Medilodge of Sterling Heights
For profit - Limited Liability company
248 Beds
MEDILODGE
Data: November 2025
Trust Grade
40/100
#306 of 422 in MI
Photo by Medilodge of Sterling Heights
Photo by Medilodge of Sterling Heights
Photo by Medilodge of Sterling Heights
1 / 5 photos
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Medilodge of Sterling Heights has received a Trust Grade of D, indicating that the facility is below average and has some concerning issues. It ranks #306 out of 422 nursing homes in Michigan, placing it in the bottom half of facilities in the state, and #25 out of 30 in Macomb County, suggesting there are only a few local options that might be better. The facility is showing improvement, with the number of issues decreasing from 21 in 2024 to 15 in 2025. Staffing is average with a 52% turnover rate, which is on par with the state average, and while there have been no fines recorded, the facility has had serious incidents, including a resident developing gangrene due to missed weekly skin checks and another resident falling from their bed and injuring their shoulder. Additionally, some residents have reported dissatisfaction with the food quality, describing it as cold and unappetizing.
- Trust Score
- D
- In Michigan
- #306/422
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 52% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Michigan facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 26 minutes of Registered Nurse (RN) attention daily — below average for Michigan. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 79 deficiencies on record. Higher than average. Multiple issues found across inspections.
40/100
Bottom 28%
Needs review
21 → 15 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 21 issues
2025: 15 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Michigan average (3.1)
Below average - review inspection findings carefully
Staff Turnover: 52%
Near Michigan avg (46%)
Higher turnover may affect care consistency
Chain: MEDILODGE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 79 deficiencies on record
2 actual harm
Jun 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0917
(Tag F0917)
Could have caused harm · This affected 1 resident
This citation pertains to Intake MI00153957.
Based on observation, interview, and record review the facility failed to ensure a mattress was comfortable and changed timely upon resident request for on...
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This citation pertains to Intake MI00153957.
Based on observation, interview, and record review the facility failed to ensure a mattress was comfortable and changed timely upon resident request for one resident (R901) of three reviewed for a room furnishings. Findings include:
On 07/01/25 at 8:17 AM, R901 was queried about a concern with uncomfortable mattresses. R901 reported the mattress feels like it has a hole in it and it feels like they are sitting on the frame of the bed. R901 further reported the mattress has been that way since they were admitted about six months ago. R901 also reported they had told different staff over the last six months and it had yet to be changed out.
On 07/01/25 at 11:29 AM, Certified Nursing Assistant (CNA) D reported R901 had told them the mattress was uncomfortable at different times over the last four to five months and had reported it to the nurse because they were the ones who could put it in the maintenance needs reporting system (TELS).
On07/01/25 at 12:11 PM, R901 was observed to be dressed and seated in a wheelchair dressed at the right side of the bed. The lunch tray was on the over bed table in front of R901. The sheets had been removed from the mattress and there was a visible wrinkle in the mattress cover in the center of the bed closer to the right side of the bed. The mattress had a firm bolster around the rim of the bed with a softer center which compressed easily.
On 07/01/25 at 12:20 PM, Licensed Practical Nurse (LPN) E reported R901 had verbalized the mattress was a concern since they arrived around five months ago. LPN E further stated they thought they had told maintenance staff or put it into TELS. A review of the progress notes did not reveal any documentation by staff of R901's concerns with their mattress.
On 07/01/25 at 12:52 PM, the identified concern was reviewed with the Assistant Administrator with a Corporate Representative present. The two staff reported they had reviewed the TELS reports for R901 and did not find a work order to change out the mattress. The administrative staff members further noted any staff can enter a work order into TELS and this is covered in orientation. A review of the TELS work orders for the last three months prior to the survey revealed mattresses were available and there were work orders which indicated other resident's mattresses had been changed out.
On 07/01/25 at 2:25 PM, maintenance Staff F, was ask about any TELS work orders for a mattress replacement for R901 and reported that no one had entered any and further noted staff will tell maintenance about items but the work order still has to be entered when the work is done.
A review of the Virtual Orientation Guide revealed, .55. Maintenance: a. All staff have the possibility of identifying equipment or items that are broken or in need of replacement. Anyone can complete a work order to notify the maintenance department so they can address the issue. The guide further noted the web site and that an application was also available to enter work orders.
Apr 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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
This citation pertains to Intake M100151122:
Based on observation, interview, and record review, the facility failed to prevent the fall of one (R705) of four residents reviewed for falls. Findings i...
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This citation pertains to Intake M100151122:
Based on observation, interview, and record review, the facility failed to prevent the fall of one (R705) of four residents reviewed for falls. Findings include:
Review of the facility record for R705 revealed an original admission date of 07/30/13 and a most recent admission of 08/22/17 with diagnoses including Primary Generalized Osteoarthritis, Spinal Stenosis, and Muscle Weakness. The record indicated R705 is receiving hospice services.
On 04/14/25 at 12:40 PM, R705 was interviewed in their room. During the conversation regarding care concerns the resident stated I wanted to tell you I fell off the bed last Monday. The hospice aide was changing me and I rolled off the bed. When it happened I had some pain in my neck so they tried to X-ray my neck but they weren't able to. R705 indicated the X-ray couldn't be completed properly due to positioning difficulties. The resident denied any residual pain and stated I'm just a little sore but I always feel that. When asked if they felt safe receiving care R705 stated, as long as there are two aides its ok.When I fell [hospice aide] was alone.
Review of R705's progress note revealed a note dated 04/07/25 indicating the hospice aide notified the resident's nurse when they turned the resident in the bed the resident rolled off onto the floor.
Review of the Incident/Accident report dated 04/07/25 pertaining to this fall included a statement from the hospice aide that indicated they were providing care to the resident without other staff assistance when the resident fell off the bed.
Review of R705's care plan revealed a fall risk-related Focus area that included an intervention dated 10/21/24 documenting care requiring bed mobility to be provided by two staff members.
On 04/14/25 at 01:42 PM, the facility Director of Nursing (DON) reported the facility was aware the hospice aide attempted to provide care to R705 without the assistance of a second person and said the expectation is the resident's care should only be provided with two-person assistance and that hospice as well as in-house personnel will review resident's plan of care prior to providing service.
Review of the facility policy Falls-Clinical Protocol dated 11/02/23 includes the entry 2. Based on the [fall risk] assessment an initial plan of care will be developed and implemented to address identified risk.
Mar 2025
11 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00150763.
Based on interview and record review, the facility failed to timely complete an in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00150763.
Based on interview and record review, the facility failed to timely complete an investigation for an allegation of abuse for one (R2) of two resident reviewed for abuse. Findings include:
A review of the Intake reported to the State Agency noted an allegation that staff in the facility failed to treat the resident with dignity and respect (on 2/27/25).
On 3/11/25, R2 was observed sitting in their room looking at their computer tablet. R2 did not recall the alleged incident or staff who cared for him on 2/27/25.
A review of R2's electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, dysphagia, delusional disorders, and mild intellectual disabilities. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Brief Interview of Mental status score of 1 which indicated severely impaired cognition.
On 3/12/25 at 9:00 AM, an interview was conducted with Maintenance Director (MD) I . When queried regarding the alleged incident MD I indicated they witnessed a female staff member (Registered Nurse (RN) L) mocking R2 (telling the resident they were misbehaving, and saying I'm going to tell on you) which led R2 to become visibly upset and crying. MD I indicated they immediately reported incident to the administrator.
On 3/12/25 at 9:30 AM, an interview was held with the Nursing Home Administrator (NHA) regarding the alleged incident and said it was investigated inhouse but was unsubstantiated. A copy of the investigation was requested at 9:40 AM and provided at 10:15 AM.
A review of the facility investigation folder revealed witness statements dated for 2/27/25 and signed by MD I and RN L on 3/12/25 (13 days after incident). The statement from MD I was not consistent the with interview conducted at 9:00 AM (on 3/12/25).
Further review of incident lead to a second interview with MD I who stated he signed the incident statement today (3/12/25), but had not signed a witness statement on 2/27/25, the day of the incident.
On 3/12/25 at 2:30 PM, RN L was queried regarding they're statement of the alleged incident and stated on 3/12/25 was the first time she was asked about the alleged incident and was asked to sign a 2/27/25 dated statement on 3/12/25.
On 3/12/25 at 3:00PM, the NHA was queried to why the incident occurred on 2/27/25 and statements not obtained until 3/12/25, she stated due to their investigation they felt it was a customer service concern.
A review of a facility policy titled, Abuse, Neglect and Exploitation Policy implemented on 07/28/2020 and revised on 01/10/2024, noted the following: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mental abuse also includes abuse that is facilitated or caused by nursing home staff taking or using photographs or recording in any manner that would demean or humiliate a resident(s).V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation. 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence). 3. Investigating different types of alleged violations. 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator,witnesses, and others who might have knowledge of the allegations. 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
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 complete an annual PASARR (Preadmission Screen and Resident Review)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete an annual PASARR (Preadmission Screen and Resident Review) for two residents (R70 and R139) of 6 residents reviewed for PASARR screening. Findings include:
R70
A review of R70's medical record revealed they were admitted into the facility on [DATE] with diagnoses including dysphagial, intellectual disabilities, functional quadriplegia. A Minimum Data Set (MDS) assessment dated [DATE] and a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment.
Further review of R70 electronic medical record revealed a PASARR dated 11/27/24 and marked Preadmission screening and revealed no level II PASAAR request.
R139
On 03/10/25 at 10:00 AM, R139 was observed lying in bed and watching television. R139 was finishing his breakfast meal. R139 verbalized concerns about wanting to meet with the social worker to discuss change in guardianship.
A review of R139's medical record revealed they were admitted into the facility on 7/08/24 with diagnoses including adjustment disorder with anxiety and depressed mood, bipolar disorder, and chronic respiratory failure with hypoxia. A Minimum Data Set (MDS) assessment dated [DATE] and a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.
Further review of R70 medical record revealed a PASARR dated 7/08/24 indicating a hospital exemption for 30 days. A request for an updated PASARR was requested by social services.
On 03/11/25 at 1:15 PM, during an interview occurred with Social Worker C regarding an updated PASARR for R139. Social Worker C confirmed there was not an updated PASARR completed nor available at this time.
A review of the facility policy titled, PASARR - Pre-admission Screen and Resident Review, noted the following: A facility must coordinate assessments with the pre-admission screening and resident review program under Medicaid in part 483, subpart C to the maximum extent practicable to avoid duplicative testing and efforts. Specialized services are those services the State is required to provide or arrange for that raise the intensity of services to the level needed by the resident. That is, specialized services are an add-on to NF services - they are of a higher intensity and frequency than specialized rehabilitation services, which are provide by the NF. 1. The statute mandates preadmission screening for all individuals with mental illness (MI) or mental retardation (MR) who apply to the NFs, regardless of Policy (PASRR) the applicant ' s source of payment, except as provided below. Residents
readmitted and individuals who initially apply to a nursing facility directly following a discharge from an acute care stay are exempt if:
a. They are certified by a physician prior to admission to require a
nursing facility stay of less than 30 days; and
b. They require care at the nursing facility for the same condition for
which they were hospitalized .
