/28/24 at 3:23 PM, a medication cart located on the Oakridge Unit, in front of room [ROOM NUMBER], was observed unlocked and unattended by authorized staff. The medications were accessible in all drawers, including the narcotic storage drawer.
Registered Nurse (RN) A returned to the cart on the Oakridge Unit indicating a medication count was being performed with another nurse, away from the assigned medication cart. RN A confirmed the cart was left unlocked, unattended, and medications, including scheduled narcotics were accessible to unauthorized personnel.
On 5/28/24 at 3:38 PM, the Director of Nursing (DON) was interviewed and acknowledged medication carts are to be locked and secured by authorized personnel.
Review of the facilities policy title; Medication and Treatment Cart Storage dated 5/4/22 documented:
.All drugs and biologicals will be stored in locked compartments (i.e., medication carts) .Narcotics and Controlled Substances: medications are stored under double-lock and key .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #s MI00143487 and MI00143823.
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 intake #s MI00143487 and MI00143823.
Based on observation, interview and record review, the facility failed to maintain a clean, comfortable, safe, and homelike environment, as evidenced by soiled floors, walls, trash/debris throughout the facility, broken chair and tile, unsecured sharps and chemicals, and visible harborage of pests. This deficient practice has the potential to affect multiple residents throughout the facility.
Findings include:
Review of multiple complaints reported to the State Agency included allegations that the facility was not clean.
During the abbreviated survey conducted on 5/28/24, the following concerns with the facility's environment were identified:
At 9:50 AM, the hallway outside room [ROOM NUMBER] and 114 was littered with debris. The chair outside room [ROOM NUMBER] had linens and used gloves stored directly on the floor behind the chair.
The flooring throughout hallway near room [ROOM NUMBER]/202 observed with scattered debris.
At 9:57 AM, the Anna's House unit was observed to have a linen cart with dried dark brownish/black splatters on bottom shelf inside cart right next to the linens.
At 10:05 AM, the hallway wall outside room [ROOM NUMBER] was observed soiled with brown debris.
At 10:08 AM, the shower room on the Oakridge unit had the door open and there was a wall cabinet that had a sticker which read, KEEP LOCKED AFTER USE. The wall cabinet was not locked and upon opening the small door, there were loose gloves (unknown if used) and a large bottle of BNC-15 (a disinfectant cleaner) that was labeled in red marker OAK SPA B and 1 bottle of skin/hair cleanser with no resident name.
At 10:16 AM, the shower room on the Oakridge unit (SPA A) was observed to have a shower bench that was leaning slightly down towards the left, with a used brief in an open bag underneath the shower chair, a gerichair recliner had used gloves stored on the seat (turned inside out), there were several towels on the floor and washcloths bunched into the handrails of the shower area. There were no staff present.
At 11:57 AM, the shower room on the Oakridge unit (SPA A) contained the same wet washcloths that hung from the assist handrails and shower floor, there were two unlabelled bottles of bodywash/shampoo, soiled washcloth, roll of trash bags, a hair brush with visible hair strands which were not labeled. Additionally, the grout appeared to have areas of a dark mold-like substance and there were several dead bugs observed behind the doors, and in the corners of the shower room. The wall cabinet had a bottle of disinfectant cleaner labeled BNC-15 stored on top of the cabinet, unsecured. The floor tile at the threshold area of the shower room was observed to have chipped tiles.
At 12:03 PM, the shower room on the Hickory unit (SPA A) was observed to have used gloves (turned inside out) on the floor, there were seven bottles of bodywash/shampoo, roll-on deodorant, three disposable razors stored on the half wall near the shower, there was a trash bag on floor, an opened brief stored on top of wall cabinet, a roll of medical tape was taped and hung down from the shelf of the wall cabinet, and multiple garbage/debris scattered throughout the flooring of the shower room. Additionally, the grout appeared to have areas of a dark mold-like substance and there were several dead bugs observed behind the doors, and in the corners of the shower room.
At 12:20 PM, the Redwood unit was observed to continue to have garbage/debris scattered throughout the flooring of the unit, and the soiled linens and gloves remained behind the chair outside room [ROOM NUMBER].
At 12:41 PM, Nurse Manager 'B' was asked to observe the Oakridge and Hickory unit and confirmed the above observations. Nurse Manager 'B' reported the personal care items should not have been left like that and were unable to identify who they were used for and would need to be discarded. When asked about the storage of the chemicals and razors, Nurse Manager 'B' reported those should've been secured.
At 2:04 PM, there was a disposable mask and used gloves (turned inside out) observed on the floor in the common area outside room [ROOM NUMBER].
At 2:09 PM, Anna's House unit was observed to have food debris in both of the lounge/dining/activity areas under the tables and throughout the floors. Additionally, there were spider webs and multiple pests on the wall by the water fountain and scattered debris throughout the flooring of the unit and resident rooms.
At 2:11 PM, there was a used glove (turned inside out) and a small white cup on the floor near the med cart. There were multiple paper wrappers and debris throughout the flooring near rooms [ROOM NUMBER].
At 2:15 PM, the Hickory unit was observed to have a blood lancet (sharps) observed on the floor by the three drawer dresser outside room [ROOM NUMBER]. The wall and baseboard behind the med cart outside room [ROOM NUMBER] was observed heavily soiled with a brown substance.
At 2:18 PM, the treatment cart next to the soiled utility room and nursing desk on the Hickory unit was observed to have trash overflowing from the receptacle secured to the cart, which forced the lid to remain open and expose the contents.
At 2:30 PM, the front conference room was observed to have a large black ant crawling on the wall and ceiling.
On 5/28/24 at 2:53 PM, an interview was conducted with the Director of Housekeeping and Laundry (Staff 'C') who reported they had been in their role since July 2023. When asked about the facility's housekeeping assignments and staffing, Staff 'C' reported each wing had one housekeeper and they tried to keep the same staff to each wing for consistency. When asked about their work schedule, Staff 'C' reported they worked usually 7:00 AM to 3:30 PM, but some worked 8:00 AM to 4:00 PM if they had children. When asked about weekend coverage, Staff 'C' reported that was the same. When asked if any staff had called-in today, Staff 'C' reported No, not today.
When asked if there was a list of what should be cleaned and when, Staff 'C' reported they have a list, but their staff know what to do and they have been at the facility a long time and Know the routine.
When asked about the cleaning of the shower rooms, Staff 'C' reported those were cleaned before they left, around 2:00 PM/2:30 PM and they use sanitizer spray and mop the floors, clean the walls and everything what is in there. When asked about the tile areas like the grout, Staff 'C' reported they power washed two times a month but their staff that did that had been on vacation.
When asked about the cleaning of the dining rooms, Staff 'C' reported housekeeping comes in to clean after every meal but that sometimes after eating, there is an activity so they might not be able to clean it. When asked who cleans after dinner, Staff 'C' reported there was no one after dinner, but should be cleaned up when they come in first thing the next morning.
On 5/28/24 at 3:00 PM, Staff 'C' was asked to observe the facility and confirmed the same observations as identified earlier. When asked about who the housekeeper was on the Redwood unit, Staff 'C' reported there wasn't anyone today and they had assisted with cleaning the resident rooms. When asked about the soiled linens behind the chair, Staff 'C' proceeded to pick them up and offered no further response.
At 3:06 PM, observations on Anna's House unit revealed the same concerns. When asked about the spider webs and pests, Staff 'C' proceeded to wipe them away with their hands and reported they were not aware of that. At that time, Staff 'C' approached a housekeeper on the hallway and asked them about the cleaning of the dining room floors and the housekeeper reported they had cleaned that earlier and was not able to since there were residents in there. When asked why at least the one side was not cleaned since there were no residents, Staff 'C' directed them to clean the flooring now.
At 3:11 PM, Staff 'C' was asked about the items observed on the Hickory unit and they reported the housekeeper that was assigned to this area was new. When asked about the overflowing trash receptacle on the treatment cart and who was responsible for that, Staff 'C' reported that was the CNA (Certified Nursing Assistant) and Nurse's responsibility to empty the trash on the medication and treatment carts.
At 3:14 PM, continued observations of the Hickory unit shower room (SPA B) revealed there was a bowl of food on the floor that had moldy contents and was covered with several small black bugs. Staff 'C' confirmed the multiple bugs and dark grout tile and reported they had someone dedicated to power-washing the shower rooms, but they had been on vacation for the past two weeks.
At 3:20 PM, continued observations of the Oakridge unit shower room (SPA B) revealed the toilet contained a dark ring of build-up on the inside of the toilet bowl. Staff 'C' reported the toilet was cleaned everyday. When asked if it was cleaned everyday, how was there a build-up of debris around the water line in the toilet bowl, Staff 'C' offered no further response. The bathtub was observed to have a stack of towels, a wheelchair cushion and there were several dead winged bugs scattered on the bottom of the tub. When asked who was responsible for maintaining the bathtub, Staff 'C' reported housekeeping didn't do that, the CNAs did. When asked to clarify earlier they mentioned that housekeeping cleaned the main flooring and areas of the shower rooms, but the CNAs had to clean the bathtub, Staff 'C' confirmed and then reported maybe they needed to change that since it was not done. When asked if the housekeeping staff cleaned the shower rooms daily, how was there molding food, build-up of webs, and bugs, Staff 'C' reported they weren't sure.
At 3:25 PM, observation of the dining room on the Oakridge unit revealed there was a chair in front of the door wall that had a broken armrest, and there were many webs and live spiders and bugs throughout the dining room (in which residents were observed eating lunch in earlier) and behind the doors. When asked to observe the area behind the plant next to the door wall, Staff 'C' stated Oh god, nobody reported that. When asked if insects/pests were observed, what was the process to notify staff, Staff 'C' reported the staff should report to the Maintenance staff.
At 3:30 PM, the shower room on the Oakridge unit (SPA A) revealed concerns with dark grout, webs and insects in corners of the room, and chipped tile at the threshold.
Review of the documentation provided by Staff 'C' of the areas of concern identified by staff included some spider and ant concerns, but did not identify concerns with bath/shower rooms or dining rooms.
According to the Safety data Sheet for product BNC-15, .Hazard Statements .Harmful if swallowed. Causes severe skin burns and serious eye damage .Store locked up .
Review of the documentation provided by the facility regarding a policy for maintaining clean, comfortable, safe, homelike environment revealed an undated, unapproved policy with no specific facility name that addressed only process for cleaning resident rooms upon discharge.
Mar 2024
7 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00142846.
Based on interview and record review the facility failed to ensure staff timely i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00142846.
Based on interview and record review the facility failed to ensure staff timely identified a worsening of condition and communicated a change of condition with the nursing staff and physician staff for one (R801) of three residents reviewed for a change of condition. Findings include:
Review of a complaint submitted to the State Agency (SA) documented concerns of the facility to have failed to assess a change of condition with R801 in a timely manner.
Review of the medical record revealed R801 was admitted to the facility on [DATE] with diagnoses that included: malignant neoplasm of cervix, abscess of vulva and acute kidney failure. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition and required staff assistance for Activities of Daily Living (ADLs).
Review of a Physician Team - Discharge Note dated 11/17/23 at 1:33 PM, documented in part . Notified by staff that was <sic> found to have low Spo.(oxygen level) 77% (normal is 90-100%) on room air. She was placed on NR (non-rebreather) at 15L (liters) and Spo2 87%. HR (heart rate) 124, RR (respirations) 8-14. Orders for breathing treatments. No improvement with oxygenation and stat labs and CXR (chest x-ray) ordered. IVF (intravenous fluids) started as well. BP (blood pressure) retaken 104/55. Given lack of improvement and acute change in condition, decision made to call 911 and she was transferred to hospital for further eval. (evaluation) discussed with nursing management as well as DON (director of nursing).
Review of the medical record revealed a 94/44 BP documented on 11/15/23 at 11:11 AM and again at 11:32 AM.
Review of the November 2024 Medication Administration Record (MAR) documented despite the 94/44 BP, staff administered multiple hypertensive (high blood pressure) medications such as amlodipine besylate 10 mg (milligram), lisinopril 40 mg and metoprolol tartrate 25 mg.
There was no documentation of the nursing staff to have notified the physician of the low blood pressure.
On 11/15/23 at 3:19 PM, a Physician Team - Progress Note documented the following, . Notified by pts (patients) daughter hat she has not been eating well and has lost weight .
Review of a Physical Therapy note dated 11/15/23, documented in part . Pt (patient) has difficulty remaining on task, req (required) freq (frequent) vc (verbal cues) for re direction Freq breaks taken . Pt exhibiting increased confusion on this date; telling PTA (physical therapist assistant) about the fire last night, and how she was so scared I wouldn't be able to get to my walker. Pt reported standing outside. Pt hyper verbal with increased confusion req constant re direction for task initiation and to remain on task . This note was documented by Physical Therapist Assistant (PTA) A.
Review of the medical record revealed there was no documentation of the therapy staff to have communicated the change in condition from the resident's baseline to the nursing staff or the physician. The resident started to have a decreased appetite and a change in mental status that was not collaboratively identified by the facility staff and relayed to the physician team, resulting in R801 to have been transferred to the hospital for the worsening of their change of condition two days later.
Review of a facility policy titled Change of Condition (Issue Date: 12/13/23) documented in part . An acute change in condition is a clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional status . Acute changes of condition can occur abruptly, over several hours, or over several days . Notification to the licensed nurse regarding a change of the resident's condition may come from the resident themselves, a visitor, or facility staff . Any facility staff that notices a change in the resident's condition should notify the licensed nurse for further evaluation .
Review of the hospital records, Emergency Medicine note dated 11/17/23 at 12:20 PM, documented in part . Admitting Diagnosis Severe sepsis . chief complaint of altered mental status . For the past 2 days, she has been steadily declining. She is less interactive and not eating as much as normal . Tachycardia present . Labial wound was purulent, with a very foul smell . She is lethargic and confused . R801 was then started on IV antibiotics by the emergency room medical team.
Review of the medical record revealed no documentation of the facility staff to have identified a purulent and foul smelling labial wound prior to the hospitalization.
On 3/12/24 at 11:17 AM, PTA A was interviewed and asked about the change of condition identified with R801 on 11/15/23, PTA A replied they wanted to review their notes for that resident and follow back up. Shortly after, PTA A returned and confirmed R801 did have a change of condition from their baseline. PTA A stated R801 had increased confusion. PTA A was asked who they reported the change of condition to, and PTA A stated they could not remember who they reported it to and did not document it, however they stated they always report change of conditions to the nursing staff.
On 3/12/24 at 1:01 PM, the DON was interviewed and asked about the low bp and change of mental status not collaboratively communicated and identified by the facility staff and communicated to the medical team to timely identify a change of condition and worsening of, the DON stated they would look into it and follow back up.
On 3/13/24 at 8:55 AM, a follow up interview was conducted with the DON. The DON stated they talked to PTA A and educated them on communicating a change of condition to the nursing staff. The DON stated they were unable to identify the nurse that PTA A stated they reported R801's change of condition to on 11/15/23. The DON stated they were reeducating all of their departments.
No further explanation or documentation was provided by the end of the survey.
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
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake(s): MI0014286, MI00143149, MI00142861 & MI00143213.
Based on observation, interview, and recor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake(s): MI0014286, MI00143149, MI00142861 & MI00143213.
Based on observation, interview, and record review the facility failed to ensure pressure wounds were identified (R801), assessed and monitored by physicians/wound clinicians consistently if at all (R's 801 & 804) , implement effective treatment for identified wounds timely (R803), implement preventive interventions (R802) for four (R's 801, 802, 803 & 804) of four residents reviewed for wounds, resulting in R801 to have developed an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) coccyx/sacrum wound, R802 to have developed a Deep Tissue Injury (DTI- Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue), R803 to have developed a Stage III (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present) coccyx wound and R804 to have developed and unstageable left heel wound. Findings include:
R801
R801 was admitted to the facility on [DATE] with diagnoses that included: malignant neoplasm of cervix, abscess of vulva and acute kidney failure. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition and required staff assistance for Activities of Daily Living (ADLs).
Review of a nursing Admission evaluation dated 10/27/23 at 7:22 PM, documented in part . Clinical Evaluation Integumentary (Skin) . Does the resident have any skin abnormalities? No .
Review of a Braden assessment (at tool used to identify a resident's risk for pressure ulcer development) dated 10/27/23 at 4:45 PM, documented a score of 15, which indicated At Risk.
Review of a Skin - Total Body Evaluation dated 11/13/23 at 10:35 PM, documented in part . wound in <sic> the coccyx. Treatment completed bed bath given .
Review of the November 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no implemented treatment for the R801's identified coccyx wound.
Review of the medical record revealed no assessments of the physician notification/follow up and monitoring of the identified coccyx wound.
Review of a Skin - Total Body Evaluation dated 11/16/23, documented in part . coccyx wound noted .
Review of the medical record revealed R801 was transferred to the hospital the next day on 11/17/23 for a change of condition.
Review of the hospital records revealed the following:
A photograph of the wound taken on 11/17/23 at 11:26 PM, revealed a large unstageable wound that covered the left and right aspects of the sacrum area.
A Surgical Wound Care Consult Note dated 11/18/23 at 10:23 AM, documented in part . Reason for consult: To evaluate the patient's sacral wound . The patient was found on nursing admission skin assessment to have a sacral wound . Sacrum (Open unstageable sacral pressure injury) . Measurements: 11 cm (centimeters) x 14 cm. Unable to determine the entire wound depth . Base: The centermost aspect of the wound with yellow/tan necrotic base. The outermost aspect of the wound with an open, moist, pale pink and yellow slough mixed base. The wound base has areas of both partial and full thickness tissue loss, with scattered areas of pink hypopigmented scarring present along the outer edges . Minimal serosanguinous drainage . wound is slightly malodorous .
On 3/12/24 at 10:48 AM, the Director of Nursing (DON) was interviewed and asked about the skin assessments completed on 11/13/23 and 11/16/23 that identified the coccyx wound, with no follow up documented, no assessments of the sacral wound, no physician notification of the wound, no treatments implemented, or care plans implemented, and the DON stated they had a soft file on R801. The DON explained once the resident was admitted to the hospital the family called to question the DON about the sacral wound that they were not informed of. The DON stated after they investigated the situation.
Review of an Investigation report provided by the DON documented the following in part, . Resident was sent to the hospital on [DATE]. At the hospital resident noticed to have coccyx wound . CONCLUSION: Resident is alert and able to make her needs known. Was favoring laying on her back in order to elevate(sic) pain and pressure from adenocarcinoma of the vulva. During stay at our facility resident developed wound on coccyx which was unavoidable due to resident medical condition.
On 3/12/24 at 1:01 PM, the DON was reinterviewed and asked about their soft file and their conclusion of R801 sacral/coccyx wound to have been unavoidable. The DON was asked how they can conclude that it was unavoidable if the facility never implemented treatment to the area or had the wound monitored and assessed by a physician and the DON acknowledged the concern. The DON stated they had identified problems with the facility's wounds and had educated staff on the correct protocols and policies of the facility for skin impairments.
No further explanation or documentation was provided by the end of the survey.
R802
Review of the medical record revealed R802 was admitted to the facility on [DATE] with diagnoses that included: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, quadriplegia, gastrostomy status and heart failure.
Review of a Physician Statement of Capacity for Medical Treatment and Decisions revealed R802 lacked the capacity to make decisions regarding their medical affairs.
Review of a nursing Admission dated 1/19/24 at 10:31 PM, documented in part . Clinical Evaluation Integumentary (Skin) . Does the resident have any skin abnormalities? No .
Review of a Braden assessment dated [DATE] at 10:28 PM, documented a score of 9.0, indicating Very High Risk.
Review of the medical record revealed the resident was transferred to the hospital on 2/3/24 for a change of condition.
Review of the hospital records identified a DTI (deep tissue injury) to the right ear .
Review of the medical record revealed no identification of the facility staff to have identified the DTI to R802's right ear.
Review of the census revealed R802 was readmitted to the facility on [DATE].
Review of the physician orders documented the following:
Helmet must be on when out of bed, every shift for Craniotomy (brain surgery) . order date 2/12/24.
Review of the progress notes revealed the following:
On 2/23/24 at 12:55 PM, a Nursing note documented in part . Opening to right ear. Resident wear helmet due to medical condition. Helmet is ill fitting and slide up and down when on. Family is aware of ill fitting helmet . asked PCP (primary care physician) for a proper fitting helmet and never was given one .
Review of the care plans revealed no preventive intervention in place to prevent the helmet opening to have developed.
Review of a Wound Rounds Note dated 2/27/24 at 4:51 PM, documented in part . ear wounds . noted to have right ear wound. Pt (patient) wears a protective helmet that is malfitting <sic>; slides across ears . As a result, she has developed a wound on her right ear . Right ear abrasion, 0.2 cm deep, scant drng (drainage), no cellulitis, base granular, Recommend Tx (treatment) apply foam dressing 3x/week.
Review of the wound photo taken by the facility staff on 2/27/24 revealed an open wound to the right ear and the wound bed could not be visualized by the photo.
On 3/13/24 at 1:28 PM, the DON was interviewed and asked how the facility staff failed to identify the development of the right ear wound, despite the hospital to have identified it during their hospitalization on 2/3/24 and why the facility did not but preventive interventions in place for the monitoring of the helmet against the residents skin and the DON responded the facility staff did not know that R802 was going to develop the right ear wound and as soon as they found out they addressed it.
No further explanation or documentation was provided before the end of the survey.
R803
Review of the medical record revealed R803 was admitted to the facility on [DATE], with diagnoses that included: acute kidney failure and diastolic heart failure.
Review of a nursing admission assessment dated [DATE] , documented in part . Coccyx - redness .
Review of a February 2024 MAR and TAR documented the following order implemented . PeriGuard external ointment . Apply to Sacrococcyx & Groin topically every shift for incontinence . this order was implemented on 2/15/23.
Review of a Nursing progress note dated 3/1/24 at 7:04 AM, documented in part .Resident coccyx area has openings with small amount of blood noted. Coccyx area cleansed and cream applied. Ordered a wound consult. Logged for dr (doctor) .
Although worsening of the wound was identified on 3/1/24, the facility nurse continued the Periguard treatment and logged the assessment in the physician's book for them to review the next time the physicians came to the facility.
Review of a care plan titled Risk for Pressure Injury Formation . dated 2/16/24, documented the following intervention . weekly nursing skin evaluations with showers. Notify PCP (primary care physician) and wound care nurse of any skin changes .
implemented 2/16/24.
Review of the medical record revealed R803 was examined by a physician on 3/3/24, however no documentation of an assessment of the coccyx area was documented.
Review of the record revealed no documentation of a physician follow up regarding the wound identified on R803's coccyx area. Further review of the medical record revealed no care plan implemented for the coccyx wound.
An additional review of the medical record revealed on 3/11/24, the facility uploaded a wound consultation dated 3/5/24, that documented the following in part, . Geriatrics Wound Consult . consult regarding coccyx . total area 8.7 x 6.0. The left side is open with yellow necrotic slough, the right side is open and dark granular tissue scant serosanguineous drainage no clinical evidence of infection . Pressure ulcer of sacral region, unstageable .
Review of the medical record revealed the resident was transferred out to an appointment and admitted to the hospital on [DATE].
Review of the hospital records revealed the buttock wounds were identified upon admission and revealed a stage III buttock wound.
On 3/12/24 at 10:31 AM, Wound Care Nurse (WCN) E was interviewed and asked the facility's protocol when a skin impairment is identified and WCN E replied they would assess the residents' skin impairment and implement the treatment they feel is sufficient for the skin impairment and document it in the doctor's log book so the skin impairment could be assessed. WCN E was asked to confirm that they would assess the area, implement what treatment they felt the resident should have with out getting an order directly from the physician? Or informing the physician of the skin impairment assessment? WCN E was asked to confirm that they are putting orders in the system for skin impairments without the physician's approval and WCN E declined to answer.
On 3/12/24 at 2:23 PM, the DON was interviewed and asked why the nurse did not immediately notify the physician on 3/1/24 of the worsening of the coccyx wound instead of logging it in the physician book for the physician to review next time they came to the facility and the DON stated the nurse that identified the worsening of the wound on 3/1/24 was educated on the proper facility protocols when identifying worsening of a wound.
On 3/13/24 at 9:19 AM, the DON and WCN E requested to talk to the surveyor to clarify WCN E statement regarding the implementation of treatment to a skin impairment without notifying the physician and writing it in the log book for the physician to review the next time they visited the facility. WCN E stated they go by the recommendations of the facility's policy that documented recommended treatments for skin impairments, both the DON and WCN E were asked if they were concerned that staff are implementing treatment from a policy recommendation, and not notifying the physician of the treatment that is being implemented under the physician's name and failing to timely report the skin impairment to the physician and the DON stated they understood the concern and will start education with their staff.
No further explanation or documentation was provided by the end of the survey.
R804
Review of the medical record revealed R804 was admitted to the facility on [DATE] with diagnoses that included: palliative care, hemiplegia and hemiparesis following infarction affecting left non-dominant side and required staff assistance for all ADLs.
Review of an Admission nursing evaluation dated 12/23/23 at 11:37 PM, documented in part . Clinical Evaluation Integumentary (Skin) . Left lower leg (front) Scar . Right lower leg (front) Scratches . Back of head redness . Right ear dark mold .
Review of an admission Braden dated 12/24/23 at 12:15 AM, documented a score of 13, which indicated Moderate Risk.
Review of a Nursing progress note dated 1/9/24 at 11:17 AM, documented in part . Writer informed by staff with new noted skin issues, fluid filled blister to left heel .
Review of a Wound Rounds consultation dated 1/16/24 at 4:44 PM, documented in part . seeing pt (patient) re (regarding) . heel wounds . Left heel unstageable ulcer, desiccating blood blister, ruptured with central eschar, 2.5 x 1.3 .
On 3/13/24 at 3:50 PM, R804 was observed sleeping on their back in bed with family at bedside. R804's daughter explained the resident was on hospice and was currently declining and transitioning.
Review of the medical record revealed no documentation of the left heel wound to have been monitored, assessed, or evaluated by the wound clinician since 1/16/24.
On 3/13/24 at 2:27 PM, the DON was interviewed and asked why R804's left heel wound had not been monitored or assessed by the wound clinician since 1/16/24 and the DON stated they would look into it and follow back up.
On 3/14/23 at 9:31 AM, the DON returned and stated the nursing staff had been educated on wounds and could provide QAPI (Quality Assurance Performance Improvement) documentation of R804's wound to have been monitored.
Review of the QAPI documentation provided revealed documentation of measurements of R804's left heel on 1/16/24, 1/24/24, 1/31/24, 2/6/24, 2/13/24, 2/20/24, 2/27/24, and 3/1/24. No additional physician wound assessments were provided.
No further documentation was provided by the end of the survey.
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: MI00143149 & MI00142861.
Based on interviews and record reviews the facility failed to ensure...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00143149 & MI00142861.
Based on interviews and record reviews the facility failed to ensure supervision for an appointment (appt) was provided for a resident who lacked capacity, one R802 of three residents reviewed for accidents. Findings include:
Review of a complaint submitted to the State Agency (SA) documented concerns of the facility staff to have failed to accompany R802 to their medical appt and once found, R802's head helmet that's worn for medical purposes was found on the floor.
Review of the medical record revealed R802 was admitted to the facility on [DATE], with diagnoses that included: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, functional quadriplegia, gastrostomy, and anoxic brain damage.
Review of a Physician Statement of Capacity for Medical Treatment and Decisions documented the resident lacked the capacity to make reasoned medical decisions and provide informed consent for their medical affairs, signed by the second physician on 2/1/24.
Review of a Physician Team - Progress Note dated 1/22/24 at 2:27 PM, documented in part . On 11/6 she had hemicraniectomy (surgical procedure where a large flap of the skull is removed) on right side . The resident was status post a surgical procedure of their skull. This was the reason for the helmet worn by R802.
Review of a Nursing note dated 2/26/24 at 9:34 AM, documented in part . out for doctor's appointment .
On 3/12/24 at 1:33 PM, a telephone interview was conducted with Family Member (FM) C. When asked about the appointment for R802 on 2/26/24, FM C stated they would usually ride on the van with R802 to all of their appointments. FM C stated for this particular appointment they walked into the room of R802, and the resident was not in the room. FM C then asked nursing staff where R802 was, and the staff stated R802 had left with the transportation personnel to their appointment. FM C asked the staff how they let R802 (a vulnerable resident who lacks capacity to make decisions for themselves) leave on a medical appointment alone. FM C stated they ran out of the building and sped to the doctor's office. FM C stated once at the doctor's office, they found R802 in the lobby in a geri chair by themselves with their medical helmet on the floor. FM C stated there was no personnel with R802 to provide supervision. FM C stated the whole incident was unbelievable and they filed a complaint with the facility's Director of Nursing (DON).
On 3/13/24 at 9:35 AM, the DON was asked to provide all of grievances filed for or on the behalf of R802.
Review of a Receipt of Concern form dated 2/27/24, documented FM C was upset that R802 was transported to the appointment without FM C. The DON documented that all staff was educated and documented in part . Staff involved in above situation was educated on importance to have family member or facility staff accompany cognitively impaired pt (patient) to outside DR (doctor) appt. (appointment) .
On 3/13/24 at 1:28 PM, the DON was interviewed and asked if R802 was able to speak or move their body and the DON stated thy resident could not. The DON stated it is not the facility's protocol to allow cognitively impaired residents with transportation staff to outside appointments without facility staff or a family member of the resident. The DON stated they re-educated all of their staff when the incident was reported to them by R802's family.
No further explanation or documentation was provided by the end of the survey.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00142846.
Based on interview and record reviews the facility failed to obtain weights per t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00142846.
Based on interview and record reviews the facility failed to obtain weights per the facility's policy for one (R801) of one resident reviewed for weight loss. Findings include:
Review of a complaint submitted to the State Agency (SA) documented a concern of R801 to have had a significant weight loss while inpatient at the facility.
Review of the medical record revealed R801 was admitted to the facility on [DATE] with diagnoses that included: malignant neoplasm of cervix, abscess of vulva and acute kidney failure. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition and required staff assistance for Activities of Daily Living (ADLs).
Review of the only documented weight obtained by the facility staff on 10/27/23 at 8:12 PM, documented 143.3 lbs (pounds).
Review of the medical record revealed the resident was transferred to the hospital on [DATE] for a change of condition.
Review of a facility policy titled Weights Issued on 5/3/22, documented in part . Residents are weighed upon admission and then weekly for a total of four weeks .
The facility failed to obtain R801's weights according to the facility's policy, three additional weights were missed.
On 3/12/24 at 2:01 PM, the Director of Nursing (DON) was interviewed and asked why R801's weight was only obtained on admission, without further weights obtained by the facility staff as directed in the facility's policy and the DON stated they would look into it and follow back up.
On 3/13/24 at 8:55 AM, a follow up interview was conducted with the DON and the DON stated they are starting education with the facility staff.
No further explanation or documentation was provided by the end of the survey.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00143213.
Based on interview and record review the facility failed to provide therapy servi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00143213.
Based on interview and record review the facility failed to provide therapy services as ordered by the physician for one (R803) of two residents reviewed for rehabilitation services. Findings include:
Review of a complaint submitted to the State Agency (SA) documented the facility failed to provide appropriate and adequate rehabilitation services. The complaint documented in part . Multiple times (R803) went 3 & 4 day stretches without PT (physical therapy) or OT (occupational therapy). When we brought this up, we were told they were short staffed & another time we were told that a stomach bug had hit their PT staff .
Review of the medical record revealed R803 was admitted to the facility on [DATE] with diagnoses that included: acute kidney failure and diastolic congestive heart failure.
Review of the documents provided to that facility by the transferring facility noted the resident was transferred for extensive rehabilitation.
Review of the physician orders documented the following orders:
Rehab: Physical Therapy recommended for skilled treatment [5] times a week until 3/21/24, Start date: 2/19/24.
Review of a Physical Therapy (PT) Evaluation & Plan of Treatment for the certification period of 2/16/24-3/11/24, documented in part . Frequency: 5 time(s)/week, Duration: 25 day(s), Intensity: Daily . Patient Goals: to get better and return home. Potential for Achieving Rehab Goals: Patient demonstrates good rehab potential as evidenced by high PLOF (Prior Level Of Functioning) Therapist accepting transfer of Plan: PT (physical therapist)/PTA (physical therapist aide) will be assigned . Further review of the PT evaluation documented the goals the PT staff would focus on while working with R803.
Review of the PT encounter notes revealed R803 was seen by therapy staff only twice the second week and three times on the third week of their inpatient stay, with two to three days passing without being seen by the PT staff .
Rehab: Occupational Therapy recommended for skilled treatment [5] times a week until 3/11/24.
Review of a Occupational Therapy OT Evaluation & Plan of Treatment for the certification period of 2/16/24 - 3/11/24, documented in part . Frequency: 5 time(s)/week, Duration: 25 day(s), Intensity: Daily . Patient Goals: Goal is to return home with spouse and temporary assist if/as needed. Potential for Achieving Rehab Goals . demonstrates good rehab potential as evidence by high PLOF, recent onset, good cognition, strong family support, ability to learn new information and able to make needs known . Therapist Accepting Transfer of Plan . Further review of the OT evaluation documented the goals the OT staff would focus on while working with R803.
Review of the OT encounter notes revealed R803 was seen by therapy staff four times within the first week and two times in the third week of their inpatient stay.
On 3/13/24 at 12:45 PM, Therapy Director (TD) B was interviewed and asked why R803 was not seen by the PT and OT staff five times a week as ordered by the physician for rehabilitation services and TD B gave an example that if the resident was seen by the OT three times one week and seen by PT twice the same week it satisfies therapy services for the resident for that week. The physician orders were reviewed with TD B who acknowledged the orders documented for both OT and PT to be provided five times a week, however TD B was adamant that the OT and PT encounters combined satisfied therapy services.
On 3/13/24 at 1:36 PM, the Director of Nursing (DON) was interviewed regarding R803 to not have received the five days weekly of PT and OT rehabilitation as documented in the physician's order and the DON replied that it was a concern for them as well and will be following up with the therapy director.
Review of a facility policy titled Physician Involvement in the Plan of Therapy (Issue Date 7/27/15), documented in part . therapists will perform evaluation and treatment of patients only under the direction of the physician . Following the evaluation, the therapist will immediately develop a Plan of Treatment . and given to the physician for approval signature .
Review of a facility policy titled Recommendations by Ancillary Services (Issue Date 1/30/24) documented in part . treatment rendered to a patient will be in accordance with the specific or standing orders signed by the licensed physician . The Rehab Clarification order for recommendation of treatment will include the frequency and duration as recommended by the therapist . recommendations will be entered into the EMR (electronic medical record) . The recommendation then becomes a physician order when noted signed electronically by the physician . When a resident requires a changed in frequency and/or extended duration the therapist will communicate with the physician using a Rehabilitation Clarification Order .
Review of the medical record revealed no Rehabilitation Clarification Order implemented to change the frequency of therapy services for R803.
No further explanation or documentation was provided by the end of the survey.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00142846
Based on interviews and record reviews the facility failed to ensure professional s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00142846
Based on interviews and record reviews the facility failed to ensure professional standards of nursing practice was provided by the nursing staff to administer pain medications as directed by the physician for one (R801) of three residents reviewed for pain. Findings include:
Review of a complaint submitted to the State Agency (SA) documented concerns of the facility staff to have failed to administer R801's pain medication as directed by the physician.
Review of the medical record revealed R801 was admitted to the facility on [DATE] with diagnoses that included: malignant neoplasm of cervix, abscess of vulva and acute kidney failure. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition and required staff assistance for Activities of Daily Living (ADLs).
Review of a Physician Team - H&P (history & physical) dated 10/29/23 at 8:08 AM, documented in part . diagnosed with stage 3C adenocarcinoma of the vulva status post 6 cycles of cisplatin and radiation therapy . Currently, she is complaining of pain in the right knee and difficulty ambulating .
Review of a Physical Medicine and Rehabilitation (PM&R) note dated 10/30/23 at 12:15 PM, documented in part . states that her pain is uncontrolled. She states that taking pain medication four time daily does improve this . Pain: Currently uncontrolled. We will schedule the patient's Norco every six hours with as needed every eight hours. Also add gabapentin (medication) .
Review of a Physician Team - Progress Note dated 11/1/23 at 12:18 PM, documented in part . continues to complaint of tenderness in peri area around wounds. She states it is painful to sit and had difficult time with therapy. Discussed with PM&R and Norco scheduled q4h (every 4 hours) and will discuss gabapentin dosing .
Review of a PM&R note dated 11/1/23 at 5:58 PM, documented in part . continues to state that her pain is uncontrolled. She is requesting to go up to every four hours for Norco which I was agreeable to .
Review of a PM&R note dated 11/8/23 at 11:34 AM, documented in part . states that her pain is uncontrolled this morning, but she has not gotten her medications .
Review of a PM&R note dated 11/13/23 at 1:48 PM, documented in part . complain of increased pain this morning; however, they did miss her morning medication. Once she did receive this, her pain improved back to baseline .
Review of the November 2023 Medication Administration Record (MAR) documented the following pain medication . Hydrocodone-Acetaminophen Tablet 5-325 MG (Milligram), Give 1 tablet by mouth every 4 hours for pain . This medication was not administered by the facility nursing staff on the following dates:
2 AM dose- 11/4, 11/7, 11/8, 11/9, 11/12 & 11/13
6 AM dose- 11/8 & 11/13
6 PM dose- 11/8 & 11/13
Review of the medical record revealed no documentation on why the resident's pain medication was not administered at the above time and dates.
Review of a care plan titled . Risk for impaired comfort documented the following intervention in part . Administer pain medication as ordered .
On 3/12/24 at 2:01 PM, the Director of Nursing (DON) was interviewed and asked why R801's pain medication was not consistently administered as prescribed by the physician and the DON stated they would look into it and follow back up.
On 3/13/24 at 8:55 AM, the DON returned for a follow up interview and stated they could not find documentation on why the pain medication was not administered, however stated they recently educated the nurses on medication administration.