3. All residents are required to have a level I PASRR screen prior to or upon admission the facility.
When indicated on the level I screen that a level II screen is required, the facility will complete
notification to the State ' s PASRR program notice for the level II screen (in accordance with State
specific laws.
4. If a resident is admitted with a level diagnosis as indicated above review is required upon change in
the resident ' s condition. For example: a. A review and determination under clause (i) or (ii) must be conducted promptly after a nursing facility has notified the State mental health authority or State mental retardation or developmental disability authority, as applicable, under subsection (b)(3)(E) with respect to a mentally ill or mentally retarded resident, that there has been a significant change in the resident's physical or mental condition.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to develop a care plan addressing Post-Traumatic Stress Disorder (PTSD) for one resident(R62) out of three reviewed for mood/beha...
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Based on observation, interview and record review, the facility failed to develop a care plan addressing Post-Traumatic Stress Disorder (PTSD) for one resident(R62) out of three reviewed for mood/behavior care plans. Findings include:
A review of the medial record revealed R62 was admitted into the facility on 6/13/2022 with the following medical diagnoses, Major Depressive Disorder and Post-Traumatic Stress Disorder (PTSD). A review of the most recent Minimum Data Assessment (MDS) set revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition.
On 3/10/2025 at 10:00 AM, an interview was conducted with R62. R62 stated they do have PTSD due to things in their past. R62 stated they have triggers, but the medicine helps manage it.
Further review of the medical record revealed a mood/behavior care plan. The mood/behavior care plan did not include the PTSD diagnosis or known triggers.
On 3/12/2025 at 10:13 AM, an interview was conducted with Social Worker (SW) F. SW F stated when they assess the resident when they admit into the facility it should be added in the mood care plan. SW F stated that is where the PTSD diagnosis would go, as well as the known triggers.
On 3/12/2025 at 1:25 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility did not have the PTSD diagnosis upon admission and it was later added and should have been communicated during the behavior meeting to ensure the care plan was developed.
A review of a facility policy titled, Comprehensive Care Plans noted the following, .1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma informed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide timely assistance for two residents (R24, R15...
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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 timely assistance for two residents (R24, R154) out of six reviewed for Activities of Daily Living (ADLs). Findings include:
R24
On 3/10/25 at 10:27 AM, R24 reported over the past weekend Saturday (3/8/25) into Sunday (3/9/25) they requested ADL care around 6:15 AM, no one on the midnight shift came in to provide care. They explained they received care on the day shift at 9:45 AM. R24 explained on another (unknown) day they put the light on around 7:00 PM on a Friday, and did not receive care until 9:30 PM.
A review of R24's medical record revealed, R24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Myocardial Infarction. A review of R24's annual Minimium Data Set (MDS), dated [DATE] noted, R24 with an intact cognition and required assistance from staff to complete activities of daily living (ADLs).
Further review of R24's concern forms provided by the facility noted, multiple days of staff not providing care timely, not at all, or passing the care on to the next shift. A concern form revealed, Date: 3/27/24, assistance needed: care, Details: [R24] stated on MN (midnight) shift [R24] was placed on a bedpan around 3am and the CNA did not come back until about 5am .
A review of R24's care plan revealed, [R24] has an ADL self-care performance deficit related to muscle weakness, limited mobility, and debility. Date initiated: 3/12/2024. Goal: [R24's] Activities of Daily Living (ADL) needs will be met through next review. Date initiated 1/5/2024, Interventions: Bed mobility: 2 person assist. Date initiated: 06/14/2024. Personal Hygiene: 1 person assist .
On 3/12/25 at 1:36 PM, the Director of Nursing (DON) was asked about staff rendering timely care. The DON explained, the facility has identified a concern on the midnight shift and they have let a lot of people go. The DON further explained, that the residents should have someone checking on them every hour between the Nurses and the Certified Nursing Assistants.
Resident #154
On 3/11/2025 at 12:00 PM, R154 was observed eating lunch in their room. R154 was observed to be shaking while picking up their fork. R154 stated they wanted to put some salt on their food, but was unable to pick up the package, open it, and shake the salt on the food. R154 was asked if they received assistance with eating and they stated the staff don't help them eat, but sometimes they could use it.
On 3/12/2025 at 11:55 AM, R154 was observed eating lunch in their room with no assistance. R154's hands were noted to be shaking while they were raising their utensils to their mouth to eat.
A review of the medical record revealed R154 was admitted into the facility on 1/30/2025 with the following diagnoses, Bacteremia and Depression. A review of the recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 11/15 indicating an impaired cognition. R154 also required staff assistance with bed mobility, eating, and transfers.
Further review of the physician's orders revealed the following order, Ordered: 2/7/2025 .1:1 feeding assistance with meals .Active .
Further review of a nutrition note dated 3/11/2025 noted the following, .Benefits from supervision/assist with meals.
On 3/1/2025 at 11:56 AM, an interview was conducted with Assistant Director of Nursing (ADON) K. ADON K was queried if R154 required 1:1 assistance with meals and stated the assistance is more for meal set up and cueing. ADON K stated someone should be in the room to help with cueing and see how much progress R154 is making.
On 3/12/2025 at 1:21 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the floor nurse confirmed the feeding assistance order.
A review of a facility policy titled, Activities of Daily Living (ADLs) noted the following, .3.A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
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 F0687
(Tag F0687)
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 timely podiatry care was provided for one 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 ensure timely podiatry care was provided for one resident (R201) of one resident reviewed for foot care. Findings include:
On 03/10/25 at 9:00 AM, R201 was observed sitting on the side of the bed. When asked about any concerns, R201 stated they are concerned about their toenails because they are too long and starting to hurt. R201 toenails were observed to be long extending past the tip of the toes. R201 could not recall the last podiatry visit.
A review of R201's medical record revealed they were admitted to the facility on [DATE] with a diagnosis of Down's syndrome, Schizophrenia, and Chronic kidney disease. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Brief Interview of Mental status (BIMS) score of 14 which indicated intact cognition.
Further review of R201's elcetronic medical record did not reveal a current podiatry consultation.
On 3/11/25 at 2:00 PM, an interview occured with the Social Service Director (SSD) O explained R201 is on the list to be seen by podiatry. SSD staff O further indicated the social services team is fairly new and they are working to connect with ancillary services.
On 3/12//24 at 3:30 PM an interview occurred with the DON. The DON confirmed R201 had long toe nails and needed cutting.
A review of a facility policy titled, Nail Care was implemented 10/20/2020 and revised 08/20/2024, noted the following: The purpose of this procedure is to provide guidelines for the care of a resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines:
1. Assessments of resident nails will be conducted on admission and readmission to determine the resident ' s nail condition, needs, and preferences for nail care, if possible.
a. Report unusual or abnormal conditions of the nails to the physician and the responsible party (e.g.,
curling, color changes, separation from the nailbed, redness, bleeding, pain, odor, infection, etc.).
b. Obtain history and preferences regarding podiatrist.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to label and date a tube feeding bottle for one resident (R75) out of two reviewed for tube feedings. Findings include:
On 3/11/...
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Based on observation, interview, and record review, the facility failed to label and date a tube feeding bottle for one resident (R75) out of two reviewed for tube feedings. Findings include:
On 3/11/2025 at 10:24 AM, R75 was observed laying in bed. R75 was observed to have a tube feeding running. The bottle was noted to be unlabeled and undated.
On 3/11/2025 at 10:24 AM, Licensed Practical Nurse (LPN) A was brought into the room and shown the tube feeding bottle. LPN A stated the tube feeding goes up on the evening shift, and that it should be labeled.
A review of the medical record revealed that R75 was admitted into the facility on 6/10/2024 with the following diagnoses, Quadriplegia and Gastrostomy. A review of the recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 99 indicating they were unable to complete the assessment. R75 also required staff assistance with bed mobility and transfers.
On 3/12/2025 at 1:24 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the tube feeding goes up at night and that the tube feeding should be labeled and dated as soon as it goes up.
A review of a facility policy titled, Feeding Tubes did not address labeling and dating.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure medications were discarded when expired from one medication cart (U100 low numbers) of three medication carts reviewed. Findings inclu...
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Based on observation and interview, the facility failed to ensure medications were discarded when expired from one medication cart (U100 low numbers) of three medication carts reviewed. Findings include:
On 3/12/2025 at 02:07 PM, along with Licensed Practical Nurse (LPN) G, two expired stock medications were located in the top drawer of Unit 100's lower numbered medication cart. The medications were Glucosamine Chrondroitin with an open date of 10/1/24 and a stamped expiration date of 01/25 and Oyster Shell Calcium 500mg (milligrams) with an open date of 9/25/24 and a stamped expiration date of 08/24.
On 3/12/2025 at 04:15 PM, the Director of Nursing (DON) indicated expired medications should be removed from use.
A policy for Medication Storage was requested but not received 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
Safe Environment
(Tag F0921)
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 resident equipment (two beside dressers, one o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident equipment (two beside dressers, one overbed table) was in good, clean, and safe condition for three residents (R20, R143, R167) of residents reviewed for homelike environment. Findings include:
On 03/10/25 at 09:55 AM an observation of the bedside dresser for R20 revealed a two-inch gap between the first and second drawer. R20 was queried regarding the gap and responded, oh without further verbalization.
On 03/12/25 a review of the record revealed R20 was admitted on [DATE] with a diagnosis of dementia. R26 has a Brief Interview of Mental Status (BIMS) score of 00 indicating severe cognitive impairment.
On 03/10/25 at 10:10 AM, an observation revealed the overbed table for R143 had many dark circular stains. R143 was asked if they found the condition of the overbed table bothersome. R143 provided a blank stare and did not respond at all.
On 03/12/25 a review of the record revealed R143 was admitted [DATE] with a diagnosis of dementia. R143 has a BIMS score of 03 indicating severe cognitive impairment.
On 03/10/25 at 09:38 AM, an observation revealed the resident bedside dresser for R167 had a top that was very stained, rough and with uneven edges. R167 was asked if the dresser top was bothersome. R167 was unable to answer.
On 03/12/25 a review of the record revealed R167 was admitted to the facility on [DATE] with a diagnosis of dementia. R167 has a BIMS score of 00 indicating severe cognitive impairment.
On 03/12/25 at 3:30 PM the Maintenance Director (MD) I reviewed bedside dressers, and overbed table. MD I reviewed the (name of) system used for maintenance requests and was unable to locate any submitted orders for bedside dressers or tables. MD I further indicated any staff member noting a concern can enter that concern into the maintenance system and concerns should report as soon as possible.
A review of the policy, Preventative Maintenance Program dated reviewed/revised 02/12/22 states, The Maintenance Director is responsible for developing and maintain a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. The policy further states, If preventative maintenance is required, the Maintenance Director may decide what tasks need to be completed . The policy further states, Documentation may be completed for all tasks and kept in the (name of) program.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
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 call lights were in reach for five residents (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure call lights were in reach for five residents (R34, R86, R147, R612, and R613) of six residents reviewed for call light accessibility. Findings include:
R612
On 3/10/25 at 1:10 PM, R612's call light was observed out of reach of R612 and on the floor.