No further explanation or documentation was provided by the end of the survey.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0773
(Tag F0773)
Could have caused harm · This affected multiple residents
This citation pertains to intake: MI00142846.
Based on interviews and record reviews the facility staff failed to ensure labs were completed as ordered by the medical clinicians for one (R801) of thr...
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This citation pertains to intake: MI00142846.
Based on interviews and record reviews the facility staff failed to ensure labs were completed as ordered by the medical clinicians for one (R801) of three residents reviewed for a change of condition. Findings include:
Review of a complaint submitted to the State Agency (SA) documented concerns of the facility to have failed to assess a change of condition with R801 in a timely manner.
Review of the medical record revealed the following:
A Complete Blood Count (CBC) report dated 11/1/23, documented a [NAME] Blood Cell (WBC) Count of 12.3, High, (normal range 3.3-10.7).
A Physician Team - Progress Note dated 11/6/23 at 1:50 PM, documented in part . WBC 12.3, repeat labs . consider UA (urinalysis) if leukocytosis (elevated WBC) persists .
Review of the physician orders revealed multiple orders to repeat the CBC labs on the following dates: 11/5/23, 11/12/23, 11/15/23 & 11/17/23.
Review of the medical record revealed no documentation of the CBC to have been repeated as directed by the medical clinician for the above dates.
A Stat (immediate) CBC was drawn on 11/17/23 when the resident had an identified change of condition and was transferred to the hospital. R801's WBC was documented as 23.2, High, normal range 3.3-10.7.
On 3/12/24 at 2:01 PM, the Director of Nursing (DON) was interviewed and asked why R801's CBC labs were not completed as ordered by the medical clinician on 11/5/23, 11/12/23 & 11/15/23 and the DON stated they would look into it and follow back up.
On 3/13/24 at 8:55 AM, a follow up interview was conducted with the DON and the DON stated the facility was having trouble with the lab company services and was in the process of changing lab companies at the time. No further explanation or documentation was provided before the end of the survey.
Review of a facility policy titled Laboratory Results (Issued: 8/18/23) documented in part . The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law .
Jan 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 Number(s): MI00141529.
Based on interview and record review, the facility failed to assess and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00141529.
Based on interview and record review, the facility failed to assess and treat a resident who expressed pain for one (R804) of two residents reviewed for changes in condition, resulting in unrelieved pain. Findings include:
Review of a complaint submitted to the State Agency revealed the following allegations: .(R804) discharged from the hospital and was transferred to (facility) around 1:30 PM on 12/7(2023). After being transported to her room, (R804) did not see another staff member until about 9:30 PM, and only after family intervened. (R804) la <sic> in her bed bleeding and in pain. She tried many times to use her call light, however, no staff came to assist her. She eventually called her daughter by phone, who then called the facility directly and also 911 to have (R804) transported back to the hospital .
Review of R804's clinical record revealed R804 was admitted into the facility on [DATE] and was discharged to the hospital on the same day with diagnoses that included: malignant neoplasm of endometrium (uterine cancer). The clinical record indicated R804 was alert and oriented to person, place, time, and situation.
Review of R804's hospital records revealed R804 arrived at the hospital on [DATE] at 10:37 PM.
Review of the ED (Emergency Department) Provider Notes dated 12/7/23 revealed R804 presented to the ED with vaginal bleeding. The following was documented, .stage III uterine carcinosarcoma and PE (pulmonary embolism) on (blood thinner) who presents with vaginal bleeding. She was discharged earlier today to SAR (subacute rehab) from (hospital) .She states the SAR was 'terrible' and that 'no one checked on me'. She reports vaginal bleeding that began today. She is unsure of the amount, but said 'it was a lot'. She has lower abdominal pain that is rated a 10/10 in severity. Patient also reports fatigue, bilateral LE (lower extremity) edema, and nausea .Physical Exam .in acute distress .generalized abdominal tenderness .
Review of a H&P (history and physical) completed in the hospital revealed, .Patient states that she had sudden onset severe vaginal bleeding .Patient called her daughter because she had been asking for help from nursing staff and had not received care of evaluation of her bleeding throughout her duration in the facility. The daughter called 911 to bring the patient from there nursing facility to the emergency department for evaluation .She also has 10/10 lower abdominal pain which is chronic for her .
Further review of R804's nursing facility clinical record revealed the following:
Review of a Pain Assessment dated 12/7/23 at 3:13 PM, R804 experienced mild pain.
Review of Physician's Orders revealed an order to assess the resident for pain every shift. R804 had the following orders for pain medications:
Hydrocodone-Acetaminophen 5-325 milligrams (MG) every six hours as needed
Oxycodone HCl 5 MG one tablet every four hours as needed
Oxycodone HCl 5 MG two tablets every four hours as needed
Review of R804's progress notes revealed the following notes:
On 12/7/23 at 4:28 PM, Licensed Practical Nurse (LPN) 'F' documented, .Denies pain or discomfort .NP (Nurse Practitioner) called and made aware of resident and meds (medications). States well <sic> be in to writer scripts (prescriptions) .
On 12/7/23 at 11:15 PM, Registered Nurse (RN) 'E' documented, Writer received report from admitting nurse at approx (approximately) (4:15 PM). Writer did rounds on patient, asked about any pain or discomfort, resident denied any pain or discomfort .Writer notified by nursing staff approx 8:30 PM that resident was having discomfort and pain. Writer checked MAR (Medication Administration Record) for PRN (as needed) medications. NP called and requested scripts for PRN medications. Pharmacy contacted and authorization to pull (narcotic) faxed at 9:30 PM (one hour after RN 'E' was notified that R804 had discomfort and pain). Writer made attempt with second nurse to retrieve PRN (Oxycodone) from Pyxis (medication back up supply), medication not available. Pharmacy contacted once more about auth (authorization) to pull and was told medication would be available within 10 minutes. Medication not available at that time again. Writer called to unit regarding patient having large amount of bleeding coming from perineal area (patch of skin between the vagina and anus). NP notified at (9:45 PM) and ordered to send patient out to hospital .911 called at (10:00 PM) .patient left building .at approx 10:15 PM .left in stable condition no signs of distress observed .HR (heart rate) 125 (beats per minute) .
On 1/30/24 at 3:17 PM, an interview was conducted with RN 'E' via the telephone. When queried about what was done when R804 expressed pain on 12/7/23, RN 'E' reported the Certified Nursing Assistant (CNA) informed her that R804 was in pain. RN 'E' explained they looked in the medical record, saw there were orders for pain medications, but there were no scripts. RN 'E' reported she then called the provider to get a script and then followed up with the pharmacy to get authorization to pull from the back up supply. RN 'E' reported when they went to pull the medication from the back up supply it wasn't available. RN 'E' explained the authorization was not available so they called the pharmacy again and they explained the authorization would be available in about ten minutes. RN 'E' waited and the authorization still did not come through so they went back to the unit and that was when they were notified that R804 was bleeding. When queried about where R804's pain was located, what the level of pain was, and if R804 had bleeding at the time the pain was expressed, RN 'E' explained they did not go into R804's room and did not assess R804 after the CNA had notified them of the pain and just went right to call the NP and try to get the medication. When queried about whether the provider was contacted when there was a delay in getting authorization for the prescribed pain medication, RN 'E' reported they did not contact the provider for potential alternative pain treatment. RN 'E' reported she would have done that, but R804 ended up going to the hospital.
On 1/30/24 at 2:37 PM, an interview was conducted with the Director of Nursing (DON). When queried about the facility's protocols to ensure residents' pain was managed and what to do if prescribed pain medication was not available, the DON reported if a script did not come over from the hospital for a new admission, the provider was contacted for a script. If the medication was needed before the medication was available, the pharmacy was contacted for authorization to pull from the back up supply. The DON further explained that if there was a delay in obtaining pain medication for a resident, the provider should be notified to see if an alternative form of pain relief could be administered. When queried about what the nurse should do if they are notified that a resident was experiencing pain, the DON reported the nurse should determine where the pain is located and what the level of pain is. When queried about whether R804 should have been assessed by the nurse after she expressed pain, the DON reported the resident should have been assessed and reported the nurse was trying to do the right thing and get the medications. The DON reported R804's family member called up to the facility and was angry and upset and spoke with a supervisor who then went to R804's room and discovered she had vaginal bleeding. When queried about why the daughter called up to the facility, the DON reported she claimed R804 had pressed her call light and nobody answered it, but the DON reported the CNA said that was not true.
Review of a facility policy titled, Pain Management Program, dated 3/1/2010, revealed, in part, the following: .The assessment will describe and characterize the pain, including location, cause of pain .type of pain, chronic vs. acute, and intensity level. A scale of 0-10 will be used .
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
This citation pertains to Intake Number(s): MI00142295 and MI00142293.
Based on observation, interview, and record review, the facility failed to ensure safe positioning in a wheelchair with access to...
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This citation pertains to Intake Number(s): MI00142295 and MI00142293.
Based on observation, interview, and record review, the facility failed to ensure safe positioning in a wheelchair with access to a call light for one (R801) of two residents reviewed for falls, resulting in a fall from the wheelchair and sustaining a bump to the head. Findings include:
Review of a complaint submitted to the State Agency revealed the following allegations: .facility staff put the resident in her wheelchair with a pillow on the seat and it was slippery .staff didn't lock the wheelchair and they didn't put the residents call light within reach before leaving the room .the resident used her cellphone to call her daughter and tell her she was falling out of her wheelchair and needed help .staff didn't get to the residents room until after she fell out her wheelchair and onto the floor .the resident hit her head and right shoulder and .blacked out .resident does have a knot on her head where it hit the floor .
On 1/29/24 at 3:05 PM, R801 was observed lying on her side in bed. Bed was not in the lowest position and the call light was observed on the recliner chair which was not within reach of the resident. R801's door was closed.
On 1/30/24 at approximately 11:00 AM, R801 was observed lying on her right side in bed, spitting up into a plastic bin. When queried about any falls, R801 reported she fell from her wheelchair a little over a week ago. R801 explained the nurse aide assisted her into the chair and did not lock the brakes. R801 reported after being up in the chair for about a half hour, she got tired and wanted to get back into the bed, but could not reach the call light. R801 reported she felt like she was slipping down in the wheelchair and called her daughter to contact the facility so that someone could come help since she could not use the call light. R801 reported she waited about 20 minutes and nobody came. At that time, R801 explained it felt like the wheelchair was moving backwards and she was slipping down. R801 reported she slid out of the wheelchair and hit her head on a scale that was nearby.
Review of R801's clinical record revealed R801 was admitted into the facility on 1/18/24 with diagnoses that included: abscess of liver, sepsis, and obstruction of the bile duct.
Review of a progress note written on 1/18/24, on the day of R801's admission, revealed R801 was alert and oriented to person, place, time, and situation.
Review of a progress note written by Licensed Practical Nurse (LPN) ' on 1/20/24 at 11:48 AM, revealed, Writer walked into resident's room, resident observed on the floor in front of her wheelchair. When asked what happened? Resident stated, 'I slide from my wheelchair to the floor and hit my head, I couldn't reach the call light because it was on the floor.' Daughter was on the phone trying to talk to her mother when I walked in .Resident reported pain on her right head .
On 1/30/24 at 1:50 PM, an interview was conducted with LPN 'B' via the telephone. When queried about R801's fall on 1/20/24, LPN 'B' reported she was charting at the nurses' station and R801's daughter called and asked to check on R801. When LPN 'B' arrived to R801's room, R801 was on the floor in front of the wheelchair. LPN 'B' asked R801 what happened and R801 reported she wanted to go back to bed and slid from the chair to the floor. When LPN 'B' asked R801 why she did not use the call light, R801 explained she could not reach it. LPN 'B' reported R801 was sent to the hospital because she said she hit her head. LPN 'B' reported it was discovered the nurse aide placed pillows in the wheelchair and they should not have been placed there.
On 1/30/24 at 1:58 PM, an interview was conducted with Certified Nursing Assistant (CNA) 'C'. When queried about R801's fall on 1/20/24, CNA 'C' reported when she assisted R801 into her wheelchair, R801 asked her to put pillows under her bottom and behind her back for support. CNA 'C' reported she placed the pillows per the resident's request and left the room. CNA 'C' reported the nurse notified her that R801 had fallen. CNA 'C' could not remember if the call light was placed in reach of R801.
On 1/30/24 at 2:27 PM, an interview was conducted with the Director of Nursing (DON). When queried about R801's fall on 1/20/24, the DON reported it was discovered the CNA placed a pillow in the wheelchair and there should be no pillow except the gel cushion made for the wheelchair. The DON reported R801 slid from the wheelchair because of the pillow. According to the DON, R801's family member called the nurse's station because R801's call light was not in reach.
Review of R801's care plans revealed a care plan that read, Resident is at risk for falls .able to use call light to seek staff assistance .
Nov 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes: MI00140611 and MI00140683.
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: MI00140611 and MI00140683.
Based on observation, interview, and record review, the facility failed to timely obtain, acknowledge and ensure a resident's choice for health care decision making prior to petitioning for a third party guardian for one (R807) of one resident reviewed for resident rights, resulting in expressions of extreme frustration, distress, fear of loss of autonomy and the increased potential for further denial of the resident's right for self-determination under a reasonable person concept for a resident who had appointed a family member as their legal representative prior to the deterioration of their health condition.
Findings include:
Review of a complaint filed to the State Agency read in part, I should file a petition for guardianship of my (age omitted) year old (relationship omitted) (blind with dementia). In Aug. 2023, I called the court and made plans to file the petition. Prior to going to court, I called (facility name omitted). The social worker informed me that they scheduled a representative to go to court to file the petition on my behalf .I got a notice via mail that the petition filed was for the facility (facility name omitted) to have unrestricted guardianship of my (relationship omitted) .saying that our family was unreachable though one of us is present, visiting my (relationship omitted) everyday.
Review of a second complaint filed to the State Agency read in part, The court sent someone unannounced to the facility to see (name of R807) as they needed to verify that (relationship omitted) had no family present and willing to assume the care for him. They saw that the family was involved and present. The court went against the guardianship (facility name omitted). There are concerns that (facility name omitted) is seeking guardianship .was attempting to get guardianship over (name of R807) and did not notify the family and were attempting to restrict and strip the family from (name of R807).
Review of the clinical record revealed R807 was originally admitted to the facility on [DATE]. R807 was hospitalized after their initial admission and most recently they were readmitted back into the facility on [DATE]. R807's admitting diagnoses included hemiplegia (stroke), dementia, glaucoma, legal blindness, and dysphagia (difficulty with swallowing). R807 was receiving their nutrition through PEG (Percutaneous Endoscopic Gastrostomy) tube. (PEG tube is a tube placed surgically into the stomach to receive nutrition directly through the stomach when there is difficulty swallowing or when oral nutrition is inadequate.)
According to a Minimum Data Set (MDS) assessment dated [DATE], R807 had severely impaired cognition, and was dependent on staff assistance with their mobility and activities of daily living (ADLs) such as mobility in bed, eating, bathing, and toileting.
An initial observation was completed on 11/14/23, at approximately 10:35 AM. R807 was observed in their bed with their eyes closed. R807's private duty care giver (J) (arranged and privately paid by R807's family) was sitting at their bedside. During this observation an interview was completed with R807's private duty care giver. Private duty care giver J was queried on who they were and what their role was. Care giver J reported that they were a private care giver appointed by the R807's family. Care giver J reported that they had been coming in to assist R807 for approximately a year. Care giver J also reported that they were coming four to five days/week for four hours, usually in the morning, and R807's spouse would usually come in the afternoon. Care giver J also reported that they were assisting in providing care for R807 while they were at the facility.
A review of R807's Electronic Medical Record (EMR) revealed an admission agreement document dated 11/10/23 and 12/08/22 signed by R807's spouse. The admission agreement also included consent to immunizations/vaccines signed by R807's spouse. Further review of R807's EMR revealed a Durable Power of Attorney (DPOA) for Healthcare and Finances, executed by R807, that designated R807's son as their first agent and the daughter as their second agent to advocate and honor their wishes. This document was executed by R807 on 11/27/18 to have their children as their advocates/legal representatives to honor their wishes.
Further review of R807's EMR also revealed a physician certification form initiated on 5/26/23, initiated approximately six months after initial admission to the facility. The form revealed that R807 was not competent to participate in medical treatment, care, and custody decision making. The form also had a check box that read If the resident has executed a Durable Power of Attorney for Medical Decision-Making or has designated a Patient Advocate in compliance with state regulations, that DPOA or Patient Advocate is now in effect. The form was signed by the physician on 6/1/23.
Review of R807's social work assessment and progress notes included an initial social work assessment dated [DATE] that documented R807's BIMS (Brief Interview for Mental Status - a cognitive exam) score was 0, which indicated severe cognitive impairment. The section of the assessment which addressed legal papers of authority was incomplete, with no boxes checked.
Another social work assessment completed on 12/7/22 documented, Patient presents as alert and oriented x 1 with confusion .Patient has a BIMS score of 0/15, indication of severe memory impairment. Social work has reviewed advance directive and current full code status which are appropriate at this time. No DPOA on file and family not interested in documents at this time. Patient's son is applying for Medicaid as plan B to remain in the facility.
This social work assessment did not address any need for advocating for a guardianship for R807, and noted the family was not interested in DPOA at that time. The documentation did not explain what it meant by family not interested as R807's family had a valid DPOA document at that time.
Review of a social work progress note dated 1/3/23 read, SW (social work) spoke with resident and family to review Advance Directives. Continue FULL CODE status per their wishes. This note did not explain who it meant by their wishes as they did not have any legal document on R807's EMR during this time frame.
Review of a social work progress note dated 1/5/23 read, SW emailed son and spouse to see if anyone had DPOA or guardianship of resident in place .discussed importance of it and reasoning behind it. Discussed guardianship process in case there was none in place. The note revealed that this discussion was done via e-mail.
On 11/14/23 at approximately 3:00 PM, the Director of Social Work (Staff K) was requested to provide a proof of this e-mail communication. Staff K reported this was handled by a different social work staff member who no longer worked at the facility and did not have any proof of communication.
Review of a social work progress note dated 1/26/23 read, SW called RP (Responsible Party) to make her aware related to guardianship process. Voiced understanding. She will look into it .
Review of a quarterly social work assessment dated [DATE] read in part, Guardianship was discussed with wife on 1/26/23, followed up on 2/22/23 in which she states that she is still considering it .Resident has supportive family who participates in care discussions. Social work obtained input from resident/family .
Review of a quarterly social work assessment dated [DATE] read in part, Guardianship has been discussed with spouse multiple times. Facility will initiate capacity evaluation and petition for guardianship. Caregiver states the spouse has her own medical issues currently and son (name omitted) would be the best candidate. VM (voicemail) left for son (name omitted) .Resident has supportive family who participates in care discussions.
Review of a social work progress note dated 5/23/23 read, patient's son called the writer back stating that he would be open for guardianship . Further review of social work progress note reveals that a capacity form was sent to the R807's son on 7/10/23.
An additional progress note dated 8/16/23 revealed that facility had referred the resident to an external entity to petition for guardianship. It must be noted that during this entire time frame R807 had a DPOA document, executed in 11/27/18. Family of R807 (spouse or children) were unaware and they were not educated that they did not need guardianship if they had a DPOA in place.
On 11/14/23 at approximately 11:15 AM, an interview was completed with the complainant. When asked if they recalled whether the facility requested a copy of the DPOA documents via email or phonecalls as noted in the progress notes and they reported they had not. They further reported they were not aware that the family did not need the guardianship if they had an active DPOA, and no one had educated or explained any of this. The complainant reported that the facility had requested the family to get the guardianship and they were willing to get the guardianship (when there was no need for one). The Complainant reported that although they lived out of state, they visited once every two to three weeks, and they drove over 30,000 miles/year to assist their parents. The complainant also reported that R807's spouse visited the resident several days every week, and the family also paid for a private caregiver for R807. The Complainant reported that when they were in town they had spoken with a facility social worker and had notified the facility that they were in the process of going to court to get their guardianship as requested by the facility. The Complainant reported that they were notified by the facility staff member that the facility would send someone a representative on the family's behalf for guardianship and family did not need to go to court. The Complainant reported that R807's spouse and children were shocked when they had received the letter from the court that the facility was requesting a third-party to have guardianship and reported that R807 would have been extremely upset with this whole situation if they understood what had happened. The Complainant reported they had reached out to the speak with the social worker many times after the court situation and they were unsuccessful, and they had reported their concerns to administrator.
Review of the guardianship documents provided by the facility revealed a publication of notice of hearing from the Probate court read that the notice for guardianship hearing that was scheduled for 10/11/23 was sent out on 9/13/23. Additionally, the facility had received a copy of the DPOA that indicated it had been scanned into the resident's EMR on 9/23/23.
On 11/14/23 at approximately 4:30 PM, during an interview with the Administrator, it was confirmed the DPOA document was scanned in on 9/23/23 and that R807's EMR did not have any documentation or explanation as to why the facility had not provided this information to the third-party agency or explain to the family the unnecessary need to pursue guardianship with the existing DPOA and capacity forms already in place. The facility failed to follow-up and intervene timely, and a guardian Ad Litem was appointed.
A review of the report by Guardian Ad Litem (GAL) dated 10/4/23 read in part, Petitioner (from the third-party guardianship agency) alleges that (R807 name) is unable to make or communicate informed, decisions because of a mental deficiency and physical disability. Specifically, Petitioner alleges that he has multiple medical diagnoses that impairs cognition including dementia and requires assistance with his basic daily needs. Petitioner further alleges that he attempted to contact with (names and relationships omitted) without success and is requesting that a third-party professional guardian be appointed . (It must be noted that R807 had a spouse visiting the facility several times a week and one of their children from out of town was visiting every two to three weeks since admission into the facility.)
The GAL report further read, On September 26, 2023, I went to (facility name omitted) to meet with (R807's name). Upon arrival to his room, (spouse name omitted) was present, and I explained the purpose of my visit as GAL. She had apparently just received service of the petition and was shocked and upset that it had been filed. She stated that she was at the facility every day to visit with her husband since he was admitted there in December 2022. She also contacted her (relationship omitted) by phone during my visit. He also expressed surprise at the filing of the petition at the request of the facility .Although (name omitted) resides in (location omitted) he usually travels to Michigan every 2-3 weeks to assist his (relationship omitted) with his (relationship omitted) care at the facility .Subsequently, (name omitted) gave me a copy of the executed POA documents and I have attached them hereto. I also attempted to contact the facility social worker however to date that has been unsuccessful.
The recommendation from the GAL read, Based on the facts and circumstances as outlined above and after review of the duly executed POA documents, I recommend that the Court deny the petition at this time. (It must also be noted the R807's EMR did not have the documentation/the petition that was filed by third part guardianship agency on behalf of the facility and the GAL report.)
On 11/14/23 at approximately 3:00 PM, an interview was completed with Staff B. When queried on the facility's process and follow up on obtaining legal documents such as DPOA, guardianship information for residents with BIMS score of 0, Staff B reported that they would complete an initial assessment, typically within five days of admission and if residents had cognitive impairments, they would follow up with families to request if they any DPOA or guardianship.
Staff B was queried on what had happened with R807 and why they were referred to a third-party agency to petition for guardianship, given the resident's supportive family and they reported that they had documented all the follow up with the spouse and son.
Staff B was queried if they had sent any official notification from the facility before they were pursuing a third-party guardianship, Staff B reported that they did not send any official notification and it is not their facility policy to send official notifications when they were pursuing third party guardianship for the residents. Staff B reported some the family communication for R807 was handled by a different social work staff member who no longer worked at the facility, and they did not have any proof of communication. Staff member reported that R807 was referred to a third-party agency for guardianship on 8/15/23. Their last official communication with the family was in July 2023. Staff B was queried why the facility did not follow up with the third-party guardianship petitioner representing the facility to notify that the facility had the DPOA documents, and no further explanation was offered.
On 11/14/23 at 4:30 PM, an interview was completed with the Administrator. When queried why the facility had pursued appointment of a third-party guardian when R807 had a supportive family who were very involved in their care, the Administrator reported that they were involved later, after the petition was filed and further agreed that R807's family was very involved and supportive.
When queried on the current facility process, why the family of R807 was not notified prior to pursuing third party guardianship, and why the guardianship process was not terminated when the facility had valid DPOA documents of R807's EMR, the Administrator reported that they had opportunities in their current facility processes and they would review and revise their process. The Administrator also reported that the intent of the referral for guardianship was to assist the family, and there had been lapse in communication on the facility end. (It must be noted that R807 had a supportive family with a valid DPOA in EMR and did not need a guardian as mentioned above. It must also be noted the R807's EMR did not have any documentation on guardianship petition that was filed by third party guardianship agency on behalf of the facility and the GAL recommendations to the court. These documents were provided by the complainant.)
A facility provided document titled, Resident Rights Under Michigan Public Health Code, dated 11/20/17, read in part, Residents of this facility have the right to a dignified existence, and to communicate with individuals and representatives of choice. The facility will protect resident rights as designated below using the federal Nursing Home Reform Law enacted in 1987 in the Social Security Act. The law requires nursing homes to promote and protect the rights of each resident and places a strong emphasis on individual dignity and self-determination.
A facility provided document titled, Decision-Making Capacity Policy, dated 11/21/20, read in part, If the resident has Durable Power of Attorney (DPOA) or Patient Advocate paperwork established, the DPOA or Patient Advocate paperwork will be activated if the resident is deemed incompetent by two physicians. A copy of the paperwork will be uploaded to the resident's medical record. If the resident has no legal paperwork in place, the social worker will speak to the resident's family member and/or emergency contact about applying for guardianship through the probate court system. The social worker should document these conversations or attempts at conversations in the resident's medical record. If the family member and/or emergency contact is not interested in obtaining guardianship or fails to obtain guardianship, the facility, or contracted vendor, should petition the probate court system for a court appointed guardian. Once the family or court-appointed guardian is approved, a copy of the guardianship paperwork will be uploaded to the resident's medical record.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00139532, MI00139080
Based on observation, interview and record review, the facility failed t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00139532, MI00139080
Based on observation, interview and record review, the facility failed to provide food in the prescribed texture/consistency for one (R803) of four residents reviewed for therapeutic diets, resulting in the increased potential for episodes of choking and aspiration to occur. Findings include:
A complaint was filed with the State Agency (SA) that alleged in part, the facility did not provide the correct diet to R803.
On 11/14/23 at 12:28 PM, R803 was observed sitting in a wheelchair eating lunch. The food on the tray appeared to be pureed. R803 was asked if they had difficulty swallowing. R803 said yes. When asked how was the food at the facility, R803 made a noncommittal sound.
Review of the clinical record revealed R803 was admitted into the facility on 3/31/20 and readmitted [DATE] with diagnoses that included: dementia, diabetes and macular degeneration. According to the Minimum Data Set assessment dated [DATE], R803 had severely impaired cognition and required the extensive assistance of staff for activities of daily living (ADL's).
Review of R803's physician orders revealed a diet order with a start date of 9/26/23 for puree texture, thin consistency (liquids) and assistance with meals.
On 11/14/23 at 12:55 PM, Speech-Language Pathologist (SLP) F was interviewed and asked about R803's diet. SLP F explained she was new to the facility and had not had any interaction with R803 yet.
On 11/15/23 at 8:40 AM, R803 was observed sitting in a wheelchair in their room eating breakfast. On the divided plate there appeared to be pureed sausage and a piece of French Toast with the crust cut into large pieces and covered in syrup. The meal ticket on the tray had an orange sticker that said PUREED. The diet order listed Pureed Texture and was highlighted in yellow. Also highlighted in yellow was No Straw and 1:1 FEEDING ASSISTANCE. The list of items included, BREAKFAST ITEMS: P Sausage Link - 2 each; S French Toast, Crustless - 1 slice.
On 11/15/23 at 8:42 AM, Assistant Dietary Manager (ADM) G was interviewed, showed R803's meal ticket, and asked what S French Toast, Crustless meant. ADM G explained it meant the crust was cut off the piece of French Toast and it was pureed with liquid to create a slurry, so it was listed as S for slurry and the P was for puree. ADM G was asked to observe R803's breakfast tray in their room. Upon observing the tray, ADM G explained it was not correct, the French Toast was not the correct texture. At that time, ADM G walked out of the room and left the tray of food in front of R803, who was still eating.
On 11/15/23 at 8:45 AM, SLP F was asked to observe R803's breakfast tray. Upon entering the room, R803 was [NAME] a piece of French Toast with a fork. SLP F asked R803 if they were having difficulty eating their breakfast. R803 said yes. SLP F explained to R803 she was going to take the tray and bring one back they would have an easier time eating and picked up the tray and removed it from the room. SLP F explained she was going to go to the kitchen and get a tray that had the French Toast slurry for the resident to eat.
On 11/15/23 at approximately 1:00 PM, the Director of Nursing (DON) was interviewed and asked why, when R803's meal ticket from breakfast had an orange sticker saying puree and highlighted pureed texture, was the tray given to R803 with a whole piece of French Toast on it. The DON explained she had been told about breakfast, but R803 had not eaten any of the French Toast. The DON was informed R803 had a piece on their fork when SLP F was brought to their room. When asked who had cut the piece of French Toast and put syrup on it, the DON had no answer.
Review of a facility document titled, Facility Pureed Diet Plan undated read in part, .This diet consists of pureed, homogenous, and cohesive foods. Food should be pudding-like. No coarse textures, raw fruits or vegetables, nuts, and so forth are allowed. Any foods that require bolus formation, controlled manipulation, or mastication (chewing) are excluded .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00139462
Based on interview and record review the facility failed to ensure narcotic medicati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00139462
Based on interview and record review the facility failed to ensure narcotic medications were documented as administered per professional standards for one (R802) of one resident reviewed for professional standards resulting in the inaccurate representation of the amount given and the effectiveness of pain medications. Findings include:
A complaint was filed with the State Agency (SA) that alleged in part that R802's record was inaccurate/false.
Review of the closed record revealed R802 was admitted into the facility on 8/25/23 with diagnoses that included: fracture of left tibia, fracture of left fibula and multiple fractures of pelvis. According to the Minimum Data Set (MDS) assessment dated [DATE], R802 was cognitively intact and required the assistance of staff for activities of daily living (ADL's).
Review of R802's pain care plan initiated 8/26/23 revealed an intervention that read, Administer pain medication as ordered. Monitor for effectiveness.
Review of R802's August 2023, September 2023 and October 2023 Medication Administration Records (MAR's) revealed an order with a start date 8/25/23 for Oxycodone 10 milligrams (mg), give 1.5 tablet by mouth every 6 hours as needed for pain. The order was discontinued 8/31/23 and a new order with a start date of 8/31/23 for Oxycodone 10 mg, give 10 mg by mouth every 4 hours as needed for pain. The MAR's revealed some days the Oxycodone was given four times a day, and some days none were given.
Review of CONTROLLED DRUG RECEIPT/RECORD/DISPOSITION FORM (C2 Form) for R802's Oxycodone revealed the medication was removed from the supply of R802's medications multiple times daily. The directions on the form read, Every dose must be accounted for and requires charting on the Medication Administration Record.
Reconciliation of R802's MAR's and the C2 Forms revealed the following discrepancies:
8/26/23 the MAR documented doses administered at 8:58 AM and 9:23 PM. The C2 Form documented the medication removed at 8:30 AM, 2:30 PM and 9:30 PM. In addition to the 2:30 PM dose not documented on the MAR, the wrong date of 8/24 was written on the C2 Form.
8/27/23 the MAR documented two doses at 4:50 AM and 10:53 PM. The C2 Form had four medications removed at 4:30 AM, 8:30 AM, 2:30 PM and 8:50 PM.
8/28/23 the MAR had one dose at 7:00 AM. The C2 Form had two removed at 6:55 AM and 11:30 PM.
8/29/23 the MAR was blank (indicating no doses given). The C2 Form had two removed at 9:53 (unknown if AM or PM) and 11:40 (unknown if AM or PM).
8/30/23 the MAR was blank. The C2 Form had two removed at 9:00 AM and 6:00 PM.
8/31/23 the MAR had one dose at 10:02 PM. The C2 Form had four removed at 1:00 AM, 9:00 AM, 5:00 PM and 10:00 PM.
9/1/23 the MAR had three doses at 3:01 AM, 10:09 AM and 9:03 PM. The C2 Form had four removed at 3:00 AM, 9:00 AM, (illegible time), 9:00 PM.
9/5/23 the MAR was blank. The C2 Form had two removed at 9:00 AM and 10:00 PM.
9/6/23 the MAR had one dose at 6:35 AM. The C2 Form had three removed at 6:30 AM, 9:00 AM and 8:00 PM.
9/7/23 the MAR was blank. The C2 Form had three removed at 9:00 AM, 3:00 PM and 10:00 PM.
9/11/23 the MAR was blank. The C2 Form had two removed at 9:00 AM and 5:00 PM.
9/13/23 the MAR and C2 Form both had three doses given, however the one medication removed had no date or time removed on the C2 Form.
9/14/23 the MAR had two doses at 2:26 PM and 11:44 PM. The C2 Form had three removed at 9:00 AM, 2:00 PM and 11:24 PM.
9/15/23 the MAR had two doses at 12:02 AM and 10:37 AM. The C2 Form had four removed at 4:00 AM, 9:00 AM, 4:00 PM and 9:35 PM.
9/16/23 the MAR had one dose at 11:23 PM. The C2 Form had two at (illegible time) and 11:20 PM.
9/17/23 the MAR had one dose at 2:15 PM. The C2 Form had two removed at 9:00 AM and 2:00 PM.
9/18/23 the MAR had two doses at 12:12 AM and 9:53 AM. The C2 Form had four removed at (re-written over) 12:15 AM, 9:00 AM, 2:00 PM and 10:00 PM.
9/19/23 the MAR and C2 Form both had two doses given, however neither medication had a time they were removed on the C2 Form.
9/20/23 the MAR had two doses at 2:00 PM and 9:23 PM. The C2 Form had three removed at 9:00 AM, 4:00 PM and 9:00 PM.
9/21/23 the MAR had two doses at 9:55 AM and 11:34 PM. The C2 Form had three removed at 9:00 AM, illegible time and possibly 9:30 PM.
9/22/23 the MAR had one dose at 9:46 PM. The C2 Form had two removed at 9:00 AM and no time documented.
9/23/23 the MAR had one dose at 9:23 PM. The C2 Form had two removed at 10:00 AM (crossed out, but counted down on the sheet) and 9:20 PM.
9/24/23 the MAR was blank. The C2 Form had one removed at 12:00 unknown if AM or PM.
9/26/23 the MAR was blank. The C2 Form had one removed at 8:43 PM.
9/29/23 the MAR was blank. The C2 Form had one removed at 8:00 PM.
9/30/23 the MAR had two doses at 1:23 AM and 9:47 AM. The C2 Form had four removed at 1:23 AM, 10:30 AM 2:00 PM and 7:00 PM.
10/1/23 the MAR had three doses at 8:25 AM, 2:39 PM and 7:21 PM. The C2 Form had five removed at 12:00 AM, 4:18 AM, 8:00 AM, 3:00 PM, and (illegible time).
10/2/23 the MAR had two doses at 2:34 AM and 8:38 PM. The C2 Form had three removed at 2:30 AM, 11:19 AM and 8:38 PM.
10/3/23 the MAR was blank. The C2 Form had three removed at 9:00 AM, 2:00 PM and (unknown time).
Review of R802's progress notes revealed the Oxycodone doses that were documented on the MAR produced an Administration Note that documented R802's level of pain. There was also an additional Administration Note approximately one hour after that documented whether the pain medication was effective or not.
On 11/14/23 at 3:00 PM, the Director of Nursing (DON) was informed of the discrepancies found between R802's MAR's and C2 Forms. The DON explained she would look into the matter.
On 11/14/23 at 4:55 PM, Licensed Practical Nurse (LPN) A was interviewed and asked about the process of giving a narcotic medication. LPN A explained she first checked to see if the medication was due to be given, then she removes the medication from the locked narcotic box, documents the removal on the C2 Form, documents as given on the MAR and gives the medication to the resident. When asked if the medication could be just documented on the MAR or the C2 Form, LPN A explained it had to be on both the MAR and C2 Form.
On 11/14/23 at 5:00 PM, LPN B was interviewed and asked about narcotic medications. LPN B explained she would check to see if there was an order for the medication, and if it was due to be given, then would document the resident's pain level and documented the medication on both the C2 Form and the MAR. When asked if it had to be documented on both the C2 Form and the MAR, LPN B said yes.
On 11/14/23 at 5:10 PM, LPN C was interviewed and asked about narcotic medications. LPN C explained she would document pain level before, document on both C2 Form and MAR and document if the medication was effective or not after. When asked if the medication could just be on one, C2 Form or MAR, LPN C explained it had to be on both.
On 11/15/23 at approximately 1:00 PM, the DON explained she had reviewed all the documentation and had determined there had been no diversion of narcotics, but the documentation of the medication was not correct, the C2 Form and the MAR should contain the same times and doses given. The DON was asked if there was any type of audit done on C2 Forms to reconcile them to the MAR's. The DON explained she does do random audits of narcotic medications, but had been at the facility for less than a month.
Review of a facility policy titled, Documentation Policy undated, read in part, .Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation . Write legibly . Record date and time of entry .
Jun 2023
18 deficiencies
2 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
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #MI00135548
Based on interview and record review the facility failed to initiate necessary trea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #MI00135548
Based on interview and record review the facility failed to initiate necessary treatments for one (R155) of seven resident's reviewed for pressure ulcers, resulting in the worsening of a pressure wound to the spine. Findings include:
A complaint was filed with the State Agency (SA) that alleged R155 did not receive proper wound treatment for their pressure sores. The complainant reported that the resident was discharge from the facility on or about 2/16/23 and ended up in the hospital on 2/21/23 with unstageable wounds.
A review of R155's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: non-displaced fracture of the right femur A review of the resident's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (cognitively intact) and required extensive one to two person assist for most Activities of Daily Living (ADLs).