On 3/12/25 at 10:55 AM, [NAME] Clerk (WC) P was observed in R612's room and was interviewed regarding the preferred location of the call light for R612. WC P stated, It should be within hand reach.
A review of R612's electronic medical record (EMR) revealed that R612 was admitted to the facility on [DATE] with diagnoses that included End stage renal disease (Damaged kidney) and Type 2 diabetes. R612's most recent minimum data set assessment (MDS) dated [DATE] revealed R612 had an intact cognition and required moderate assistance to supervision for all activities of daily living (ADLs).
R613
On 3/10/25 at 2:32 PM, R613's call light was observed on the floor by the end of their bed.
On 3/12/25 at 10:32 AM, R613's call light was observed on the floor by the end of their bed.
At 10:41 AM, Licensed Practical Nurse (LPN) Q was observed to enter and exit R613's room. On 3/12/25 at 10:44 AM, upon LPN Q's exit from R612's room, an observation was made of R612's call light remaining on the floor. At 11:04 AM and 1:13 PM, R613's call light was observed to remain on the floor out of reach of the R613.
A review of R613's EMR revealed that R612 was admitted to the facility on [DATE] with diagnoses that included Osteomyelitis (Bone infection) and Cerebral infraction (Stroke). R612's nursing admission evaluation dated 3/8/25 revealed that R612 had an impared cognition.
On 3/12/25 at 1:18 PM, an interview was conducted with Unit Manger, Registered Nurse (RN) R regarding their expectations for placement of call lights in residents' rooms. RN R stated, They should be within reach of the resident when they are in their room.
R86
On 3/11/25 at 1:34 PM, R86's call light was observed to be on the floor by the bed out of reach of R86.
A review of R86's EMR revealed R86 was admitted to the facility on [DATE] with diagnoses that included, Sepsis (Infection) and Respiratory failure. R86's most recent MDS dated [DATE] revealed that R86 had an intact cognition and required partial to substantial assistance for all ADLs other than eating.
R34
On 3/10/2025 at 9:28 AM, R34 was observed laying in bed. R34 stated that sometimes they call for help, and it takes a while for staff to come and answer their call light. R34 stated they were unable to locate their call light now. R34's call light was observed on the floor and out of reach of the resident.
At 12:03 PM, R34 was observed sleeping. Their call light was still noted to be on the floor and out of reach.
On 3/11/2025 at 10:13 AM, R34's call light was still noted to be out of reach and on the floor. R34 stated they did not have their call light all night.
A review of the medical record revealed that R34 was admitted into the facility on [DATE] with the following diagnoses, Hemiplegia and Cerebral Infarction. A review of the most recent Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 15/15 indicating an intact cognition. R34 also required staff assistance with bed mobility and transfers.
R147
On 3/10/2025 at 9:28 AM, R147 was observed in the bed. R147 stated they often do not have their call light within reach. R147's call light was observed on the floor behind their curtain and out of reach. At 2:48 pm, R147 stated they never know where their call light is located and that they asked for their call light, and no one handed it to them. R147's call light was observed to still be located on the floor, behind their curtain and out of reach.
On 3/11/2025 at 10:11 AM, R147's call light was noted to still be out of reach and on the floor, behind their curtain. R147 stated they did not have their call light all night and that they asked for it and no one gave it to them. At 10:31 AM and 11:59 AM, R147's call light was observed to still be out of reach and on the floor, behind the curtain.
A review of the medical record revealed that R147 admitted into the facility on 3/21/2024 with the following medical diagnoses, Muscle Weakness and Dysphagia. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental status score of 6/15 indicating an impaired cognition. R147 also required staff assistance with bed mobility and transfers.
On 3/12/2025 at 12:27 PM, the Administrator (NHA) was interviewed and asked about their expectations for placement of call lights in residents' rooms and confirmed staff should ensure the call light is placed where the resident wants it.
On 3/12/2025 at 1:27 PM, an interview was conducted with the Director of Nursing (DON) and they stated the Unit Managers complete rounds each morning and have huddles with everyone in the morning, and they should be looking for call lights to be within reach.
A review of a facility policy titled, Call Lights: Accessibility and Timely Response noted the following, .1. Staff are educated in the proper use of the resident call system, including how the system works and ensuring resident access to the call light.
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
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R21
On 3/10/25 at 11:48 AM, R21 reported the only concern they had was the food. R21 stated, the food is cold and sometimes burn...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R21
On 3/10/25 at 11:48 AM, R21 reported the only concern they had was the food. R21 stated, the food is cold and sometimes burnt.
A review of R21's medical record noted, R21 was admitted to the facility on [DATE] and readmitted [DATE], a review of R21's quarterly Minimum Data Set (MDS) assessment dated [DATE] noted, R21 with a moderately impaired cognition.
R22
On 3/10/25 at 10:05 AM, R22 explained, the food was nasty and cold. R22 requested for a temperature check of their lunch meal today.
On 3/10/25 at 1:03 PM, R22's lunch meal temperature was as follows; 117.8 °F pork slices, 115.8 °F mashed potatoes, and 99.6 °F sliced carrots. R22 explained the food was as hot as they liked their food.
A review of R22's medical record noted R22 was admitted to the facility on [DATE] with a diagnosis of Incomplete at T11-12 level of Thoracic Spinal Cord. A review of R22's MDS assessment noted, R22 with an intact cognition.
R24
On 3/10/25 at 10:27 AM, R24 reported the food is terrible and breakfast is really bad. R24 explained, they order out to restaurants.
A review of R24's medical record revealed, R24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Myocardial Infarction. A review of R24's annual MDS, dated [DATE] noted R24 with an intact cognition.
R60
On 3/10/25 at 9:56 AM, R60 was asked about the care at the facility and stated, Food, it sucks. R60 further explained the food doesn't taste good and they have spent a lot of money buying food from the outside.
A review of R60's medical record revealed, R60 was admitted to the facility on [DATE] with diagnosis of Heart Disease. A review of R60's quarterly MDS dated [DATE] revealed R60 with an intact cognition.
Seven confidential group participants.
On 3/11/25 at 1:40 PM, during the group interview all seven participants reported the food was a hot button topic. They explained the food did not taste good and was served mostly warm not hot.
On 3/12/25 at 2:05 PM, the Dietary Manager and the Corporate Manager were asked for the food temperature at the point of service. They both reported there is no set number, but what is palatable for the residents. The Dietary Manager explained she attends food committee meetings and it is usually the same residents that attend the meeting.
A review of the food committee notes revealed, 2/24/25 . 3. Does the food taste good? 60% like the food saying its tasty, 20% not enough variety . 20% sometimes saying the food is hit or miss . 4. Are food served at the proper temperature: Last meeting we were about the same 65% saying it's hot . 35% say warm or not hot enough .
A review of the facility's policy titled, Food: Quality and Palatability undated, noted, Policy statement: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature . Food palatability refers to the taste and/or flavor of the food. Proper (safe and appetizing) temperature: Food should be at the appropriate temperatures as determined by the type of food to ensure resident's satisfaction and minimizes the risk for scalding and burns .
Based on observation, interview, and record review, the facility failed to ensure food was served in a palatable manner and at the preferred temperature for nine residents (R6, R21, R22, R24, R60, R74, R108, R146, R188) and six confidential group residents, of sixteen residents reviewed for food palatability. Findings include:
R188
On 3/10/25 at 10:44 AM, R188 was interviewed about the palatability of the food at the facility and indicated the food was, lousy and frequently cold.
A review of R188's electronic medical record (EMR) revealed that R188 was admitted to the facility on [DATE] with diagnoses that included Partial amputation on left mid foot and COPD (Chronic obstructive pulmonary disease) (Lung disease). R188's most recent minimum data set assessment (MDS) dated [DATE] revealed R188 had an intact cognition.
R108
On 3/10/25 at 10:56 AM, R108 was interviewed about the palatability of the food at the facility and stated, I don't like the food.
A review of R108's EMR revealed R108 was admitted to the facility on [DATE] with diagnoses that included Osteomyelitis (Bone infection) and Protein-Calorie malnutrition. R108's most recent MDS dated [DATE] revealed that R108 had an intact cognition.
R146
On 3/10/25 at 11:29 AM, R146 was interviewed about the palatability of the food at the facility and indicated the food did not taste good, was not prepared in a palatable manner, and the meat was hard to chew.
A review of R146's EMR revealed R146 was admitted to the facility on [DATE] with diagnoses that included Respiratory failure and Heart failure. R146's most recent MDS revealed that R146 had an intact cognition.
R6
On 3/10/25 at 2:26 PM, R6 was interviewed about the palatability of the food at the facility and stated, It's terrible and the portions are small.
On 3/12/25 at 10:31 AM, R6 was further interviewed regarding the palatability of the food and indicated the food was not good saying, The food is better when you're (survey team) here.
A record review of R6's EMR revealed R6 was admitted to the facility on [DATE] with diagnoses that included Sepsis (Infection) and Respiratory failure. R6's most recent MDS dated [DATE] revealed that R6 had an intact cognition.
On 3/12/25 at 12:15 PM, a lunch tray was pulled off of a lunch cart in the facility and temperature checked by District Dietary Manager (DDM) M. The results were the following, Cranberry orange chicken: 119.8 Degrees Farenheight (F); Brussel sprouts: 121.3 F; [NAME] Pilaf: 122.1 F. DDM M was interviewed regarding their preferred temperatures for the food and indicated that it was based upon the resident preference.
On 3/12/25 at 12:20 PM, the chicken and rice was taste tested by the survey team members and was noted to be luke warm and the brussel sprouts were mushy and lacked flavor.
On 3/12/25 at 12:27 PM, the Administrator (NHA) was interviewed regarding their expectation for food palatability regarding food served to the residents at the facility. The NHA indicated food palatability was all related to resident preference.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to maintain the dish machine area in the kitchen in a clean manner, resulting in the presence of gnats. This deficient practice ...
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Based on observation, interview, and record review, the facility failed to maintain the dish machine area in the kitchen in a clean manner, resulting in the presence of gnats. This deficient practice had the potential to affect all residents, staff and visitors. Findings include:
On 03/10/25 at 9:15 AM, there were numerous gnats observed underneath the dish machine tank and drainboard. The flooring was wet with murky standing water, and the pipes underneath the drainboard were coated with a black slimy substance.
When queried about the gnats, Dietary Manager S provided no explanation.
Review of the pest control service reports noted:
8/20/24 Upon inspection of the kitchen it was found there was heavy gnat activity. The cause of the gnat activity is the cleanliness in the kitchen. Areas all around and underneath dish tank were so soiled with debris that they were creating harboring spaces for gnats.
9/20/24 Upon inspecting the kitchen, many gnats were present. Kitchen staff must do a better job of cleaning.
1/15/25 Upon inspection of the kitchen there was heavy gnat activity. This is mostly due to build up of grime and residue throughout the kitchen but mostly harboring underneath sinks, corners and drains.
According to the 2017 FDA Food Code section 6-501.111 Controlling Pests, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: .4. (D) Eliminating harborage conditions.