Continued review of R155's clinical record documented, in part:
1/17/23: Wound Rounds Note (authored by Wound Nurse Practitioner (NP) Z : I was referred by (name redacted) physician to consult re: back, hip, coccyx wounds .at the time of admission noted to have aforementioned wounds. Tx (treatment) and advanced pressure downloading interventions were implemented .T-Spine DTPI (deep tissue pressure injury), dark nonblanching, no drng (draining), no cellulitis, significant bony processes .Recommend Tx: foam dressing (an ultra-soft foam that protects and cushions wounds) 3 x/week .
1/24/23: Skin and Wound Evaluation: Type: .Pressure .Stage DTI .Location: Spine .Area: 1.8 cm, length 3.1, width 1.0 cm .Wound Bed .100% wound covered .Goal of Care: healable .Dressing appearance: missing.
1/31/23: Wound Rounds Note (authored by NP Z): .Pt. very resistant to turning/repositioning .T-spine previous DTPI now open stg 2 ulcer, .open area granular surrounding tissue fading darkness, slow blanching, scant drng, .recommend Tx: foam dressing 3x/week .
1/31/23: Skin and Wound Evaluation: Type .Pressure .Stage 2 .Location: spine .Wound measurements .Area: 1.8 cm .length 3.2cm .width .9 cm .
2/7/23: Wound Round Note (authored by NP Z ): .T-spine stg 3 ulcer .open area darkened with dark nonviable tissue, surrounding tissue darkened, minimal drng .recommend Tx: Apply M. (Medi honey gel) cover with foam dressing 3x week . *It should be noted that following a review of R155's treatment orders for the spine showed no documentation that an order for Medi honey gel cover with foam dressing 3x per week was implemented as noted in NP Z's note above.
A review of R155's Medication/Treatment Administration (MAR/TAR) record for February 2023 was conducted. The TAR indicated the following: cleanse spine with wound care and apply Medi honey gel and cover with foam gauze change 3 times a week. Every day shift every Tues, Thu, Sat for wound care. Start date 2/9/2023 .D/C date 2/8/2023. There was no indication that this treatment was provided to the resident.
2/14/23 Wound Care Note: (authored by NP 'Z): .T-spine ulcer unstageable. Covered with dark necrotic eschar (dead tissue) .Recommend: Apply M. Honey cover with dry dressing daily and prn.
2/14/23 Skin and Wound Evaluation: .Type .Pressure .Stage: Unstageable .location: spine .Area: 10.6 cm .Length 13.8 cm .width 1.7 cm .
On 6/29/23 at approximately 2:33 PM, a phone interview and record review were conducted with Wound NP Z. NP Z reported that they do not work exclusively for the facility but are in the building generally on Tuesdays to work with residents referred by the facility staff. NPZ was asked about R155 and their recommendation dated 2/7/23 for R155 to receive Medihoney, NP Z stated that to their knowledge the treatment recommendation should have been followed. NP Z was noted that they were not able to review R155's MAR/TAR. NP Z was asked if failure to provide the recommended treatment possibly led to the decline in the resident's pressure ulcer on their spine from a stage II to unstageable. NP Z noted again that R155 should have received the recommended Medihoney treatment. NP Z noted that after reading their notes, that R155 often refused to be turned. When asked where that information came from, NP Z stated that it might have been something I observed myself and/or reported to me by staff. When asked if the R155 ever declined treatment, NP Z stated that they did not. *It should be noted that there were no nurses' notes indicating the resident's refusal to be turned.
On 6/29/23 at approximately 2:51 PM, an interview and record review were conducted with the Director of Nursing (DON). The DON was queried as the facility's protocol for ensuring resident's receive necessary treatments for wounds. The DON reported that NP Z works at the facility generally on Tuesdays along with Wound Nurse P. After rounds, NP Z will give verbal orders and it should be uploaded to the electronic record. When asked about R155, the DON reviewed the resident's record and stated that the recommendation was not placed correctly into R155's record and thus was not given. When asked if the treatment should have been provided to prevent a decline , the DON stated Yes.
The facility policy titled, Skin and Wound Policy (revised 1/22) was reviewed and documented, in part: Policy: it is our policy to perform a full body skin assessment .as part of our systematic approach to pressure injury prevention and management. It is also our policy to follow the treatment plans for any wound/skin concerns as ordered by physicians .wound treatments will be provided in accordance with physician orders, including cleansing method, type of dressing and frequency of dressing change .
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
Incontinence Care
(Tag F0690)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #MI00134725
Based on observation, interview and record review the facility failed to timely rev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #MI00134725
Based on observation, interview and record review the facility failed to timely review abnormal lab results for one (R58) out of four residents reviewed for Urinary Tract Infection (UTI) resulting in a delay in treatment for a UTI and hospitilization.
Findings include:
A complaint was filed with the State Agency (SA) that alleged R58 had a UTI (urinary tract infection) that was left untreated resulting in R58 being sent to the hospital on 1/29/23 after they were observed with a change in mental status.
On 6/27/23 at approximately 10:45 AM, R58 was observed lying in bed. The resident was alert but not able to answer most questions asked including a history of UTI(s) or Hospitalization. The resident expressed that they were in pain but were not able to activate their call light with their hand. A nurse was asked to come assist the resident.
A review of R58's clinical record noted the resident was initially admitted to the facility on [DATE] with diagnoses that included, in part: heart disease, brain and bone cancer and depressive disorder. A review of the resident Minimum Data Set (MDS) noted the resident was significantly cognitively impaired and required extensive one to two person assist for most activities of daily living (ADL) and was incontinent of both bladder and bowl.
Continued review of R58's clinical record revealed, in part, the following:
1/21/23: Nursing Note: .wife told writer she noticed resident has pain on groin when urinating. Logged the complains<sic> in MD (medical doctor) book .
1/23/23: Physician Team: (R58) is seen today for general medical visit . family report that he has groin pain with urination. On my arrival he is groaning in pain as CENA (certified nursing assistant) is washing him up. He admits to pain with using the bathroom .will order a UA (urinalysis) to r/o (rule out) infection .
1/24/23: Spoke with (MD HH) to review Urinalysis .
1/25/23: Physician Team: .R58 is seen today for .f/u (follow up) on pain and urinary complaints .UA obtained to r/o (rule out) infection, and it appears contaminated .
1/27/23: Laboratory Results: 1/27/23 (9:57 PM) Culture, Urine .Reviewed (1/29/23 at 8:26 AM) .Collection Date .1/24/23 .Reported date: 1/27/23 .Ord. Provider: Dr. HH Results for R58 . Culture, Urine . Escherichia Coli .>100,000 .Source: Urine, Clean Catch.
1/27/23: Nursing Progress Note: Labs placed in MD book for review.
1/27/23: Nursing Progress Note: While giving resident afternoon pain pill, resident was reluctant to take water .
1/29/23: Nursing Progress Note: .checked with Dr. HH to clarify she was aware of urine culture results No new orders received. Dr. HH said she would review notes .
1/29/23: Physician Team: Results of urine culture reveals a single, pan-sensitive E. Coli He is afebrile, allergic to penicillin, has chronic kidney disease .Use of IM (intramuscular) gentamicin (an aminoglycoside used to treat serious bacterial infections) .as a single dose could be used if he develops more symptoms. I will evaluate him in the morning. *It should be noted that IM gentamicin was not provided to the resident.
1/29/23: Nursing Progress Note: .Assign CENA notified writer resident did not eat breakfast .family came in around lunch and have concerns of residents .mental state. Log for physician to contact family .
1/29/23 (6:07 PM): Nursing Progress Note: .Pt. (patient) observed with stroke like symptoms .Pt sent to (name redacted Hospital) .
A facility Concern Form along with an attached e-mail was reviewed and it documented, in part: .Date received: 2/7/23 .Documentation of Concern .per hospital record family expressed quality of care .(R58) positive for UTI .e-mail .Patient was reportedly positive for UTI on 1/24 as tested by facility, however the UTI was left untreated .patient was hospitalized 1/29. Patient was discovered by family member to be unresponsive in his room, contracted and lying in bed .
Hospital records dated 1/29/23 were reviewed and documented, in part: (R58) presents with complaint(s) of Altered mental status .stopped eating 2 days ago .spoke with patient's sister .she notes last week (R58) was complaining of burning with urination. A UA (urinalysis) and UC (urine culture) were completed on 1/24/23 with E-Coli (bacteria that originates in the intestine and migrated to the bladder causing UTIs) . She notes (R58) did not get ABX (antibiotics) at the facility. She notes he subsequently started eating and drinking less .Reported fever at facility .Temp 100.2.admitted to our hospital secondary to worsening levels of alertness, reduced oral intake .sepsis, complicated UTI .The patient was identified to have a UTI with E. coli .Infectious Disease Consultation .Date of admission 1/29/23 .Date of Consultation .1/30/23 .urine cultures form 1/24/23 had recovery of E. coli .Empiric antibiotic therapy consisting of Vancomycin and Cefepime has been initiated .
On 6/28/23 at approximately 5:22 PM and 6/29/23 at approximately 9:19 AM, attempts were made to contact Dr. HH via phone. While a return call was attempted by Dr. HH no phone interview was conducted before the end of the Survey. *It was noted by the facility that Dr. HH was no longer providing physician services at the facility.
On 6/29/23 at approximately 9:43 AM an interview and record review were conducted with Medical Director (MD) K. MD K again reported that Dr. HH no longer provided services at the facility. MD K was asked as to the facility policy/protocol for reporting lab results to resident's physicians. MD K noted that abnormal lab results should be reported immediately to a resident's treating physician. When asked if R58's lab results (Friday: 1/27/23) should have been reviewed on the date reported as they noted the resident was positive for E Coli, MD K reported they should have. MD K stated that sometimes the results end up in the logbook, however the physicians also need to be contacted especially when results arrive on the weekend. When asked if a quicker response to the positive E. Coli results (1/27/23) may have prevented R58 change in condition and hospital stay, MD K noted that an earlier antibiotic treatment might have been helpful.
On 6/29/23 at approximately 3:23 PM, an interview was conducted with the Director of Nursing (DON). The DON was queried as to the protocol/policy pertaining to lab results. The DON reported that the facility is to timely report the results of abnormal lab results so as not to delay any necessary treatment.
The facility policy for labs results was reviewed and documented, in part, as follows:
Policy: It is the policy of this facility to promptly notify the attending physician or physician extender of laboratory values .Explanation and Compliance Requirements: The facility must promptly notify the attending physician of lab results. Delayed notification may contribute to delay in changing the course of treatment or care plan. The lab will determine parameters for Panic/Abnormal or Normal lab results .Abnormal notifications: a. Notify physician or physician extender with lab result and resident current condition. b. Add Review to document notification of result(s) and condition (date, time, name of individual reported to, new orders if applicable) .Physician or physician extender will sign off on .Abnormal lab result .5. If there is not response from the physician or physician extender within 2 hours of notification of Panic/Abnormal lab, contact the Director of Nursing or his/her designee for further instructions.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure medication administration was performed according to professional nursing standards of practice for two (R90 and R253)...
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Based on observation, interview, and record review, the facility failed to ensure medication administration was performed according to professional nursing standards of practice for two (R90 and R253) residents. Findings include:
On 6/28/23 at 8:24 AM, Nurse 'JJ' was observed passing medications to R90's roommate. After passing medications to R90's roommate, Nurse 'JJ' entered R90's side of the room carrying a cup of medications to administer to R90. At that time, Nurse 'JJ' took R90's vital signs and discovered their heart rate was low. Nurse 'JJ' took the medication cup to the medication cart and removed a tablet from the cup and discarded it and then administered the remaining medication to R90. When queried about when medications should be prepared, Nurse 'JJ' reported medications were prepared at the time of administration. When queried about when vital signs were taken to determine whether a medication with parameters was required or needed to be held, Nurse 'JJ' reported vital signs were taken before preparing the medication. When queried about why Nurse 'JJ' had R90's medications with them when they were administering the roommate's medications, Nurse 'JJ' reported they were not supposed to prepare medications like that and should have prepared R90's and R90's roommate's medications individually.
Review of R90's clinical record revealed R90 was admitted into the facility on 6/7/23 with diagnoses that included: peripheral vascular disease, acquired absence of other right toe, and legal blindness.
On 6/27/23 at 9:55 AM, R253 was observed sitting upright in bed. Nurse 'X' was observed securing a nebulizer aerosol mask to cover R253's nose and mouth. Medication was administered via the nebulizer at that time. At 10:00 AM, there was no nurse observed in R253's room and R253 had the nebulizer mask secured to their face with medication being delivered via nebulizer. At 10:19 AM, R253 was observed with the nebulizer mask removed from their face and lying on their chest. The nebulizer remained on. When queried about whether they completed their breathing treatment, R253 reported they did not know and explained they removed the mask because it was pinching my eye. At that time, a plastic cup that contained multiple tablets of medication was observed on R253's over bed table. When queried about the cup of medication, R253 reported they did not know what medications were in the cup and that the nurse left it on the table. R253 stated, They left the medicine and said to take it, but I couldn't take it with the mask (nebulizer) on.
On 6/27/23 at 12:11 PM, an interview was conducted with Nurse 'X'. When queried about the proper way to administer a nebulizer/breathing treatment, Nurse 'X' reported they were supposed to stay in the room with the resident until the treatment was complete. When queried about whether medications were supposed to be left at the resident's bedside, Nurse 'X' reported they should observe the resident to ensure the medication is taken. When queried about why that did not happen with R253, Nurse 'X' did not offer a response.
Review of R253's clinical record revealed R253 was admitted into the facility on 6/13/23 with diagnoses that included: heart failure, Alzheimer's disease, hemiplegia, chronic pulmonary edema, and chronic respiratory failure.
On 6/28/23 at 11:41 AM, an interview was conducted with the Director of Nursing (DON). When queried about procedures for administering a nebulizer treatment, the DON reported the nurse assessed the resident before and after the treatment and sat with the resident for the duration of the treatment unless they were assessed as appropriate to self administer medications. The DON further explained medications were not supposed to be left at the bedside and the nurse was to watch to ensure the resident took the medications. The DON confirmed R253 was not assessed as appropriate for self administration of medications.
A policy regarding medication administration was requested from the Administrator. A policy was provided regarding medication orders and timeliness of administration, but did not address medication administration protocols related to the deficiency.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #MI00136649
Based on interview and record review, the facility failed to ensure a resident was ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #MI00136649
Based on interview and record review, the facility failed to ensure a resident was adequately prepared for discharge home for one (R156) of three sampled residents reviewed for discharge planning from a total of three, Findings include:
A complaint was filed with the State Agency (SA) that alleged R156 was discharged from the facility without their necessary pain medication, insulin and medical equipment. The complainant reported that R156 suffered from a spinal injury that caused severe pain. They further reported that R156 did not receive a shower chair, grab bars and an extended toilet seat prior to their discharge resulting in the resident not being able to take a shower at home.
A review of R156's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: end stage renal disease, spinal injury.
Continued review of R156's record revealed, in part:
Discharge Summary & Instructions: .discharge date : [DATE] .Medical Equipment Arrangements:2. Yes-arranged .Medical equipment ordered: ShCh (shower chair), .Equipment already in home (answer was blank) cognitive: .Cooperative .Behavior appropriate .Toilet Use .3. Assistance x1 .Bathing .Assistance x1 Where Medication Orders given? YES .
A second Discharge Summary & Instructions (lock date 5/12/23) documented: .discharge date : [DATE] .Discharge to home alone .Medical Equipment Arrangements: .Yes -arranged .equipment already in home (blank) .
A Controlled Drug Receipt/Record/Disposition Form located in R156's electronic record noted the following: Hydrocodone .take 2 tablets every 6 hours as needed .5/12/23 .left 22 and Gabapentin cap 100MG .take 2 capsules by mouth .5/12/23 .left 14 . *It should be noted that there was no indication of the forms that the remaining medication was sent with R156 upon discharge.
On 6/29/23 at approximately 10:15 AM, an interview was conducted with Social Worker (SW) AA. SW AA noted that they were familiar with R156's discharge and that the resident had submitted information that noted they did not receive their necessary medications and necessary equipment upon discharge. SW AA reported that nursing staff are responsible for the ensuring the proper medication is provided to a resident upon discharge but again noted that they were aware of a glitch in providing pain medication upon discharge and/or ensuring a proper script was timely provided. With respect to the medical equipment, SW AA noted that due to R156's insurance status they did not receive all the discharge equipment needed. SW AA reported that a representative from (name redacted) human service agency was trying to obtain the necessary medical equipment, but still had not provided all the necessary equipment.
On 6/29/23 at approximately 11:37 AM, an interview was conducted with the Director of Nursing (DON). When asked as to the facility policy/protocol to ensure residents with a planned discharge receive their necessary medications and/or equipment, the DON reported that for those residents on Medicaid they generally will be given all the medication they have left in the building and also physicians can provide them with scripts for their medications. With respect to R156, the DON reported that they should have been given R156 their remaining medications, including their pain meds.
On 6/29/23 at approximately 5:20 PM, the DON provided via email: Controlled Drug Receipt/Record/Disposition Form that documented, in part, the following: Hydrocodone .take 2 tablets every 6 hours as needed .5/12/23 .left 22 and Gabapentin cap 100MG .take 2 capsules by mouth .5/12/23 .left 14 . *It should be noted that unlike the form noted in the resident's electronic record the form provided by the DON had wording that noted the medication (14 Gabapentin sent with the patient/ 22 hydrocodone sent home with the patient).
The facility policy titled, Transfer and Discharge (8.8.22) was reviewed and documented, in part: .Compliance Guidelines: .The facility may initiate transfers or discharges in the following limited circumstances: .The resident's heal has improved .6. Non-Emergency Transfers or Discharges .at least 30 days before the resident is transferred or discharged , the Social Service Director will notify the resident .9. Anticipated Transfers or Discharges .The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes .Reconciliation of all pre-discharge medication with the resident's post-discharge medications .a post discharge plan of care that is developed which will assist the resident to adjust to his or her new living environment .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation has two deficient practices.
Deficient practice #1.
This citation pertains to Intake #MI00137787 and MI00137804.
...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation has two deficient practices.
Deficient practice #1.
This citation pertains to Intake #MI00137787 and MI00137804.
Based on interview and record review the facility failed to ensure neuro checks were completed following a resident's fall causing injury to the head for one (R162) of seven residents reviewed for falls/accidents. Findings include:
A Complaint was filed with the State Agency (SA) that alleged on 2/23/23 they observed R162 with a bruise on the left side of their head. The Complainant noted that staff did not know what happened, but told them they put R162 back to bed at about 7:00 PM on 2/22/23 and did not provide medical attention. On 2/23/23 the resident was transferred to the hospital and diagnosed with a subdural hematoma and a concussion.
A facility policy titled, Neurochecks on those Residents who Hit their Head (10/1/2017) was reviewed and documented, in part: .Policy: Any resident who sustains a fall with head involvement shall have neurochecks times 48 hours .Any resident who sustains a fall with involvement in the head area shall have a neurocheck using the Neuro Flow Sheet as follows: a. Initially then every hour for two hours. b. Every 2 hours times 3. C. Every 4 hours times 4. D. Every shift for the next day (24 hours) .Each time a neurocheck is done the following items must be checked: a. Vital signs b. LOC (altered level of consciousness). C. pupils .d. Grasps e. any complaint of blurred vision, headache or nausea .Document all findings on neurocheck list .5. Neurocheck is currently scanned and found in the document management section of the electronic record .
A review of R162's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: right frontal brain mass with craniotomy. The clinical record noted the resident had a Brief Interview for Mental Status (BIMS) score of 12/15 (moderately cognitively impaired) and required two person assist for transfers.
Continued review of the clinical record revealed, in part:
2/22/23 (6:56 PM) Nursing Progress Note: Patient tried to get out of bed while eating dinner. No bruising or wounds from injury. Neuro checks were started at 7 PM. *It should be noted that no neuro checks were found in the resident's electronic record. The vital section of the electronic record noted the last vitals taken for R162 were done on 2/22/23 at 8:19 AM.
2/23/23 (3:49 PM) Physical Medicine and Rehabilitation: Late Entry .patient is generally sleepy during my exam .daughter reports that there was an incident overnight which ended with R162 having a swelling/ecchymosis (discoloration) over the left side of their head .we are unclear on this story as it was unwitnessed, but nursing did document that patient had a fall last night.
2/23/23 (3:45 PM) Nursing Progress Note: Resident sent out to hospital due to mental status change, resident sent to (name redacted) hospital .
Incident/Accident (IA) Report: .Writer interviewed assigned nurse who stated that upon entering the room R162 was facing the floor with legs partially on the bed and head touching the floor .Nurse said R162 was trying to answer phone that was on opposite side of the bed .stated that they bumped their head . 2/22/23 (7 PM).
A review of R162's Hospital records noted, in part, the following: .R162 is presenting with increased confusion over the last day and a fall. Patient sustained a head injury yesterday at his care facility with story altering from being pushed and falling on his own. Family notes that he is more confused than normal and is typically AxOx4 .Hospital Principal Problem (Discharge Diagnoses) 1. Fall with head trauma and altered mental status .Functional History: .requiring max assist for bed mobility and mod-max assist x people to stand .Mental Status Examination .Patient is drowsy and not arousable. Mood is confused .Patient. is hallucinating delusional times .Patient was seen in bed, alert and pleasant but confused .mentioned that this is not patient's baseline and prior to fall, the patient was recovering from .surgery, but was not confused .2/23/23 .had emesis x1 .
On 6/29/23 at approximately 11:30 AM, an interview and record review were conducted with the Director of Nursing (DON). The DON was queried as to the facility protocol following a fall. The DON reported that if a fall was not observed and/or if the resident hit their head, Nursing staff should complete neuro checks per their policy. The DON was asked if they were able to locate any documentation on the electronic record that noted neuro checks were completed. The DON could not find any documentation. The DON then contacted the medical record's department to determine if there was any paper documentation noting neuro checks were completed. The medical record's department was not able to find any documentation. When asked if neuro checks should have been completed, the DON reported that they should have been.
Deficient Practice #2
Based on observation, interview, and record review, the facility failed to perform skin and wound assessments consistently, administer wound treatments according to physician's orders, and clarify and discontinue orders for a Jackson Pratt (JP) drain (a device to drain fluids from a surgical site) for one (R90) of one resident reviewed for non-pressure skin conditions. Findings include:
On 6/27/23 at 10:04 AM, R90 was observed lying in bed. An interview was conducted with R90 regarding their care in the facility. R90 expressed concern that the bandage on their right foot where they had toes amputated had not been changed since they last saw the surgeon. R90 further reported they had surgery and used to have a drain in their leg, but it was removed. A healed incision (scar) was observed on R90's right leg.
On 6/28/23 at approximately 8:15 AM, R90 was observed lying in bed. R90 reported nobody had changed the bandage on their right foot.
On 6/28/23 at 8:24 AM, an observation of the bandage on R90's right foot was performed with Nurse 'X'. No date was written on the dressing applied to R90's right foot. When queried about who was responsible to perform R90's wound care, Nurse 'X' reported they were not sure who would do the dressing change.
On 6/28/23 at approximately 8:45 AM, the Director of Nursing (DON) was notified that an observation of R90's wound care was needed.
On 6/28/23 at approximately 9:15 AM, the DON and Nurse 'P', the facility's wound care coordinator, reported Nurse 'P' already did R90's dressing change. When queried about whether Nurse 'P' saw a date on the dressing applied to R90's right foot when they performed wound care, Nurse 'P' reported the dressing was not dated. At that time, R90's Treatment Administration Record (TAR) was reviewed with Nurse 'P' and the DON and it revealed that prior to 6/28/23, R90's wound treatment had not been completed since 6/25/23. Based on that documentation and the lack of date on R90's dressing, the DON and Nurse 'P' reported they were unable to determine that R90 received any wound treatment to their right foot since 6/25/23. The DON reported if the treatment was done, the nurse should have signed off on the TAR that it was completed. Further review of R90's TAR revealed the wound treatment to R90's right foot was not done on 6/13/23, 6/16/23, 6/17/23, 6/18/23, 6/20/23, 6/23/23, 6/24/23, 6/26/23, and 6/27/23. The physician's order read, Wound Gel External Gel .Apply to right foot surgical area topically every day shift for surgical. Cleanser with wound cleanser pat dry. Apply wound gel and cover with dry dressing. Wrap with kerlix daily.
Further review of R90's Physician's Orders and TAR revealed active orders to Cleanse area around JP drain daily with wound cleanser, pat dry. Cover with dry dressing every night shift for surgical.
Further review of R90's clinical record revealed the last documented Total Body Evaluation was completed on 6/7/23, 21 days earlier. There was no documented assessment of R90's surgical wound to their right toes.
On 6/28/23 at 11:41 AM, an interview was conducted with the DON. The DON reviewed R90's clinical record and confirmed there were no documented wound assessments for R90. When queried about whether R90 still had the JP drain, the DON indicated he did not. When queried about why there was an active order to cleanse the area around the JP drain, the DON reported it needed to be discontinued.
Review of R90's clinical record revealed R90 was admitted into the facility on 6/7/23 with diagnoses that included: peripheral vascular disease, acquired absence of other right toe, and legal blindness. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R90 had moderately impaired cognition and no behaviors, including rejection of care.
Review of a facility policy titled, Skin & Wound Policy dated 4/2022, revealed, in part, the following: A full body, or head to toe, skin and oral cavity assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter .Wound treatments will be provided in accordance with physician orders .Treatments will be documented on the Treatment Administration Record .The effectiveness of the treatments will be monitored through ongoing assessment of the wound .
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 #'s MI00136943 and MI00136471.
Based on observation, 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 #'s MI00136943 and MI00136471.
Based on observation, interview, and record review, the facility failed to perform a wheelchair transport in a safe manner and thoroughly investigate the root cause of an injury; and failed to follow the plan of care for two (R4 and R110) of eight Residents reviewed for accidents hazards, resulting in an injury (bruising, redness, swelling, and pain) to R4's ankle and potential for further falls. Findings include:
R4
On 6/27/23 at 10:48 AM, R4 was observed in their bed. An interview was conducted at that time. When queried about their care in the facility, R4 reported they had pain in their leg due to an incident that occurred with the physical therapist the week prior. R4 explained that the therapist had them in a wheelchair and it did not have foot rests. R4 reported the therapist instructed them to place their right foot on top of their left foot and began rolling the wheelchair. R4 explained their right food fell off of their left foot and went under the wheelchair as the therapist pushed the wheelchair forward. R4 yelled for the physical therapist to stop pushing the wheelchair. Later when R4 was back in their room, they experienced pain in their right foot and it turned purple and was bruised and swollen. R4 stated, It still hurts!.
Review of an incident report for R4, completed by Nurse 'KK', dated 6/15/23 revealed, Writer called to room, observed resident's right leg swollen and bruised. Resident stated therapy was pushing her down the hallway, she didn't have any leg rest on her wheelchair, resident stated therapist told her to cross her right leg over her left, when the right leg fell off the other leg, she stated as the therapist pushed her, her leg went under the wheelchair .
On 6/28/23 at 4:58 PM, an interview was conducted with Nurse 'KK'. When queried about the incident that happened to R4 on 6/15/23, Nurse 'KK' reported R4 asked them to look at their leg and said when the physical therapist took them in the wheelchair there were no footrests. The therapist asked R4 to cross their legs and their leg came uncrossed and went under the wheelchair as it was being pushed. Nurse 'KK' explained that R4 reported they yelled for the therapist to stop . Nurse 'KK' reported when they assessed R4's leg, it was red, swollen, and bruised from the ankle up the leg and was warm to touch.
On 6/29/23 at 12:15 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked about any investigation that was done to look into the incident documented on the incident report for R4 on 6/15/23. The DON reported the therapy director had completed an investigation and would provide it. The DON stated, It was a one time occurrence and education was done.
Review of a Witness Statement written and signed by Physical Therapy Assistant (PTA) 'LL' on 6/16/23 revealed the following: .PTA taking pt (patient) back to room. Pt's leg fell off leg rest, pt stated, Stop. PTA stopped and placed RLE (right lower extremity) back on leg rest. PTA asked pt is she was ok or in pain. Pt stated she was ok and had no pain. PTA brought pt to her room and left her in w/c (wheelchair) and removed leg rests.
On 6/29/23 at 1:56 PM, an interview was conducted with PTA 'LL'. When queried about what happened with R4 during wheelchair transport on 6/15/23, PTA 'LL' stated, I did not see her leg at any time go under the wheelchair. PTA explained they were bringing R4 back to their room in a wheelchair, R4 said to Stop!. PTA reported R4 had leg rests and that R4 did not like one of the leg rests. When queried about why R4 said there were no leg rests used, PTA 'LL' reported R4 was not telling the truth. When queried about how R4's leg ended up bruised, red, and swollen afterwards, PTA 'LL' reported R4 did not report any pain to them.
On 6/29/23 at approximately 2:00 PM, the DON was further interviewed. When queried about whether anyone investigated to see if R4's wheelchair did in fact have foot rests, the DON indicated they did not.
Review of R4's clinical record revealed R4 was admitted into the facility on 9/18/20 and readmitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease and bilateral primary osteoarthritis of the knees. Review of a MDS assessment dated [DATE] revealed R4 had intact cognition and required limited assistance with locomotion in the wheelchair.
R110
R110 was admitted to the facility on [DATE]. R110's admitting diagnoses included Stroke with left sided weakness, glaucoma, legal blindness, dementia, aphasia (inability to speak or comprehend due to damage to the brain) and dysphagia (difficulty swallowing food). R110 had a Brief Interview of Mental Status (BIMS) 00/15, indicative of severe cognitive impairment. R110 was receiving their nutrition through Percutaneous Endoscopic Gastrostomy (PEG) tube (A tube inserted through the wall of the abdomen directly into the stomach. It allows air and fluid to leave the stomach and can be used to give drugs and liquids, including liquid food, to the patient).
Review of R110's Electronic Medical Record (EMR) revealed a Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/16/22. MDS assessment revealed that R110 needed extensive assistance from two staff members to assist with their positioning and mobility in bed. R110 was totally dependent on two staff assistance with their toileting. Review of R110's [NAME] read, Bed mobility - 2 person assist. Review of R110's care plan revealed R110 was at risk of falls due to impaired safety awareness due to impaired cognition, vision, and comprehension.
Further review of R110's EMR revealed a nursing progress note dated 6/9/23, that read in part, Resident alert with some confusion. Resident is mostly non-verbal, but does appear to think and process questions when asked. Approximately 6:20 am, Writer was passing am meds and heard a noise in resident's room. Writer called out to assigned CENA, what's wrong? CENA responded '' (omitted) on the floor. Writer asked CENA (Certified Nursing Assistant) what happened? and CENA responded ''I turned (omitted) over to change (omitted) and (omitted) rolled out of bed''. Resident noted lying face up on floor on window side of bed eyes open. Resident was alert and writer asked if (omitted) hit (omitted) head? Resident answered'' no'' CENA stated also that resident did not hit (omitted) head. Writer assessed resident for injuries. No injuries noted .
Incident report and facility investigation was requested on 6/28/23. Incident report received via e-mail revealed the description of the incident as noted in the above paragraph. The facility did not have any additional documentation on the investigation, root cause analysis, and follow up after the incident.
Nursing Progress note dated 6/11/23 completed at 19:19 read, Xray of head/neck, and right hip requested by (relationship omitted) and (relationship omitted). Ordered by MD (Name Omitted), on call NP.
An initial observation was completed on 6/27/23 at approximately 4:10 PM. R110 was observed in their bed. R110's head of the bed was up partially. R110 was not responding appropriately to any questions. A facility signage on the resident message board read, Transfers - Hoyer.
Locomotion - Geri chair; Bed mobility - x 2; Toileting - Bed Level x 2.
A second observation was completed on 6/28/23, at approximately, 12:45PM. R 110 was observed in their bed with their eyes closed. A private duty care giver GG was sitting next to R110's bed. Pvt duty care giver GG was interviewed during this observation. Care giver GG was arranged by R110's family and they reported that they had been providing care for R110 for approximately two years. The care giver was queried about the fall. Care giver GG reported that R110 rolled out of their bed on the right side, during care. Care giver GG Reported that R110 needed two-person assistance and the care giver was providing assistance without a second staff member.
An interview was completed with Director of Nursing (DON) on 6/29/23 at approximately 1 PM. The DON was queried about R110's fall incident. DON reported that, if a Resident's plan of care indicated two-person assistance, there should have been two staff members. The staff member did not have a second person to assist R110 during the incident. The DON verified and confirmed that the staff member no longer worked at the facility, after the incident.
A facility document titled Accident and Incident Report, dated 6/20/22, read in part,
The purpose of this policy is:
(a) to comply with State and Federal rules.
(b) to provide prompt medical care for injured residents.
(c)to monitor frequency, severity and location of resident incidents/accidents.
(d) to look for Facility or resident trends.
(e) to properly care plan for residents.
(f) to prevent a re-occurrence of a similar incident.
(g) to provide timely follow-up of corrective measures.
(h) to evaluate the efficacy of the corrective measures; and
(i) to provide an immediate reference source for a more thorough investigation (if needed).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure assessment and monitoring of hydration for one ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure assessment and monitoring of hydration for one (R51) of one resident reviewed for hydration. Findings include:
On 6/27/23 at 9:51 AM, R51 was observed lying in bed. An intravenous (IV) catheter was observed in R51's right wrist connected to an IV bag of 0.9% Sodium Chloride Injection USP (United States Pharmacopoeia) hanging on a pole.
Review of the clinical record revealed R51 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: kidney disease, dementia and stroke. According to the Minimum Data Set (MDS) assessment dated [DATE], R51 had moderately impaired cognition and required the extensive assistance of staff for activities of daily living (ADL's).
Review of R51's nutritional care plan initiated 6/14/23 revealed an intervention that read, Offer food and beverage selections.
Review of R51's June 2023 Medication Administration Record (MAR) revealed an order dated 6/26/23 that read, Sodium Chloride Intravenous Solution 0.9 % (Sodium Chloride), Use 75 ml/hr (milliliters/hour) Intravenously every shift for Dehydration x2 Liters. An additional order dated 6/20/23 read, Sodium Chloride Solution 0.9%, Use 75 ml/hr intravenously every shift for dehydration for 1 Day administer 2 L (Liters). Both orders were documented as given.
Review of R51's progress notes revealed:
A Nursing Note dated 6/21/23 at 12:35 AM read in part, IV access initiated on the Left forearm and resident started on Sodium Chloride Solution 0.9 % 2L for dehydration, bag 1 of 2 infusing at 75 ml/hr .
A Physician Team Note dated 6/23/23 at 2:25 PM read in part, .Patient received 2 L IVF (intravenous fluid) per lab results elevated BUN (blood urea nitrogen) and CR (creatinine) . Per patient poor appetite, RD (Registered Dietitian) following . LABS AND DIAGNOSTICS: 6/19- . BUN 31, CR 2.46 . It should be noted that elevated BUN and CR levels can indicate dehydration.
A Physician Team Note dated 6/26/23 at 1:33 PM read in part, .Labs reviewed and IVF ordered due to elevated BUN and CR . Per patient poor appetite, RD following . LABS AND DIAGNOSTICS: .6/26- . BUN 27, CR 2.01 .
Further review of R51's progress notes revealed one Dietary Note dated 12/14/21. No other Dietary progress notes were found.
On 6/28/23 at 2:29 PM, RD J was interviewed and asked about R51 receiving 2 L of IVF two separate times. RD J explained she had been notified about R51 receiving 2L of IVF on 6/27/23, but had not known about R51 receiving 2 L of IVF on 6/20/23 . had seen R51 on 6/27/23 and brought her ice water and ice cream . R51 drank the ice water like she was thirsty and ate all the ice cream. When asked what was being done to prevent further dehydration, RD J explained she would have to look into it a little more, but would add more liquids to R51's meal trays.
On 6/28/23 at 3:22 PM, Dr. K, R51's attending physician, was interviewed and asked about R51 receiving 4 L of IVF in a week's time. Dr. K explained R51's BUN and CR indicated dehydration, so IVF was ordered. When asked about the Physician Team progress notes documented that the RD was following, but RD J saying she was unaware of R51's dehydration and IVF order, Dr. K explained there appeared to be a lack of communication, that everyone should be aware and that all staff should be encouraging the resident to drink more fluids.
On 6/29/23 at 9:05 AM, Certified Nursing Assistant (CNA) L was interviewed and asked how she knew if a resident needed encouragement to drink fluids. CNA L explained the nurse would tell the CNA's if someone needed encouragement to drink fluids.
On 6/29/23 at 9:29 AM, CNA M was interviewed and asked how she knew if a resident needed encouragement to drink fluids. CNA M explained all residents should be encouraged to drink fluids, but the nurse would tell them in the morning if there was anyone that needed extra encouragement.
On 6/29/23 at 9:15 AM, the Director of Nursing (DON) was interviewed and asked about the apparent lack of communication with R51's first 2 L of IVF and then the subsequent second 2 L of IVF needed. The DON explained she would look into the matter. The DON was asked if a resident would readily drink fluids, like when RD J gave R51 ice water, should staff be encouraging the resident to drink more fluids. The DON agreed they should.
No further information was provided prior to the end of the survey.
Review of a facility policy titled, Hydration dated 9/29/17 read in part, .It is the policy of this Facility to provide ample fluids to all residents . Fluid needs will be evaluated by the dietitian on the initial nutritional assessment, annual nutritional assessment, and as needed. If the resident is deemed to have higher fluid needs, the dietitian may adjust the fluids provided at meals accordingly .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #MI134568
Based on observation, interview and record review, the facility failed to ensure cons...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #MI134568
Based on observation, interview and record review, the facility failed to ensure consistent communication between the hemodialysis center and the facility for one (R152) of three residents reviewed for dialysis. Findings include:
A complaint was filed with the State Agency (SA) that alleged R152 had missed dialysis appointments and often left for dialysis without a coat.
A review of R152's clinical record revealed R152 was initially admitted on [DATE] and had diagnoses that included: CVA (stroke), type II diabetes and end stage renal disease. A review of R152's MDS (minimum data set) noted the resident had a BIMS score (brief interview of mental status) of 12/15 (moderately impaired cognition) and required extensive two-person assistance for transfers and bed mobility.