Feb 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
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 M100150293
Based on interview and record review, the facility failed to complete weekly skin c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake M100150293
Based on interview and record review, the facility failed to complete weekly skin checks for one (R704) of ten residents reviewed for skin checks, resulting in the development of gangrene of the right great toe, right foot pain and hospitalization. Findings include:
Review of intake M100150293 revealed a concern that a family member visited R704 on 12/25/24 during which the resident reported right foot pain. The family member reportedly removed the resident's sock and found the right great toe to have what they believed to be gangrene.
Review of the facility record for R704 revealed an admission date of 01/10/24 with diagnoses including Osteoarthritis, Gout, Adult Failure to Thrive, and End Stage Renal Disease requiring Renal Dialysis. Review of R704's Care Plan dated 01/10/24 revealed the Focus statement [R704] is at risk for impaired skin integrity related to muscle weakness, incontinence and a diagnosis of failure to thrive. The Interventions associated with this Focus area included Complete skin inspection weekly and as needed.
Review of R704's facility record of assessments revealed a skin assessment dated [DATE] that indicated no new abnormal skin areas. The next skin assessment was dated 12/25/24 and identified the concern of swelling in right foot and black skin on right great toe.
On 02/18/25 at 1:45 PM, the facility Director of Nursing (DON) was interviewed and reported they were first made aware of R704's right foot condition on 12/25/24. The DON reported that family was visiting and had reported the concern to nursing staff. Staff contacted the DON by phone and they initiated response measures which led to the resident being transferred to the hospital that day. The DON expressed that they knew that the gangrenous condition of the toe would have taken time to develop and they recognized that there had been a deficient practice. The DON was asked about the nearly eight week gap between the 10/31/24 and 12/25/24 skin assessments and they acknowledged the assessments had not been completed.
Review of R704's hospitalization records indicated the resident and was hospitalized from [DATE] until 01/10/25 at which time they returned to the facility. The hospital record verified the resident was diagnosed with Right Foot Gangrene, Dry as well as Sepsis, likely due to Gangrene and that the resident continued to report right foot pain during hospitalization.
Additional review of R704's facility record revealed that following readmission on [DATE] the resident continued to report right foot pain as recently as 02/05/25 per the Physical Medicine and Rehab Nurse Practitioner's note dated 02/09/25.
On 02/19/25 at 2:15 PM, the DON reported their expectation is that R704 should have had a head to toe skin assessment weekly as well as skin assessments during twice weekly baths/showers. The DON reiterated that they recognized a deficient practice had occurred and they began corrective measures on 12/25/24.
Review of the facility policy Pressure Ulcer/Skin Breakdown-Clinical Protocol dated 10/30/22 revealed the section 7. Continued Assessment and Management which included the entry - Weekly skin evaluation/assessment by the licensed nurse on residents who have no current pressure ulcers/injuries.
During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included:
The facility identified an inconsistency with the documentation of the provision of potential identified treatment/wound care.
1. What corrective action(s) will be done for residents found to have been affected by the deficienct practice(s).
(R704) sent to the hospital with skin discoloration noted to right foot with great toe included. No documentation of discoloration mentioned on weekly skin checks or nursing admission notes. We were out of compliance with treatment orders and was not assessed by the wound care team on date of admission. He was admitted prior to the PNC and we were out of compliance with his weekly skin assessments.
2. How will facility identify other residents having potential to be affected by practice and what corrective action will be taken. Skin assessments completed on all current residents by December 28, 2024.
Residents with noted changes to skin integrity were evaluated by a licenced nurse and treatment in place if needed, appropriate, and in compliance with treatment order schedule.
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur.
The above action plan will be presented in QAPI (Quality Assurance Performance Improvment), January 23, 2025 meeting. Pressure Ulcer/Skin Breakdown - Clinical Protocol has been reviewed and deemed appropriate. The action plan and audits will be brought to QAPI monthly and will continue until discontinued by QAPI.
The DON/Unit Managers will be responsible for the ongoing oversight of the provision of skin/wound assessments and documentation. Skin assessments will be monitored for completion during morning meetings, Monday thru Friday.
4. How the corrective actions will be monitored to ensure the deficient practices will not recur.
The DON/designee will audit 10 residents weekly for timely and accurate completion of skin assessments and treatment orders in place if needed or extending as determined necessary, then monthly thereafter until substantial compliance is met and audits are discontinued by QAPI.
The DON is responsible for sustained compliance.
Signed by DON on 12/28/24. Supportive documentation/audits verified and available in survey folder.
The facility was able to demonstrate monitoring of the corrective action and maintained compliance.
Jan 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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertians to Intakes MI00149291, MI00149568, and MI00149398.
Based on observation, interview, and record review, th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertians to Intakes MI00149291, MI00149568, and MI00149398.
Based on observation, interview, and record review, the facility failed to ensure incontinence care, repositioning or water was provided for three dependent residents (R703, R706, and R707) of three reviewed for Activites of Daily Living (ADL) care. Findings include:
R703 and R707
On 01/22/25 at 8:52 AM, R707 reported they did not have any water and had been left an extended amount of time waiting to be assisted with incontinence care. R707 had finished their breakfast.
On 01/22/25 at 8:55 AM, R703 was observed to be in bed. A wedge was visible at the right side of the torso. The resident verbalized concerns about being changed (providing care) timely in the after dinner hours. R703 reported they had not been turned since earlier in the morning and was supposed to be turned every two hours. The resident was able to read the clock in the room. The time stated by R703 was correct. R703 reported the breakfast tray had been removed and noted they did not have any water.
Additionally, R703 did not have a water cup and R707 had two empty cups on the night stand. Both residents reported they would like to have water cups between meals.
On 01/22/25 at 10:39 AM through 10:55 AM, R703 had not been turned or repositioned. R703 nor R707 had a water cup. Nursing and nurse aide staff were observed in the hallway.
No water cups were observed in the room for R703 nor R707. The cart that held the water cups was observed between rooms [ROOM NUMBERS].
On 01/22/25 at 11:37 AM, R703 was observed to be in bed dressed in a hospital style gown. The wedge was observed at the left side of R703's torso and no water cups had been delivered to the room of R703 and R707.
R703 remained in bed, and demonstrated ability to move their head up and down with the bed control. The tray table was observed to be at the end of the reach for R703.
On 01/22/25 at 11:44 AM, R707 was observed to be in bed, the empty tray from breakfast for R707 remained in the room. The tray table was parallel to left side of bed and with no water cup.
On 01/22/25 at 12:31 PM, R703 was observed to be in bed as before with the wedge on their left side. There was no water bedside for R703 nor R707 and the cart remained parked between rooms [ROOM NUMBERS]. A Certified Nurse Assistant (CNA) entered the room of R703 and placed the lunch tray on the over bed table. At 12:36 PM, the CNA returned and assisted R703 to eat. At 2:09 PM R703 remained faced toward the right side of the bed with the wedge behind the torso at the left side. No fresh no water cups had been delivered. The cart that was between rooms [ROOM NUMBERS] had been removed. At this time the unit manager was asked if R703 and R707 were able to have bedside water and reported they were.
R706
On 01/22/25 at 9:15 AM, R706 was observed to be in bed and appeared to be asleep, laying on their right side. The head of the bed was up and two lollipops were observed in the bed behind R706's back. A vague odor of urine was noted and the brief appeared wet and soiled and a brown ring had developed on the bed behind R706's buttocks and torso.
At 10:27 AM, the soiled brown ring was visible from around the resident's backside and onto their gown and R706 appeared in the same position as before. The resident appeared to be asleep and the two lollipops remained on the bed behind the resident.
At 11:13 AM, R706 continued in bed. The soiled brown ring was visible from around the resident's backside and R706 appeared in the same position as before. The two lollipops remained on the bed behind the resident.
From approximately 11:18 AM to 12:19 PM the following events occured, two staff entered the hallway of R706 from the back hall, with a laundry cart .food items were brought out from back hall into the hallway .R706 continued in bed as before but with their eyes opened. A nurse was at the medication cart .a CNA was observed at the wall kiosk and appeared to have been charting .R706 remained in bed as before though more onto their back and with their eyes open .CNA E brought the lunch tray into the room of R706, placed the lunch tray bed side on the tray table, then pulled up the sheet up to the waist of R706 and raised the head of the bed to greater than 45 degrees .the nurse for R706 entered the room with the blood pressure machine then quickly exited .the nurse returned, noted the soiled area around R706 and reported they told staff that R706 needed to bed changed .R706 continued to eat with their fingers as the assigned nurse and CNA C walked in and reported they were going to change R706.
A review of the record for R706 revealed R706 was admitted in the facility on 02/04/19 and had been moved to the current room on 01/06/25. R706 had a history of candida (fungal infection) of the genital area and skin irritations to the thigh were documented on 01/10/25 per a nurse practitioner (NP) note. A progress noted dated 12/02/24 documented foul smelling and dark urine and R706 had a urinary tract infection.
The active care plan documented impaired cognitive function and an ADL (activities of daily living) self-care performance deficit, toileting was supervision with set up and personal hygiene was supervision with one person assist. The care plan initiated 09/25/23 and revised 11/19/24, further noted R706 had episodes of bowel and bladder incontinence related to neuromuscular dysfunction of the bladder and to assist resident with toileting needs as needed.
On 01/22/25 at 2:10 PM, the observations of R706 were reviewed with CNA C. CNA C reported they had checked at R706 at the start of their shift (between 7 AM and 8 AM) and displayed a note which indicated R706 to be independent.
On 01/22/25 at 4:51 PM, upon review of the identified incident with the Director of Nursing (DON) and Administrator, the DON acknowledged the need for repositioning, incontinence care and water pass for dependent residents. The DON further reported there were no fully independent residents in the facility and the nurse and CNA should have checked on and assisted R706.
A review of the policy titled, Activities of Daily Living (ADLs) implemented 10/30/20 revealed, .A resident who is unable to carry out activities of daily living receives the necessary services to
maintain good nutrition, grooming, and personal and oral hygiene .
A review of the policy titled, Hydration implemented 10/30/20 revealed, .The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health .
Oct 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
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00147415 and MI00147559.
Based on observation, interview, and record review, the facility failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00147415 and MI00147559.
Based on observation, interview, and record review, the facility failed to ensure resident rooms, common areas, and shower rooms were homelike on two nursing units (units 100 and 200) of four units reviewed. Findings include:
A review of the intake dated 10/18/24 revealed, .bathroom had no working lights, and the piping underneath the sink was not attached to the sink . It was also noted there was a burnt outlet in the room. A further comment noted, staff were asked to switch bed to a pressure release bed, but staff did not switch it until the last day . and .there are sharp metal objects sticking out the floor in the hallway .
On 10/22/24 at 9:21 AM, the main hall to the 100 and 200 units was noted to have a round metal disc in the center of the hallway outside the main dining room. The disc was held down with a screw in the center. The edges of the disc were bent upwards above the level of the floor and the disc was loose when stepped on. A piece of the baseboard was noted peeled away from the wall in the same area.