Continued review of R152's clinical record noted, in part, the following:
Order (1/19/23): Dialysis Treatment Center (name redacted) .Tues, Thurs, Sat . *It should be noted that on 1/20/23 the Order was changed to Mon, Wed, and Friday at the same Dialysis Treatment Center.
1/21/23: Nursing Note: Resident missed chair time to Dialysis due to improper Hoyer pad. Resident arrived back to facility at 1:00 PM . Dialysis appointment rescheduled for Monday .
Hemodialysis Communication (1/30/23): Pre-Dialysis .What medications were given prior to dialysis? None .Medications sent with resident: none .For Dialysis Center to Complete .Complications during dialysis: patient yelling out. Please give pain med .post-Dialysis: patient screaming in pain . *It should be noted that no additional Hemodialysis Communication forms were found in R152's electronic record.
On 6/29/23 at approximately 11:50 AM, the Director of Nursing (DON) was asked to provide any additional Hemodialysis communication forms from 1/19/23 through 2/1/23. The DON stated that they were not able to locate any additional communication forms. When asked if the forms should be completed each time the resident goes to dialysis, the DON reported that the forms should be completed.
The facility policy titled, Hemodialysis (4/1/22) was reviewed and documented, in part: .The facility will provide the necessary care and treatment, consistent with professional standards of practice. This will include:ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments at a certified dialysis facility .ongoing communication and collaboration with the dialysis facility regarding dialysis care and services .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure two (Nurse 'PP' and Nurse Aide 'N') of 11 nursing staff reviewedf had the skills and competencies necessary to care fo...
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Based on observation, interview, and record review, the facility failed to ensure two (Nurse 'PP' and Nurse Aide 'N') of 11 nursing staff reviewedf had the skills and competencies necessary to care for residents' needs. Findings include:
Review of a complaint submitted to the State Agency revealed an allegation that a newly licensed nurse was assigned to a unit with residents who had high acuity medical issues and they did not feel comfortable working on that unit.
On 6/23/23 at 4:12 PM, a phone interview was conducted with the complainant who reported they ended up leaving the facility after they were assigned to a high acuity unit that they were not comfortable with as a newly licensed nurse. The complainant explained that the rehabilitation unit had residents who had tracheotomies and were unstable. The complainant reported they received orientation when they started working at the facility, but they were paired with another new nurse for training on the floor who did not know how to do everything.
On 6/27/23 at 10:34 AM, Nurse 'PP' was observed entering a resident's room and administering medication without donning personal protective equipment required for contact precautions and did not properly sanitize items brought into the room.
Review of a list of employees provided by the facility revealed nurse aide 'N' was not certified.
On 6/29/23 at 10:47 AM, an interview was conducted with Human Resources Coordinator (HR) 'OO. When queried about training for new employees and how nursing staff were evaluated for competencies prior to working the floor on their own, HR 'OO' explained nurses and nurse aides were provided training on the floor and had a set of skills that were signed off on by a preceptor to ensure they were competent with the skills needed to meet the residents' needs. HR 'OO' explained that was done over multiple days as all skills may not need to be done on the same day. The former staff development nurse provided additional training as needed. HR 'OO' explained that they currently did not have Staff Development personnel. Personnel files including any competency evaluations/skills checklists were requested for nurse aide 'N' and Nurse 'PP'
Review of nurse aide 'N's personnel file revealed their date of hire was 3/7/23. Review of a Certificate of Completion that indicated they completed the nurse aide training program on 4/7/23.
Review of a CNA New Hire and Annual Skills Checklist for nurse aide 'N' indicated they were a new hire and they were competent in all skills required as of 3/20/23. The skills included hands on tasks and patient care tasks that were documented they were verified competent via demonstration. It should be noted that on 3/20/23, nurse aide 'N' had not yet completed a nurse aide training program.
Review of Nurse 'PP's personnel file indicated they were hired on 5/11/23. Review of a Nursing .New Hire and Annual Skills Checklist revealed all skills were deemed competent by demonstration or discussion on one day, 5/17/23. The auditor signed the form, but the employee (Nurse 'PP') did not sign the form to indicate they completed the competencies.
On 6/29/23 at 3:35 PM, HR 'OO' was further interviewed. When queried about why Nurse Aide 'N' was able to complete a competency evaluation for CNA skills prior to completing a nurse aide training course, HR 'OO' did not have a response. HR 'OO' reported Nurse Aide 'N' should not have been demonstrating CNA skills prior to completing a training course. HR 'OO' explained the competency evaluation for Nurse 'PP' should have been signed by both the auditor and the staff member to ensure it was complete.
On 6/29/23 at 4:40 PM, an interview was conducted with the Director of Nursing (DON) who did not know why Nurse Aide 'N' had competencies evaluated prior to completing an official nursing assistant training program.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00137804.
Based on observation, interview and record review the facility failed to ensure a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00137804.
Based on observation, interview and record review the facility failed to ensure a Physician ordered laboratory diagnostic were completed in a timely manner for one resident (R67) of one residents reviewed for laboratory diagnostics. Findings include:
On 6/29/23 the medical record for R67 was reviewed and revealed the following: R67 was initially admitted to the facility on [DATE] and had diagnoses including Dementia, Chronic obstructive pulmonary disease and Severe Protein Calorie Malnutrition. A review of R67's MDS (minimum data set) with an ARD (assessment reference date) of 6/9/23 revealed R67 needed extensive assistance from facility staff with with most of their activities of daily living. R67's BIMS score (brief interview of mental status) was 11 indicating moderately impaired cognition.
A Physician progress note dated 6/22/23 revealed the following: following up on pelvic pain Notified by staff that pt (patient) has been complaining of lower pelvic pain and dysuria last few days. tramadol was adjusted to q8h (every eight hours) and labs ordered. Will check UA (urine analysis) and urine cx (culture). she also admits to burning on skin while urinating and flucanazole ordered x1 for possible yeast infection. Continue to monitor closely .Plan: .8. routine labs showing Cr (creatinine)0.64, Hg (hemoglobin)11.0, WBC (white blood cell)11.0, repeat labs pending .12. Plan discussed with nursing In detail Plan as written, will follow up on labs .
A physician's order dated 6/22/23 revealed the following: CBC (complete blood count), BMP (basic metabolic panel) An attempt to review of R67's laboratory results for the CBC/BMP on 6/22/23 did not reveal any results and was not available in the record.
On 6/29/23 at approximately 9:02 a.m., Nurse Manager O (NM O) was queried regarding the missing lab results ordered on 6/22/23. NM O Stated there was a miscommunication between the Nurse Practitioner and the Nursing staff to process the lab and that no lab request form was noted to be in the laboratory binder and it was never done.
On 6/29/23 a facility document pertaining to laboratory diagnostics was reviewed however it did not describe the process for ensuring the timely completion and processing of Physician ordered labs.
No lab results from the CBC/BMP ordered on 6/22/23 for R67 were provided before the end of the survey.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0847
(Tag F0847)
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 legally authorized representative signed a binding arbitrat...
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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 legally authorized representative signed a binding arbitration agreement (a legal contract that dictates an out-of-court alternate form of dispute resolution) for one resident (R152) of four residents reviewed for binding arbitration agreements. Findings include:
On 6/27/23 the medical record for R152 was reviewed and revealed the following: R152 was initially admitted on [DATE] and had diagnoses that included: CVA (stroke), type II diabetes and end stage renal disease. A review of R152's MDS (minimum data set) noted the resident had a BIMS score (brief interview of mental status) of 12/15 (moderately impaired cognition) and required extensive two-person assistance for transfers and bed mobility.
An Arbitration Agreement located in the resident's electronic record was reviewed. The Agreement documented, in part, the following: .This voluntary Arbitration Agreement .is entered into by .facility and between R152 and if applicable (no name was placed in this section) Resident's Legally Authorized Representative .The Arbitrator has Sole Jurisdiction. The arbitrators will be the only ones with the authority and jurisdiction to resolve all party disputes, including wrongful death .by signing this agreement you are waiving the right to have all disputes decided by a judge, jury or by trail. The arbitrator's decision is final and binding . This form was signed not by the resident but by (name redacted) family member on 1/19/23.
Further review of R152's clinical record did not reveal any documentation that R152's family member had any legal authority to sign R152's binding arbitration agreement. There was no documentation that R152 had been declared incompetent.
On 6/29/23 at approximately 11:05 AM, an interview was conducted with admission Staff II. Staff II was asked as to the facility protocol/policy regarding binding Arbitration. Staff II reported that they will go over the Arbitration agreement with the resident and/or the resident representative so that they have an understanding of what binding arbitration means. When asked as to why R152's Arbitration Agreement was signed by a family member who had not yet been designated as a legal representative, Staff II stated that they would look into the matter.
A form titled Appointment of Resident Representative was provided by Staff II. The form documented, in part: I R152 have applied for admission as a resident to (name redacted) facility .In order to assist me in the admission process, and assist me during my stay in the facility, I hereby designate as my Resident Representative .X (typed name of R152's family) . *It should be noted that the form was not signed by R152 and a signature by Resident Representative was noted as an e signed.
A review of the facility policy titled, Arbitration Agreement Policy (9/1/2021) noted, in part: It is the policy of FACILITY NAME .to present the Arbitration Agreement to Resident/Resident's Legally Authorized Representative (emphasis added) after the admission paperwork is completed .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to ensure a homelike dining experience based on the reasonable person standard for one resident (R94) and multiple other residents...
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Based on observation, interview and record review the facility failed to ensure a homelike dining experience based on the reasonable person standard for one resident (R94) and multiple other residents with cognitive impairments who ate their meals in the Anna's Place dining room. Findings include:
On 6/28/23 at approximately 9:33 a.m., An observation of the breakfast meal was made on the Anna's Place dining room in which four residents were observed sitting at the tables eating the breakfast meal. All of the residents were observed to be served their food on cafeteria style meal trays without the plates being taken off and put on the table for consumption.
On 6/28/23 at approximately 1:35 p.m., During the lunch meal, facility staff were observed serving the lunch meal to the residents in the Anna's Place dining room. The staff were observed to serve the meal on cafeteria style meal trays and leaving the plates and silverware on them while the residents were served the food.
On 6/28/23 at approximately 1:40 p.m., R94 was observed eating their lunch meal off of the cafeteria meal tray. R94 was queried if they would have preferred staff remove the meal tray and place their plates on the table like in a home and they stated, You bet I would. At that time, four other residents were observed eating their lunch meal atop the cafeteria style meal trays.
On 6/29/23 at approximately 1:15 p.m., during an observation of the lunch meal, two residents in the Anna's house dining room were observed being assisted with the lunch meal by facility staff. Both of residents were observed to have their lunch meals served atop cafeteria style meal trays without the staff removing the plates to provide a homelike experience.
On 6/28/23 at approximately 1:49 p.m., during a conversation with Dietary Manager S, DM S was queried if the facility emphasizes a home-like dining experience and they indicated that they try to. DM S was queried why the residents who ate in the Anna's Place dining room all had to eat their meals on the cafeteria trays verses a traditional home-like experience with the plates on the tables and table linens like the residents in the main dining room and they indicated that they were the corporate dietary manager that that the Anna's Place dining room was for residents with Dementia and that they were unsure what the policy was about the Dementia unit.
On 6/29/23 a facility document titled Dining Room Meal Service POLICY: To improve the dining experience, residents in the main dining room will be served their meal restaurant-style (plates brought to the table) Residents eating in the unit dining rooms will have meals provided via tray line (trays brought to the table) .3. If dining room meals are delivered on a tray, items will be removed from trays and placed on the table in front of the resident .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R118
R118 was a long-term resident of the facility and was originally admitted to the facility on [DATE]. R118's admitting diagn...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R118
R118 was a long-term resident of the facility and was originally admitted to the facility on [DATE]. R118's admitting diagnoses included left hemiplegia and hemiparesis, osteoarthritis, congestive heart failure, and had history of heart valve replacement surgery. R118 had a BIMS score of 15/15, indicative of intact cognition. Based on the most recent Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 5/18/23, R118 needed one-person (staff) extensive assistance with bed mobility and two-person (staff) extensive assistance for transfers in and out of their bed.
An initial observation was completed on 6/27/23, at approximately 11:30 AM. R118 was observed in their bed. R118 had a wider bed with a low air loss mattress. An interview was completed with R118 during the initial observation. R118 reported that they had been at this facility for over a year. R118 reported they came over to this facility after they had a stroke and had a left sided weakness. R118 had a Geri chair next to their bed. R118 reported that they came over to get stronger and they were working full time prior to the stroke.
When queried about how often they were getting out of their bed, R118 reported that they did not get the assistance when they had asked to get up. R118 reported that staff used the lift, and it takes ten minutes to assist and get them out of their bed. R118 reported that the last time they were assisted to get out of bed was over a week ago.
A 2nd observation was completed the same day at approximately 2PM. R118 was observed laying in their bed. R118 added that that they would like to get stronger and stated, I am only 58 and I don't want this to be my final stop.
A 3rd observation was completed at approximately 4 PM and R118 was in their bed.
On 6/28/23, at approximately, 8:50 AM, R118 was observed in their bed and was speaking to a staff member. At approximately 11:30 AM, during another observation, R118 was observed in their bed. Their feet were hanging over the mattress and R118 repositioned themselves in the bed by holding on to the bed frame with their right upper extremity when brought it to their attention. During this observation, a second interview was completed with R118. During this interview, R118 reported that they had used a wheelchair when they were getting therapy, but now staff had been using this (Geri) chair. R118 reported that they would like to sit up in a wheelchair and move around. R118 reported that if they did not feel good on a day, they had let the staff know on that day. R118 had confirmed they did not get out of bed on 6/27/23. R118 also reported they were not offered the assistance to get up and sit in their chair as they preferred, at least 3 times/week.
Review of R118's Electronic Medical Record (EMR) revealed the transfer (in and out of bed) task completed in last 30 days. The transfer task report between 6/29/23 and 5/31/23 were reviewed. The task report read that R118 was out of bed seven days in the last thirty days. The dates R118 was out of bed were recorded as follows: 6/27/23, 6/26/23, 6/20/23, 6/19/23, 6/14/23, 6/9/23, and 6/8/23. The rest of the dates were marked Activity did not occur.
An interview was completed with Director of Nursing (DON) on 6/29/23 at approximately 9:10 AM. The DON was queried about the facility protocol on staff assisting residents who wanted to get of their bed. The DON reported that it was the resident's preference and staff should be accommodating the preferences and assisting the residents.
This citation pertains to Intakes: MI00134568, MI00134669, MI00134725, MI00135548, MI00136878, MI00136943, and MI00137185.
Based on observation, interview and record review, the facility failed to ensure residents were consistently provided with showers, removal of facial hair and getting out of bed for four (R132, R153, R124 and R118) of 12 residents reviewed for activities of daily living (ADL's). Findings include:
Review of a facility policy titled, Activities of Daily Living (ADLs), Supporting dated 10/2021 read in part, .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming including hair and nail care, and oral care); b. Mobility (transfer and ambulation, including walking); .
R132
A complaint was filed with the State Agency on 5/22/23 that alleged R132 was not consistently receiving ADL care.
Review of the closed record revealed R132 was admitted into the facility on 5/2/23 with diagnoses that included: brain cancer, hemiplegia (paralysis or weakness), and epilepsy. According to the Minimum Data Set (MDS) assessment dated [DATE], R132 had moderately impaired cognition, and required the extensive assistance of staff for ADL's including showers.
Review of R132's ADL care plan initiated 5/3/23 revealed an intervention that read, Bathing / hygiene with 1 assistance.
Review of Bathing Assist 30 day Look Back for R132 revealed no documentation of showers or bed baths.
Review of PRN (as needed) Shower 30 day Look Back for R132 revealed no documentation of showers or bed baths.
Review of Shower Sheets revealed three showers documented on 5/9/23, 5/15/23 and 6/7/23.
On 6/28/23 at 11:32 AM, Certified Nursing Assistant (CNA) F was interviewed and asked how often residents receive showers at the facility. CNA F explained residents received two showers a week.
It should be noted that while a resident is at the facility, R132 should have received 10 showers, however, there were only three showers documented as given.
Resident #124
On 6/27/23 at approximately 11:04 a.m., R124 was observed in their room, up in their wheelchair. R124 was queried if they had any concerns about facility staff helping them with grooming and they indicated that they have asked to be clean shaved multiple times but that the staff say they do not know how to clean shave. At that time, R124 was observed with an unkept beard. R124 was queried if they are getting regular bathing provided to the them and they reported that they have missed showers.
On 6/29/23 at approximately 10:59 a.m., R124 was observed in their room, laying in their bed. R124 was still observed to still have an unkept beard. R124 was queried if they liked the beard and again R124 indicated they preferred to be clean shaven and reported that they have asked staff to shave it off, however, the staff tell them that that they do not know how. R124 then reported that they were supposed to get showers on Tuesdays and Fridays but have not gotten them.
On 6/28/23 the medical record for R124 was reviewed and revealed the following: R124 was initially admitted to the facility on [DATE] and had diagnoses including Spinal stenosis and Fusion of spine. A review of R124's MDS (minimum data set) with an ARD (assessment reference date) of 3/26/23 revealed R124 needed extensive assistance with most of their activities of daily living. R124's BIMS score was 10, indicating moderately impaired cognition.
On 6/29/23 at approximately 11:06 a.m., A review of the shower schedule for R124's room revealed R124 was scheduled to be provided regular bathing on Tuesdays and Fridays every week.
A review of Certified Nursing Aide (CNA) bathing documentation for R124 in the electronic medical record revealed only one shower was provided to R124 which was on 6/23/23.
On 6/29/23 at approximately 11:09 a.m., paper shower sheet documentation of R124's completed scheduled bathing for the previous 30 days was reviewed with Nurse Manager O (NM O). NM O was only able to provide one bathing sheet for R124 which was for 6/13/23. NM O was queried where the other bathing documentation was for the previous 30 days and indicated they did not have any others. NM O was queried regarding R124's multiple requests to be clean shaved and the responses they had received of not knowing how to complete a shave. NM O reported that it was concerning and that they would have to do education with the staff. NM O was queried if a CNA did not know how to provide a clean shave, could they have asked a team member to perform the shave and NM O indicated that would have been the appropriate way to handle the request.
R153
A complaint was filed with the SA that alleged R153 was not receiving weekly showers two times per week.
A review of R153's clinical record documented the resident was admitted to the facility on [DATE] with diagnoses that included: cellulitis, gangrene and type II diabetes. A review of the resident's MDS indicated the resident had a Brief Interview for Mental Status (BIMS)score of 15/15 (cognitively intact) and required extensive one to two person assist for most ADLs.
On 6/28/23 at approximately 10:11 AM, the facility was asked to provide any documentation pertaining to R153's showers during their stay at the facility. The following paper shower documents were provided:
1/24/23: R (refused)
2/1/23: Shower not provided
2/10/23: Shower not provided
* There were not further documentation as to resident receiving showers during their stay at the facility from 1/24/23 to discharge on [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
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake # MI00134296
Based on observation, interview, and record review the facility failed to ensure o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake # MI00134296
Based on observation, interview, and record review the facility failed to ensure over an extended period that residents with limited mobility were assessed timely for appropriate assistive devices to maintain or improve functional mobility for one (R118) of one Residents reviewed for mobility and assistive devices resulting in the potential for a decline their bed mobility/self-care, dissatisfaction, and frustration with care.
Findings include:
A record review revealed R118 was a long-term resident of the facility and was originally admitted to the facility on [DATE]. R118's admitting diagnoses included left hemiplegia and hemiparesis, osteoarthritis, congestive heart failure, and had history of heart valve replacement surgery. R118 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicative of intact cognition. Based on the most recent Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 5/18/23, R118 needed one-person (staff) extensive assistance with bed mobility and two-person (staff) extensive assistance for transfers in and out of their bed.
An initial observation was completed on 6/27/23 at approximately 11:30 AM. R118 was observed in a wider bed with a low air loss mattress. An interview was completed with R118 during the initial observation. R118 reported that they had been at this facility for over a year. R118 reported they came over to this facility after they had a stroke and had a left sided weakness. R118 had a Geri chair next to their bed. R118's feet were observed hanging over the edge of the mattress. When queried further R118 reported that they had requested a longer bed.
During the interview, R118 lowered the head end of bed to reposition. R118 used their right hand to reach over to the end of the bed frame to pull and reposition in the bed. R118 was successful in their repositioning. R118 reported that it would help if they had a bar or device on their bed to hold on so they could move and reposition in their bed as needed as it would help them get better with their mobility in bed. When queried if they had spoken with anyone, R118 reported that they had spoken with therapy staff and nursing staff, and they received a response that the facility was not able to provide a trapeze (overhead bar used to assist with mobility in bed) because of the lift that was being used to get them in and out bed. When queried if they had spoken with the facility staff about the mobility or assist bar on their bed, R118 answered YES and reported that were notified that facility did not allow any device on the bed. R118 had been at the facility from 2/7/22 (approximately over a year and five months). R118 had multiple physical and occupational evaluations during their stay at this facility.
A 2nd observation was completed the same day at approximately, 2PM. R118 was observed laying in their bed. R118 added that that they would like to get stronger and stated, I am only 58 and I don't want this to be my final stop. R118 reported that they would like to get stronger and would like to use a wheel chair.
A 3rd observation was completed at approximately 4 PM and R118 was in their bed.
On 6/28/23 at approximately 8:50 AM, R118 was observed in their bed and was speaking to a staff member. At approximately11:30 AM, during another observation, R118 was observed in their bed. Their feet were hanging over the mattress and R118 repositioned themselves in the bed by holding on to the bed frame with their right upper extremity when brought it to their attention. During this observation, a second interview was completed with R118. During this interview, R118 reported that they had used a wheelchair when they were getting therapy several months ago, but now staff had been using this (Geri) chair. R118 reported that they would like to sit up in a wheelchair and move around.
A review of R118's Electronic Medical Record (EMR) revealed a Physical Therapy (PT) evaluation dated 4/28/23. Functional mobility assessment in this PT evaluation read, Bed mobility - Total dependence with attempts to initiate. Prior level(s) of function read, Bed mobility = Max (A) (Maximal Assistance); Transfers = Total Dependence with attempts to initiate; patient currently at baseline-referral for LUE (Left upper Extremity) splinting and LUE edema. The Musculo skeletal section of the PT assessment did not reveal any assessment of strength and Range of Motion (ROM) of the right lower extremity. R118 used their right arm and right leg for mobility and positioning in bed. The neuro muscular assessment section read in part, Sitting Balance = Static sitting - DNT (Did Not Test) and Dynamic sitting - DNT (Did Not Test). R118's PT evaluation did not have any baseline assessment for sitting balance, however had goal for standing in the standing frame. It should be noted that moderate upper body strength and trunk control are needed to be able to use a standing frame safely. A goal was established without a base line assessment of the critical neuromuscular elements. The evaluation and plan of care did not address the change in bed mobility from the prior level of function as noted on this evaluation. The evaluation did not assess or address the need for any assistive devices to improve R118's mobility in bed. Occupational Therapy (OT) evaluation dated 4/26/23, revealed that R118 needed assistance with their bed mobility, it was not addressed under the current plan of care established by OT that nursing will continue to provide assistance. R118's care plan revealed that they were at risk for loss of mobility and risk for pressure ulcer.
An interview was completed with staff member BB and staff member CC on 6/28/23 at approximately 1:15 PM. Staff members BB and CC were queried on the assessment for use for positioning and assistive devices in bed. Staff member BB reported that they had assessed the need for assistive device(s) in bed to maintain or improve mobility in bed. Staff member BB was queried specifically on R118 and why they were not assessed for assistive devices. Staff member BB reported that the facility did not use any assist bars in the beds. They would do an assessment for a trapeze. No further explanation was provided on why this was not addressed prior even after R118 had brought it to the attention of the staff members.
An interview was completed with Director of Nursing (DON) on 6/29/23 at approximately 9:10 AM. The DON was queried about the facility protocol on staff assisting residents who wanted to get of their bed. The DON reported that it was the resident's preference and staff should be accommodating the preferences and assisting the residents. The DON was queried on the assistive devices in Resident's beds to assist with their mobility and positioning. The DON reported that they were providing assistive devices as needed after assessments. When queried further about assist bars in bed, The DON reported that the facility currently did not have any residents using the assist bars on the beds. They would follow up with the team and provide an assistive as needed.
A request for policy on assistive devices and positioning devices was requested and received the Critical Element Pathway for Positioning, Mobility, and Range of Motion via e-mail.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 6/27/23 at approximately 9:41 a.m., An unlocked-unattended medication cart was observed next to room [ROOM NUMBER].
On 6/27/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 6/27/23 at approximately 9:41 a.m., An unlocked-unattended medication cart was observed next to room [ROOM NUMBER].
On 6/27/23 at approximately 9:44 a.m., Nurse X was observed coming down the hall and was queried regarding the unlocked-unattended medication cart. Nurse X indicated that the cart should be locked and was observed locking it.
On 6/28/23 at approximately 2:35 p.m., a medication cart was reviewed for labeling and storage and the following was observed: 1. An opened and undated lantus Pen-Lantus SoloStar Subcutaneous Solution Pen-injector, was observed in the cart opened and undated. 2. An opened and undated insulin pen for a discharged resident). 3. An opened and undated insulin pen that did not contain a resident name. and 4. An opened and undated Latanoprost Ophthalmic Solution (Latanoprost) eyedrop.
On 6/28/23 at approximately 2:48 p.m., a second medication cart was reviewed for labeling and storage and an opened vial of insulin was observed in the cart with Licensed Practical Nurse Y. The vial indicated that it should be refrigerated when stored. LPN Y was queried why the vial was in the medication cart and they indicated that it should have been put back in the refrigerator. LPN Y was queried regarding the labeling and storage of medications in the medication carts and they indicated that they should be dated on the day they are opened and refrigerated if the medication says it should be.
Based on observation, interview and record review, the facility failed to ensure appropriate storage and/or labeling of medications and treatments/biologicals in three of five medication carts and one treatment carts reviewed, resulting in the potential for unauthorized entry, misuse, contamination, and diversion of narcotics and controlled substances. This deficient practice has the potential to affect multiple residents in the facility.
Findings include:
According to the facility's policy titled, Medication & Treatment Cart Storage dated 5/4/2022:
.It is the policy of this facility to ensure all supplies for treatments and medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls .Only authorized personnel will have access to the keys to locked compartments .
On 6/27/23 at 10:19 AM, an unlocked treatment cart was observed in the hallway outside of room [ROOM NUMBER]. There was no nursing staff in view of the treatment cart. Nurse 'P' was observed to exit from the room and proceeded to access treatment supplies from the unlocked drawer of the cart and re-enter room [ROOM NUMBER] without ensuring the cart was locked.
On 6/27/23 at 12:09 PM, the medication cart outside the roof access room on Anna's House (facility's secured unit) was unlocked with no nursing staff nearby. The drawers of the cart were able to be opened and were accessible to all residents/visitors/staff.
On 6/27/23 at 12:11 PM, Nurse Manager 'O' was observed coming down a hallway around the nursing desk and was asked if they knew where a nurse was. Nurse Manager 'O' acknowledged the unsecured medication cart and proceeded to ask a nursing assistant if they knew where the Nurse was. That staff reported Nurse 'E' was in a room (approximately four doors down the hallway).
On 6/27/23 at 12:13 PM, Nurse 'E' exited the room and was asked by Nurse Manager 'O' to come to the medication cart. When asked about the unlocked medication cart, Nurse 'E' reported they shouldn't have left it like that, but help was needed in a room.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
On 6/29/23 at 8:23 AM, R55's Family Member was interviewed by phone. When asked about concerns at the facility, R55's Family Member explained the meals are frequently served late, as an example, on 6/...
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On 6/29/23 at 8:23 AM, R55's Family Member was interviewed by phone. When asked about concerns at the facility, R55's Family Member explained the meals are frequently served late, as an example, on 6/28/23, lunch was not served until 1:40 PM and dinner will sometime be served at 6:30 PM, an hour after it is supposed to be served .it is ridiculous because the residents are just sitting in the dining room with nothing to do, they just sit there for hours.
Based on observation, interview, and record review, the facility failed to ensure meals were served in a timely manner and per facility scheduled times for residents that resided within the Anna's House (secured unit), resulting in delayed meal service and dissatisfaction with the dining experience.
Findings include:
According to the documentation of facility scheduled mealtimes, the meals were to be provided for Breakfast from 7:30 AM - 8:30 AM; Lunch from 11:30 AM - 12:30 PM; and Dinner from 4:30 PM - 5:30 PM.
On 6/28/23 at 12:15 PM, observations of the facility's lunch meal setup revealed an adequate number of dietary staff, including the Interim Dietary Manager (Staff 'S'). It was reported the last unit to be served meals was on Anna's House. It was also identified there were three food transport carts to be delivered to the unit.
The first food cart left the kitchen at 1:13 PM; the second food cart left the kitchen at 1:28 PM; and the third food cart left the kitchen at 1:30 PM.
On 6/28/23 at 1:32 PM, Dietary Aide 'V' was asked about why the lunch meal was so late and they reported the food was behind because of short staff.
On 6/28/23 at 1:33 PM, Interim Dietary Manager (Staff 'S') was asked about the dietary staffing and reported they were not sure, but would obtain the actual staffing for today. When asked about why the lunch meal was so late today, Staff 'S' reported it wasn't because they were short-staffed, it was due to having new staff and the increase in facility census from 140 to 160's.
On 6/28/23 at 1:40 PM, the final food tray for Anna's House was removed from the food cart.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were followed for one (R148) of three residents reviewed for transmission-based pre...
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Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were followed for one (R148) of three residents reviewed for transmission-based precautions (TBP). Findings include:
On 6/27/23 at 10:34 AM, signage was observed on R148's door that indicated they were on Contact Precautions (Contact precautions prevent transmission of infectious agents that are spread by direct or indirect contact with the resident or their environment). The signage also indicated a gown, gloves, and separate and/or sanitized equipment was required when entering that room. At that time, Nurse 'PP' was observed entering R148's room without a gown. R148 was observed passing medication to R148 without gloves. Nurse 'PP' was holding a plastic basket that contained a glucometer and was full of unused lancets. Nurse 'PP' exited R148's room and wiped the outside of the basket that contained the lancets with a sanitizing wipe and placed it into the medication cart immediately without waiting for the sanitizer to dry. When queried about why a gown and gloves were not donned before entrance to R148's room, Nurse 'PP' reported they did not know and reported they wore gloves. Nurse 'PP' did not offer a response when queried about bringing the basket of lancets into the room and using improper sanitizing techniques.
On 6/27/23 at 10:43 AM, Certified Nursing Assistant (CNA) 'QQ' was observed to enter R148's room without donning a gown or gloves. CNA 'QQ' entered the room, touched the privacy curtain, did not perform hand hygiene, then exited the room, grabbed clean gloves located outside of R148's room, and entered another resident's room down the hall.
6/27/23 at approximately 12:20 PM, a CNA entered R148's room without donning a gown. The CNA reported there were no more gowns in the PPE bin. The CNA delivered a lunch tray to R148 making contact with their environment, and left the room.
On 6/28/23 at approximately 11:41 AM, an interview was conducted with the Director of Nursing (DON). When queried about PPE use for residents on contact precautions, the DON reported they were required to don a gown and gloves prior to entrance to the room, doff the PPE prior to exiting, and performing hand hygiene. When queried about whether Nurse 'PP' should have brought the basket of lancets into R148's room, the DON reported they should not have and they should have waited 4 minutes after using sanitizing wipes before placing it back into the medication cart.
Review of R148's clinical record revealed R148 was admitted into the facility on 6/9/23 with diagnoses that included: pneumonia.
Review of R148's physician's orders revealed an order started on 6/16/23 for Contact Precautions Reason: r/o (rule out) C-Diff (Clostridium Difficile) .
Review of a facility policy titled, Isolation Precautions dated 7/1/20, revealed, in part, the following: .'Contact precautions' are measures that are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident ' s environment .Recommendations for Personal Protective Equipment (PPE) .Contact .Gloves Whenever touching the patient ' s intact skin or surfaces and articles in close proximity to the patient (e.g., medical equipment, bed rails). [NAME] gloves upon entry into the room or cubicle .Gowns Whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. [NAME] gown upon entry into the room or cubicle .
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to maintain a sanitary kitchen; ensure food items were properly labeled, dated, and stored; monitor and maintain refrigerator an...
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Based on observation, interview, and record review, the facility failed to maintain a sanitary kitchen; ensure food items were properly labeled, dated, and stored; monitor and maintain refrigerator and freezer temperature logs; and ensure proper functioning of the dish machine, resulting in the increased potential for cross-contamination and foodborne illness. These deficient practices had the potential to affect all residents that consume food from the kitchen.
On 6/27/23, during an initial tour of the kitchen with Interim Dietary Manager (Staff 'S') between 8:56 AM - 9:45 AM, the following items were observed:
In the dry storage room, there was an opened plastic bag of pecans that were stored on a top shelf. The package was not properly sealed and was open to air, and there was no date of when it had been opened.
The temperature log on the outside of the walk-in freezer was documented as last completed on 6/26/23 for evening shift.
In the walk-in freezer, the entire left side of the freezer ceiling, wall and storage shelving underneath had thick build-up of ice. Staff 'S' reported there was a problem with the seal on the door which had been an issue for a while now, but a new door had been ordered. There were multiple food items stored underneath the left side of the freezer which were contaminated and covered with thick, frozen ice build-up.
There were several opened boxes of frozen hamburger patties stored at the back of the freezer that had thick, frozen ice build-up on the box. When asked about those items, Staff 'S' reported those were part of their always available menu.
Staff 'S' began to move several boxed items that had been contaminated from the left side of the freezer to the storage unit on the right side and when asked about moving the items, Staff 'S' reported those would be discarded. When asked why they had moved the contaminated items with those that were not, Staff 'S' offered no further response and began to remove the items again.
There were several other food items that were not wrapped properly, exposed to air with visible ice build-up on the food product which included a package of white turkey patties, flour tortillas, cookie dough, beef patties, corn and mixed vegetables and English muffins.
In the walk-in cooler, there was a large plastic container of hard cooked eggs that were observed to have an arrived date of 6/23/23. The lid to this container of hard cooked eggs was broken, ill-fitting and exposed the contents to open air. Inside the container, there was a clear bag of hard boiled eggs that was filled with liquid. The bag was not sealed and the liquid had spilled out of the bag and into the plastic container.
Additionally, there was an opened and unsealed package of whipped cream; there was a metal storage shelving unit on wheels that contained several trays of food that had a large piece of meatloaf (gray in color) that was undated, loosely wrapped and exposed to air.
When asked who was responsible for monitoring the food items for proper storage, labeling, and discard, Staff 'S' reported every morning the manager monitors that and goes through fridges, and also it was normally done by afternoon supervisor. Staff 'S' reported there were several changes to the dietary management within the last few weeks.
The high temp dish machine was not observed in use as of 9:17 AM. The log to document temperatures twice daily (in the morning and in the evening) had not be done for 6/27/23. When asked when the high temp dish machine should be tested, Staff 'S' reported when staff first came in (at beginning of shift).
The ice machine was observed to have an ice scoop container secured on the left side of the machine. The inside of the ice scoop container was observed to have a build-up of standing water with brownish colored debris in the bottom.
There was a large accumulation of debris underneath the juice and coffee machines.
The flooring behind the oven was heavily soiled with food debris (tater tots) and crumbs.
The flooring under the meal prep/tray line area was observed to have a thick build-up of debris.
The under shelving of the meal prep/tray line contained various sized bowls and plates that were stored right side up. Several bowls were observed to be soiled with a dark colored substance. When asked about the storage of the above items and whether they should be stored right side up, Staff 'S' reported since they were stored underneath, that was ok. When asked about the contaminated bowls, they reported that was not good and proceeded to remove the soiled bowls.
The shelf under the meal prep/tray line across from the oven was observed to have a clear plastic container with several heavily soiled, greased/soiled rags, sponges and a grill scraper. When asked about the storage of these items, Staff 'S' asked Dietary Staff 'Q' who reported that had been there a while.
The reach-in cooler near the prep sink was observed to have two large containers of chicken flavored base and one large container of beef flavored base. The three containers were observed to have broken tops which did not properly seal and exposed the inside contents.
The small prep sink located next to the oven was observed to have a small drawer underneath. Observation of the contents of the drawer revealed several utensils (spoons, ladles, etc) were soiled with dried food debris and there was also dried food debris on the bottom of the drawer.
On 6/28/23 at 11:30 AM, a follow-up visit to the kitchen with Staff 'S' revealed ongoing concerns with improper sealing of the chicken and beef flavored base; soiled flooring and food remained behind the oven and under the meal prep/tray line area; soiled surfaces near the juice and coffee machines.
Additionally, the high-temp dish machine was observed to be in use. Review of the temperature log revealed there was no temperature monitoring done for 6/27/23 morning shift or 6/28/23 morning shift. When asked about whether staff had monitored the high temp dish machine since the log was blank, Staff 'S' proceeded to run their thermometer through the dish machine. One of the dietary staff was asked about how they were to monitor the temperature and reported there were strips that they couldn't find, so they used the digital reading on the outside of the dish machine. Staff 'S' was asked about the protocol for monitoring the temperature and they reported that dietary staff should be testing at start of each shift, but deferred to the maintenance staff and reported they also monitored it every day, so they weren't concerned.
On 6/28/23 at 12:04 PM, Activity Aide (Staff 'T') was observed to enter the kitchen from the north door, and go into the walk-in freezer, without hand-washing or using hand-sanitizer. Staff 'T' exited the freezer and was asked about what the process was for hand-washing upon entering the kitchen. Staff 'T' reported they had washed their hands before entering the kitchen and attempted to show how they opened the door with their wrist behind the door handle, unsuccessfully. When asked about what they had been educated on regarding infection control practices in the kitchen, they offered no further response.
On 6/28/23 at 12:37 PM, signage posted on the wall outside of the kitchen's south door read, Health Department Regulation Prohibits Entry to Kitchen by Anyone Other than Kitchen Personnel.