On 10/22/24 at 9:23 AM, room [ROOM NUMBER] was observed to have a resident in the bed by the door. The resident was in a low bed with a mattress on floor on one sides of bed. Eleven or more white patches of spackle were observed on the walls of the room. The bathroom did not have a towel dispenser and eight similar white patches were observed on the walls of the bathroom. A piece pipe covering was on the floor under the sink.
On 10/22/24 at 9:30 AM, the 100 unit nurse station had 25 or more patches of white spackle visible from the common area. Three powered wheelchairs were stored at the right hand hall for the exit door from the same common area.
On 10?22/24 at 9:31 AM, the shower and bathroom areas were observed. The first shower room to the right had a wash cloth left on the assist bar. The cove base was missing to the right of the doorway to the shower. The opposite shower room was full of multiple items which included laundry bin frames, two used foam wedges and a shower chair with items piled to the level of the arms. The restroom at the end of the same hall had a toilet with brown water stains in the bowl, dead flies and small trash particles on the floor, the cabinet doors were at odd angles and the toe kick for the cabinet was missing.
On 10/22/24 at 9:39 AM, room [ROOM NUMBER] was observed occupied by a resident dressed and seated in a recliner. The resident did not respond to questions. A visitor reported the resident had moved from room [ROOM NUMBER]. An observation of the room areas revealed the cover (around 18 inches high, 18 inches deep and three feet long) for the air unit was on the floor in front of the unit. Further observation revealed five white spackled wall patches, the cover was off the phone jack behind head of the residents bed, the lights over both beds did not work. The pull chain for the second bed did not work. The bathroom light also did not work when the switch was turned on. (A maintenance person noted they had changed the bulbs and they still did not work.) The sink had a repair of an area of missing porcelain rusting through.
On 10/22/24 at 9:50 AM, room [ROOM NUMBER] was noted to have a light cover missing from the overhead light at the door. room [ROOM NUMBER] had nine or more areas of white spackled wall patches. Patches were also noted at the side of the windows. The hub of a call light cord had pulled away from one of the cords to reveal the wires. Toilet paper, a pencil, and a patch of soil were on the floor across the room and assist bars were stored in one of the resident closets.
On 10/22/24 at 10:04 AM, a resident was observed to be in bed in room [ROOM NUMBER]. [NAME] spackled patches were noted around the two windows, bed parts were under the head of the bed, and a piece of dried and soiled tissue was stuck to the first closet door. room [ROOM NUMBER] was observed with a made up bed. A soiled yellow plastic wash basin rested on top of the trash can in the bathroom. The toilet appeared with mildew in the bowl.
On 10/22/24 at 11:11 AM, the resident in room [ROOM NUMBER] reported they did not have a toilet seat or a television when first admitted to their room. The toilet seat arrived the next day and the TV a couple of days later.
On 10/22/24 at 11:35 AM, and observation of the shower room area for the 200 unit revealed the right side shower room with a tray table, a laundry cart, chair pad, floor mat, and arms for a raised toilet seat stored in the room. A bed mattress, a full trash can and laundry bin were in the hallway for the showers. The opposite shower room had a wet floor on the open stall and the opposite stall had a shower chair, a brush and comb on the floor. A refill for the soap dispenser was on top of the pony wall in between the stalls. The ledge also had clear plastic cup one third full with an orange liquid.
On 10/22/24 at 3:10 PM, environmental concerns were reviewed with the Administrator. The Administrator reported the admissions person, maintenance and housekeeping all should do room readiness checks prior to placement of a resident in the rooms.
A review of the October 22, 2024 resident council minutes noted maintenance issues had not been resolved.
A review of the maintenance logs (TELS) reports revealed: room [ROOM NUMBER] had an above bed light not working reported 09/23/24 and closed 09/23/24 and heat not working reported 10/02/24 and closed 10/21/24; room [ROOM NUMBER] also had a needs air mattress opened 10/10/24 and closed 10/16/24. A review noted the prior resident left on 10/17/24. The report for room [ROOM NUMBER] revealed, needs toilet seat . was opened 10/02/24 and closed 10/10/24.
A review of the policy titled, Safe and Homelike Environment with date implemented of 07/28/2020, revealed: In accordance with residents ' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the
facility maximizes resident independence and does not pose a safety risk.
Definitions: Adequate lighting means levels of illumination suitable to tasks the resident chooses to perform or the facility staff must perform.
Comfortable lighting means lighting that minimizes glare and provides maximum resident control, where feasible, over the intensity, location, and direction of lighting to meet their needs or enhance independent
functioning. Comfortable and safe temperature levels means that the ambient temperature should be in a relatively narrow range that minimizes residents ' susceptibility to loss of body heat and risk of hypothermia/hyperthermia and is comfortable for the residents .
A review of the policy titled, Preventative Maintenance Program with date implemented: 7/1/2021, revealed, A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Policy Explanation and Compliance Guidelines:
1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from manufacturer ' s recommendations, maintenance requests, life safety requirements, or experience. 3. If preventative maintenance is required, the Maintenance Director may decide what tasks need to be completed and how often to complete them. 4. The Maintenance Director may develop a calendar to assist with keeping track of all tasks. 5. Documentation may be completed for all tasks and kept in the TELS program.
Jul 2024
4 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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00145616.
Based on interview and record review, the facility failed to develop and implement ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00145616.
Based on interview and record review, the facility failed to develop and implement actions to prevent repeated falls for one (R703) of one resident resulting in nine falls without goals and interventions to prevent further falls. Findings include:
On 7/30/2024 st 10:57 AM, phone contact with the complainant was attempted. A voicemail was left when the call was unanswered. A return call was not received.
On 4/18/2024, R703 was admitted to the facility on [DATE] after falling and sustaining a fractured left wrist and left femur prior to admission. Other pertinent diagnoses include, dementia, heart disease, difficulty walking, cognitive communication deficit, and muscle weakness. R703's BIMS (Brief Interview for Mental Status) documented a 9 out of 15, indicating moderate cognitive impairment.
On 7/30/2024 a facility record review revealed R703 experienced falls on the following dates, 4/19/2024, 4/20/24, 5/1/2024, 5/2/2024, 5/1/2024. 5/24/2024, 5/29/2024, 6/12/2024, and 7/1/2024. The care plan regarding falls was first initiated on 4/18/2024. A fall pad was added to the care plan after the 6/12/2024 fall. The care plan was revised again on 7/16/2024 (15 days after the 7/1/24 fall). There were no care plan interventions put into place after the other falls.
The Director of Nurses (DON) was interviewed at 11:25 am, and asked about the care plan interventions and said a fall mat was added to the care plan after the 6/12/24 fall.
On 7/30/2024 the policy, Fall Prevention Program, revised 10/26/2023 was reviewed. The policy review revealed, When any resident experiences a fall, the facility will: e. Review the resident's care plan and update as indicated and f. Document all assessments and actions.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains in part to intake #145421.
Based on observation, interview, and record review, the facility failed to ser...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains in part to intake #145421.
Based on observation, interview, and record review, the facility failed to serve food in a palatable manner and at the preferred temperature for three residents (R704, R705, R706 ) of three reviewed for food palatability, resulting in dissatisfaction during meals. Findings include:
A review of a complaint submitted to the state agency (SA) revealed the following, Complainant states the food is terrible .The complainant(s) state they have to spend their own money on food and they can't afford it.
On 7/30/24 at 12:40 PM, the surveyor taste tested a random lunch meal and the results revealed that the cheeseburger and fries were [NAME] warm, the [NAME] slaw lacked flavor, and the pickle spear was soggy. All of these issues had a negative impact upon the palatability of the meal.
On 7/30/24 at 2:25 PM, Dietary Manager (DM) B was interviewed regarding preferred food temperatures for meals to the residents and stated, Hot food should be hot and cold food should be cold. DM B was further interviewed about the [NAME] Warm taste of the food on the test tray sampled by the surveyor. DM B stated, It was the last tray served, I'm not sure why it wasn't warmer.
On 7/30/24 at 4:05 PM, R706 was interviewed regarding food palatability at the facility. R706 stated, The food is terrible.
A review of R706's electronic medical record (EMR) revealed that R706 was admitted to the facility on [DATE] with diagnoses that included Lymiphocytic colitis (Inflammation of the large intestine) and Muscle weakness. R706's most recent minimum data set assessment (MDS) dated [DATE] revealed that R706 had an intact cognition.
On 7/3/24 at 4:10 PM, R705 was interviewed regarding food palatability at the facility. R705 stated, The food is terrible.
A review of R705's electronic medical record (EMR) revealed that R705 was admitted to the facility on [DATE] with diagnoses that included Kidney disease and Heart failure. R705's most recent MDS dated [DATE] revealed that R706 had an intact cognition.
A facility policy titled Food .Palatability Revised 9/2017 Policy Statement: Food will be .palatable .and served at a .appetizing temperature.
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 F0920
(Tag F0920)
Could have caused harm · This affected 1 resident
This pertains to Intake MI00145962.
Based on observation, interview, and record review, the facility failed to maintain adequate lighting in one (East Dining Room) of two dining rooms reviewed for hom...
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This pertains to Intake MI00145962.
Based on observation, interview, and record review, the facility failed to maintain adequate lighting in one (East Dining Room) of two dining rooms reviewed for homelike environment. Findings Include:
On 7/30/2024 at 10:30 AM, during an interview with R701 they said the East Dining Room lights had been out for some time. They further revealed staff had been made aware and were very frustrated with the maintenance in the facility.
On 7/30/2024 observation was made regarding lighting in the East Dining Room. It was observed that 5 lights were not illuminated. With the assistance of the Activities Director, the surveyors tried all switches controlling the lights without success.
On 7/30/2024 at 1:20 pm, the Nursing Home Administrator (NHA) indicated staff have the ability to enter into their maintenance system and was unaware of the lights being out until the Activities Director notified them. The NHA indicated maintenance requests need to go through the electronic maintenance request system.
The policy, Preventative Maintenance Program, revised 3/12/2022, revealed A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents staff, and the public. The policy further reveals documentation may be completed for all tasks and kept in the electronic maintenance request system 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
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
This pertains to Intake MI00145962.
Based on based on observation, interview, and record review, the facility failed to maintain steam tables in a sanitary condition in one of three steam tables in th...
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This pertains to Intake MI00145962.
Based on based on observation, interview, and record review, the facility failed to maintain steam tables in a sanitary condition in one of three steam tables in the East Dining Room. Findings Include:
On 7/30/2024 at 11:20 am, an observation was made of the steam tables in the East Dining Room. While observing the condition and cleanliness of the steam tables, loose crusted material and mold was noted on the third steam table with a small hood. When the material was touched, it fell onto the area where food would be sitting when in use.
On 7/30/2024 at 12:35 pm, The Nursing Home Administrator (NHA) was shown the area of concern and indicated their expectation is the steam table hoods should be clean and free of mold and materials that could drop into food.
The cleaning policy for cleaning steam table hoods was requested and received, Cleaning and Sanitizing Training by (name of cleaning company). The training document revealed Cleaning and sanitizing properly is one of the most important things we continually do in our kitchens to keep our operation safe for our residents. The Cleaning paragraph reveals, When you clean a surface your remove all visible debris from an area. The document also reveals, When you sanitize a surface you remove most harmful bacteria from the area.