On 6/28/23 at 12:53 PM, an interview was conducted with the Maintenance Director (Staff 'U'). When asked about their department's monitoring of the dish machine temperatures as reported by Staff 'S', they reported they monitored the water temperatures for the kitchen, but not the final rinse temperature as that should be done by the dietary staff before using, to make sure it was the correct temperature. Staff 'U' also reported there was a log that the kitchen staff documented on. Staff 'U' was informed that the log had been reviewed and was not documented as completed for the morning on 6/27/23 or 6/28/23, and that Staff 'S' 'had deferred to the maintenance staff for monitoring documentation.
On 6/28/23 at 1:32 PM, an interview was conducted with Dietary Aide (Staff 'V'). When asked about the process of infection control practices for when anyone enters this kitchen, Staff 'V' reported all staff were to wash hands immediately upon entering. When asked about if they've observed other staff entering without washing hands, Staff 'V' reported they had, especially at the north door.
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 and: .(E) After handling soiled equipment or utensils; .(I) After engaging in other activities that contaminate the hands.
According to the 2017 FDA Food Code section 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation, (A) Food shall be protected from cross contamination by: .(2) Except when combined as ingredients, separating types of raw animal foods from each other such as beef, fish, lamb, pork, and poultry during storage, preparation, holding, and display by: .(b) Arranging each type of food in equipment so that cross contamination of one type with another is prevented,.
According to the 2017 FDA Food Code section 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.
According to the 2017 FDA Food Code section 3-304.12 In-Use Utensils, Between-Use Storage, During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: .(E) In a clean, protected location if the utensils, such as ice scoops, are used only with a food that is not potentially hazardous (time/temperature control for safety food) .
According to the 2017 FDA Food Code section 3-305.11 Food Storage.
1.
(A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD:
1.
(1) In a clean, dry location;
2.
(2) Where it is not exposed to splash, dust, or other contamination; and
3.
(3) At least 15 cm (6 inches) above the floor.
According to the 2017 FDA Food Code section 3-307.11 Miscellaneous Sources of Contamination, FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.
According to the 2017 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.
According to the 2017 FDA Food Code section 4-302.13 Temperature Measuring Devices, Manual and Mechanical Warewashing, (B) In hot water mechanical warewashing operations, an irreversible registering temperature indicator shall be provided and readily accessible for measuring the utensil surface temperature.
According to the 2017 FDA Food Code Section 4-601.11 Equipment, Food-Contact Surfaces, NonfoodContact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.
According to the 2017 FDA Food Code section 4-602.13 Nonfood-Contact Surfaces, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
According to the 2017 FDA Food Code section 4-701.10 Food-Surfaces and Utensils, Equipment food-contact surfaces and utensils shall be sanitized.
According to the 2013 FDA Food Code section 4-703.11 Hot Water and Chemical, After being cleaned, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED in: (B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under §§ 4-501.15, 4-501.112, and 4-501.113 and achieving a utensil surface temperature of 71 degrees Celsius (160 degrees Fahrenheit) as measured by an irreversible registering temperature indicator;
According to the 2017 FDA Food Code Section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles.
(A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLEUSE ARTICLES shall be stored:
(1) In a clean, dry location;
(2) Where they are not exposed to splash, dust, or other contamination; and
(3) At least 15 cm (6 inches) above the floor.
(B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored:
(1) In a self-draining position that allows air drying; and
(2) Covered or inverted .
According to the 2017 FDA Food Code Section 6-501.12 Cleaning, Frequency and Restrictions.
(A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.
(B)Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing.
According to the facility's policy titled, Kitchen Sanitation to Prevent the Spread of Viral Illness dated 2/21/2023:
.Hand washing i. Employees must wash their hands and exposed portions of their arms at designated hand washing facilities at the following times .Immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles; - During food preparation, as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks .After engaging in other activities that contaminate the hands .The food service director or designee will ensure that all standards of practice are maintained regarding cleaning, sanitizing wares, equipment and all food contact surfaces .The food service director or designee will ensure that the dishmachine is effectively sanitizing either by the hot water method or with chemical sanitizer and logged. Logs will remain on file for 90 days .All other food contact surfaces and equipment shall be washed, rinsed and sanitized per USDA Food Code Recommendations .
According to the facility's policy titled, Food Storage dated 12/26/2022:
.It is the responsibility of the Dietary staff and supervisors to ensure that food is stored, labeled and used within the recommended time guidelines to prevent food borne illness .Temperatures of the food storage areas, including dry storage, refrigeration and freezers shall have thermometers and be monitored and recorded daily .Guidelines for food labeling and dating must be adhered to by all food service personnel and closely monitored by the food service manager .All foods removed from original packing and must have an arrival date. If food has a manufacturers expiration date, an open date will be added to the label, which includes food like: cottage cheese, bulk yogurt, sour cream etc .All food packaging that is open for use and returned like deli meat must be labeled with arrival date and open date .Leftover foods must be immediately frozen, labeled and dated for later use. If refrigerated, the food must be discarded within 72 hours. Frozen leftovers must be used within 30 days .
Feb 2023
6 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** DPS #2
This citation pertains to Intake Number(s): MI00131467.
Based on interview and record review, the facility failed to addr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** DPS #2
This citation pertains to Intake Number(s): MI00131467.
Based on interview and record review, the facility failed to address changes in condition in a timely manner and thoroughly evaluate the root cause of a change in condition for one (R807) of six residents reviewed for changes in condition, resulting in a delay in sending R807 to the hospital where it was determined the resident had a stroke. Findings include:
R807
A Complaint was filed with the State Agency (SA) that alleged R807 had a stroke on 7/17/22 on or about 5-6 AM. The facility was asked to send the resident to the hospital but was told they needed to get approval from the Administrator. The resident was sent to (name redacted) hospital on 7/17/22 at 8:30 AM and passed away in the hospital on 7/24/22. The Complaint was interviewed on the phone and indicated that Nurse J informed them that the resident had already had a stroke when they got to work at 7:00 AM and the supervisor (name not known) told them not to send the resident to the hospital.
A review of (name redacted) hospital records documented, in part: .ED (emergency department) notes (9:14 AM) .Pt to EMS for extremity weakness .upon arrival pt. has fixed gaze preference to R side. L side weakness .unable to squeeze on L side .Stroke Team: 7/17/22: Time arrived: 8:50 AM: .slight drift noted on the L side .does not have dentures in and not sure of slight facial .daughter stated that resident does not want aggressive measures .I informed her that patient is having another major stroke with symptoms of fixed gaze/Aphasia .Hospital Course: .presented to hospital on 7/17/2022 from facility with a chief complaint of possible stroke. Patient suffered a CVA and was deemed a 21(severe stroke) on the NIH (National Institutes of Health) stroke scale .After 48 hours patient had no improvement I neurological recovery, a decision was made to have the patient be made comfort care .passed away peacefully on 7/24 .
A review of R807's clinical record revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Gastrointestinal hemorrhage, hypertensive heart and chronic kidney failure, personal history of transient ischemic attack (TIA) and dementia. A review of the resident's Minimum Data Set (MDS) indicated the resident was severely cognitively impaired and required extensive one to two person assist for most Activities of Daily Living.
Continued review of R807's clinical record documented, in part:
7/17/22 -Progress Note (7:40am): Resident able to use call light .upon entering room at 6:30 am resident was staring and not alert Resident non-verbal Notified 11-7 am supervisor who assessed resident also Notified. Dr. B who requests for resident to be sent out 911. 11-7 am supervisor notified DON (name redacted) and said there (sic) not sending resident out. 7-3 am supervisor aware and 7-3 nurse aware .7-3 am supervisor aware and will update Dr. B. (Authored by Nurse I).
7/17/22- Progress Note (8:29 am): Resident received stroke like symptoms. Nurse writer spoke to Nurse Supervisor and DON, and they agreed to send resident to (name redacted) hospital. Nurse writer spoke to Resident daughter (name redacted), and she is aware of what is going on .'. (Authored by Nurse J).
An attempt to contact Nurse J via phone was made on 2/1/23 at approximately 2:50 PM. A voice mail message was left, and no return call was made before the end of the survey. It should be noted that Nurse J is no longer employed by the facility.
On 2/2/23 at approximately 9:51 AM a phone interview was conducted with Nurse I. Nurse I reported that they had been employed by the facility for over 20 years and generally worked the night shift (11 PM to 7 AM). Nurse I was queried about the R807 and the note that was authored on 7/17/22. Nurse I recalled that they noticed the resident was showing signs of mental status change and they contacted Dr. B who indicated based on their observation that the resident should be sent to the hospital via 911. Nurse I reported they told Nurse Supervisor K that the resident was showing significant mental status changes and Dr B wanted the resident sent to the hospital. Nurse I stated that Nurse K called the DON and was told not to send the resident out to the hospital. Nurse I stated they endorsed the information on to Nurse J and then left the facility.
On 2/2/23 at approximately 1:46 PM an interview and record review were conducted with the DON. When asked about R807 and why there was a delay in sending R807 after Nurse I spoke to Dr. B, the DON indicated that they recalled speaking with Nurse Supervisor K who noted that the resident was stable and sending the resident out was not urgent.
On 2/2/23 at approximately 4:15 PM a phone interview was conducted with Nurse K. Nurse K reported that they had worked at the facility for approximately two years as a House Supervisor on the afternoon and mid-night shifts but was no longer employed by the facility. When queried as to the incident involving R807 on 7/17/23, Nurse K reported that Nurse I did report that the resident was exhibiting some changes but was not able to recall what they were. Nurse K stated that they recalled the resident had a history of starring into space and noted that when they went to see the resident, they took some vitals that were fine, remembered the resident was reaching for their TV remote and did not believe there was anything wrong with the resident. They then informed the DON, and the resident was not sent out. When asked if they had completed an assessment or documented their observation, Nurse K responded that they did not. When informed that the resident was sent to the hospital that day at approximately 8:30 AM, they noted that they had left the building by that time.
On 2/3/23 at approximately 4: 15 PM, a phone interview was conducted with Dr. B. Dr. B was queried as to R807 and their recommendation to send the resident to the hospital after being notified of a change in mental status by Nurse I. Dr. B reported that they did not have the resident's records in front of them but stated that if they indicated a resident should be sent out to the hospital the facility should have sent the resident out. When asked if the facility policy indicated the DON needed to confirm the resident needed to be sent out following their recommendation, Dr. B noted that was not the policy.
A review of the facility policy titled, Change in Condition (8/8/2022) revealed, in part: .Resident who exhibit signs and symptoms of change in condition shall be evaluated by the nurse immediately upon identification .3. A progress note, or .Assessment should be documented .detailing the assessment and all interventions performed .
This citation has two deficient practice statements (DPS).
DPS #1
This citation pertains to Intake Number(s): MI00132706, MI00131102, and MI00129114.
Based on interview and record review, the facility failed to implement treatment in a timely manner, administer treatment consistently according to physicians orders, and identify the worsening condition of an arterial ulcer for one (R804) of two residents reviewed for non-pressure skin impairments, resulting in a maggot infestation of the wound located on R804's left great toe. Findings include:
Review of a complaint submitted to the State Agency revealed it was alleged R804's left foot wound had maggots in it and the dressing had not been changed in a while.
Review of a second complaint submitted to the State Agency revealed it was alleged maggots were found in R804's wound.
An unannounced, onsite investigation was completed from 1/31/23 through 2/2/23.
Review of R804's clinical record revealed R804 was admitted into the facility on 8/11/22 and discharged on 9/5/22 with diagnoses that included: peripheral vascular disease, gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection), congestive heart failure (CHF), type 2 diabetes mellitus, and anemia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R804 had moderately impaired cognition, no behaviors, required extensive assistance for bed mobility, had two unhealed stage 2 pressure ulcers (partial thickness skin loss with exposed dermis) that were present on admission, four venous and arterial ulcers (ulcers caused by damaged veins and arteries due to lack of blood flow), and a surgical wound.
Review of a run sheet completed by the local fire department revealed they responded to R804 at the facility on 9/5/22 and documented, .weak and hypotensive (low blood pressure) .covered in feces .On assessment, clusters of maggots found on .foot wrapped .due to peripheral vascular disease and gangrene .
Review of R804's hospital records revealed the following:
An ED (emergency department) Provider Note dated 9/5/22 at 9:33 AM, noted, .dry gangrene (gangrene associated with arterial obstruction) on both BL (bilateral) LE (lower extremities) .presenting to the ED with AMS (altered mental status). Patient lives at nursing facility and was last visited by his friend and daughter on Saturday. Patient at the time was well per daughter. Over the past 2 days nursing staff noted the patient to become more altered. He was attempting to have a bowel movement and had been constipated over the weekend and nursing staff gave him a bowel regimen. He was found today in feces .BL LE gangrene with maggots .ED Course/Medical Decision Making: .Upon arrival to the ED patient was noted to be hypotensive blood pressure 82/53 otherwise saturating 98% on room air. Temp was noted to be 99.2. On exam, patient is altered but awake, responds to painful stimuli. Notable bilateral lower extremity dry gangrene with maggots .
An ED Nurse Note dated 9/5/22 at 9:45 AM noted, Patient has dressings applied to multiple sites on lower extremities dated last changed 9/2. Multiple maggots moving in between left foot toes once dressing taken off and wound exposed .
Further review of R804's clinical record from the facility revealed the following:
Review of a Skin & Wound - Total Body Skin Evaluation dated 8/11/22 revealed, Stitches to left inner thigh and calf. IV to left upper arm. Port to left side of neck with 3 lumen. Bruises to abdomen, hands, and arms. Scratch to left inner arm. Healing abrasion to left knee. Open area to left buttocks 3x6 cm
Review of a Nursing - Progress Note dated 8/11/22 revealed, Skin assessment in place. Resident has catheter 16 FR (french). IV (intravenous) to left upper arm. Port to left side of neck with 3 lumen. Stitches to left inner calf and thigh. Scratches to left upper arm. Healing abrasion to left knee-tissue pink intact. Bruises to abdomen,arms. Gangrene to bilateral great toes. Open areas to left buttocks 3x6 cm (centimeters). Open area to right buttocks 3x7 cm. Open area to left outer ankle 3x7 cm. Open area to left outer calf 4x5 cm. Blister noted by calf stitches.
Review of Physician's orders for R804 revealed the following orders dated 8/11/22:
1. Cleanse outer ankle with NS (normal saline) then apply dry dressing Q (every) daily, every day shift
2. Cleanse outer left calf with normal saline then apply dry dressing Q daily every day shift
3. Consult Wound Care: Gangrene bilat (bilateral) feet. Multiple wounds
There were no orders to address the surgical wound to the left inner calf or the gangrene to bilateral great toes.
Review of a Wound Rounds Note dated 8/16/22 (five days after R804 was admitted into the facility) revealed the following documentation: Wound Consult .I was referred ro consult re: (regarding) numerous wounds .At time of admission noted to have multiple wounds .
.Left lateral leg surgical incision line proximal half CDI (clean, dry, intact) approximated with sutures. Distal half dehiscence, base covered with loosening nonviable tissue . Recommend Tx (treatment): M.Honey (medihoney) cover with dry dressing 3x/week .
.Left medial (inner) leg vascular wound, minimal drng (drainage) .base covered with destabilizing eschar (dead or devitalized tissue) Recommend Tx (treatment): M Honey cover with dry dressing 3x/week .
. Left lateral ankle vascular wound .base granular rim surrounding tight necrotic tissue .Recommend Tx: M.Honey cover with dry dressing 3x/week .
.Left great toe to 1st MTH (metatarsal head - bone in the foot behind the big toe) arterial wound .base covered with stable eschar .Recommend Tx: wipe with betadine (an antiseptic solution to aide in prevention of infection) cover with dry dressing 3x/week .
.Right great toe to 1st MTH arterial wound .base covered with stable eschar .Recommend Tx: wipe with betadine cover with dry dressing 3x/week .
Further review of R804's Physicians Orders revealed the following orders dated 8/17/22:
1. Wound Care Order Site: Left Great Toe .cleanse wound cleanser .Wiper with betadine wipes .Wrap in kerlix (rolled gauze dressing) if indicated every day shift every Tue (Tuesday), Thu (Thursday), Sat (Saturday) for wound care
2. Wound Care Order Site: Right Great Toe .cleanse wound cleanser .Wiper with betadine wipes .Wrap in kerlix (rolled gauze dressing) if indicated every day shift every Tue (Tuesday), Thu (Thursday), Sat (Saturday) for wound care
3. Wound Care Order Site: Left medial leg .cleanse .pat dry .apply medihoney .cover with ABD (abdominal pad) .wrap in kerlix .every Tue, Thu, Sat for wound care .
4. Wound Care Order Site: Left lateral ankle .cleanse .Pat dry .Apply medihoney .Cover with ABD (5x9 gauze) .wrap in kerlix .every day shift every Tue, Thu, Sat for wound care .
Review of the physician's orders revealed the treatment for R804's left lateral leg surgical incision was not changed to Medihoney according to the wound consult note on 8/16/22. The order remained in place to cleanse with normal saline and apply dry dressing with a start date of 8/12/22.
It should be noted that there were no treatment interventions put into place for the vascular/arterial wounds to R804's left medial leg and bilateral great toes until five days after they were admitted into the facility.
Review of R804's Treatment Administration Records (TAR) for August and September 2022 revealed multiple missed treatments, as evidenced by no nurse's signature to indicate the treatment was completed. The following treatments were missed:
Treatment to the left great toe was not done on 8/20/22, 8/25/22, and 9/3/22. Because the treatment to this site was ordered on Tuesday, Thursday, and Saturday, there were gaps of four to five days between treatments due to the days missed. The last treatment prior to R804 being transferred to the hospital was on 9/1/22. When R804 was assessed by EMS (emergency medical services) and in the ED, maggots were found in that wound.
Treatment to the left lateral ankle was not done on 8/20/22, 8/25/22, and 9/3/22. Because the treatment to this site was ordered on Tuesday, Thursday, and Saturday, there were gaps of four to five days between treatments due to the days missed.
Treatment to the left medial leg was not done on 8/20/22, 8/25/22, and 9/3/22. Because the treatment to this site was ordered on Tuesday, Thursday, and Saturday, there were gaps of four five days between treatments due to the days missed.
Treatment to the right great toe was not done on 8/20/22, 8/25/22, and 9/3/22. Because the treatment to this site was ordered on Tuesday, Thursday, and Saturday, there were gaps of four five days between treatments due to the days missed.
Treatment to the outer left calf was not done on 8/12/22, 8/17/22, 8/19/22, 8/20/22, 8/21/22, 8/22/22, 8/26/22, 9/3/22, and 9/4/22.
On 2/2/23 at 9:05 AM, an interview was conducted with the Director of Nursing (DON). When queried about the facility's skin management protocols, the DON reported upon admission, the floor nurse did the initial skin assessment and documented any skin issues on the Total Body Assessment. The DON explained, the floor nurse was not supposed to stage or diagnose the wound, but to document the description of the wound. The DON further explained, if a skin impairment was identified, the unit manager was notified and they would assess the resident's skin the next day and determine if they needed to be evaluated by the wound care practitioner. If the resident was determined to need a wound consult, the wound practitioner evaluated the resident the next time they were in the facility on Tuesdays. At that time, R804's clinical record was reviewed with the DON. When queried about why there were no treatments implemented upon admission for the arterial wounds to R804's right and left great toes and medial left leg, the DON reported the nurse may have thought it did not need a treatment. The DON further explained that due to the amount of wounds R804 was admitted with, the nurse should have called the attending physician to discuss any needed treatments until the wound practitioner could come see the resident. When queried about the missing treatments on R804's TARs, the DON reported the treatments should have been done according to the physician's orders. The DON reported they received a grievance regarding the maggots found in R804's wound, investigated it, they did not substantiate anything. At that time, the DON provided the facility's investigation and the grievance form.
Review of a Grievance Documentation, Investigation & Follow-Up form dated 9/9/22. The following was documented, Nurse liaison reported concern from (hospital) that resident had maggots in his left lower extremity and gangrene .Investigation: .Nurses that provided wound care to (R804) on Saturday 9/3 and Sunday 9/4 report no findings of maggots to bilateral feet and feet were noted to be clean and dry eschar . It should be noted that R804's TAR indicated no wound care treatment was provided on 9/3/22 or 9/4/22 and the last time it was signed off as completed was on 9/1/22.
Review of a facility policy titled, Skin & Wound Policy revised 2/2022, revealed, in part, the following: .All wounds will have treatment orders from the physician team .Wound treatments will be provided in accordance with physician orders .In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse .Treatments will be documented on the Treatment Administration Record .
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
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake #MI00132138
Based on interview and record review the facility failed to consistently monitor, o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake #MI00132138
Based on interview and record review the facility failed to consistently monitor, obtain monthly weights and implement interventions to prevent a significant weight loss for one (R803) of two residents reviewed for nutrition/hydration, resulting in R803 sustaining a significant weight loss (25.3) pounds (lbs.) in two months, change in mental status and hospitalization.
Findings include:
A Complaint was filed with the State Agency (SA) that alleged R803 was not eating and was found emaciated on or about 11/12/23, was transferred to the hospital and diagnosed with severe dehydration.
A review of (name redacted) Hospital records documented, in part: R803 was admitted to the emergency department with dehydration on 11/12/22 .Physician consult dated 11/13/22 .R803 presents to hospital on 11/12 with decreased mentation and poor oral intake .sister visited her yesterday and was alarmed at her decrease in mental status .Impression: .the patients delirium is attributed to dehydration .Weight is 115 lbs. Patient's Hospital Course .was admitted for hypernatremia dehydration, improved with IVF(intravenous fluid) .severe protein calorie malnutrition, had peg tube placed. 11/12/22 .Need for artificial feeding is needed .patient remains at risk of malnutrition due to weight loss, inadequate energy intakes and increased nutrient needs .Gastroenterology consult .reason for consultation: PEG (percutaneous endoscopic gastrostomy) tube placement Interventions .insert enteral feeding tube .peg placed 11/25, tf (tube feeding) started .
A review of R803's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: vascular dementia, chronic pain and history of stroke. A review of the Minimum Data Set (MDS) indicated the resident was severely cognitively impaired and required extensive one person assist for eating.
Continued review of the R803's clinical record documented, in part, the following:
Weight Summary: three weights were taken in June 2022 with an end weight on 6/16/22 of 156.8 lbs. Five weights were taken in July 2022 with an end weight on 7/26/22 of 144.0 lbs. Three weights were taken in August 2022 with an end weight on 8/18/22 of 140.2 lbs. Only one weight was taken in September 2022 dated 9/1/22 with a weight of 139.8 lbs. No weights were obtained in the Month of October 2022. One weight was obtained in November (11/9/22) with a weight of 114.5 lbs. indicating a 25.3 lbs. weight loss/18.2%.
R803's Care Plan: Focus: Resident is at nutritional risk with risk for . weight loss. Chronic illness, variable oral intake, Need for altered diet, with risk of dehydration (date initiated 6/7/22) .Goal: Resident will have no significant wt. loss (6/7/22) .Interventions/Tasks .Monitor and record weight per policy (6/7/22) .Monitor for signs of malnutrition (pale skin, dull eyes, swollen lips, swollen gums, magenta tongue, poor skin tugur .physical evidence of muscle and fat loss (6/7/22) .Pt requires 1:1 assist with meals (6/7/22) .Supplements as ordered . *It should be noted that no interventions were place in the resident's care plan after 6/7/22. Further, there was no indication in R803's care plan that indicated they refused to eat.
[NAME] review: one person assists for feeding.
Nutritional/Dietary Note (7/19/22): .Current weight is 144lbs as re-weight with first weigh last week of 144.4 lbs. x30 days 155.8 lbs. reflecting 7.1% loss in one month which is significant . *It should be noted that no interventions and/or supplements were ordered.
Nutritional/Dietary Note (7/25/22): Nutritional follow-up; resident seen today at lunch .Resident eating independently .Oral intake is variable.
There were no further Nutritional notes found in the resident's clinical record until 11/10/22: .Weight loss follow up: Weights: 114.5 lbs. as of this month, refused 30 days ago .Continue on diet as ordered .Refuses to eat .weight loss of 25 lbs. in 60 days .
On 2/1/23 at approximately 1:55 PM an interview and record review were conducted with Registered Dietician (RD) H. RD H was queried as to the facility policy pertaining to obtaining resident weights. RD H reported that upon entry weights are obtained every week for four weeks and once per month thereafter unless a resident was having nutritional concerns. When queried as to why the resident was not weighed in October 2022, RD H reported that the resident had refused. RD H was asked to provide documentation that indicated the resident refused to be weighed in October 2023. When queried as to whether staff communicated concerns as to the resident's refusal to eat and/or observations that the resident was losing weight, RD H reported that she was not aware of the weight loss until 11/10/22. When asked what interventions they might have recommended if they had been notified earlier as to the resident's refusal to eat and/or weight loss, RD H reported that they would have suggested interventions such as Hospice, tube feeding, food stimulant medication and/or enhanced food options.
*It should be noted that no documentation pertaining to October 2022 weights was provided by the end of the survey.
On 2/1/23 at approximately 3:41 PM an interview was conducted with the Director of Nursing (DON). When asked as to the facility policy pertaining to resident weights, the DON indicated that weights should be obtained weekly upon admission for four weeks and then monthly unless nutritional concerns are noted. When asked about R803's 25 lb. weight loss in two months, the DON indicated that the resident should have been weighed at least monthly and if weight loss and/or refusal to eat was noted additional interventions should have been implemented.
The facility policy titled, Nutritional Management Policy (approved 10.22) was reviewed and documented, in part: .Policy: the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in context of his or her overall condition .Compliance Guidelines: a. Nursing staff shall obtain the resident's height and weight upon admission, and subsequently in accordance with facility policy .c. Developing and consistently implementing pertinent approaches .d. Monitoring the effectiveness of interventions and revising them as necessary .4. Care plan implementation: The resident's goals and preferences regarding nutrition will be reflected in the resident's plan of care .b. The resident will be monitored for complications associated with interventions. c. The care plan will be updated as needed, such as when the resident's condition changes .d. The physician will be notified of 1. Significant changes in weight, intake or nutritional status .6. Informed consent: .The comprehensive care plan should describe any interventions offered but declined by the resident or the resident's representative .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0551
(Tag F0551)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00134162
Based on interview and record review, the facility failed to consider the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00134162
Based on interview and record review, the facility failed to consider the resident's input regarding their code status for one (R818) of two residents reviewed for resident rights, resulting in the resident's legal guardian changing their code status to Do-Not-Resuscitate (DNR) when the resident voiced their wish to receive Cardiopulmonary Resuscitation (CPR). Findings include:
Review of R818's clinical record revealed R818 was admitted into the facility on [DATE], readmitted on [DATE], and discharged on [DATE] with diagnoses that included: end stage renal disease (ESRD) with dependence on renal dialysis, hypertensive chronic kidney disease, and vascular dementia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R818 had intact cognition and rejected care. Review of an MDS assessment dated [DATE] revealed R818 had moderately impaired cognition and no behaviors.
Review of a Letters of Guardianship form for R818 revealed R818 was assigned a legal guardian on [DATE].
Review of Physician's Orders for R818 revealed an order dated [DATE] that read Adv (advance) Directive: Full Cardiopulmonary Resuscitation (an emergency lifesaving procedure performed when the heart stops beating). This order was discontinued on [DATE]. The documented reason was signed DNR (a directive to medical professionals to inform them the resident does not want CPR/life saving procedures performed) received from Guardian. An order dated [DATE] revealed, Adv. Directive: Do Not Resuscitate .
Review of a Do-Not-Resuscitate Order at Skilled Nursing Facility form revealed the order was issued by Physician 'C' for R818. The form was signed by R818's legal guardian on [DATE] in the section that noted, 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 form was signed by Physician 'C' on [DATE]. In the section titled, Attestation of Witnesses, it was noted, The individual who has executed this order appears to be of sound mind, and under no duress, fraud, or undue influence. Upon executing this order, the individual has received an identification bracelet that indicates a DNR. Two witnesses signed the form, one on [DATE] and the second two days later on [DATE].
Review of R818's progress notes revealed the following:
A COMMUNICATION - with Family/NOK (next of kin)/POA (power of attorney) progress note, dated [DATE], noted, Manager placed call to guardian (public guardian) .Manager spoke to .case manager. We discussed resident slow but progressive decline w/AMS (altered mental status) and refusing dialysis, medications and vital signs. (Case Manager) stated she would need a letter from physician requesting advance directives to be changed. Then Guardian would complete a face time call with resident. manager will be following up as needed and keeping guardian updated as well.
A Nursing - Progress Note dated [DATE] noted, Manager met with physician to discuss advance care planning due to general decline. Physician provided verbal order for psych services and psychology for 1:1 (one on one) visits .Physician will see resident tomorrow.
A Psychiatry progress note dated [DATE] noted, .complaint: Depression/anxiety .First contact with .Psychiatrist .Her mood has been stable. No anxiety or psychosis reported. She has a public guardian .She was calm and did not appear to be in any distress .PSYCH EXAM .Eye Contact: Good .Level of Consciousness: Alert .Mental Status Exam: .cooperative .Orientation: Person; Place; Situation .Attention/Concentration: Good .Judgment: Fair .Insight: Fair .Impulse Control: Has been good .Thought Process: Organized .Flight of Ideas: None .Loosening of Associations: Normal .Thought Content: Normal .Memory/Immediate: Grossly Intact .Memory/Recent: Grossly Intact .Memory/Remote: Grossly Intact .Fund of Knowledge: Normal .Mood: Normal .Affect: Congruent with mood .Delirium: Absent .No psychotropic medication changes recommended at this time .
A Palliative Progress Note dated [DATE] noted, The reason for this initial Palliative Care consult is for opinions/advice regarding symptoms management and advanced decision making .CHIEF COMPLAINTS: ESRD .Generalized weakness .Goals of care .(R818) was seen today sitting up in her wheelchair, she is alert and oriented x 3 .Per medical record, she has hx (history) of non-compliance with medications, showers, dialysis, etc. Her BP (blood pressure) often remains high d/t (due to) medication non-compliance .On examination patient is well nourished, afebrile, not in any distress, alert and oriented x 3 .Patient is pleasant, cooperative. Mood and affect appropriate .(R818) agreed to the Palliative Care consult. Palliative discussed with goals of care, symptom management and palliative recommendations .Alternative management options discussed .Code status including all resuscitative measures were explained. Discussed that the prognosis in the event of cardiopulmonary resuscitation in the setting of advanced malignancy or terminal diagnosis will result in poor outcome with less than 5 (percent) of patients returning to their baseline health status. Patient is unlikely to survive or benefit from cardiopulmonary resuscitation as quality of life would be dramatically changed .ADVANCE DIRECTIVES DISCUSSED: Yes .DISCUSSED WITH: patient .CODE STATUS: FULL code .RECOMMENDATIONS: .Goals of care .(R818) is alert and oriented x 3. palliative discussed with goals of care, symptoms management and palliative recommendations including DNR. She states she wants to have CPR done if needed in the future, because she wants to be here for her children. She does not appear to fully understand the potential of a poor outcome if undergoing CPR in the future .Code Status: FULL code .
A COMMUNICATION progress note dated [DATE] noted, MD (physician) letter to Guardian to change advance directives emailed to Guardian case manager. Awaiting next step. Letter given to medical records to scan .
A Social Work progress note dated [DATE] noted, DNR document sent to pt (patient) case worker. Case worker is waiting to hear back from pt family regarding code status .
An I-SNP (Institutional Specialized Needs Plan) progress note written by Nurse Practitioner (NP) 'G' on [DATE] noted, .Resident reports she would still like CPR performed in the case she would need it - does not fully understand the poor outcomes associated with CPR. Continue to have goal of care conversation at next visits .
A COMMUNICATION progress note dated [DATE] noted, Manager assisted resident with face time call with guardian. Awaiting further guidance from Guardian. SW Director updated.
A Nursing - Progress Note dated [DATE] noted, Manager received signed DNR from Guardian via email. Guardian also approving hospice. Manager spoke with physician and received verbal order for DNR and Hospice eval (evaluation) and tx (treatment) .
On [DATE] at 1:28 PM, an interview was conducted with the Director of Social Services (DSS 'A'). When queried about when a legal guardian could change a resident from a full code status to a DNR, DSS 'A' reported the guardian had to have communication with the resident and the doctor within a 14 days window before signing a resident on as DNR. When queried about whether the resident, despite having a legal guardian, should have been included in the discussion and if their expressed wishes should have been honored, DSS 'A' reported if the resident wanted to be a full code, the doctor discussed that decision with the resident and their guardian and the residents wishes would have been taken into consideration. When queried about why R818 was changed to a DNR after they expressed wanting CPR during the palliative care consultation, DSS 'A' reported they would have to look into it.
On [DATE] at approximately 2:00 PM, DSS 'A' provided a letter written by Physician 'C' on [DATE] (eight days prior to R818's documented conversation with palliative care where R818 expressed the wish for CPR) that documented, .The patient has recently been on a downward trend of increased confusion, paranoia, increasingly refusing medications and vital signs to monitor condition. (R818) has also occasional refused dialysis treatment as recent as [DATE] .The gradual decline has become significantly enough to require advance care planning. Due to the patient's frail disposition the risks of cardiopulmonary resuscitation (CPR) outweigh the benefits. (R818's) comorbidities and other factors leave her to be less likely to survive CPR and, in the event, medical staff are successful in resuscitation her there is a likelihood of detrimental consequences and lack of quality of life. it is in my professional opinion the patient is a candidate for palliative care and for a do-not-resuscitate (DNR) order for the symptom management and perseverance of her dignity . It should be noted that on [DATE], R818 was evaluated by a psychiatrist who documented R818 did not have any impairment to alertness, orientation, mood, thought process, and memory. The psychiatric consultation occurred on the same day ([DATE]) as the palliative care consultation where it was documented that R818 wanted CPR despite the risks being discussed with them.
On [DATE] at 8:40 AM, an interview was conducted with the Director of Nursing (DON). When queried about why R818 was changed to a DNR by their legal guardian despite R818's documented wishes to receive CPR, the DON reported R818 refused dialysis at times and medications and fluctuated with cognition. The DON reported that the guardian and the physician felt it was in R818's best interest. When queried about whether R818's stated wishes should have been considered, the DON reported she acknowledged that they should have.
Policies regarding advance directives and code status changes were requested from the Administrator. However, the policies were not received prior to the end of the survey. a
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 #MI00131224
Based on observation, interview and record review the facility failed to notify the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #MI00131224
Based on observation, interview and record review the facility failed to notify the resident's legal guardian/representative of a change in condition (peg tube cellulitis) for one of one resident reviewed for change in condition. Findings include:
A complaint was filed with the State Agency (SA) that alleged the facility failed to inform the legal guardian that R809 had cellulitis around their peg tube and was put on IV antibiotics.
On 1/31/23 at approximately 10:05 AM, R809 was observed lying in bed. The resident was alert but unable to answer questions asked.
A review of R809's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: cerebral infarction, malignant lung cancer, anxiety disorder and vascular dementia. A review of the resident's Minimum Data Set (MDS) indicated the resident was significantly cognitively impaired and required extensive one to two person assist for most activities of daily living. R809 had enteral feeding via PEG tube.
Continued review of the resident's clinical record documented, in part, the following:
8/18/22 Nursing Progress Note: .Resident peg tube site is red with odor .Logged for Dr.
8/22/22 Nursing Progress Note: Pt peg was bleeding around the site doctor notified and verbal order given to clean area bandage and to monitor site .
8/22/22 Physician Team -Progress Note: Reason for visit .PEG site bleeding .will order zinc oxide cream qday. Wound care consult .
8/24/22 Physician Team - Progress Note: .*There was no documentation from Physician B that noted the resident's PEG site.
8/29/22: Physician Team- Progress Note: Reason for visit . for cellulitis .1. Cellulitis: foul drainage and redness around PEG, will start IV (intravenous) Vanco. Pharmacy to dose. Will monitor .
*It should be noted that there was no documentation that indicated R809's legal guardian was notified about the resident's Cellulitis and order for IV antibiotic (Vanco).
On 2/2/23 at approximately 8:45 PM an interview and record review were conducted with the Director of Nursing (DON). The DON was asked to provide any documentation that noted R809's Guardian was notified of their change in condition. The DON reported that there was no documentation and confirmed that per the facility's policy the Guardian should have been notified.
On 2/2/23 at approximately 10:44 AM, an interview and record review were conducted with the facility Medical Director (MD)C. When queried as to a possible delay in treating R809's Cellulitis at their PEG site, specifically the 8/18/22 note that indicated a red area with order around the peg site and the 8/22/22 note that indicated the PEG site was bleeding and a start date of the Antibiotic on 8/29/22, MD C indicated that they most likely would have started the antibiotic sooner. When asked if the family/guardian should have been notified as to the infection, MD 'C responded that they should have been notified.
A request for a facility policy pertaining to informing resident's guardians/representatives of a change in condition. The document provided titled, Change in Condition (8.8.2022) did not address informing guardians/family.
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
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00131549.
Based on interview and record review, the facility failed to provide jus...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00131549.
Based on interview and record review, the facility failed to provide justification for the use of antipsychotic and antianxiety medication given on an as needed (PRN) basis, identify targeted behaviors, and consistently implement person-centered non-pharmacological interventions prior to administering the medications for one (R806) of one resident reviewed for unnecessary medications. Findings include:
Review of a complaint submitted to the State Agency revealed an allegation that R806 was administered unnecessary psychotropic medications without consulting with their long time psychiatrist which resulted in the resident being sedated.
On 2/2/23 at 10:00 AM, a phone interview was conducted with the complainant. The complainant expressed concern about the regimen of psychotropic medications prescribed to R806. The complainant explained that R806 had bipolar disorder and had been treated long term by a psychiatrist and had been stable for many years. The complainant reported multiple requests to discuss R806's medication regimen were made and there was a delay in consulting with R806's long time psychiatrist. The complainant further reported the facility administered an injection of antipsychotic medication on multiple occasions even after the facility's consultant psychiatrist discontinued it.
Review of R806's clinical record revealed R806 was admitted into the facility on 7/28/22 and discharged on 9/1/22 with diagnoses that included: wedge compression fracture of first lumbar vertebra, generalized anxiety disorder, bipolar disorder, chronic obstructive pulmonary disease, and major depressive disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R806 had clear speech, severely impaired cognition, no behaviors, required limited assistance with walking, had two or more falls since their admission date of 7/28/22, and received antipsychotic, antianxiety, and antidepressant medications.
Review of R806's hospital discharge summary revealed R806 was prescribed the following psychotropic medications:
Depakote (a medication used to treat manic episodes of bipolar disorder 500 mg (milligrams) QAM (every morning)
Depakote 500 mg ER (extended release) 3 tablets QHS (at bedtime)
Neurontin (a medication used to treat anxiety associated with bipolar disorder) 300 mg QHS
Lorazepam (a medication used to treat anxiety) 0.5 mg (there were no instructions regarding frequency of use)
Paxil (a medication used to treat depression and anxiety) 20 mg (there were no instructions regarding frequency of use)
Seroquel (a medication used to treat psychosis) 400 mg take 200 mg QID (four times a day)
Risperdal (a medication used to treat psychosis) 2 mg take 0.25 mg QD (every day)
Trazodone (a medication used to treat depression) 150 mg QHS
Review of R806's physician's orders implemented at the facility upon admission included the following:
Depakote ER 250 mg daily and 500 mg 3 tablets QHS
Lorazepam 0.5 mg Q12 (every 12 hours) PRN
Neurontin 300 mg QHS
Paxil 20 mg daily
Seroquel 200 mg QID
Risperdal 0.25 mg daily
Trazodone 150 mg QHS
Further review of R806's physician's orders revealed the following changes were made:
On 8/3/22 at 12:45 PM, Haldol 1 mg IM Q4 hours PRN was ordered for agitation for 14 days and discontinued on 8/4/22.
On 8/6/22, Haldol 1 mg IM was ordered one time only.
On 8/6/22, Haldol 5mg/ml 1 mg IM Q6 hours PRN was ordered and discontinued on 8/8/22.
On 8/8/22, Haldol 5 mg/ml 1 mg IM Q6 hours PRN was ordered and discontinued on 8/16/22.
On 8/6/22, lorazepam was increased to 0.5 mg 2 tablets every 6 hours (which doubled the dose and increased the frequency). This was not ordered PRN. This order was discontinued on 8/22/22.
On 8/16/22, Lorazepam Solution 2 mg/ml 0.5 IM Q8 hours PRN was added and discontinued on 8/22/22. (This was in addition to the scheduled lorazepam order above).
Review of R806's Medication Administration Record (MAR) from August 2022 revealed Haldol IM was administered to R806 on 8/3/22 at 3:17 PM, 8/6/22 at 12:26 PM and 8:02 PM, and 8/8/22 at 5:01 PM.
Review of R806's progress notes revealed there was no documentation prior to the administration of IM Haldol at 3:17 PM to indicate the psychotic symptoms and/or behaviors exhibited by R806 and what non-pharmacological interventions were attempted prior to administering the antipsychotic medication.
Review of a progress note written by attending Physician 'B' on 8/3/22 did not document justification for administration of a PRN antipsychotic medication (Haldol). The progress note documented, Dementia w/ (with) behavioral disturbance: multiple reports from nursing staff of patient agitation. Will increase Ativan (lorazepam) 0.5 mg PO q6 prn . There was no indication that the root cause of R806's agitation was determined. Physician 'B's progress note did not document anything about Haldol.
Review of a Psychiatry progress note written by the facility's consulting psychiatric Nurse Practitioner (NP) 'L' revealed, .Complaint: initial evaluation for bipolar disorder and med management .She is on multiple psychiatric medications. Per notes she is restless at times. She has had falls. She was originally non verbal. They are using both PRN Ativan and Haldol but unsure of behaviors prompting use. Nurse reports she has been doing good. She is minimally verbal. Mostly yes and no answers. No issues noted with sleep or appetite. Unable to reach any family for additional history. She is her own responsible party. She denies concerns. She does not appear in any distress .General: Calm, attentive and in no acute distress . ASSESSMENT & PLAN
Plan: continue PRN Ativan will DC (discontinue) PRN Haldol .Plan: Will DC Risperdal as she is only on 0.25 QD and is already on Seroquel 200 4 x a day. Continue all other current medications. She has a long psychiatric history .
As mentioned above, the initial Haldol IM order was discontinued by NP 'L'. However, additional orders were implemented by the attending physician and the medication was administered on 8/6/22 and 8/8/22.
Further review of R806's progress notes revealed on 8/6/22, Physician 'B' documented, .reports of agitation. Haldol 1 mg IM given. Will increase Ativan to 1 mg PO q6 PRN .Ativan increased for agitation . There was no documentation that any underlying causes for R806's agitation were explored. It should be noted that Physician 'B's documented the Ativan was to be increased to 1 mg q6 PRN. However, the order that was implemented was not PRN and was every 6 hours.
Further review of R806's MAR revealed they received Ativan (lorazepam) every six hours between the dates of 8/6/22 and 8/22/22 and not PRN as the physician documented in their progress note.
Review of a nursing progress note dated 8/6/22 at 4:27 PM revealed R806 had a fall in the dining room while self transferring, was aggressive and combative towards staff .difficult to redirect. The nurse documented the physician was notified and an order to administer 1 ml of Haldol IM was given. A second nursing progress note dated 8/6/22 at 9:57 PM documented the physician was contacted for order of Haldol because R806 was extremely agitated and combative with staff and was unable to be controlled safely after they were redirected with snacks, magazines and wheeled pt around unit. There was no documentation of any psychotic symptoms to justify the use of an antipsychotic medication and no indication that the root cause of R806's agitation was explored.
Review of a nursing progress note dated 8/8/22 revealed R806 made numerous attempts to get up unassisted and was combative toward staff. It was documented that R806 was toileted but there were no other documented non-pharmacological interventions or documented attempted to determine the cause of R806's agitation. It was documented R806 was administered Haldol IM.
Further review of R806's nursing progress notes revealed R806 was Napping for long intervals on 8/10/22, had decrease in oxygen levels which required supplemental oxygen on 8/13/22, and very unsteady on her feet on 8/14/22.
Review of a Psychiatry progress note dated 8/14/22 revealed, .Reviewed chart including progress notes, mediations and labs. Haldol IM was started again since last visit by PCP (primary care physician) at request of nurse. She was also started on scheduled Ativan every 6 hours. It has been used several times .She is sleepy and briefly arousable .Plan: will DC PRN Haldol and start PRN Ativan IM .
Review of a Physical Medicine and Rehabilitation (PM&R) progress note dated 8/17/22 revealed, .Per nursing, she has been having issues with increased tiredness during the day .
Review of a PM&R progress note dated 8/22/22 revealed, .She appears lethargic .
Review of a Psychiatry progress note dated 8/22/22 revealed, .I received a call from the nurse, patient has been more sedated and confused. She has been falling. I also received a message from social worker to call her son .I spoke with (son) who is very concerned about her cognition decline. Prior to and after the surgery she was alert and oriented. She was living independently and managing without issues. Her bipolar was stable with close follow up with psychiatrist .who she has been seeing for over 15 years. He reports she could not be on the Ativan. Which was started at 1 mg Q6 hrs (hours) by the PCP. I did order to DC all Ativan
Review of a second Psychiatry progress note dated 8/22/22 revealed, I spoke with .patients long time psychiatrist. Discussed current status. Reviewed her medications .He also reports she has a hx of alcohol abuse sober for years and has never done well on benzos (benzodiazepines - Ativan/lorazepam).
Review of R806's PT notes revealed the following:
On 8/1/22, a PT note documented R806 fully participated with session.
On 8/2/22, a PT note documented R806 fully participated in the session.
On 8/5/22, a PT note documented, Multiple attempts to see pt today, in AM, midday and late PM, pts in bed asleep, unarousable .
On 8/9/22, a PT note documented, Pts son came in .per son will move to an ILF (independent living facility) with an option to be an ALF (assisted living facility) .difficulty staying awake .Per (son), pt's been through this before he wanted her medications reviewed 'she will snap right back if they straighten her meds first' .pleasant but not alert .unable to recite her back precautions. Nurse is aware. Pts son came in to talk to medical team re: pts meds . (It should be noted that R806's medications were not reviewed with R806's son and R806's long time psychiatrist until 8/22/22) .
On 8/10/22, a PT progress note documented, .Pt demonstrates excellent progress this reporting period .
On 8/16/22, a PT note documented, Patient difficult to rouse this session and needed max prompting to participate in session.
On 8/17/22, a PT note documented, Shortened session d/t (due to) patient being difficult to rouse and she required max prompting to participate in session.
On 8/18/22, a PT note documented, Shortened session d/t patient becoming tearful and confused .unable to follow direction throughout session .
On 8/22/22, a PT note documented, approached numerous times to participate in therapy and was unable d/t lethargy .
Review of R806's care plans revealed no behavior care plans that identified targeted behaviors and person-centered non-pharmacological interventions in relation to the use of PRN Haldol and Ativan.
On 2/2/23 at 10:41 AM, an interview was conducted with the facility's Medical Director, Physician 'C'. Physician 'C' reported that the underlying cause of a resident's behaviors should always be determined before resorting to IM Haldol.
On 2/2/23 at 11:40 AM, Psych NP 'L' was interviewed via the telephone. When queried about the use of IM Haldol PRN for R806, NP 'L' reported they did not generally use PRN antipsychotic medications unless there are serious hallucination and delusions. NP 'L' reported they would not have ordered Haldol for agitation and that decision was made by R806's attending physician. NP 'L' reported she was not made aware of R806's son's attempt to provide R806's long time psychiatrist contact information or that he had concerns regarding R806's medications until 8/22/22. It should be noted that R806's family member was in the facility and expressed concerns to the PT on 8/9/22, 13 days earlier.
On 2/2/23 at 2:49 PM, a telephone interview was conducted with Physical Therapy Assistant (PTA) 'M' who reported they could not remember anything about R806 and no longer provided therapy services at the facility.
On 2/2/23 at 3:05 PM, an interview was conducted with the Director of Social Services, SS 'A'. When queried about the targeted behaviors and non-pharmacological interventions for the use of IM Haldol for R806, SS 'A' reported they would have to look into it.
On 2/2/22 at 3:57 PM, SS 'A' reported the Haldol order was determined by the physician after the nurse contacted them. When queried about who consented to the use of Ativan and Haldol, SS 'A' reported no consent was given because the facility could not get a hold of the family until 8/22/22 when they were given the information about R806's long time psychiatrist. SS 'A' reported she was unaware that R806's family member expressed concerns about R806's mental state and medication regimen during therapy on 8/9/22. SS' A' further explained that they did not think there was a care plan that outlined non-pharmacological interventions to use prior to administering PRN Haldol.
On 2/2/23 at 4:35 PM, Physician 'B' was interviewed via the telephone. Physician 'B' did not have access to a computer and was not sure of details. When queried about why R806 was getting Haldol IM PRN, Physician 'B' reported he ordered it for a short period of time to calm her down. When queried about whether R806 exhibited any psychotic symptoms, Physician 'B' reported he ordered it due to R806's agitation and confusion. Physician 'B' further explained that since Haldol was not a controlled substance it could be obtained quicker. Physician 'B' stated, I wouldn't order more than two to three doses max. When queried about what was done to rule out any underlying conditions that could have contributed to R806's agitation and confusion and whether they were contacted when R806 became lethargic, sleepy, and unable to participate in therapy, Physician 'B' reported he did not have access to a computer and could not remember, but reported anything he addressed would be documented in a progress note.
On 2/2/23 at 5:04 PM, an interview was conducted with the Director of Nursing (DON). When queried about who consented to the use of PRN IM Haldol and Ativan for R806 and why R806's long time psychiatrist was not collaborated with until 8/22/22, the DON reported the facility was unable to get in touch with R806's family. The DON reported they were unaware the son brought concerns up to PTA 'M' on 8/9/22.
Review of a facility policy titled, Use of Psychotropic Medication dated 9/2022, revealed, in part, the following: .Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s) .The attending physician or designated psych services will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents, their families and/or representatives, other professionals, and the interdisciplinary team .The indications for use of any psychotropic drug will be documented in the medical record .For psychotropic drugs that are initiated after admission to the facility, documentation shall include the specific condition as diagnosed by the physician .Psychotropic medications shall be initiated only after medical, physical, functional, psychosocial, and environmental causes have been identified and addressed .Non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation .PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration .Acute of emergency situations A clinician in conjunction with the IDT (interdisciplinary team) shall evaluate and document the situation to identify and address any contributing and underlying causes of the acute condition and verify the need for a psychotropic medication .Enduring conditions .An evaluation shall be documented to determine that the resident's expressions or indications of distress are .Not due to a medical condition or problems that can be expected to improve or resolve as the underlying condition is treated or the offending medication(s) are discontinued .Not due to psychological stressors, anxiety, or fear stemming from misunderstanding related to his or her cognitive impairment that can be expected to improve or resolve as the situation is addressed .Persistent, and negatively affect his or her quality of life .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R811
On [DATE] at approximately 10:22 AM, R811 was observed lying in bed. The resident was alert and able to answer most questio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R811
On [DATE] at approximately 10:22 AM, R811 was observed lying in bed. The resident was alert and able to answer most questions asked. The resident reported that they had been at the facility for over a year and went to dialysis three times per week.
A review of R811's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: End Stage Renal failure and Type II diabetes and received dialysis treatment at (name redacted) center on Monday, Wednesday and Fridays.
A review of the facility Hemodialysis Communication forms contained three sections. Section one was to be completed by the facility prior to sending a resident to dialysis and required the facility to answer questions including, but not limited to notes, vitals, medications and resident code status Section two was to be completed by the Dialysis center and required the Dialysis center to enter information including, but not limited to: Vitals, notes etc. Section three was to be completed by the facility upon the resident's return from dialysis and requires the facility to enter a resident's vitals and any notes.
A review of R811's Dialysis Communication forms from [DATE] to [DATE] noted the following forms were missing documentation:
Section 1 [DATE]
Section 2 [DATE], [DATE], [DATE]
Section 3 [DATE], [DATE], [DATE]
On [DATE] at approximately 1:10 PM an interview was conducted with the Director of Nursing (DON). The DON was asked about the facility's policy pertaining to Dialysis communication. The DON reported that the forms should be fully completed by the facility and the Dialysis center.
Review of a facility policy titled, Hemodialysis dated [DATE], revealed, in part, the following: .The facility will assure that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice. This will include: .The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility .Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments .Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services .The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: .Timely medication administration .by the nursing home and/or dialysis facility .vital signs .Advance Directives and code status .Dialysis treatment provided and resident's response .
This citation pertains to Intake Number(s): MI00134162
Based on interview and record review, the facility failed to ensure consistent coordination of care between the facility and dialysis center for two (R818 and R811) of two resident reviewed for dialysis. Findings include:
Review of a complaint submitted to the State Agency alleged on [DATE], R818 arrived at the dialysis center after missing several sessions, did not appear well, and needed to be sent to the hospital. The complaint noted that the dialysis center contacted the facility and spoke with Nurse 'E' (Nurse Manager) who told the dialysis center not to send R818 to the hospital because she was DNR/DNH (Do-Not-Resuscitate/Do Not Hospitalize) at the facility. The complaint further alleged that they were notified R818 was sent to the hospital a few days later from the facility and later died. They were concerned that the proper information was not being communicated with the dialysis center by the facility.
Review of R818's clinical record revealed R818 was admitted into the facility on [DATE], readmitted on [DATE], and discharged to the hospital on [DATE] with diagnoses that included: End Stage Renal Disease (ESRD). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R818 had moderately impaired cognition.
Review of R818's progress notes revealed R818 refused to go to dialysis on [DATE] and [DATE]. On [DATE], the following was documented in a Nursing -Progress Note: Resident assisted to WC (wheelchair) and taken to front lobby for Dialysis. Resident changing her mind back and forth about going to dialysis. Several staff members encouraging resident to attend treatment. Resident stated she wasn't feeling good. Staff explained to resident that was due to missing 2 dialysis treatments and not taking scheduled medications. Resident eventually consented to attend dialysis. Manager spoke to Dialysis Nurse regarding her direction to assigned nurse to send to ER. Manager reminded her resident is comfort care, DNR/DNH. Dialysis verbalized understanding.
On [DATE] at 2:03 PM, Nurse Manager, Nurse 'E' was interviewed. When queried about any communication with R818's dialysis center about being sent to the hospital on [DATE], Nurse 'E' reported the dialysis nurse told them if R818 did not go to dialysis on that day, they would not be able to accept them for dialysis any longer and would have to go to the emergency room. Nurse 'E' reported R818 agreed to go to dialysis and they did not have any further conversation with the dialysis center. When queried about the documentation that R818 was DNH, Nurse 'E' reported that might have been a mistake. When queried about how the facility and dialysis center coordinated and communicated about the resident, Nurse 'E' reported a communication sheet was completed by the facility before leaving for dialysis and after the resident returned to the facility and the dialysis completed a portion of the form as well. At that time, Nurse 'E' was asked to provide the dialysis communication sheet for R818 for the date of [DATE].
On [DATE] at 8:45 AM, a telephone interview was conducted with a manager at the R818's dialysis center, Dialysis Staff 'N'. When queried about whether they had any documentation on file from R818's dialysis session on [DATE], Dialysis Staff 'N' reported they did not keep the communication sheets on file and they were sent with the resident back to the facility. Dialysis Staff 'N' confirmed R818 was dialyzed on [DATE]. When queried about whether they were aware of any need for R818 to go to the hospital during that time, Dialysis Staff 'N' reported there was nothing on file that said R818 needed to go to the hospital, but the nurse who worked that day was told by the facility nurse manager that R818 was not to be sent to the hospital due to their code status and DNH order. It was explained that the dialysis nurse was surprised when they found out R818 was sent to the hospital by the facility a few days later when they called to see why the resident had not been to dialysis.
A dialysis communication form for R818 on [DATE] was not provided by Nurse 'E'.
On [DATE] at 8:40 AM, the Director of Nursing (DON) was interviewed. When queried about how the facility and dialysis communicated with one another about residents, the DON reported a communication form was completed by both the facility and dialysis center. When queried about any communication about R818 needing to go to the hospital while at dialysis, the DON was not sure. At that time, the DON was asked to provide all dialysis communication forms for R818 from [DATE] through [DATE], including [DATE].
Review of R818's Hemodialysis Communication forms revealed the following:
On [DATE], the Pre-Dialysis Vital Signs section was not complete and a weight was not documented, the section to be completed by the dialysis center was left blank, and the Post-Dialysis Vital Signs section was left blank and a weight was not documented. R818's code status was not documented.
On [DATE], the section to be completed by the dialysis center was not signed by staff and post-dialysis vital signs were not documented.
On [DATE], the Pre-Dialysis Vital Signs section was not complete and no weight was documented, the section to be completed by the dialysis center was left blank, and the Post-Dialysis Vital Signs section was left blank and no weight was documented.
On [DATE], the Pre-Dialysis Vital Signs section was not complete and a weight was not documented, the section to be completed by the dialysis center was left blank, and the Post-Dialysis Vital Signs section was left blank and a weight was not documented.
On [DATE], the Pre-Dialysis Vital Signs section was not complete and no weight was documented, the section to be completed by the dialysis center was left blank, and the Post-Dialysis Vital Signs section was left blank and no weight was documented.
On [DATE], the section to be completed by the dialysis center was not signed by staff and post-dialysis vital signs and weight were not documented.
On [DATE], the Pre-Dialysis Vital Signs section was not complete and a weight was not documented, the medications given prior to dialysis and medications sent with resident was left blank, and Post Dialysis Vital Signs were not completed and a weight was not documented. R818's code status was not consistent with what was on file at the facility (DNR). The form documented R818 was Full Code.
On [DATE], a pre-dialysis weight was not taken, the section to be completed by the dialysis center was left blank, and a post-dialysis weight was not documented.
There were no Hemodialysis Communication forms for the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].
May 2022
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME]-[NAME], [NAME]
Based on observation, interview, and record review, the facility failed to ensure three (R52, R9...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME]-[NAME], [NAME]
Based on observation, interview, and record review, the facility failed to ensure three (R52, R99, and R22) of four residents reviewed for dignity were treated in a dignified manner, resulting in R52 and R99 remaining covered in food from lunch for approximately four hours and R22 sitting with a puddle of urine underneath their wheelchair. Findings include:
On 5/23/22 at approximately 12:30 PM, R52, R99, and R22 were observed seated in the small dining room across from the nurses' station on the Anna's Place unit waiting for lunch to be served.
On 5/23/22 at 2:32 PM, the following was observed in the small dining room on Anna's Place unit:
R52 was observed, seated at a table alone. Their face and hands were covered with food. The table R52 was seated at was dirty with food from lunch. R52 was observed rubbing their hands into the spilled food on the table and talking nonsensically. The floor was observed with multiple plastic lids, garbage, food, and spilled liquid. R52 talked nonsensically, banged on the table, and sang loudly.
R99 was observed seated in a reclined geriatric chair (geri-chair) at a table with R22. R99 had brown, chocolate-like substance dripping from their nose. Their beard was covered in the brown liquid and other food. R99's arm was covered in the chocolate-like substance. When addressed, R99 did not respond.
R22 was observed seated in a wheelchair at a table with R99. R22 repeatedly asked What is the chance of survival for the baby? and Can you stay longer?
On 5/23/22 at 3:20 PM, R52 remained at the same table in the small dining room. The food remained on R52's face, hands, and table. The spilled liquids remained on the floor. R99 remained at the same table and had not been cleaned up. Brown, chocolate-like liquid dripped from R99's nose, saturated their beard, and was covering their arm. R22 remained at the same table in a wheelchair and asked if anyone was going to give my daughter a proper burial.
On 5/23/22 at 3:32 PM R52 continued to talk to self with no interaction from staff. R52 remained in the same condition, with food on their hands and face, food on the table, and spilled liquid on the floor. R99 remained in the same condition and had not been cleaned up or moved from the small dining room.
On 5/23/22 at 4:40 PM, R52, R99, and R22 remained in the small dining room, seated at the same tables they had been at since 12:30 PM. R52 talked to their self and was still covered in food from lunch. R99 remained in the geri-chair and was still covered in food from lunch. R22 was positioned poorly in the wheelchair with their buttocks toward the edge of the seat. A puddle of liquid was observed underneath the wheelchair that had not been there during previous observations and appeared to be urine. When queried if they had been taken to the bathroom, R22 reported she had not and that she was uncomfortable.
During all observations no staff were observed to be in the small dining room with R52, R99, and R22.
On 5/23/22 at 4:50 PM, Registered Nursing (RN) 'OO' entered the small dining room. When queried about the condition of R22, RN 'OO' reported she needed to be taken to the bathroom and was not in a safe position in the wheelchair. RN 'OO' reported the afternoon shift began at 3:00 PM and the day shift Certified Nursing Assistants (CNAs) were responsible to cleaning up residents after lunch and ensuring incontinence care (checking and changing briefs) was completed at least every two hours. RN 'OO' did not have an explanation as to why the afternoon shift had not yet checked on R52, R99, and R22 in the small dining room almost two hours into their shift.
On 5/24/22 at 10:42 AM, CNA 'GG' (who was assigned to Anna's Place unit on 5/23/22 during the day shift) was interviewed. When queried about why R52, R99, and R22 sat in the small dining room unattended from lunch time until 4:50 PM, CNA 'GG' reported there were only two CNAs working on that unit and they did the best they could. When queried about whether CNA 'GG' asked for assistance from anyone else due to being unable to tend to all their residents, CNA 'GG stated, They know when we are short.
On 5/24/22 at approximately 10:50 AM, CNA 'JJ' (who was assigned to Anna's Place unit on 5/23/22 during the day shift) was interviewed. When queried about why R52, R99, and R22 sat in the small dining room unattended from lunch time until 4:50 PM, CNA 'JJ' reported they were short on staff on 5/23/22. When queried about whether CNA 'JJ' reached out to anyone to assist them with task they were unable to complete, CNA 'JJ reported the managers knew they were short staffed.
On 5/25/22 at 2:13 PM, the Director of Nursing (DON) was interviewed. The above observations were shared with the DON who reported the CNAs were responsible to clean up the residents and provide incontinence care, however, any nurse, myself, or anyone can assist.
Review of R52's clinical record revealed R52 was admitted into the facility on 7/1/20 with diagnoses that included: Alzheimer's Disease. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R52 had severely impaired cognition, physical and verbal behaviors, was totally dependent on staff for toilet use, and was always incontinent.
Review of R99's clinical record revealed R99 was admitted into the facility on 4/21/21 with diagnoses that included: convulsions, dementia, and moderate intellectual disabilities. Review of a MDS assessment dated [DATE] revealed R99 had severely impaired cognition and required physical assistance of at least two staff members for toilet use and was frequently incontinent.
Review of R22's clinical record revealed R22 was admitted into the facility on 8/27/21 with diagnoses that included: dementia, anxiety disorder, and psychotic disorder. Review of a MDS assessment dated [DATE] revealed R22 had severely impaired cognition, required extensive physical assistance for toilet use, and was always incontinent.
Review of a facility policy titled, Promoting and Maintaining Resident Dignity, issued on 1/2018, revealed, in part, the following: It is the practice of this facility to protect and promote resident right and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality .All staff members are involved in providing care to residents to promote and maintain resident dignity .
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 interview and record review, the facility failed to ensure accurate advance directive information, including a physicia...
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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 accurate advance directive information, including a physician order for a Do-Not-Resuscitate (DNR) was in place for one (R128) of one resident reviewed for advance directives.
Findings include:
According to the facility's policy titled, Advanced Directive dated [DATE]:
.If the resident has provided to the Facility .an Advance Directive .it is the policy of the Facility to recognize and comply with the resident's wishes found in these documents .
Review of R128's clinical record included a code status banner at the top of the electronic record that indicated the resident's code status was Full Cardiopulmonary Resuscitation (CPR).
Review of the actual advance directive form signed and dated by R128 on [DATE] and the physician on [DATE] documented R128's code status was to be a DNR.
Further review of the clinical record revealed R128 was admitted into the facility on [DATE] with diagnoses that included: acute on chronic diastolic heart failure, chronic kidney disease stage 4 (severe), bilateral primary osteoarthritis of knee, primary pulmonary hypertension, anemia, trigeminal neuralgia, hyperlipidemia, malignant neoplasm of thyroid gland, and dependence on renal dialysis.
According to the Minimum Data Set (MDS) assessment dated [DATE], R128 had intact cognition and had no communication concerns. Per the profile information, R128 was their own responsible party.
On [DATE] at 1:13 PM, an interview was conducted with Nurse 'N' who was currently assigned to R128. When asked what documentation was reviewed to determine a resident's code status in the event of an emergency, Nurse 'N' reported they would look at the electronic medical record (EMR) and at that time, confirmed R128's code status was full CPR. When asked to clarify if that meant resuscitation would be provided in the event it was necessary, Nurse 'N' reported Yes. When asked to review the advance directive documentation available in the EMR, Nurse 'N' confirmed R128 and the physician signed the DNR form, but the physician order had not been written as of this review.
On [DATE] at 1:22 PM, an interview was conducted with the Director of Nursing (DON). When asked what the facility's process was to change from a full code to DNR, the DON reported the process should be immediately when the DNR is implemented and when the form was signed, the physician should write the DNR order. The DON was informed of the concern about the resident's advance directives and reported they would follow up immediately. The DON was also asked to clarify which physician signed the DNR, as the name was illegible, but there was no further clarification provided by the end of the survey.
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** This citation pertains to Intake Number MI00128160.
Based on interview and record review, the facility failed to ensure one (R33...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number MI00128160.
Based on interview and record review, the facility failed to ensure one (R33) of one resident reviewed for abuse did not experience verbal abuse from staff. Findings include:
Centers for Medicare and Medicaid Services (CMS) define Mental and Verbal abuse as the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.
Review of a facility reported incident (FRI) reported to the State Agency revealed on 4/11/22, R33's family member reported a Certified Nursing Assistant (CNA) stated, I hated coming in this room, you all have put that light on and I have more than one person to take care of.
Review of a facility policy titled, Abuse Program: Elder Justice Act (Abuse, Neglect, Mistreatment, Misappropriation, Suspicion of Crime, Investigation, and Reporting) revealed, in part, the following: It is our policy to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal .abuse .Verbal Abuse: defined as use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance to describe residents regardless of their age, ability to comprehend, or disability. Examples of Verbal Abuse: .Use of disparaging .terms .
Review of R33's clinical record revealed R33 was admitted into the facility on 3/11/22 and discharged on 5/13/22 with diagnoses that included: cerebral infarction, congestive heart failure, type 2 diabetes, and post-traumatic stress disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R33 had intact cognition.
Review of the facility's investigation into the allegation of verbal abuse revealed the following:
An Investigation Summary documented, on 4/11/22 4:30 (PM) (R33's) daughter voiced to .Assistant Director of Nursing (ADON) and Director of Nursing (DON) that the CNA her mother had today was very rude. She said this CNA stated, 'I hated coming in this room'. Also, was in the hallway yelling, 'I hate this room@ you all put that light on and I have more then <sic> on <sic> person to take care of'. (R33's family member) notified us that this CNA toileted resident, placed her in bed and told her mother she needs to stay there. (R33's family member) also notified us that she brought in a mirror for her mother and this CNA tossed it in the chair .Investigation: .(R33) was interviewed by Director of Social Services (SW 'MM') and resident stated that she did hear (CNA 'NN') state the above concerns. Resident's roommate .also interviewed by (SW 'MM') and validated she heard (CNA 'NN') the above concerns .Facility is unable to substantiate any allegation of alleged abuse or any deficient practice. Even though allegation of abuse was not substantiated as a proactive measure facility has terminated this CNA because this conduct was against companies' <sic> mission statement .
A typed statement signed by SW 'MM' documented, Re: (R33's roommate) Writer, (SW 'MM'), met with patient regarding CNA concerns. Patient voiced CNA was standing outside of her room in ear shot talking about how she did not like 'this room' . R33's roommate was no longer a resident at the time of the survey and therefore an interview was not conducted.
On 5/26/22 at 11:45 AM, the DON was interviewed. When queried about what occurred between CNA 'NN' and R33 on 4/11/22, the DON reported the ADON brought to her attention that R33's family member made a complaint about CNA 'NN'. The DON reported that R33 and R33's roommate both validated that they heard CNA 'NN' talking in the hallway about how she 'hated that room' and had more than one person to take care of. The DON reported CNA 'NN' was terminated after the investigation was complete.
On 5/26/22 at 12:54 PM, the Administrator, who was designated as the facility's Abuse Coordinator, was interviewed. When queried as to how it was determined the abuse allegation was unsubstantiated when it was confirmed to have happened by R33's family member, R33, and R33's roommate, the Administrator reported R33 did not have a negative effect, but they terminated CNA 'NN' because they did not want to continue the employment due to the CNA 'NN''s behavior. When queried about the definition of verbal abuse, the Administrator reported she did not consider it verbal abuse.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide physician ordered treatments for a skin tear ...
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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 physician ordered treatments for a skin tear for one (R52) of two residents reviewed for skin condition. Findings include:
On 5/23/22 at 1:50 PM, 2:32 PM, 3:20 PM, and 4:40 PM, R52 was observed to have an undated adhesive bandage to their left elbow.
Review of R52's clinical record revealed R52 was admitted into the facility on 7/1/20 with diagnoses that included: Alzheimer's Disease. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R52 had severely impaired cognition and required extensive physical assistance for transfers and bed mobility. Review of an Incident Report dated 5/17/22 documented R52 was found on the floor of the dining room and sustained a skin tear to the left elbow. Review of Physician's Orders revealed an order was written on 5/17/22 for cleanse skin tear to left arm with soap and water, cover with dry dressing in the evening for Health & Wellness. Review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) for R52 revealed the above order was not included on the TAR or MAR for May 2022.
On 5/24/22 at 3:17 PM, R52 was observed to have an undated adhesive bandage to their left elbow. When asked what happened, R52 responded nonsensically and began singing.
On 5/24/22 at 3:22 PM, Nurse Supervisor, Licensed Practical Nurse (LPN) 'J' was interviewed. When queried about the bandage on R52's left elbow, LPN 'J' reported she thought it was just for 'protection'. At that time, an observation of R52's skin underneath the bandage was conducted with LPN 'J'. LPN 'J' had some difficulty removing the bandage. The dressing was observed to have multiple dark/black dried spots on it and R52's left elbow was observed to have what LPN 'J' described appeared to be a 'skin tear'. When queried about whether there was a physician's order to treat the skin tear, LPN 'J' reviewed R52's clinical record and reported there was an order entered on 5/17/22 to cleanse with soap and water and cover with dry dressing. When queried about the last time the treatment was administered, LPN 'J' reported she would look into it.
On 5/24/22 at approximately 4:00 PM, LPN 'J' reported the nurse who entered the order for the skin tear treatment did not enter the correct order type and therefore it did not transfer to the Treatment Administration Record (TAR). LPN 'J' reported there was no way to verify if treatment was done since 5/17/22 as the bandage was not dated when applied.
On 5/25/22 at 2:15 PM, an interview was conducted with the Director of Nursing (DON). When queried about the protocol when a resident sustained a skin tear, the DON reported they would try to determine the cause, put a treatment order in place, contact family and the physician, and complete an incident report. Regarding R52, the DON reported the nurse entered the order incorrectly and therefore it was not transferred to the TAR.
Review of a facility policy titled, Skin and Wound Policy, revised 2/2022, revealed, in part, the following: .It is also our policy to follow the treatment plans for any wound/skin concerns as ordered by physicians .All wounds will have treatment orders from the physician team .Wound treatment will be provided in accordance with physician orders .Treatments will be documented on the Treatment Administration Record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one (R31) of two residents reviewed for vision...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one (R31) of two residents reviewed for vision and hearing was evaluated by the eye doctor in a timely manner, resulting in continued poor and double vision, headaches and discomfort. Findings include:
On 5/23/22 at approximately 1:00 PM, R31 was observed seated in bed. R31 was observed not wearing eye glasses. When asked if they had any concerns about their care in the facility, R31 reported she had a concern with having to wait months to see an optometrist (eye doctor). R31 reported she experienced headaches and double vision when she tried to focus on things, such as the television. R31 reported she notified the physician of her concerns and had not seen an eye doctor since she was admitted into the facility in 2021.
Review of R31's clinical record revealed R31 was admitted into the facility on 6/8/21 with diagnoses that included: nontraumatic intracerebral hemorrhage. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R31 had intact cognition, had vision impairment, and did not have corrective lenses.
Review of an Authorization for Dental, Optometry & Podiatry Services form signed by R31's resident representative on 6/21/21, revealed, Optometry .I wish to use the services of the Facility's contracted Optometrist as ordered by my Attending Physician .
Review of Physician Orders revealed the following orders:
An order dated 10/28/21 for (ancillary services company) Consult for : Blurry Vision.
An order dated 1/5/22 for .Consult for: vision.
An order dated 3/15/22 for Consult Ophthalmology: Evaluation/new glasses.
Further review of R31's clinical record revealed no consultations from an optometrist or ophthalmologist.
Review of R31's progress notes revealed the following:
A Physician Progress Note dated 11/2/21, documented, .She also requests visit from eye doctor, questioning need for glasses .4) poor vision .she is scheduled for (ancillary services company), for which she will be seen by visiting eye doc (doctor); f/u on recommendations, as provided .
A Physician Progress Note dated 1/5/22, documented, .With exception of inquiry about visiting eye doctor d/t (due to) poor vision and need for glasses, she denies having medical questions/concerns .2) poor vision .will place consult for visiting eye doctor to evaluate need for new script on corrective lenses .
A Physician Progress Note dated 3/15/22, documented, Patient being followed by (ancillary services company); given her request for eye exam, unit clerk alerted to schedule visit .
A Nursing Progress Note dated 3/17/22, documented, Order has been submitted to (ancillary services company) for vision consult waiting to here <sic> when they'll be coming to (facility name) .
A Physician Progress Note dated 4/26/22 documented, .She denies change in vision, but has already been requesting ophthalmology visit, inquiring about need for new glasses .ophthalmology consult already in place to evaluate for new glasses/script .
A Physician Progress Note dated 5/19/22, documented, .Her only additional complaint today is regarding her vision, reiterating visual change/strain since her stroke. She says this provokes a headache at times 4) impaired vision- r/t (related to) CVA (cerebral vascular accident); this has been ongoing/chronic, and (ancillary services company) has been consulted here at least a couple times for follow up; will message unit manager to ensure visit .
On 5/26/22 at 10:57 AM, Nurse Manager, Licensed Practical Nurse (LPN) 'J' was interviewed. When queried about why R31 had not yet been seen by the eye doctor, LPN 'J' confirmed there were multiple physician orders since October 2021 and reported the eye doctor was seeing residents in the facility on that day (5/26/22). LPN 'J' did not know why R31 had not been seen previously, as they come to the facility every three months.
On 5/26/22 at 11:40 AM, an interview was conducted with the Director of Nursing (DON). The DON explained that the unit clerk was responsible for setting up vision appointments and a consent was signed upon admission for ancillary services, including vision services, that were coordinated by a contracted company that came to the facility. The DON did not have an explanation as to why R31 was not seen sooner as ordered by the physician.
Review of a facility policy titled, Hearing and Vision Services, revised 4/30/19, revealed, in part, the following: It is the policy of this facility to ensure that residents have access to and receive proper treatment and assistive devices to maintain vision and hearing abilities .Employees should refer any identified need for hearing or vision services/appliances to the social worker service designee .Once vision or hearing services have been identified the social worker/social service designee will assist the resident by making appointments and arranging for transportation .
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 implement the plan of care to ensure restorative servi...
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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 the plan of care to ensure restorative services and treatment to maintain or improve Range of Motion (ROM), strength and mobility for one resident (R62) of 3 residents reviewed for limited ROM.