Jun 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
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00144848.
Based on observation, interview, and record review, the facility failed to provide ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00144848.
Based on observation, interview, and record review, the facility failed to provide a clean and comfortable environment for two residents (R701 and R705 ) of three reviewed for environment, resulting in feelings of anger and frustration. Findings include:
A review of a complaint submitted to the state agency (SA) revealed the following, There is bugs in room, there is black mold or oil leaking from the air conditioner on the floor both the roommate and [complainant] are not getting any help to get it fixed .
On 6/12/24 at 11:55 AM, R705 was met in their room (room [ROOM NUMBER]) and interviewed about the room environment. R705 stated, Look at the carpet by the air conditioner, black stuff comes out of the air conditioner and there are black stains on the rug. R705 further indicated there were Pincher bugs that Pinch seen. R705 proceed to show the surveyor pictures on their phone of bugs which they indicated had been identified in their room. R705 indicated this situation had been going on for two to three months and had been reported to the facility with no solution. R705 said they were Upset and Angry over the situation. The surveyor observed a dried blackish substance on R705's rug under the air conditioner.
On 6/12/24 at 12:05 PM, R701 was interviewed about their room environment (room [ROOM NUMBER]) and indicated there was a black substance on the rug underneath the air conditioner and bugs in the bathroom. R701 stated, It upsets me.
On 6/12/24 at 12:10 PM, Housekeeping Aide (HA) A was interviewed regarding R701 and R705's room and confirmed they had observed bugs in the resident's bathroom.
On 6/12/24 at 12:22 PM, HA B was interviewed regarding R701 and R705's room and indicated they attempted to shampoo the rug to remove the black substance but was unsuccessful. HA B said I reported it to maintenence. HA B confirmed they had observed Pincher bugs in the resident's bathroom.
On 6/12/24 at 12:30 PM, R705 summoned the surveyor back into their room and a small black bug was observed crawling on R705's bedding. R705 asked the surveyor to Get rid of it.
On 6/12/24 at 12:45 PM, Maintenence Director (MD) C was interviewed regarding R701 and R705's room evironment and indicated they was unaware of any environmental issues in the room. MD C was asked about the black substance on the residents' rug and said, typically that would be a housekeeping issue. MD C indicated that bug spray had been sprayed in the room but a pest control contractor had not inspected and/or treated the room saying, I thought the issue was taken care of.
On 6/12/24 at 1:15 PM, the account manager for environmental services (EVS) D was interviewed regarding the carpet in the residents' room and indicated they were filling in for the facility manager of EVS and had just arrived at the facility today (6/12/24). EVS D was asked what their expectations would be for cleaning carpets in resident rooms. EVS D stated, If there was a stain on the carpet we would do a stain extraction and if not effective, I would speak with the Administrator (NHA) and MD about doing a carpet extraction.
On 6/12/24 at 2:30 PM, the NHA was interviewed regarding their expectations for resident room cleanliness. The NHA stated, Rooms should be deep cleaned on a schedule. The NHA further indicated that if stains on room carpet cannot be removed they should be notified so they can contact the chemical company contractor come to the facility and try other methods for stain removal. Regarding the bugs in the residents' room, the NHA indicated that Pest control was comming out soon.
A review of R701's electronic medical record (EMR) revealed that R701 was originally admitted to the facility on [DATE] with diagnoses that included Acute chronic respiratory failure with hypoxia (Lack of oxygen in blood) and Chronic obstructive pulmonary disease (COPD) (Lung disease). R701's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R701 had an intact cognition.
A review of R705's EMR revealed that R705 was originally admitted to the facility on [DATE] with diagnoses that included Acute phelonephritis (Inflamation of the kidney) and Morbid obesity. R705's most recent quarterly MDS dated [DATE] revealed that R705 had an intact cognition.
A review of a facility policy titled Safe and Homelike Environment Date Reviewed/Revised: 01/01/2022 stated the following, Policy: In accordance with residents rights, the facility will provide a safe, clean, comfortable and homelike environment .Policy Explanantion and Compliance Guidelines: 3. Housekeeping and Maintenance Services will be provided as necessary to maintain a sanitary, orderly, comfortable environment.
A review of a facility policy titled, Pest Control Program Date Reviewed/Revised: 01/01/2022 stated the following, Policy: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests.
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May 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
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 MI00143948.
Based on interview and record review, the facility failed to notify guardian of tra...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00143948.
Based on interview and record review, the facility failed to notify guardian of transferring out to the hospital for one (909) of two residents reviewed for notification of changes resulting in the guardian not being informed of resident's condition. Findings include
A record review of R909's medical record revealed, R909 was admited on 9/04/15 with diagnoses of Vascular Dementia, Acute Kidney Failure, and Hypertension. A review of the most recent Minimum Data Set (MDS) dated [DATE] noted, R909's Brief Interview for Mental Status (BIMS) score of 0, which indicates severe cognitive impairment.
On 5/07/24, a record review of R909's medical record revealed on 11/28/2023 at 12:00 a note stated,Writer was rounding on unit and approached resident's bedside, resident was found to be tachypneic on room air. Initiated oxygen immediately via nasal cannula at 8liters per minute . (Medical Doctor)MD was called, orders to have (Nurse Practitioner)NP at bedside and administer breathing treatment if necessary. Per MD, if treatment does not raise oxygen satuarations .Per NP at bedside, send out via EMS. Floor nurse initiated EMS transfer and RP will be notified of change in condition.
On 5/07/24 an interview occurred with the Assistant Director of Nursing and was asked what was the expectation regading notification of family members of change. The ADON stated It is my expectation the responsible party would be notified as soon as possible about a change in condition.
On 5/07/24 an interview occurred with the Nursing Home Administrator (NHA) and was asked about the expectation regading notification of family members of change. The ADON stated It is my expectation the responsible party or family would be notified in a timely manner about a change in condition.
A review of the facility's policy titled Notification of Changes with a revised date of 1/01/22 revealed, the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent to his or her authority, resident's representative when there is a change requiring notification.
Feb 2024
14 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a toilet was maintained in working conditi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a toilet was maintained in working condition for one resident (R136) of three reviewed for clean, comfortable, homelike conditions, resulting in resident dissatisfaction with living conditions. Findings include:
On 1/30/24 at 9:01 AM, during an initial tour of the facility R136 was interviewed about their satisfaction with the care and services that they were receiving at the facility. R136 stated, My toilet doesn't flush. It hasn't flushed in three weeks. It has overflown. R136 expressed dissatisfaction with the functioning of the toilet in their room and further indicated that maintenance has unplugged their toilet, but it gets plugged up again frequently and on a consistent basis.
On 1/30/24 at 9:02 AM, urine was observed in R136's toilet and when the toilet was flushed it did not completely drain.
On 1/31/24 at 2:13 PM, a follow up visit was conducted with R136 in their room and R136 was asked if their toilet was flushing properly. R136 stated, They say they fixed it but they didn't.
On 1/31/24 at 2:15 PM, R136's toilet was observed with feces in it and when the toilet was flushed it did not completely drain.
On 1/31/24 at 2:22 PM, a review of R136's electronic medical record (EMR) revealed that R136 was admitted to the facility on [DATE] with diagnoses that included Malignant neoplasm of prostrate (Prostrate cancer) and Type 2 diabetes. R136's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R136 had a moderately impaired cognition.
On 1/31/24 at 2:39 PM, Maintenance Director (MD) J was interviewed regarding maintenance and inspection of resident room toilets at the facility. MD J indicated that toilets are unplugged as needed. MD J indicated that the plumbing at the facility was Old. MD J was asked for toilet inspection records/or logs and was unable to provide any documentation related to inspection of the toilets at the facility.
On 2/1/24 at 1:00 PM, the Administrator (NHA) was interviewed regarding their expectations for maintenance of the facility and indicated that MD J was new and the NHA acknowledged that MD J needed additional training.
On 2/1/24 at 2:23 PM, a facility policy titled Preventative Maintenance Program Date Reviewed/Revised: 03/12/2022 was reviewed and stated the following, Policy: A preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents .Policy Explanation And Compliance Guidelines: 1) The Maintenance Director is responsible for developing, and maintaining a schedule of maintenance service to ensure the building .equipment are maintained in a safe and operable manner.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent resident to resident abuse for one (R38) of seven residents...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent resident to resident abuse for one (R38) of seven residents reviewed for abuse. Findings include:
On 01/30/24 at 10:13 AM, R38 reported that R60 stuck their hand down the front of their (R38's) blouse twice. R38 stated They (staff) came and talked to me about it. It just happened two or three days ago.
Review of the facility record for R38 revealed an admission date of 04/19/23 with diagnoses that included Left Hip Osteoarthritis with Left Hip Replacement, Diabetes Mellitus, Anxiety Disorder and Depression. The 10/24/23 Brief Interview for Mental Status (BIMS) assessment score of 15/15 indicated intact cognition.
Further review of R38's record revealed a progress note dated 01/25/24 authored by Licensed Practical Nurse (LPN) A stating Resident stated resident of room [ROOM NUMBER]-2 put [their] finger down [their] shirt into [their] breast area. Resident did not sustain any injuries during event. Writer contact Admin (NHA), DON (Director of Nursing), and MD (physician) to report occurrence. Pain and Skin assessment performed. No change in baseline vitals in normal range, noted in MAR (medication administration record). No new orders at this time. Resident returned to room for remainder of nightshift.
On 01/31/24 at 12:10 PM, The facility Administrator (NHA) was interviewed regarding the alleged incident and reported that they were aware of the incident reported by R38 involving R60. The NHA stated that they were notified of the incident by LPN A who allegedly directly witnessed the incident and reported that R60 had grabbed and pulled on the front neckline of R38's shirt and did not put their hand inside the shirt or touch the resident in a sexually inappropriate manner. The NHA indicated that based on this information the incident was not reported to the State agency.
Review of the facility record for R60 revealed an admission date of 01/07/22 with diagnoses that included Cerebral Infarction, Traumatic Brain Injury, Post-Traumatic Stress Disorder and Schizophrenia. The 01/15/24 BIMS score of 5/15 indicated severe cognitive impairment. The facility record also establishes a history of inappropriate sexual behavior as evidenced by R60's Care Plan dated 01/29/24 that includes the Focus statement Resident has exhibited inappropriate social behaviors of attempting to bring female residents into [their] room and shuts door to have sexual encounter. Resident will also attempt to enter female resident's room to attempt sexual encounter.
On 01/31/24 at 12:23 PM, R38 was interviewed further and asked to recount the reported incident. R38 reported that they were sitting in their scooter in the common area talking with R39 and R156 when R60 approached and punched or smacked them on the right shoulder twice then reached into the top of their shirt twice and moved their hand around on their chest area. R38 reported that they yelled at R60 to get away from them. R38 was asked how they felt about the incident and stated that they felt violated and angry but denied feeling traumatized or having any residual side effects. R38 stated I just want [R60] to stay away from me, [R60] doesn't have a right to do that.
Review of the facility record for R156 revealed an admission date of 05/12/23 with no diagnoses indicating significant visual impairment. The 01/03/24 BIMS score of 15/15 indicated intact cognition.
On 01/31/24 at 12:52 PM, R156 was interviewed in their room and reported that they did recall and witness the reported incident involving R38 and R60. R156 reported that they were sitting and talking with R38 and R39 when R60 approached and [R60] kinda hit [R38] in the arm and then stuck their fingers down [R38]'s shirt twice. R156 was asked if their vantage point allowed them to see the contact clearly and R156 stated Oh yeah, I was sitting right next to [R38]. [R60]'s hand was definitely inside [R38]'s shirt.
On 02/01/24 at 9:36 AM, LPN A was interviewed via phone call. LPN A reported that they did recall the incident involving R38 and R60. LPN A stated [R38] told me that [R60] had stuck their fingers down the front their gown so I separated them and reported the incident and I assessed [R38]. LPN A was asked if they directly witnessed the incident and they indicated that they did not view it directly and that their report was based on what R38 reported to them. LPN A reported that they did recall R39 and R156 being with R38 at the time of the incident.
On 02/01/24 10:13 AM, R60 was interviewed in their room. R60 indicated they recalled the reported incident involving R38 and expressed that they touched R38 on the forearm area and denied touching them inside their shirt.
Review of the facility record for R39 revealed an admission date of 09/30/20 with no diagnoses indicative of significant visual impairment. The 01/03/24 BIMS score of 15/15 indicated intact cognition.
On 02/01/24 at 10:20 AM, R39 was interviewed in person and reported that they did recall the incident involving R38 and R60. R39 reported that they were sitting and talking with R38 and R156 when R60 approached from the rear and side and stopped near R38 and looked around then stuck their fingers down the front of R38's gown. R39 reported that they viewed this action clearly and they had no doubt as to what took place.
On 02/01/24 at 2:55 PM, the NHA was asked to recount how they became aware of the incident involving R38 and R60 and how they responded. The NHA reported that LPN A called them and reported that R60 had used their fingers to pull on the front neckline of R38's shirt or gown and that LPN A had completed an assessment of R38 and no injury or harm was reported. The NHA reported that they did not complete any further investigation including not interviewing any reported or potential witnesses. The NHA indicated that no additional investigation or reporting was completed based on the information LPN A provided.
Review of the facility policy Abuse, Neglect and Exploitation dated 1/10/24 includes the Policy statement It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation, and misappropriation of resident property. The Definitions section of the policy includes the entry Sexual Abuse is non-consensual sexual contact of any type with a resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to thoroughly investigate and report a sexual abuse allegation for one (R38) of seven residents reviewed. Findings include:
On 01/30/24 at 10:...
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Based on interview and record review, the facility failed to thoroughly investigate and report a sexual abuse allegation for one (R38) of seven residents reviewed. Findings include:
On 01/30/24 at 10:13 AM, R38 reported that R60 stuck their hand down the front of their (R38's) blouse twice. R38 stated They (staff) came and talked to me about it. It just happened two or three days ago.
Review of the facility record for R38 revealed an admission date of 04/19/23 with diagnoses that included Left Hip Osteoarthritis with Left Hip Replacement, Diabetes Mellitus, Anxiety Disorder and Depression. The 10/24/23 Brief Interview for Mental Status (BIMS) assessment score of 15/15 indicated intact cognition.
Further review of R38's record revealed a progress note dated 01/25/24 authored by LPN A stating Resident stated resident of 517-2 put [their] finger down [their] shirt into [their] breast area. Resident did not sustain any injuries during event. Writer contact Admin (NHA), DON (Director of Nursing), and MD (physician) to report occurrence. Pain and Skin assessment performed. No change in baseline vitals in normal range, noted in MAR (medication administration record). No new orders at this time. Resident returned to room for remainder of nightshift.
On 01/31/24 at 12:10 PM, The facility Administrator (NHA) was interviewed regarding the alleged incident and reported that they were aware of the incident reported by R38 involving R60. The NHA stated that they were notified of the incident by LPN A who allegedly directly witnessed the incident and reported that R60 had grabbed and pulled on the front neckline of R38's shirt and did not put their hand inside the shirt or touch the resident in a sexually inappropriate manner. The NHA indicated that based on this information the incident was not reported to the State agency.
Review of the facility record for R60 revealed an admission date of 01/07/22 with diagnoses that included Cerebral Infarction, Traumatic Brain Injury, Post-Traumatic Stress Disorder and Schizophrenia. The 01/15/24 BIMS score of 5/15 indicated severe cognitive impairment. The facility record also establishes a history of inappropriate sexual behavior as evidenced by R60's Care Plan dated 01/29/24 that includes the Focus statement Resident has exhibited inappropriate social behaviors of attempting to bring female residents into [their] room and shuts door to have sexual encounter. Resident will also attempt to enter female resident's room to attempt sexual encounter.
On 01/31/24 at 12:23 PM, R38 was interviewed further and asked to recount the reported incident. R38 reported that they were sitting in their scooter in the common area talking with R39 and R156 when R60 approached and punched or smacked them on the right shoulder twice then reached into the top of their shirt twice and moved their hand around on their chest area. R38 reported that they yelled at R60 to get away from them. R38 was asked how they felt about the incident and stated that they felt violated and angry but denied feeling traumatized or having any residual side effects. R38 stated I just want [R60] to stay away from me, [R60] doesn't have a right to do that.
Review of the facility record for R156 revealed an admission date of 05/12/23 with no diagnoses indicating significant visual impairment. The 01/03/24 BIMS score of 15/15 indicated intact cognition.
On 01/31/24 at 12:52 PM, R156 was interviewed in their room and reported that they did recall and witness the reported incident involving R38 and R60. R156 reported that they were sitting and talking with R38 and R39 when R60 approached and [R60] kinda hit [R38] in the arm and then stuck their fingers down [R38]'s shirt twice. R156 was asked if their vantage point allowed them to see the contact clearly and R156 stated Oh yeah, I was sitting right next to [R38]. [R60]'s hand was definitely inside [R38]'s shirt.
On 02/01/24 at 9:36 AM, LPN A was interviewed via phone call. LPN A reported that they did recall the incident involving R38 and R60. LPN A stated [R38] told me that [R60] had stuck their fingers down the front their gown so I separated them and reported the incident and I assessed [R38]. LPN A was asked if they directly witnessed the incident and they indicated that they did not view it directly and that their report was based on what R38 reported to them. LPN A reported that they did recall R39 and R156 being with R38 at the time of the incident.
On 02/01/24 10:13 AM, R60 was interviewed in their room. R60 indicated they recalled the reported incident involving R38 and expressed that they touched R38 on the forearm area and denied touching them inside their shirt.
Review of the facility record for R39 revealed an admission date of 09/30/20 with no diagnoses indicative of significant visual impairment. The 01/03/24 BIMS score of 15/15 indicated intact cognition.
On 02/01/24 at 10:20 AM, R39 was interviewed in person and reported that they did recall the incident involving R38 and R60. R39 reported that they were sitting and talking with R38 and R156 when R60 approached from the rear and side and stopped near R38 and looked around then stuck their fingers down the front of R38's gown. R39 reported that they viewed this action clearly and they had no doubt as to what took place.
On 02/01/24 at 2:55 PM, the NHA was asked to recount how they became aware of the incident involving R38 and R60 and how they responded. The NHA reported that LPN A called them and reported that R60 had used their fingers to pull on the front neckline of R38's shirt or gown and that LPN A had completed an assessment of R38 and no injury or harm was reported. The NHA reported that they did not complete any further investigation including not interviewing any reported or potential witnesses. The NHA indicated that no additional investigation or reporting was completed based on the information LPN A provided.
Review of the facility policy Abuse, Neglect and Exploitation dated 1/10/24 includes the section Investigation of Alleged Abuse, Neglect and Exploitation. This section includes the following entries:
A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation or reports of abuse, neglect, or exploitation occur.
B. Written procedures for investigation include:
4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who may have knowledge of the allegations.
6. Providing complete and thorough documentation of the investigation.
A. The facility will have written procedures that include:
1. Reporting of alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies within specified timeframes as required by state and federal regulations:
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a Level I Preadmission Screening (PAS)/Annual Resident Review (ARR) Mental Illness/Intellectual Disability/Related Conditions Identi...
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Based on interview and record review, the facility failed to ensure a Level I Preadmission Screening (PAS)/Annual Resident Review (ARR) Mental Illness/Intellectual Disability/Related Conditions Identification was completed timely and sent to the local community mental health (CMH) for a level II OBRA (Omnibus Budget Reconciliation Act of 1993) evaluation for one resident (R135) of one resident reviewed for PASARRs. Findings include:
A review of R135's medical record revealed that they were admitted into the facility on 7/13/23 with diagnoses of Hemiplegia and Hemipresis, Dysphagia, Depression, Anxiety, and Diabetes. Further review revealed that the resident was cognitively intact and required 1-2 person assistance for Activites of Daily Living.
Further review of R135's medical record revealed that a PASARR was completed on 4/28/23
by the acute care setting that referred the resident to the facility.
On 2/1/24 at 9:48 AM, all of R135's PASARRs were requested from the facility, however the only documentation received was the 4/28/23 PASAAR, and an exemption form completed by the acute care facility.
On 2/1/24 at 12:24 PM, the Social Work Director was asked about the facility's procedure for the completion and submission of PASARRs. He explained that there were some PASAARs that had not been completed, and that he will be working on completing them, as the completion of them were just reassigned to him.
On 2/1/24 at 3:40 PM, the Director of Nursing (DON) was asked about the facility's procedures for the completion of PASARRs however, she admitted that she was not familiar with the process.
A review of the facility's PASARR - Pre-admission Screen and Resident Review policy revealed the following, 3. All residents are required to have a level I PASRR screen prior to or upon admission to the facility. When indicated on the level I screen that a level II screen is required, the facility will complete notification to the State ' s PASRR program notice for the level II screen (in accordance with State specific laws .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement care planned interventions to prevent falls,...
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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 care planned interventions to prevent falls, and skin breakdown, for two sampled residents (R118 and R135) of seven residents reviewed for person centered comprehensive care plans. Findings include:
R118
On 1/31/24 at 10:12 AM, R118 was observed in bed feet lying flat on the mattress, bed not in its lowest position. Attempts to interview R118 were unsuccessful as the resident was pleasantly confused.
A review of R118's medical record revealed that they were admitted into the facility on 5/21/21 with diagnoses that included Dementia, Chronic Obstructive Pulmonary Disease (COPD), and Dysphagia. Further review of R118's medical record revealed that they required 1-2-person assistance for Activities of Daily Living.
Further review of R118's medical record revealed the following care plans:
Resident is at risk for impaired skin integrity related to confined to a bed all or most of the time r/t (related to) decreased mobility. Date Initiated: 07/31/2023. Interventions: Encourage/assist as needed to elevate heels off the mattress as tolerated. Date Initiated: 07/31/2023. Place heel lift boots on while in bed. Date Initiated: 10/18/202. Revision on: 07/31/2023 .