Review of the clinical record revealed R62 was admitted into the facility on 4/5/22 with diagnoses that included in part: alcoholic cirrhosis, liver failure, lower extremity lymphedema (swelling of the legs), and diabetes. According to the Minimum Data Set (MDS) assessment dated [DATE], R62 had intact cognition.
During an observation on 5/23/22 at approximately 3:30 PM, R62 was sleeping. There was a two wheeled walker near R62's bed and a wheelchair in the corner of room.
During an interview on 5/24/22 at 1:44 PM, R62 explained they needed to get up out of bed more often. R62 said they felt as if they were pinned to this bed for the last 4 days. R62 clarified that they used to have Physical Therapy and Occupational Therapy every morning. R62 shared they are not understanding the reason as to why they are not getting their exercises or getting up out of the bed. R62 further stated that her family was wondering also as to why I am not walking to the end of the hall. R62 explained they thought they would only be here for a short time for rehab (rehabilitation) and then back home.
On 5/25/22 at approximately 3:15 PM, an interview was conducted with Occupational Therapist (OT) AAA from the Rehabilitation Department. OT AAA explained that R62 had been discharged from Physical Therapy (PT) and should be receiving restorative services from nursing.
On 5/26/22 at 10:05 AM, an interview was conducted with Nursing Manager P who explained they have responsibility for the management of the restorative services. Nursing Manager P further explained that there is a restorative aide that works with the residents 4 days a week. R62 was not receiving restorative services because there was not an order to start restorative services. Also, Nursing Manager P clarified that their review of the medical record revealed that R62 was to receive physical therapy until 5/27/22. Nursing Manager P explained their process was for an order to be put into the electronic medical record from the therapy department. Also, paper documentation would be brought over from the Rehabilitation Department with the follow up treatment program information. Then, Nursing Manager P would have placed R62's treatment program information into the restorative services binder.
At 10:20 AM on 5/26/22, spoke with the Director of Therapy BB and shared that the restorative services had not been started for R62 on 5/17/22. There had not been an order entered into the electronic medical record and the usual documentation had not been given to Nursing Manager P with oversight for the restorative services. The Director of Therapy BB shared that the therapist had forgotten to place the order. The Director of Therapy BB further explained that this therapist was on an LOA (Leave of Absence) and the therapist would receive reeducation on this expected process when they returned to work.
The facility provided documentation on their policy titled, Restorative Nursing Program with approval date of 5/3/22 that states in part, . 11. The discharging therapist, Restorative Nurse or designated licensed nurse will communicate to the appropriate restorative aide, the provisions of the resident's restorative nursing plan, providing any necessary training to carry out the plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow it's policy and complete an Incident and Accid...
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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 it's policy and complete an Incident and Accident report for one resident (R35) of three residents reviewed for accidents, resulting in the potential for future falls and injury. Findings Include:
On 5/23/22 at 1:26 p.m., R35 was observed sitting in a wheelchair. R35 stated, I fell out of the bed last night (5/22/22). I hurt my right arm. R35's right arm was observed with a bruise near the wrist. When asked how he got up off the floor, R35 stated, They (staff) put me back in the bed. My arm is stiff. I can't move it .
Review of the clinical record revealed R35 was admitted into the facility on 3/12/22 and readmitted on [DATE] with diagnoses that include in part: Cerebral Aneurysm, Hemiplegia, Epilepsy, and Repeated Falls. Further review of the clinical record revealed R35
The facility's Fall care plan initiated 5/11/22 revealed the following: Focus: The resident is at risk for falls and potential injury r/t (related to) Deconditioning, Paralysis, Unaware of safety needs . Interventions/Tasks: Anticipate needs Q shift, Pt (Patient) evaluate and treat as ordered or PRN (as needed), Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. Seizure disorder: Monitor for change in LOC and seizure activity. Provide protective environment during seizure activity. Notify physician .
Review of Fall Risk & Injury Prevention assessment dated [DATE] revealed a score of 15.0 which indicated R35 was at High Risk for potential falls.
On 5/25/22 at 5:28 p.m., during an interview with the Director of Nursing (DON), when notified that R35 reported that they had a fall on 5/22/22 and hurt their right arm, the DON was unaware and left to go investigate what was reported to her. The DON explained the only I &A (Incident & Accident) report she had was dated 3/13/22 .
On 5/25/22 at 5:45 p.m., DON returned and explained that she was trying to gather information, and she did not know about the fall and Unit Manager (UM) 'P' did not know about it either. The DON then stated, I did see the progress note from the nurse practitioner.
On 5/25/22 at 5:47 p.m., the DON and UM 'P' was in R35's room asking questions about the fall. R35 further stated, it was two female nurses that got them off the floor. R35 stated again that he hurt his arm (pointing to the right arm and saying it is stiff). When asked about the bruise, resident stated he did it when he fell.
On 5/26/22 at 9:50 a.m., an interview was conducted with the DON about the facility's protocol after a resident fall. The DON stated, They (staff) should have reported it. The problem is they did not do an incident report and they should have. The DON further stated, We are going to put strips at the bed . There were no interventions in place after the resident's fall.
On 5/26/22 at 1:25 p.m., Licensed Practical Nurse (LPN) 'XX' returned the call. When asked about R35's fall that occurred on 5/22/22 LPN 'XX' stated, I was walking down the hall and saw him. I got another nurse, (LPN 'CCC') and an aide I forgot their name. We got R35 up and put him in bed and asked what happened. He was sleeping and rolled out of bed . When asked who assessed R35, LPN 'XX' stated, It should have been the nurse that had him. We told her what happened, and she took over. At that time, LPN 'XX' was asked what they should have done after R35's fall. LPN 'XX' stated, Since the nurse was on the hall, we let her know. She should have done the report. If she would have been at lunch or something. I would have done an incident report.
On 5/26/22 at 10:40 a.m., a phone interview was conducted with LPN 'YY'. At that time, LPN 'YY' stated she did not assist with R35's fall but did hear about it. At 1:33 p.m., a call was made and LPN 'YY' was asked if they were R35's nurse on the night of the fall. LPN 'YY' stated, Yes I did assess R35, and I did neuro checks . LPN 'YY' further explained that R35 had a history of rolling out of bed. I asked if R35 was ok, and R35 said, Yes. LPN 'YY' was asked why they did not document that R35 had a fall. LPN 'YY' stated, I am sorry, I was preoccupied .
A review of the facility provided document titled Accident & Incident Report Policy dated 10/2021 revealed the following: Policy: Accident/Incident reports will be completed on any accident or incident involving a Facility resident . An accident/incident report must be completed for residents regardless of location while in our care and any visitor who suffers an accident or injury while on premises. An accident/incident report should be completed as soon as the facility gains knowledge of an incident . Procedure . 1. All accident/incidents involving residents will be documented in the Risk Management Section in PCC . 2. a. The nurse who discovers the incident or the nurse assigned to the resident will initially complete the accident / incident report at the time of the incident. b. For each incident the physician team will be notified. c. The IDT or designee will review incidents weekly. Care plan will be updated and therapy will be notified if an evaluation is needed. d. The nurse manager or designee should review the post-incident investigative reports initiated by the nurse and assist to complete them within 72 hours of the incident. e. Unless requested by a competent resident, the resident's representative should be notified of all incidents regardless of severity of injury. f. Any accident/incident that is unusual/ suspicious that causes harm to a resident, must be reported to the Director of Nursing and/or Administrator as soon as discovered for proper investigation, follow-through, and possible reporting as required by Federal Regulations .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three (R22, R52, and R99) of four residents re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three (R22, R52, and R99) of four residents reviewed for bowel and bladder, received timely incontinence care, resulting in the residents not being taken to the bathroom or changed for four and a half hours and R22 soaking through their brief causing a puddle of urine under their wheelchair. Findings include:
Review of a facility policy titled, Incontinence, dated 5/9/2019, revealed, in part, the following: Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services .Residents that are incontinent of bladder ow <sic> bowel will receive appropriate treatment to prevent infections and any adverse side effects .Incontinent residents will be monitored frequently and timely throughout the nursing staff working shifts .CNA's will document once per shift under ADL documentation, bladder and bowel status. The documentation does not reflect each incontinence episode, it does reflect that care was rendered during their working shift .
On 5/23/22 at approximately 12:30 PM, R52, R99, and R22 were observed seated in the small dining room across from the nurses' station on the Anna's Place unit waiting for lunch to be served.
On 5/23/22 at 1:50 PM, 2:32 PM, 3:20 PM, 3:30 PM, and 4:40 PM the following was observed in the small dining room on Anna's Place unit:
R52, R99, and R22 were seated in wheelchairs at tables. R52's hands, face, and clothing were covered with food from lunch. R52 remained in the same spot during all observations. R99's face, arms, and clothing were covered in food from lunch. R99 remained in the same spot during all observations. R22 remained seated in a wheelchair in the same spot. During all observations no staff was observed engaging with the residents.
On 5/23/22 at 4:40 PM, R52, R99, and R22 remained in the small dining room, seated at the same tables they had been at since 12:30 PM. R22 was positioned poorly in the wheelchair with their buttocks toward the edge of the seat. A puddle of liquid was observed underneath the wheelchair that had not been there during previous observations and appeared to be urine. When queried if they had been taken to the bathroom, R22 reported she had not and that she was uncomfortable. R22 did not have any beverages that could have been spilled. R99 was asked if he had been taken to the bathroom since lunch time and stated, No. R52 was unable to answer questions.
On 5/23/22 at 4:50 PM, Registered Nursing (RN) 'OO' entered the small dining room. When queried about the condition of R22, RN 'OO' reported she needed to be taken to the bathroom. RN 'OO' reported the afternoon shift began at 3:00 PM and the day shift Certified Nursing Assistants (CNAs) were responsible for providing incontinence care (checking and changing briefs or assisting residents with using the toilet) and should be completed at least every two hours. RN 'OO' did not have an explanation as to why the afternoon shift had not yet checked on R52, R99, and R22 in the small dining room almost two hours into their shift.
On 5/24/22 at 10:42 AM, CNA 'GG' (who was assigned to Anna's Place unit on 5/23/22 during the day shift) was interviewed. When queried about whether R52, R99, and R22 were provided with incontinence care between 12:30 PM and 4:50 PM. CNA 'GG' reported there were only two CNAs working on that unit on 5/23/22 and they did the best they could, but they did not provide care to the residents in the small dining room after lunch. When queried about whether CNA 'GG' asked for assistance from anyone else due to being unable to tend to all their residents, CNA 'GG stated, They know when we are short.
On 5/24/22 at approximately 10:50 AM, CNA 'JJ' (who was assigned to Anna's Place unit on 5/23/22 during the day shift) was interviewed. When queried about whether incontinence care was provided to R52, R99, and R22 between 12:30 PM and 4:50 PM, CNA 'JJ' reported they were short on staff on 5/23/22 and did not provide care to those residents after lunch. When queried about whether CNA 'JJ' reached out to anyone to assist them with task they were unable to complete, CNA 'JJ reported the managers knew they were short staffed.
On 5/25/22 at 2:13 PM, an interview was conducted with the Director of Nursing (DON). When queried about the protocol for ensuring residents received incontinence care, the DON reported the standard of practice was to check residents for incontinence every two hours at a minimum. The DON further explained the CNAs were responsible for providing incontinence care, But any nurse, nurse manager, or myself can assist.
Review of R22's clinical record revealed R22 was admitted into the facility on 8/27/21 with diagnoses that included: dementia, anxiety disorder, and psychotic disorder. Review of a MDS assessment dated [DATE] revealed R22 had severely impaired cognition, required extensive physical assistance for toilet use, and was always incontinent.
Review of the CNA Task for ADL (activities of daily living) - Toilet Use Assist x (times) 2 revealed documentation by CNA 'GG' at 12:32 PM that indicated ACTIVITY DID NOT OCCUR. Review of the CNA Task for B&B (bowel and bladder) - Bladder Elimination revealed documentation by CNA 'GG' at 12:32 PM that indicated R22 was incontinent.
Review of R22's care plans revealed a care plan initiated on 9/2/20 that documented, ALTERATION IN ELIMINATION r/t (related to): Dementia, impaired cognition .Assist with toileting and hygiene needs PRN (as needed) (initiated 8/31/21) .Incontinence care per facility policy (initiated 8/31/21) .
Review of R52's clinical record revealed R52 was admitted into the facility on 7/1/20 with diagnoses that included: Alzheimer's Disease. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R52 had severely impaired cognition, physical and verbal behaviors, was totally dependent on staff for toilet use, and was always incontinent.
Review of CNA Tasks for B&B - Bladder Elimination and ADL - Toilet Use Assist x 1 bed level Incontinent; briefs for R52 revealed CNA 'JJ' documented R52 was incontinent at 1:54 PM and was totally dependent with two-person physical assist. However, R52 remained in the small dining room from approximately 12:30 PM until 4:50 PM.
Review of R52's are plans revealed a care plan initiated on 9/2/20 that documented, The resident has bladder incontinence r/t Alzheimer's, Confusion, Impaired Mobility .Continue current plan of care (initiated 11/25/20) .Establish voiding patterns (initiated 9/2/20) . A care plan initiated on 10/12/20 documented, ALTERATION IN ELIMINATION r/t: Dementia .Incontinence care per facility protocol .
Review of R99's clinical record revealed R99 was admitted into the facility on 4/21/21 with diagnoses that included: convulsions, dementia, and moderate intellectual disabilities. Review of a MDS assessment dated [DATE] revealed R99 had severely impaired cognition and required physical assistance of at least two staff members for toilet use and was frequently incontinent.
Review of CNA Tasks for Toilet Use assist x 2 bed level, for R99 revealed CNA 'JJ' documented R99 was provided one person assist with toilet use at 1:44 PM. However, R99 remained in the small dining room from approximately 12:30 PM until 4:50 PM.
Review of R99's care plans revealed a care plan initiated on 7/20/21 that documented, ALTERATION IN ELIMINATION r/t: cognitive impairment, debility and generalized weakness .Urinary catheter care per facility protocol (Review of R99's physician's orders did not indicate R99 had a urinary catheter, and a catheter was not observed). A care plan initiated on 5/19/22 documented, ACTUAL INFECTION of UTI (urinary tract infection) .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assist residents with eating per their plan of care, ...
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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 assist residents with eating per their plan of care, implement weekly weights, increase nutritional supplements, and ensure residents were evaluated by the physician for three (R22, R52, and R99) of six residents reviewed for nutrition who experienced significant/severe weight loss. Findings include:
R22
On 5/24/22 at approximately 8:00 AM, R22 was observed eating breakfast in bed. R22 appeared able to eat without physical assistance from staff.
Review of R22's clinical record revealed R22 lost 14.1 pounds (#) in one month, between 4/3/22 and 5/9/22. Review of R22's Weight Summary revealed R22 weighed 165.7# on 4/3/22 and 151.6# on 5/9/22 (8.51 percent, a severe loss of body weight in one month).
Further review of R22's clinical record revealed R22 was admitted into the facility on 8/27/21 with diagnoses that included: dementia, dysphagia (difficulty swallowing), contractures, and right-side hemiplegia (paralysis on one side of the body). Review of a MDS assessment dated [DATE] revealed R22 had severely impaired cognition and required supervision and setup help only for eating.
Review of R22's progress notes revealed a Nutrition/Dietary Note written on 5/10/22 that documented, Weight differentiation under investigation, will follow. The previous Nutrition/Dietary Note was dated 2/25/22. There were no other Nutrition/Dietary Notes that addressed R22's weight loss between 4/3/22 and 5/9/22.
Review of R22's Physician Progress Notes revealed R22 was seen by Physician CCC. The note does not address R22's significant weight loss.
Review of a Therapy Progress Note (Speech-Language Pathology) dated 5/19/22 revealed R22 did not have any concerns with eating.
On 5/26/22 at 10:04 AM, an interview was conducted with Registered Dietitian (RD) 'S'. When queried about the cause of R22's weight loss and what interventions were put into place to prevent further weight loss, RD 'S' reported she had been investigating the cause of R22's weight loss. RD 'S' reported it could have been due to edema in R22's lower extremities. RD 'S' further explained that she observed R22 at during various meals and R22 ate independently once her meal was set up by staff. RD 'S' reported R22 ate 75 to 100 percent of her meals. When queried about whether R22 was evaluated by a physician to determine if there was a medical reason for the weight loss, RD 'S' reported she would look into it.
On 5/26/22 at 12:16 PM, RD 'S' followed up and reported a physician had not evaluated R22 for weight loss as of that date. No additional interventions were implemented since significant weight loss was identified on 5/9/22.
R52
On 5/24/22 at 8:26 AM, R52 was observed in bed eating breakfast. R52 had scrambled eggs, chopped meat, grits, and juice. R52 was talking nonsensically and then stated, I can't do it. I can't get it. No staff were observed to assist R52 with their meal.
On 5/24/22 at 8:43 AM, R52 was alone in their room eating breakfast. Food was observed to be on the floor, on the bed, and on the resident. R52 was observed trying to eat scrambled eggs with their hands. No staff were present in R52's room.
On 5/25/22 at 9:30 AM, a large amount of food crumbs was observed on the bed sheets and R52's shirt.
Review of R52's clinical record revealed R52 was admitted into the facility on 7/1/20 with diagnoses that included: Alzheimer's Disease, Adult Failure to Thrive, protein-calorie malnutrition, and anorexia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R52 had severely impaired cognition and required supervision by one staff member for eating.
Review of R52's Weight Summary revealed R52 lost 22.6# between 3/3/22 and 4/1/22 (R52's weight was 130.6# on 3/3/22 and was 108# on 4/1/22) and lost an additional two pounds between 4/1/22 and 5/9/22 (R52 was 106# on 5/9/22). R52 had a severe weight loss of 18.84 percent of their body weight within one month.
Review of R52's Nutrition/Dietary Notes revealed the following:
A Nutrition/Dietary Note dated 4/1/22 documented, Noted weight loss since admission, wt. (weight) scale was calibrated. Dx (diagnosis) FTT (failure to thrive). 4/1 108# x 2, 3/3 130.6#, 1/1 133#, 8/1 n/a, 7/13 137.3# .Rec (recommend) increase medpass 180 cc (cubic centimeters) QID (four times a day). Will continue to monitor weekly weights.
A Nutrition/Dietary Note dated 4/2/22 documented, WILL RECOMMEND TO DOWN GRADE DIET TO PUREED AND SWALLOWING EVAL /SCREEN TO ASSESS APPROPRIATENESS OF DIET CONSISTENCY.
A Nutrition/Dietary Note dated 4/7/22 documented, .Quarterly Nutrition Review: . Wt: 108# 30d (days): 130# 180d: 152.2# Significant Wt. Change: [ x ] Yes [ ] No Diet: mechanical soft .PO (by mouth) Intake: [ x ] 25% [ x] 50% [ x ] 75% [ x ] 100% Feeding Assist: .[ x ] Total Assist . Summary & Recommendations: Resident is currently receiving a mechanical soft diet and is assisted with all meals. Her po intake varies consuming 25-100%. There has not been any coughing noticed with current diet or any additional swallowing difficulty .Her recent weights .indicates a significant weight loss. She is currently receiving med pass 2.0 120 cc BID (two times a day) (Note that the Nutrition note dated 4/2/22 recommended Med Pass to increase to QID) and magic cups BID in addition to an appetite stimulant which seems to be working as she does consume all of her meals on occasion. Her average po intake lately has been about 50%. Will continue this current diet at this time as long as she is able to tolerate and accept. She now has severe PCM (protein calorie malnutrition) at this time and her care plan has been updated. Will make changes as needed.
A Nutrition/Dietary Note dated 5/10/22 documented, Weight differentiation under investigation, will follow.
A Nutrition/Dietary Note dated 5/15/22 documented, Current weight is 106lbs (pounds); X 30day 109lbs; X180days 135lbs showing 19.7% significant weight loss .She is also getting med pass 120cc BID and magic cup BID for nutritional support with variable Continue with current diet/supplement interventions and weekly wts (weights) .
Review of Physician Notes revealed the following:
On 1/17/22, a Physician Note documented, .anorexia - staff reports that she eats well and enjoys snacks between meals .she has 1:1 (one to one) assist at meals, nutritional supplements and a liberal diet. Although weights are generally stable at this time, we do expect a decline as her condition progresses. will continue to monitor .
On 3/14/22, a Physician Note documented, .anorexia - staff reports that she eats well and enjoys snacks between meals. She is on marinol (medication to stimulate appetite). weights are stable over the last year. she has 1:1 assist at meals, nutritional supplements, and a liberal diet. Although weights are generally stable at this time, we do expect a decline as her condition progresses. will continue to monitor .
On 4/5/22, a Physician Note documented, Writer collaborated with today's nurse and other staff members regarding intake. Per staff, she routinely consumes (less than) 50% (percent) of provided trays and is a feeder/requires physical assist with feeding .she has more recently required increased assist with feeding, which is attributed to her advanced dementia, and intake decreased, per staff report; .continue to assist w/feeding .
On 4/12/22, a Physician Note documented, (R52) is seen today for general medical visit, including f/u (follow up) on anorexia/weight loss .In collaboration with nurse, patient does well with self-feeding, though intake fluctuates. Nurse states patient generally consumes 25-50% of provided trays.anorexia/wt loss- in collaboration with nursing, patient consuming 25-50% of provided trays, along with supplements; will update weight and f/u to monitor response to discontinuation of marinol .
On 4/16/22, a Physician Note documented, .anorexia - review of weight trends show a significant decline in the last month (13-22 pounds). I do question the accuracy of some of the weights. She does appear thin in my exam but not more cachexic than her usual appearance of the last year. staff reports that she eats well and enjoys snacks between meals .Appetite does not seem to have declined .she has 1:1 assist at meals, nutritional supplements and a liberal diet. unfortunately, we do expect a decline as her condition progresses. will continue to monitor .
On 5/8/22, a Physician Note documented, .anorexia - review of weight trends show fluctuant weights with a significant decline one month and then a large improvement in the last month. I do question the accuracy of some of the weights. She does appear thin in my exam but not more cachexic than her usual appearance of the last year. staff reports that she eats well and enjoys snacks between meals. She is on a mechanical soft diet with thin liquids. Per staff, appetite is good and she has 1:1 assist at meals, nutritional supplements and a liberal diet. unfortunately, we do expect a decline as her condition progresses. will continue to monitor .
Review of R52's physicians orders revealed the following orders:
Add Diagnosis: Protein Calorie Malnutrition: severe PCM R/T advanced age, Alzheimer's dementia, low po intake at times, severe fat and muscle wasting throughout, significant weight loss, low BMI (body mass index) & assist needed with all meals started on 4/7/22.
Weekly weights as recommended in the Nutrition/Dietary note were not ordered.
There was no order for a swallow evaluation as recommended by the dietician as documented on 4/2/22.
Review of the Certified Nursing Assistant (CNA) care guide ([NAME]) revealed the following instructions for Eating/Nutrition:
ADL-Eating Assist 1:1 Location: room .Assistance needed with feeding .EATING: 1 person assist .
Review of the CNA Tasks for ADL - Eating Assist 1:1 revealed on 5/12/22, R52 received no setup or physical help or setup help only, on 5/24/22 R52 received setup help only and was not assisted with feeding.
Review of R52's care plans revealed the following:
A care plan initiated on 3/30/21 that documented, Resident is at nutritional risk with risk for weight loss R/T advanced age, Alzheimer's dementia AEB (as evidenced by) PO intake (less than) 75 % of all meals .Assisted with meals as needed . There was no updated care plan when R52 lost a significant amount of weight between 3/3/22 and 4/2/22 a year later.
Further review of R52's Weight Summary revealed R52 was not weighed weekly after significant weight loss was identified on 4/1/22. R52's weights were as follows: 4/2/22 (109.1#) and 5/9/22 (106#).
On 5/26/22 at 10:04 AM, RD 'S' was interviewed regarding R52. When queried about the cause of R52's significant weight loss and whether the documented interventions were implemented (increased med pass to QID, weekly weights, and swallow evaluation) RD 'S' reported she would look into it. RD 'S' reported R52 was on her radar to monitor very closely. RD 'S' further reported that nursing reported R52's cognition declined over the last few months and the resident's intake was more variable and required more cues to eat. At that time, RD 'S' reviewed R52's clinical record and reported weekly weights were not completed and med pass was never increased to QID. RD 'S reported she would clarify whether a swallow evaluation was done.
On 5/26/22 at approximately 12:16 PM, RD 'S' reported a speech evaluation was not completed for R52.
R99
On 5/24/22 at 8:45 AM and 5/25/22 at approximately 12:30 PM, R99 was observed eating breakfast and lunch, respectively. R99 appeared to have some difficulty feeding himself, but when offered help, declined assistance.
Review of R99's clinical record revealed R99 was admitted into the facility on 4/21/21 with diagnoses that included: hypotension, chronic kidney disease, benign prostatic hyperplasia, convulsions, GERD, chronic embolism, asthma, dementia, moderate intellectual disabilities, and esophagitis with bleeding. Review of a MDS assessment dated [DATE] revealed R99 had severely impaired cognition and required supervision by one staff member for eating.
Review of R99's Weights Summary revealed R99 had a significant weight loss of 30.4# (22.16 %) between 2/1/22 (137.2#) and 3/1/22 (106.8#).
Review of R99's Nutrition/Dietary Notes revealed the following:
A Nutrition/Dietary Note dated 2/7/22 documented, Quarterly Note: .PO intake improved .Med pass supplement increased to TID (three times a day) during last quarter .CBW (current body weight) is 137.2 Increase of 11% in 2 months .No edema .Weight gain d/t improvement in meal intake and increase in med pass supplement. Resident able to feed himself regular mechanical soft diet after set up with no difficulty swallowing or chewing .Will continue regular mechanical soft diet, med pass, and monthly weights .
A Nutrition/Dietary Note dated 3/16/22 documented, Weight verified by unit manager. 3/1 106.8#, 2/1 137.2#, 9/1 123.8#. Res had significant weight loss decreased 30.4#/22.2% x 1 month. Res appears malnourished. Res intake remains sporadic - consuming 0-100% .on a mech soft diet. Res takes 120 cc med pass 2.0 supplement TID. Staff reports no recent changes in intake from 1-2 months ago .Res states never tried choc (chocolate milk) - will provide BID with lunch and dinner meal, apple juice TID with an alternate cottage cheese 3x/wk, and pudding 4x/wk at lunch .Rec increase medpass 120 cc QID, monitor weekly weight and provide food preferences/extra foods to promote wt gain .Logged for physician to evaluate .
A Nutrition/Dietary Note dated 3/23/22 documented, .RESIDENT IS PLACED ON WEEKLY WEIGHTS. WILL MONITOR WEIGHT .
A Nutrition/Dietary Note dated 4/1/22 documented, Noted continued weight loss despite preferences and medpass 2.0 120 cc TID provided. Visited res at breakfast ate 100% french toast, eggs, juices and drinking and consuming >75% choc milk and sausage. CBW: 105.6#. Res enjoying choc milk. Will add 206 juice at breakfast and 2 choc. milk with lunch meal to prevent further weight loss. Continue to monitor weekly weights and provide accepted foods/fluids .
A Nutrition/Dietary Note dated 5/2/22 documented, Quarterly Nutrition Review: . Wt: 105.6 30d: 106.8 90d: 137.2 Significant weight change: [x ] Yes [ ] No [ ] Unknown Diet: mechanical soft PO intake: [x ] 25% [x ] 50% [ x] 75% [ x] 100% Feeding Assist: [ ] Independent [ x] Setup [ ] Total Assist .
Summary & Recommendations: Resident .is on a mechanical soft diet, feeds himself with a variable appetite consuming 26-100% of his meals. His recent weights: 4/30/21 (1 year ago)=138#; 2/1=137.2#; 3/1=106.8#; 4/1= CBW = 105.6# which indicates a significant weight loss .he is receiving med pass 2.0 120 cc TID, chocolate milk at breakfast and two chocolate milks at lunch, magic cups at lunch & dinner has recently been added as he was refusing the 206 juice (beverage used to increase calorie intake) that he was receiving on his breakfast trays. He loves chocolate and this is his preferred flavor of choice .He is at nutritional risk d/t severe PCM > sig. wt. loss x 90 days and 1 year, low BMI, severe muscle and fat wasting throughout, low po intake at times and mechanically altered diet. Will continue to monitor his weight, po intake and labs as avail and will make changes prn. Care plan updated at this time .
A Nutrition/Dietary Note dated 5/10/22 documented, Weight differentiation under investigation, will follow.
Review of Physician Note revealed no physician evaluations regarding R99's significant weight loss to rule out any underlying medical condition.
Further review of R99's Weight Summary revealed R99 was not weighed weekly. R99 was weighed on the following dates after significant weight loss was identified on 3/1/22: 3/24/22 (106.5#), 4/1/22 (105.6#), and 5/9/22 (110#).
Review of R99's care plans revealed the following:
A care plan initiated on 4/28/22 (almost 2 months after significant weight loss was identified on 3/1/22) documented, The resident has unplanned/significant weight loss r/t severe PCM, significant weight loss x 90 and 1 year, low BMI, severe muscle/fat wasting throughout, low po intake at times, mechanically altered diet . Interventions initiated on 4/28/22 included, .Monitor and evaluate any weight loss and weight weekly .
On 5/26/22 at 12:16 PM, an interview was conducted with RD 'S' regarding R99's significant weight loss and whether the recommended interventions were implemented (weekly weights, physician evaluation). RD 'S' reviewed R99's clinical record and reported weekly weights were not completed and there was no physician evaluation to address R99's weight loss. RD 'S reported R99 was on her radar and is being monitored closely.
At that time RD 'S' was further interviewed about why multiple residents experienced a significant weight loss between February 2022 and April 2022. RD 'S' reported she started in the position as RD in April 2022 and was aware of the amount of weight loss residents experienced. RD 'S reported they were in the process of working on prioritizing weekly weights to ensure they were completed so that residents with significant weight loss could be monitored closely. RD 'S' reported it was questionable whether the scales were calibrated, but it was not questioned at the time of the weight loss (with the previous RD).
On 5/26/22 at 11:27 AM, the Medical Director was interviewed. When queried about whether she was aware of the significant and severe weight loss for multiple residents since March 2022, the Medical Director reported she was aware and reported the previous RD was not doing what she needed to do
On 5/26/22 at 11:39 AM, the Director of Nursing (DON) was interviewed. When queried about why R22, R52, and R99 experienced significant weight loss and why weekly weights, physician visits, and interventions were not implemented, the DON reported the former RD was not competent in her position and they were currently working on weight loss as a priority. When queried about R52 and the physician notes, care plan, and [NAME] that indicated R52 required 1:1 feeding assistance, the DON reported R52 did not required 1:1 feeding assistance, but if it changed it should have been updated. The DON was not aware that a swallow evaluation had not yet been completed.
Review of a facility policy titled, Weight Policy dated 5/3/22, revealed, in part, the following: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status .The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: .Developing and consistently implementing pertinent approaches .Monitoring the effectiveness of interventions and revising them as necessary .Residents with weight loss - monitor weight weekly ongoing .
Review of a facility policy titled, Assistance with Meals dated 5/3/22, revealed, in part, the following: It is the Center's Policy that all patient/residents shall receive assistance with meals in a manner that meets their individual needs and per Plan of Care .It is the responsibility of the Nursing staff and supervisors to assure that the patients/residents are receiving adequate assistance as related to meals .Nursing staff will serve patient/resident meals and will help patients/residents who require assistance with eating .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure appropriate treatment and services to encourage ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure appropriate treatment and services to encourage the improvement of eating skills for one (R46) of one resident reviewed for feeding tubes. Findings include:
On 5/23/22 at 1:14 PM, R46 was observed lying in bed, a tray of pureed food was sitting on the overbed table and R46 was eating from a bowl of gelatin. A bag of tube feeding formula was hanging on a pole connected to a tube feeding pump delivering 60 milliliters (ml) of the formula per hour with 60 ml of water also being delivered via the tube every hour. R46 was asked if she would eat much of the food on the lunch tray. R46 explained she had not eaten much because she had been getting nauseated when she ate.
Review of the clinical record revealed R46 was admitted to the facility on [DATE] and readmitted 12/16//20 with diagnoses that included: stroke, dementia, and anxiety disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R46 had moderately impaired cognition, and required the extensive assistance of staff for activities of daily living (ADL's). The MDS assessment also indicated R46 was not marked for: Loss of liquids/solids from mouth when eating or drinking; Holding food in mouth/cheeks or residual food in mouth after meals; Coughing or choking during meals or when swallowing medications.
Review of R46's nutrition care plan revealed an intervention initiated 2/2/22 that read, Provide oral diet for pleasure and oral gratification.
Review of physician orders revealed an Enteral Feed Order dated 5/3/22 that read, Peptamen 1.5, Rate: 60 cc (cubic centimeters), Frequency: per hour x 20 hours, Total Dose: 1200 cc, Duration: HANG AT 1:00 pm, TAKE DOWN 9:00 AM, Specify Type of Tube: PEG (percutaneous endoscopic gastrostomy - a tube passed into the stomach through the abdominal wall), Specify Method: Via pump, Auto flush 60 cc H20 (water) every hour while pump is running. It should be noted that breakfast, lunch, and dinner trays were usually all delivered while the tube feed was running.
On 5/24/22 at 12:55 PM, R46 was observed lying in bed. R46 was asked if she had eaten anything for breakfast or lunch. R46 explained at breakfast she was nauseated, and did not even look at the food, and had not eaten lunch either.
Review of R46's progress notes revealed a Nutrition/Dietary note dated 3/25/22 at 6:39 AM that read in part, Quarterly Nutrition Review: . Recommendation is to shorten time on enteral, in attempt to stimulate appetite, have SLP (Speech Therapy) review again, increase rate to 75 cc perhour [sic] X 16 hours .
Review of a Speech Therapy Discharge summary dated [DATE] read in part, .Prognosis to Maintain CLOF (current level of function) = Good with consistent staff follow-through .Supervision or Oral Intake = No supervision/assistance required . Progress & Response to Tx (treatment: Pt (patient) is appropriate for puree and NTL (nectar thick liquids) pleasure trays at this time. She will present with varying engagement and activity tolerance, often fatiguing half way through meal .
On 5/26/22 at 10:30 AM, Registered Dietician (RD) S was interviewed and asked about R46 eating while the tube feed was running. RD S explained R46 was receiving all nutrition through the tube feed and was only getting pleasure trays and there was no plan to stop the tube feed. RD S was asked if R46 would eat more if the tube feed was not consistently running while she was eating. RD S explained generally tube feed is stopped when a person is eating to promote appetite. When asked how it could be determined if the tube feed could be weaned if R46 was not given a chance to eat without tube feed running. RD S had no answer.
On 5/26/22 at 10:54 AM, Registered Nurse (RN) AA, R46's assigned nurse, was interviewed and asked about R46's tube feed. RN AA explained the way the order was written, the tube feed was not stopped for meals. RN AA was asked how much R46 usually ate. RN AA explained R46 usually did not eat much, sometimes just a bite, and sometimes half. When asked if R46 ate more if the tube feed was not running, RN AA explained she had never paid attention to that.
On 5/26/22 at 11:43 AM, Certified Nursing Assistant (CNA) T was interviewed and asked about R46 eating. CNA T explained usually R46 ate some gelatin or sherbet and some juice but did not eat much. When asked if R46 ate more if the tube feed was off, CNA T explained she did not know, as sometimes it was running and sometimes it was not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure updated menus were posted for all residents tha...
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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 updated menus were posted for all residents that receive food from the facility, including R66 and R131. This deficient practice resulted in a lack of autonomy with their choice of food preferences, multiple complaints over meal services and the potential for hunger and weight loss.
Findings include:
According to the facility's policy titled, Dining Room Meal Service dated 1/16/20:
.Residents eating in the unit dining rooms will have meals provided via tray line. Therapeutic diets for these residents will be followed according to the corporate menus .
On 5/24/22 from 12:30 PM to 12:45 PM, observation of the menu slots posted just outside of Anna's House, Redwood and Oakridge units were observed to have old menu choices from 5/16/22 and 5/17/22. The Hickory unit had no menus posted.
On 5/24/22 at 1:01 PM, an interview was conducted with the Certified Dietary Manager (CDM 'Q'). When asked who was responsible for posting the menus, CDM 'Q' reported their clerk usually posts the menus for two days at a time. When asked to observe the menus on the Oakridge unit, CDM 'Q' confirmed the above observation and reported they had been off work the past three weeks. When asked who was responsible when they were off, CDM 'Q' reported, their Assistant Dietary Manager (Staff 'EE') was covering while they were off.
When asked what their process was for obtaining resident choices regarding their food preferences and menu options, CDM 'Q' reported residents either got a paper menu or staff went around with an electric tablet to ask them their choices, and there were menus posted on the tv. When asked how residents were informed of this and whether those residents with physical and cognitive limitations could manage adequately, CDM 'Q' reported there were several that might not be able to. When asked if they were aware of concerns regarding the lack of choices recently, CDM 'Q' reported they were not aware of any food concerns. They did report there had been staffing challenges they were working through.
R131
On 5/23/22 at 12:42 PM, R131 was observed sitting in her wheelchair in the room. R131 was asked about food at the facility. R131 explained she kept getting foods she did not like, especially peas, that she had filled out what her dislikes were, but she kept getting food that was on her dislike list. While talking with R131, her lunch tray was brought in and placed on the overbed table. It was observed to have a serving of peas on the plate. R131 said I hate peas, and I've told them I don't want them. When asked if anyone had come and asked her what she wanted for lunch, R131 explained she never knew what was being served before it came, it was just a surprise when she took the cover off the plate.
Review of the clinical record revealed R131 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included: diabetes, heart disease and kidney disease. According to the Minimum Data Set (MDS) assessment dated [DATE], R131 was cognitively intact and required only the supervision of staff for activities of daily living (ADL's).
On 5/25/22 at 1:45 PM, Registered Dietician (RD) S was interviewed and asked about R131's food dislikes. RD S explained R131 had filled out she did not like pancakes, peas, and zucchini. RD S was asked about the process of noting residents' food preferences. RD S explained on admission, she would go ask the residents, and she would put it into the computer, and it would flag a food as a dislike so they would not get it. When told R131 had said she kept getting peas, and they had been observed to have been served, RD S explained they had changed over to a new system, and there had been a glitch in the system.
R66
On 5/23/22 at 1:21 PM, R66 was observed lying in bed. R66 was asked about the food at the facility. R66 explained she had filled out a list of foods she did not like, but that is what she usually received. When asked if she could get something different if she did not like what was being served, R66 explained the night before, she had gotten something she did not like, and was told there was nothing else she could get, she asked for tuna on a plate, but was told she could only get a tuna sandwich, she could not get it on a plate. R66 explained she did not eat bread, so she did not have anything to eat.
Review of R66's meal ticket revealed, no bread, highlighted, in the Notes section.
Review of the clinical record revealed R66 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included: chronic kidney disease, heart failure and diabetes. According to the MDS assessment, R66 had moderately impaired cognition, and required the extensive assistance of staff for ADL's.
On 5/25/22 at 2:16 PM, CDM Q was interviewed and asked about residents receiving food listed as dislike in the system. CDM Q explained it was printed as a (D) on the meal ticket when it was a dislike, and they were not served that food. When told of the observation of R131 receiving peas when it was listed as a dislike, CDM Q had no explanation. CDM Q was asked about R66 being told she could only have tuna on a sandwich and not on a plate. CDM Q explained they often serve tuna on a plate and did not know why she was told it could only be on a sandwich. CDM Q was informed of multiple residents stating they did not know what they were going to get at a meal until they took the lid off their plate after it was served. CDM Q explained they should know ahead of time so they could request an alternative meal before it was served.
Review of a facility policy titled, Dining Room Meal Service dated 1/1/20 read in part, .Meal items will be served to the resident based on their selection from options available to the prescribed diet . Alternative items will be offered to residents if they are unhappy with the meal provided .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure dependent residents were consistently provided ...
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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 dependent residents were consistently provided with fingernail care and facial hair removal for four (R35, R241, R243, and R247) of 11 residents reviewed for Activities of Daily Living (ADLs), resulting in dissatisfaction with hygiene and grooming, long jagged fingernails, unshaven facial hair, and delayed incontinence care. Findings Include:
Resident 35
On 5/23/22 at 1:35 p.m., R35 was observed to have very long fingernails. When asked the last time they had a shower or a bath, R35 stated they had a shower yesterday (5/22/22) but was not offered to have their nails clipped. When asked if they were offered do they want their fingernails clipped, R35 stated, Yes.
Review of the clinical record revealed R35 was admitted into the facility on 3/12/22 and readmitted on [DATE] with diagnoses that include in part: Cerebral Aneurysm, Hemiplegia, Epilepsy, and Aphasia.
The facility's ADL care plan initiated 5/11/22 revealed R35 has an ADL self-care performance deficit r/t (related to) Activity Intolerance . Interventions/Tasks . Personal Hygiene/Oral Care: 1 person assist.
On 5/25/22 at 10:27 a.m., R35 was observed in bed with fingernails still long. R35 stated, They told me they were going to cut them a couple of days ago.
On 5/25/22 at 10:40 a.m., during an interview with Certified Nursing Assistant (CNA) 'QQ' , when asked if they were assigned to R35, CNA 'QQ' stated that they only worked at the facility two days a week and they bounce all over the building, they were familiar with R35. CNA 'QQ' further stated they gave R35 a shower about two weeks ago. When asked when nail care was provided for residents, CNA 'QQ' stated, As needed.
On 5/25/22 at 11:08 a.m., during an interview with Licensed Practical Nurse (LPN) 'RR', when asked about resident nail care, LPN 'RR' stated, We (nurses) clip them (nails) when you see they have grown. The only ones we don't do are diabetics . The nurses clip the nails. The CNAs don't do nails. The CNAs come tell us.
Resident 241
On 5/23/22 at 1:07 p.m., R241 was observed in bed with long grown facial hair (unkempt beard). When asked if they received routine showers, R241 stated, Last Monday. When asked if staff offered to shave their facial hair, R241 stated, I don't know how to get rid of it. At that time, R241 was also observed to have a buildup of matter on their teeth and long jagged fingernails.
Review of the clinical record revealed R241 was admitted into the facility on 5/17/22 with diagnoses in part: Acute Respiratory Failure with Hypoxia, Chronic Kidney Disease, and Dependence on Supplemental Oxygen. A Brief Interview for Mental Status (BIMS) was conducted on 5/18/22 revealed R241 scored 15 out of 15 indicating intact cognition.
The facility's ADL care plan initiated 5/18/22 revealed R241 has an ADL self-care performance deficit r/t Activity Intolerance . Interventions/Tasks . Bathing/Showering: 1 person assist.
A review of CNA Task documentation for bathing revealed R241 received a shower/bed bath on 5/23/22. Further review of CNA Task documentation for personal hygiene revealed ADL activity did occur on 5/19/22.
On 5/25/22 at 11:20 a.m., R241 was observed in bed resting. R241 still had long grown facial hair. When asked if he wanted to be shaved, R241 stated, You think they will? The resident was told if that was what they wanted. R241 stated, Yes .
On 5/25/22 at 11:25 a.m., during an interview LPN 'RR', was asked when residents were usually shaved. LPN 'RR' stated, When they have a bath or shower. The aides usually do that.
On 5/25/22 at 3:35 p.m., an interview was conducted with the Director of Nursing (DON). When asked about hair removal for residents who were dependent on staff for care, the DON stated, The staff need to offer that (facial hair removal) when they are providing care.
Resident 243
ON 5/23/22 at 2:45 p.m., during a family interview, Family Member 'SS', stated, There is someone (Family) here every day. We take two-hour shifts and leave around 7:45 p.m. for the day. Family Member 'SS' explained they had concerns about R243 being soaking wet when they arrived at the facility to visit that morning (5/23/22). Family Member 'SS' further reported on Friday 5/20/22, R243 was found lying in dried poop by another Family Member 'BBB' who was very upset, because R243 had dried poop underneath their fingernails and on their face . Family Member 'SS' stated they reported it to CNA 'TT' who was in the hall, and CNA 'TT' reported it to the nurse (Interim Nurse Manager 'J'), and they said they would look into it. Family Member 'SS further stated, We have not heard anything since then.
On 5/23/22 at 3:09 p.m. during an interview, when asked about the reported lack of care, CNA 'TT' stated, When I came in Friday (5/20/22) afternoon at 3:00 p.m., Family Member 'BBB' asked me who had R243 for the morning shift because when they came to visit, R243 had poop all under her nails, and they had to clean R243 up. CNA 'TT' further stated, Family Member 'BBB' told them that they had already cleaned R243 up and whoever (CNA 'UU') had F243 before, they did not want that CNA to have R243 anymore. CNA 'TT' further explained that they also cleaned the feces underneath R243's fingernails and told (Nurse 'J'), then (Nurse 'J') switched their assignment and CNA 'TT' took the hall for R243. CNA 'TT' confirmed Family Member 'BBB' was upset.
Review of the clinical record revealed R243 was admitted into the facility on 5/6/22 with diagnoses that include in part: Cerebral Infarction, Neurologic Neglect Syndrome, Facial Weakness and Neurologic Neglect Syndrome. The Minimum Data Set (MDS) assessment dated [DATE] revealed R247 had a Brief Interview for Mental Status exam score of 6 out of 15 indicating severely impaired cognition and required extensive assistance to total dependence with two-person physical assist for ADLs.
On 5/25/22 at 3:25 p.m., an interview was conducted with the DON about the reported incident. The DON stated, I do not know anything about that at all
On 5/25/22 at 3:55 p.m., during an interview, when asked about the reported incident, Nurse 'J' stated, (CNA 'TT') came to me and said the family was upset that (CNA 'UU') had left R243 with stool on their hands and nails. I told (CNA 'TT') to go ahead and take over (R243's) care. When asked if they spoke to CNA 'UU' about what was reported, Nurse 'J' stated, I think they had left for the day. When asked if they told anyone about what happened, Nurse 'J' stated, I never witness any stool on the patient because they had already been cleaned up. When asked if they had told the DON, Nurse 'J' stated, No I did not notify the DON. I did not know it was that serious. I would have gone in to talk to the family. When asked about the facility's protocol, Nurse 'J' stated, The CNA is supposed to let the supervisor know. Then the supervisor will go and address the issue. Nurse 'J' was asked if they addressed the issue when they heard about it, and stated, No I did not. The CNA only told me that there was stool under the resident's nails. Nurse 'J' further stated CNA 'TT' told me that family had some concerns about CNA 'UU' that had taken care of R243 before.
On 5/25/22 at 4:47 p.m., an interview was conducted with the Administrator who explained that the facility had Customer Service that comes in seven days a week . If the CNA ('UU') failed to provide the care, then that is a problem.
Resident 247
During an observation on 5/23/22 at 3:03 p.m., R247 was in bed with swollen/blistered/bruised hands and fingers. R247 stated they had surgery . Resident 247's fingernails were exceptionally long. When asked if they had a shower or bed bath since their admission into the facility, R247 stated, I had one (bed bath) before I left the hospital. When asked if they want their fingernails clipped, R247 stated, They are long. I didn't have a chance to get them done before I went into the hospital, because I got sick.
Review of the clinical record revealed R247 was admitted into the facility on 1/13/21 before a readmission on [DATE] with diagnoses that included Vascular Implants and Grafts, Acute Embolism and Thrombosis, Rhabdomyolysis, Dementia, and Obesity. The record further revealed R247 had a BIMS score of 10 out of 15 indicating moderately impaired cognition.
The facility's care plan initiated 5/21/22 revealed The resident has an ADL self-care performance deficit r/t ADL . abilities will fluctuate between therapy staff and nursing staff . Assist with ADLs: eating, toileting, personal hygiene, bathing, bed mobility and wheelchair mobility q (every) shift and PRN (as needed) .
Review of the CNA Task (Personal Hygiene: Self Performance) documented R247 received care from 5/21/22 to 5/25/22 for hygiene (including combing hair, brushing teeth, shaving, applying makeup, washing/drying face, and hands .
On 5/24/22 at 12:40 p.m., R247 was sitting in a wheelchair with their lunch tray on an overbed table. R247 stated, I had a shower this morning. When asked if staff offered to clip their long fingernails, R247 stated, No. I need them cut.
On 5/25/22 at 9:55 a.m., R247 was in bed resting. R247 stated, The foot doctor came in and cut my toes nails. I told him about my fingernails . R247 further stated, I want them (fingernails) cut off .
On 5/25/22 at 10:00 a.m., during an interview with R247's assigned CNA 'VV', when asked if R247 received a shower/bath, CNA 'VV' stated, I gave R247 a bed bath. CNA 'VV' was asked to explain what was included in a bed bath. CNA 'VV' stated, It covers from head to toe, lotion, dressed if able brushed their teeth or swab them if they let me, change linen if necessary if it is not their shower day. When asked about nail care, CNA stated, Fingernails are basically every day. It should be done whenever you see them, but with her hands swollen and bandaged, I feel the nurse should do that.
On 5/25/22 at 10:06 a.m., during an interview with LPN 'WW', when asked if they were assigned to R247, LPN 'WW' said, Yes. When asked who was responsible for nail care, LPN 'WW' stated, It is a shared responsibility . I was not aware.
On 5/25/22 at 10:20 a.m., during an interview Unit Manager (UM) 'P', was asked when should nail care be provided to residents. UM 'P' stated, during showers, baths, or upon request.
On 5/25/22 at 3:20 p.m., an interview was conducted with the DON. The DON explained we (staff)should have completed it (nail care). If R247 had a bed bath or shower, you do nail care at that time.
A review of the facility's policy titled Activities of Daily Living dated 04/01/2022 documented the following: Policy: . Resident needs for ADL care will be met according to resident specific care plan. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care . Compliance Guidelines . 4). A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
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 provide individualized, meaningful, and scheduled acti...
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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 individualized, meaningful, and scheduled activities for four (R22, R52, R62 and R99) of four residents reviewed for activities resulting in feelings of loneliness, boredom, decreased quality of life and the potential for depression, falls and behaviors. Findings include:
R62
During an observation on 5/23/22 at approximately 3:30 PM, R62 was sleeping in bed with the television playing and a walker near the bed.
During an interivew on 5/24/22 R62 expressed feelings of loneliness. R62 shared they missed their roommate that was recently discharged . When asked about activities they liked to do, R62 responded they enjoyed attending the ice cream socials. R62 further shared they are a big fan of the ice cream here but unsure on how to attend the socials. R62 thought the ice cream was an everyday event. R62 said they must need to flag someone down. R62 also added that they liked going down to the group physical therapy. R62 said the group physical therapy was a great way to meet others. R62 clarified that by the end of the beach ball game at therapy they knew every one's name that had played. Also, asked R62 if they liked to play Bingo and R62 said they liked to play bingo but R62 was unsure of the time to attend and needed help to get there.
Review of the clinical record revealed R62 was admitted in to the facility on 4/5/22 with the diagnoses that included in part: alcoholic cirrhosis, liver failure, lower extremity lymphedema (swelling of the legs), and diabetes. According to the Minimum Data Set (MDS) assessment dated [DATE], R62 had intact cognition.
Review of the Recreational Therapy Referral Form dated 4/29/22 for R62 revealed, . How important is it to you to do things with groups of people? R62 responded to the question, 1. Very important.
On 5/26/22 at 8:43 AM, an interview was conducted with the Recreational Therapist KK. When asked what the process for ensuring that residents who want to attend the ice cream social are included, KK explained that they have a list. KK further clarified that they visited every residents' room every morning to find out if the resident would like ice cream and what kind as well as if the resident wanted to attend. If the resident would like the ice cream in their room KK would ensure the ice cream was delivered. Asked to have a copy of the residents' ice cream list. KK said this list would be provided but did not receive the resident ice cream list before survey's end.
During an interview on 5/26/22 the Activities Director LL started this position on 5/24/22 and shared the ice cream social is every day. Each resident is asked if they would like to participate and the kind of ice cream the resident would like of the four flavors available that day. When the Activity Director LL was asked what the process would be to ensure a resident is included. The Activity Director LL explained the Recreational Therapist should work with nursing staff to ensure the resident was up and ready to attend. This surveyor shared with the Activities Director LL that R62 had wanted to attend the ice cream social but R62 stated they had not.
On 5/26/22 at 9:16 AM, the clinical record under the Activity POC (Plan of Care) Response History was reviewed for the month of May. This showed no check marks documented to indicate attendance at Bingo or the Ice Cream Social for 5/21 through and including 5/25/22.
During an interview on 5/26/22 at 11:20 AM, R62 shared that they had not participated in the ice cream social yesterday or received ice cream yesterday and they would have liked to have been included.
R52, R99, and R22
On 5/23/22 at approximately 12:30 PM, R52, R99, and R22 were observed seated in the small dining room across from the nurses' station on the Anna's Place unit waiting for lunch to be served.
On 5/23/22 at 1:50 PM, 2:32 PM, 3:20 PM, and 4:40 PM, R52, R99, and R22 were observed to be seated in the small dining room on the Anna's Place unit. No structured activities were observed during this time and no staff were observed to engage or interact with the residents.
The following was observed in the small dining room on Anna's Place unit:
On 5/23/22 at 2:32 PM, R52 was observed, seated at a table alone. A television was on with low volume. R52's face and hands were covered with food, and they were rubbing their hands in the food and talking nonsensically and singing at times. R99 was observed seated in a reclined geriatric chair (geri-chair) at a table with R22. R22 repeatedly asked What is the chance of survival for the baby? and Can you stay longer? No structured activities were provided to the residents and no staff were observed to interact with the residents.
On 5/23/22 at 3:20 PM and 3:32 PM, R52 remained in the small dining room, talking, and singing to their self. R99 remained seated in the geri-chair with food on their face, hands, and clothing. R22 repeatedly asked if anyone is going to give my daughter a proper burial. No structured activities were provided to the residents and no staff were observed to interact with the residents.
On 5/23/22 at 4:40 PM, R52, R99, and R22 remained in the small dining room, seated at the same tables they had been at since 12:30 PM. R52 continued to talk to their self, R99 remained in the geri-chair without an activity, and R22 was observed poorly positioned in their wheelchair with no activity.
During all observations no staff were observed to be in the small dining room with R52, R99, and R22, no activity was provided other than the television being on, and no attempts to interact or engage the residents were observed.
Review of R52's Task for Activity - Social revealed Recreational Therapist (RT) 'KK' documented R52 was offered a Games activity on 5/23/22 at 2:59 PM and was Not Dressed/Unavailable.
Review of R99's Task for Activity - Social revealed Recreational Therapist (RT) 'KK' documented R99 was offered a Games activity on 5/23/22 at 2:59 PM and Resident Refused.
Review of R22's Task for Activity - Social revealed Recreational Therapist (RT) 'KK' documented R22 was offered a Games activity on 5/23/22 at 2:59 PM and was Not Dressed/Unavailable.
On 5/25/22 at 10:40 AM, R52 was observed in the small dining room with other residents and a recreational therapy assistant. All residents were given a coloring page except R52. R52 rambled nonsensically, scratched at their arms, pulled up their shirt and put it into their mouth. A television was on, but R52 was not engaged in watching it. R52 began clenching hands together and making a growling noise. The recreational therapy aide placed a chair to sit with another resident which placed the staff's back to R52. When Recreational Therapy Assistant engaged with R52 at 10:55 AM, R52 calmed down, however, the staff went back to engaging with the other resident.
On 5/25/22 at 11:44 AM, R52 remained seated in the same spot in the small dining room, talking to self and picking at their clothing.
On 5/25/22 at 2:05 PM, R52 remained seated in the same spot at a table facing the large screen television. RT 'KK' placed a stand with a computer screen directly in front of the television which remained on. The computer screen had pictures and karaoke lyrics on the screen while the television was on and visible behind it. There were no other staff in the dining room. The residents in the dining room were not engaged in the activity and RT 'KK' was unenthusiastically singing the song that was playing from the computer and making slight gestures to the music.
On 5/26/22 at 8:40 AM, an interview was conducted with RT 'KK', who explained their role was a Recreation Therapy Assistant. When queried about activities provided to the residents who were seated in the small dining room of the Anna's Place unit on Monday, 5/23/22 between the time of approximately 1:00 PM (after lunch) and 4:50 PM, RT 'KK' reported he did not provide any activities to the residents on the Anna's Place unit on 5/23/22 during the day shift. When queried about the documentation of R52 and R22 not being available and R99 refusing a Games activity at 2:59 PM, RT 'KK' reported he played games at 6:00 PM but did not provide activities to those residents during the day shift because he was the only activities staff working that day.
On 5/26/22 at 9:19 AM, an interview as conducted with Recreational Therapy Director, RT 'LL'. When queried about the lack of activities provided to residents on the Anna's Place unit on 5/23/22, RT 'LL' reported her first day working in the facility was 5/24/22. At that time, a calendar for activities scheduled for the Anna's Place unit for May 2022 were reviewed. The calendar documented the following activities were scheduled for 5/23/22: Victoria Day Tea Party at 2:00 PM and Familiar Faces Bingo at 3:30 PM. RT 'LL' reported the activities should be provided as scheduled and that she had not yet started working in the facility as of 5/23/22. When queried about activities specifically for residents with dementia, RT 'LL' reported they had a program that they followed. When queried about the placement of the computer screen in front of the television, RT 'LL reported that would be over stimulating to a resident with dementia and the computer should not have been placed there.
On 5/26/22 at 2:13 PM, the Director of Nursing (DON) was interviewed. The above observations were shared with the DON who reported R52, R99, and R22 should have been provided some kind of recreation and that the activities provided should be tailored to each individual resident.
Review of R52's clinical record revealed R52 was admitted into the facility on 7/1/20 with diagnoses that included: Alzheimer's Disease. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R52 had severely impaired cognition, physical and verbal behaviors, was totally dependent on staff for toilet use, and was always incontinent. Review of R52's care plans revealed a care plan initiated on 8/12/20 that documented, RESIDENT COULD BENEFIT FROM GROUP ACTIVITIES: Resident does not initiate or is unable to engage in activities and could benefit from group activities. Review of a care plan initiated on 9/2/20 revealed the following documentation, The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t (related to) Alzheimer's disease .Invite the resident to scheduled activities .The resident prefers activities which do not involve overly demanding cognitive tasks. Engage in simple, structured activities such as coloring, movies .
Review of R99's clinical record revealed R99 was admitted into the facility on 4/21/21 with diagnoses that included: convulsions, dementia, and moderate intellectual disabilities. Review of a MDS assessment dated [DATE] revealed R99 had severely impaired cognition and required physical assistance of at least two staff members for toilet use and was frequently incontinent. Review of R99's care plans revealed a care plan initiated on 4/23/21 that documented, ASSIST WITH INDEPENDENT ACTIVITIES: Resident needs assistance to obtain and set up material for independent activities of getting outside when it's nice, watching TV shows, pet therapy with dogs, exercising, cooking, socializing with others, etc .Encourage individual and group activities daily .Provide resident with independent activities supplies PRN (as needed) . A care plan initiated on 1/24/22 documented, RESIDENT COULD BENEFIT FROM GROUP ACTIVITIES: Resident does not initiate or is unable to engage in activities and could benefit from group activities. Review of R99's readmission Activities Assessment revealed R99 enjoyed card games, bingo, getting out into community, exercises, any kind of music, getting outside, and watching television. It was documented R99 wanted to participate in activities including social events.
Review of R22's clinical record revealed R22 was admitted into the facility on 8/27/21 with diagnoses that included: dementia, anxiety disorder, and psychotic disorder. Review of a MDS assessment dated [DATE] revealed R22 had severely impaired cognition, required extensive physical assistance for toilet use, and was always incontinent. Review of R22's care plans revealed a care plan initiated on 9/3/20 that documented, RESIDENT COULD BENEFIT FROM GROUP ACTIVITIES: Resident does not initiate or is unable to engage in activities and could benefit from group activities. A care plan initiated on 8/26/21 documented, REDIRECTION IN GROUP: Resident needs frequent re-direction within group programs to maximize attention span .Invite and assist resident as needed to activities of interest .
Review of a policy provided by the facility titled, Activities dated 4/1/22, revealed, in part, the following: It is the policy of this facility to provide an ongoing program of activities designed to meet the interest, choice, and preferences as well as to meet the interest of and support the physical, spiritual, mental and psychosocial well-being of each resident, encouraging both independence and interaction in the community .Activities will be designed with the intent to: .Enhance the resident's sense of well-being .Promote or enhance cognition .Promote or enhance emotional health .Promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure two of five medication carts were locked, and medication was properly secured.
Findings include:
According to the facil...
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Based on observation, interview and record review, the facility failed to ensure two of five medication carts were locked, and medication was properly secured.
Findings include:
According to the facility's policy titled, Medication Storage dated 5/4/22:
.It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms .to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .all drugs and biologicals will be stored in locked compartments (i.e., medication carts .Narcotics and Controlled Substances .are stored under double-lock and key .
On 5/24/22 at 3:19 PM, upon entry to the Redwood unit, the medication cart was observed unlocked, without any nurse supervising the cart. During this time, several staff were observed walking by the unlocked cart.
On 5/24/22 at 3:30 PM, Nurse 'C' approached the medication cart and when asked about the cart being unlocked, Nurse 'C' stated they were not sure what happened, and they had just finished counting off the medications for shift change.
On 5/24/22 at 3:32 PM, upon entering another hallway on the Redwood unit, another medication cart was observed unlocked and unattended by any nursing staff. Upon further observation, when the top drawer was opened, there was a small clear cup which contained two round white pills that had no identifying information.
On 5/24/22 at 3:34 PM, Nurse 'D' came over to the medication cart and when asked if that was their assigned medication cart, Nurse 'D' reported they were about to take over the cart from another nurse. When asked about the unlocked medication cart, Nurse 'D' reported they were not sure how the cart was unlocked, and that they only had the keys to the cart as they were about to take over for the other nurse that was currently on break. When asked about the storage of the unidentified pills inside the top drawer, Nurse 'D' reported they were not sure what they were meds should not be stored like that and began to remove them to dispose of in the small trash bag attached to the medication cart. Nurse 'D' was asked to stop just before the medication was discarded.
On 5/24/22 at 3:39 PM, Nurse 'G' arrived at the medication cart and reported they were just coming back from break. When asked who was responsible for the current medication cart, Nurse 'G' reported they had been working on another hallway and that Nurse 'E' had been assigned to that medication cart, but had to leave, so they finished counting medications with Nurse 'E', then went on break until Nurse 'D' arrived. When asked if they could identify the two white pills, Nurse 'G' reported they could not and would dispose of them. When asked about the unlocked medication cart, Nurse 'G' reported the cart should be locked when not by the cart.
On 5/24/22 at 3:45 PM, an interview was conducted with the Administrator. When informed of the concerns about the unsecured medication carts and medications, the Administrator reported that should not have occurred and would follow up immediately.
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** On 5/23/22 at approximately 12:40 PM, Certified Nursing Assistant (CNA) 'GG' was observed on the Anna's Place unit wearing a sur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 5/23/22 at approximately 12:40 PM, Certified Nursing Assistant (CNA) 'GG' was observed on the Anna's Place unit wearing a surgical mask that did not cover their mouth and nose.
On 5/25/22 at 8:08 AM, CNA 'GG' was observed charting at the electronic kiosk wearing a surgical mask that did not cover their mouth and nose.
On 5/25/22 at 11:49 AM, Nurse 'II' was observed seated at the nurse's station with Nurse 'J'. Nurse 'II' was observed with a KN95 mask covered with another mask hanging from one ear which exposed their nose and mouth. Nurse 'J' stood in very close proximity to Nurse 'II'. Nurse 'II' coughed into their hand, then applied their mask, and did not perform hand hygiene.
On 5/25/22 at 3:24 PM, Nurse 'HH' was observed standing with other staff members on the Anna's Place Unit. A surgical mask was observed in Nurse 'HH''s hand and not worn on their face. When queried, Nurse 'HH' reported they were supposed to wear a mask while on the unit.
Based on observation, interview and record review, the facility failed to follow infection control practices related to proper use of personal protective equipment (PPE).
Findings include:
According to the Centers for Disease Control (CDC) guidance for healthcare workers, updated 2/2/22 Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic:
.Implement Source Control Measures .Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing .Source control options for HCP include .A well-fitting facemask .Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting .
On 5/23/22 at 12:48 PM, Nurse 'F' was observed at a medication cart outside of room [ROOM NUMBER], not wearing any facemask. The blue surgical mask was observed hooked around their right ear and hung down the right side of their neck.
On 5/23/22 at 12:51 PM, Nurse 'F' was asked about their donning/doffing of the facemask, and they reported, It was a little warm. Took down to breath and put it on. Maybe off five minutes.
On 5/24/22 at 3:07 PM, Nurse 'H' was observed at the nursing desk wearing an N-95 mask that had only the top strap secured around the top of their head. The bottom yellow strap was observed hanging below their chin. When asked about how the mask should be worn, Nurse 'H' reported Should have two straps secured.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R66
On 5/23/22 at 12:15 PM, R66 was observed lying in bed. R66 was asked about the care at the facility. R66 explained staffing ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R66
On 5/23/22 at 12:15 PM, R66 was observed lying in bed. R66 was asked about the care at the facility. R66 explained staffing was really bad on the midnight shift on the weekends. When asked what happened when staffing was bad, R66 explained no one answered call lights, and she would not get changed until the day shift would come in.
Review of the clinical record revealed R16 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included: paraplegia, heart disease and anxiety disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R16 had moderately impaired cognition, and required the extensive assistance of staff for activities of daily living (ADL's).
Based on observation, interview and record review, the facility failed to ensure sufficient nursing staff were provided to meet resident needs including timely incontinence care and supervision which affects all 140 residents, including six (R16, R20, R22, R52, R64 and R99) of 31 sampled residents reviewed for staffing.
Findings include:
According to the facility's Facility Assessment Tool last reviewed 11/9/21:
.average daily census: 129 .Staffing Plan .RN, LPN, providing direct care 1:12 ratio days, 1:12 ratio evenings, 1:25 ratio midnight .Direct care staff (CNA) 1:10 ratio days, 1:10 ratio evenings, 1:15 ratio nights .Facility considers the number of patients and resident's needs to determine the number of staff required to care for residents. If facility/resident staffing needs are outside of facility's usual ranges, Administrator and Director of Nursing will assess needs to add additional staffing to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by individual plans of care .
Review of the current census on 5/23/22 revealed 140 residents residing in the facility.
Review of the actual nurse staff assigned on Friday 5/20/22 revealed on the midnight shift (11:00 PM to 7:00 AM), there was only one CNA and one nurse assigned to the Oakridge unit which had a census of 35 resident. There was another nurse assigned, but only worked from 10:57 PM to 11:26 PM.
Review of the actual nurse staff assigned on Saturday 5/21/22 revealed on the day shift (7:00 AM to 3:00 PM), there were only two CNAs and two nurses assigned to the Anna's Place unit (designed for more cognitively impaired residents) which had a census of 35.
Review of the actual nurse staff assigned on Sunday 5/22/22 revealed on the midnight shift, there was only one CNA (CNA 'A') and one nurse assigned (Nurse 'R') to the Oakridge unit which had a census of 35. There was another nurse assigned but only worked from 10:57 PM to 11:26 PM.
On 5/26/22 at 10:42 AM, a phone interview was attempted with CNA 'B' but there was no return call by the end of the survey.
On 5/26/22 at 10:47 AM, a phone interview was attempted with CNA 'A' but there was no return call by the end of the survey.
On 5/26/22 at 10:51 AM, a phone interview was conducted with Nurse 'R'. When asked if they could recall the other nurse that was documented as only working about a half an hour on the schedule, they reported they had worked alone. When asked if there were any concerns in which they couldn't perform duties since they worked alone, Nurse 'R' reported, If I had more time, I could have put in progress notes. In fact, last night I had to stay with this resident who needed one to one, this time was a little bit tricky cause I think I had one CNA on the unit and another doing a split, so I had to stay with that resident. Nurse 'R' further reported that although most residents didn't require medication administration on the midnight shift, they did report that around 5:00 AM That gets a little tricky with most needing their morning meds. When asked if they had a nursing supervisor offer to assist as they were identified as an in-house supervisor on the schedule documentation provided for review, Nurse 'R' reported Might come in if really short, and might take a cart, depends on who's a supervisor, some will help more than others.
On 5/26/22 at 1:09 PM, an interview was conducted with the staffing scheduler (Staff 'PP') who reported they had been in that position since February of this year. Staff 'PP' reported the facility did not utilize any staffing agencies and that the CNAs worked 7.5 hours and nurses worked 8-hour shifts. When asked about how the current staffing was determined, if there were staff to resident ratios considered, Staff 'PP' reported they don't have a set number, so if there were for example 33 residents on a unit, there would be three nurses and three CNAs. Staff 'PP' reported there were many challenges with call-ins and tried to do the best they could. When asked about staff openings, Staff 'PP' reported they would have the Director of Nursing (DON) provide that documentation.
Review of the documentation for current open positions included:
For the day shift (7:00 AM to 3:00 PM):
1 part-time (PT) Registered Nurse (RN); 3 PT Licensed Practical Nurses (LPN); 3 full-time (FT) CNAs; 5 PT CNAs
For the afternoon shift (3:00 PM to 11:00 PM):
2 FT RNs; 2 PT RNs; 6 FT LPNs; 4 PT LPNs; 7 FT CNAs; 6 PT CNAs
For the midnight shift (11:00 PM to 7:00 AM):
1 FT RN; 1 PT RN; 1 FT LPN; 1 PT LPN; 4 PT CNAs
On 5/24/22 at 1:30 p.m. during a confidential resident meeting, residents were asked about staffing and call light response times. One resident stated, they have waited an hour or more. They don't pay no attention to the lights. I have had to get up out of my bed and act a fool . The resident further reported they requested snacks, and staff say they are going to bring them, but then they go home. The resident further reported they have laid in bed wet, and the CNA said, She was going to come back to change me, and she went home. If you don't want to do it, send somebody else to do it.
Review of the clinical record revealed this resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition and required extensive assistance with one-person physical assist for most activities of daily living (ADLs) including toilet use.
During the confidential resident meeting, another resident stated, I have been left wet for two hours before.
Review of the clinical record revealed this resident required extensive assistance with one-to-two-person physical assist for most ADLs including toilet use.
On 5/25/22 at 10:52 a.m., during an interview with CNA 'QQ' when asked if the facility was short of staff, CNA 'QQ' stated, Some days we are. We have 2-3 aides. On the Cedar Unit. There are 42 residents. Sometimes aides call off then we are short.
On 5/25/22 at 3:35 p.m., during an interview LPN 'J' stated, We need more help because of the acuity of the residents. Some of the patients are more challenging and require more help. We staff good. It's just a lot of people that call off unfortunately.
On 5/26/22 at 8:55 a.m., during an interview with Activities Recreational Assistant 'KK', when asked if call light response times are discussed during Resident Council, if residents voiced complaints about call light response times and what was the facility's process, Activities Recreational Assistant 'KK' stated, Yes we talk about call lights a lot. I have reported certain things to nurses and head nurses.
On 5/26/22 at 9:18 a.m., during an interview with Certified Recreational Therapy Director 'LL', when asked about residents reporting concerns about the facility's staffing and what the protocol was when residents report call lights that are not answered in a timely manner, Recreational Therapy Director 'LL' stated they have heard residents say there needs to be more staff. Sometimes they say it can be on any of the shifts. Recreational Therapy Director 'LL' further explained they take the concern to the managers right after the Resident Council Meeting. Within 48 hours, the managers would complete the form and give it to the Administrator. It is the responsibility of management to follow through on what is needed, what they did, and sign off on it.
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 provide handwashing signage at the handwashing sinks, failed to ensure food items were dated, failed to store dishware in a s...
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Based on observation, interview, and record review, the facility failed to provide handwashing signage at the handwashing sinks, failed to ensure food items were dated, failed to store dishware in a sanitary manner, failed to store wiping cloths in chemical sanitizer, and failed to maintain the pantry microwave and refrigerator in a sanitary manner. These deficient practices had the potential to affect all residents that consume food from the kitchen. Findings include:
On 5/23/22 between 11:15 AM -11:45 AM, during an initial tour of the kitchen with Certified Dietary Manager (CDM) Q, the following items were observed:
There was no handwashing signage at any of the handwashing sinks.
According to the 2013 FDA Food Code section 6-301.14 Handwashing Signage, A sign or poster that notifies food employees to wash their hands shall be provided at all handwashing sinks used by food employees and shall be clearly visible to food employees.
There were numerous pans stacked on the clean dishware rack, which had moisture/water droplets inside. When queried, CDM Q confirmed that clean dishware should be completely dry before stacking.
According to the 2013 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying;.
In the walk-in cooler, there was an opened, undated package of deli turkey, and a container of cut melon that was undated. CDM Q confirmed the turkey and melon should have been dated.
According to the 2013 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.
There was a wiping cloth on the counter next to the steam table. CDM Q confirmed the wiping cloth should be stored inside the sanitizer bucket.
According to the 2013 FDA Food Code, Section 3-304.14 Wiping Cloths, Use Limitation, .(B) Cloths in-use for wiping counters and other equipment surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under § 4-501.114;
There were 2 spatulas hanging with the clean utensils, which was jagged around the edges, and no longer smooth and easily cleanable. CDM Q stated she would throw out the spatulas.
According to the 2013 FDA Food Code section 4-202.11 Food-Contact Surfaces, (A) Multiuse FOOD-CONTACT SURFACES shall be: (1) SMOOTH; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections;.
In the Oakridge pantry, the interior of the microwave was soiled with dried on food debris. In the Hickory pantry, the shelves inside the refrigerator were soiled with a dried, brown substance. CDM Q stated housekeeping is responsible for cleaning the microwaves and refrigerators in the nutrition rooms.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 7 harm violation(s), $71,130 in fines. Review inspection reports carefully.
- • 76 deficiencies on record, including 7 serious (caused harm) violations. Ask about corrective actions taken.
- • $71,130 in fines. Extremely high, among the most fined facilities in Michigan. Major compliance failures.
- • Grade F (5/100). Below average facility with significant concerns.
Bottom line: Trust Score of 5/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Evergreen Health And Rehabilitation Center's CMS Rating?
CMS assigns Evergreen Health and Rehabilitation Center an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Michigan, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Evergreen Health And Rehabilitation Center Staffed?
CMS rates Evergreen Health and Rehabilitation Center's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 47%, compared to the Michigan average of 46%.
What Have Inspectors Found at Evergreen Health And Rehabilitation Center?
State health inspectors documented 76 deficiencies at Evergreen Health and Rehabilitation Center during 2022 to 2025. These included: 7 that caused actual resident harm and 69 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Evergreen Health And Rehabilitation Center?
Evergreen Health and Rehabilitation Center 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 OPTALIS HEALTH & REHABILITATION, a chain that manages multiple nursing homes. With 172 certified beds and approximately 159 residents (about 92% occupancy), it is a mid-sized facility located in Southfield, Michigan.
How Does Evergreen Health And Rehabilitation Center Compare to Other Michigan Nursing Homes?
Compared to the 100 nursing homes in Michigan, Evergreen Health and Rehabilitation Center's overall rating (2 stars) is below the state average of 3.1, staff turnover (47%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Evergreen Health And Rehabilitation Center?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Evergreen Health And Rehabilitation Center Safe?
Based on CMS inspection data, Evergreen Health and Rehabilitation Center has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Michigan. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Evergreen Health And Rehabilitation Center Stick Around?
Evergreen Health and Rehabilitation Center has a staff turnover rate of 47%, which is about average for Michigan nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Evergreen Health And Rehabilitation Center Ever Fined?
Evergreen Health and Rehabilitation Center has been fined $71,130 across 2 penalty actions. This is above the Michigan average of $33,790. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Evergreen Health And Rehabilitation Center on Any Federal Watch List?
Evergreen Health and Rehabilitation Center 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.