[R118] has experienced an actual fall. Date Initiated: 07/31/2023 .Interventions: Date Initiated: 07/31/2023 . Nursing will ensure bed is in lowest position when not providing care. Date Initiated: 07/31/2023. Revision on: 12/01/2023 .
Further review of R118's medical record revealed a Braden Score for Predicting Pressure Ulcers assessment dated [DATE] revealed a score of 8 indicating that the resident was Very High Risk for the development of pressure ulcers.
On 1/31/24 at 12:11pm, 1:16pm, 2:38pm, and 4:22pm, R118's feet were observed bare and lying flat on the bed. In addition, the resident's bed remained in a high position.
On 2/1/24 at 08:30am, 11:17am, and 12:58pm, R118's feet were observed lying flat on the bed.
R135
On 1/31/24 at 9:10 AM, R135 was observed in bed. There were no floor mats in place.
A review of R135's medical record revealed that they were admitted into the facility on 7/13/23 with diagnoses of Hemiplegia and Hemiparesis, Dysphagia, Depression, Anxiety, and Diabetes. Further review revealed that the resident was cognitively intact and required 1-2-person assistance for Activities of Daily Living.
Further review of R135's medical record revealed the following progress note:
12/31/2023 18:52 (6:52pm) Nurses' Notes .Resident observed laying on right side next to bed in room. Resident stated [they were] reaching for [their] table and slid out of bed. No apparent injury noted, no change in ROM (range of motion)/mentation, no c/o(complaint of) pain. Resident placed back into bed via mechanical lift, tray table placed at bedside.
1/8/2024 13:38 (1:38pm) IDT (interdisciplinary team)-Interdisciplinary Progress Note
Note Text: IDT reviewed resident related to a fall without injury. Care plan interventions include floor mats while in bed, activities of interest based on cognition, nonskid footwear, monitoring comfort, and encouraging resident to use call light for staff assistance in adjusting bed. Care plan reviewed and updated. Risk for fall related to muscle weakness, hemiplegia, joint stiffness, COPD, and cognition.
On 1/31/24 12:18pm and 4:28pm, R135 was observed in bed. No fall mats observed on the floor.
On 2/1/24 at 8:39 AM, R135 was observed in bed, no floor mats observed on the floor.
On 2/1/24 at 3:36 PM, the Director of Nursing (DON) was asked if interventions should be implemented for residents that are care planned to receive them, and she indicated that they should.
A review of the facility's Comprehensive Care Plan policy revealed the following, 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, but are not provided due to the resident ' sexercise of his or her right to refuse treatment .
A review of the facility's Pressure Injury Prevention and Management policy revealed the following, .2.The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00141406 and MI00141058.
Based on observation, interview and record review, the facility fai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00141406 and MI00141058.
Based on observation, interview and record review, the facility failed to provide the preferred bathing method and frequency for one (R78) of seven residents reviewed for bathing. Findings include:
Review of the facility record for R78 revealed an admission date of 08/21/23 with diagnoses that included Liver Contusion/Laceration, Chronic Obstructive Pulmonary Disease and Bipolar Disorder. The Minimum Data Set (MDS) assessment dated [DATE] indicated R78 required maximum assistance for bathing. The Brief Interview for Mental Status (BIMS) score of 15/15 indicated intact cognition.
On 01/30/24 at 10:43 AM, R78 reported they had not received a shower in about three weeks. R78 stated When I ask for a shower they say they can only do a bed bath or they say they can't because they don't have towels. I've had about four showers and four bed baths since I came here at the end of August. R78 indicated that they were scheduled for a shower for that afternoon.
On 01/31/24 at 12:02 PM, R78 was asked about their scheduled bathing the previous evening and reported that staff did not offer bathing and that they had to request a shower. R78 reported that staff returned following the request and reported that they had to provide a bed bath and provided no explanation as to why a shower was not an option. R78 reported that two staff completed the bed bath, Certified Nurse Assistant (CNA) B and CNA C. R78 reported that they prefer showers to bed baths and stated that they could not recall ever having refused a shower. R78 reported that their scheduled shower days are Tuesday and Saturday afternoons.
Review of R78's Task checklist for bathing (the electronic medical record documentation of resident care completion) verified that bathing assistance was scheduled for Tuesday and Saturday afternoons and specifies that R78 preferred showers. The checklist documentation indicated that during the 30 day period from 01/01/24 to 1/30/24, R78 received a bed bath on 01/09/24 and showers on 01/16/24 and 01/30/24. This documentation indicated that R78 received bathing assistance three times in a month and that a shower was documented on two occasions when R78 denies having received a shower. The showers documented on the 16th and 30th were both entered by CNA B. No resident refusals of bathing were documented.
Review of R78's Care Plan dated 12/01/23 revealed the activities of daily living Intervention statement Honor resident's choices and preferences whenever possible.
On 01/31/24 at 4:30 PM, CNA B was interviewed by phone and reported that they did provide R78's bathing on the evening shift of 01/30/24. CNA B reported that R78 was offered a shower and refused in favor of a bed bath. CNA B reported that showers/bathing are documented in the electronic medical record only and not on paper shower sheets. CNA B reported that CNA C assisted with R78's bed bath the previous evening.
On 01/31/24 at 4:33 PM, CNA C was interviewed in person and reported that they did assist CNA B the previous afternoon with R78's bed bath. CNA C reported that they did not know if R78 had been offered a shower or not as they assisted but were not the assigned aide for R78 and therefore were not involved in the planning. CNA C reported there understanding is that residents are supposed to be offered a shower unless care planned otherwise.
On 02/01/24 at 3 PM, the facility Administrator (NHA) reported that the expectation regarding resident bathing is that baths/showers be scheduled and offered twice weekly and that any missed bathing day be rescheduled if possible. The NHA reported the expectation regarding bathing method preference is that the resident's preference be honored.
The NHA indicated that the facility did not have a policy that addresses bathing/showering frequency or preference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide restorative services per therapy recommendation for one of one resident (R132) reviewed for range of motion. Findings...
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Based on observation, interview, and record review, the facility failed to provide restorative services per therapy recommendation for one of one resident (R132) reviewed for range of motion. Findings include:
On 1/30/24 at 12:55 PM, was observed eating lunch with their left hand as their right hand was contracted. There were no observations of any interventions in place for R132's contracture. Attempts to interview R132 were unsucessful as they smiled and ate their lunch.
A review of R132's medical record revealed that they were admitted into the facility on 8/5/21 with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction, Dysphagia, and Vascular Dementia. Further review of R132's medical record revealed that the resident had a moderately impaired cognition, and required one person assistance for Activities of Daily Living.
A review of R132's Occupational Therapy discharge recommendations dated 12/27/23 revealed the following, .Discharge Recommendations: Recommend RNP (restorative nursing program) for Contracture management. Restorative Program Established/Trained=Restorative Splint and Brace Program. Splint and Brace Program Established/Trained: RNP for contracture management of Rt (right) hand.Prognosis to maintain CLOF (current level of functioning)=Good with consistent staff follow-up
On 1/31/24 at 8:45am and 1:08pm, there were no interventions in placed for R132's right hand contracture.
On 2/1/24 at 11:10 AM, Occupational Therapist L (OT L) was asked about their recommendations for R132's right had contracture. OT L explained that the recommendations for the resident was a palm protector three times a week for four weeks. OT L was asked about the referral process for the RNP, and explained that a form is completed and provided to the Director of Nursing (DON) or Assistant Director of Nursing (ADON), and implementation should go from there.
A review of R132's care plan did not reveal a goal or interventions for R132's right hand contracture.
On 2/1/24 at 1:09 PM, R132 was observed without any interventions for their right hand contracture.
On 2/1/24 at 3:26 PM, the Director of Nursing (DON) was asked about her expectations for ensuring that recommendations from therapy are being implemented, and she acknowledged that recommendations should be implemented.
A review of the facility's Restorative Nursing Programs policy revealed the following, Policy:
The goal(s) of Restorative Nursing includes improving and/or maintaining independence in activities of daily living and mobility. A Restorative Nursing Program, when appropriate is based on a the comprehensive assessment and resident .Once determined that the resident would benefit from a restorative nursing program, implement the following:
-Determine if the resident is willing and able to participate
- Document refusal in the medical record with education regarding risks and benefits.
- Re-visit at least quarterly to determine if the resident would still benefit. Determine willingness and ability and document refusals as previously completed
-Determine resident and/or family goals for restorative care
-Review during care plan review meeting .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide oxygen and tracheostomy (a surgical opening i...
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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 oxygen and tracheostomy (a surgical opening into the neck to allow for breathing) care, for one resident (R429) of one resident reviewed for tracheostomy care. Findings include:
On 1/30/24 at 10:03 AM, R429 was observed lying in bed with a tracheostomy collar on with oxygen attached. The oxygen concentrator read 7 Liters.
On 1/31/24, at 3:50 PM, R429 was observed lying in bed without being hooked up to their oxygen. Nurse E was asked about R429. Nurse E entered the room and reconnected the oxygen concentrator. Nurse E checked the resident's oxygen and reported that the pulse oximeter was at 86% (normal range between 95-100%). R429 was asked how long they had been without their oxygen, and stated, I returned from dialysis at around 2:15 PM and was put in the bed.
On 2/1/24 at 8:28 AM, R429 was observed lying in bed with their tracheostomy collar on with the oxygen concentrator on at 7 liters. The resident was asked about their use of oxygen, and R429 stated, I am short of breath at times, last week I had to be suctioned and a mucous plug was removed. I have been on oxygen ever since.
On 2/1/24 at 12:04 PM, the oxygen and tracheostomy orders for R429 were requested from Nurse E. Upon review Nurse E replied, There are no orders.
A review of the medical record for R429 revealed that there were no orders for oxygen or tracheostomy care, nor were there any care plans for oxygen or tracheostomy care.
A review of the medical record revealed that the R429 was initially admitted into the facility on 1/12/24 and sent to the hospital on 1/18/24 related to difficulty breathing, and readmitted on [DATE]. Diagnoses included Acute Respiratory Failure with Hypoxia, Pnuemonia; Diseases of the Upper Respiratory Tract, Morbid Obesity, Hypoventilation and Hypertension.
On 2/1/24 at 1:31 PM, Respiratory Therapist F was asked about R429's tracheostomy needs and stated, R429 gets (tracheostomy) trach care every morning for suctioning. R429 doesn't need much due to low secretions. I think (R429) is on 7 liters continuously around the clock, and I was trying to wean them down and was not successful. Respiratory Therapist F was asked to confirm R429's physician orders, and Respitatory Therapist F stated, The orders must not have been put in when (R429) readmitted . Respiratory Therapist F was aked to confirm R429's care plan and stated, The care plan is not there.
On 2/1/24 at 3:40 PM, The Director of Nursing (DON) was interviewed regarding expectations for a resident admitted with a tracheostomy and on oxygen. The DON stated, My expectation is that the staff would have the room set up and ready .nurse to have orders confirmed .and nurses do trach care. When asked about R429's admission, the DON replied, I am aware that (R429) admission audit got missed. We had several admissions that day.
A review of the facility's policy/procedure titled, Tracheostomy Care, implemented 10/30/20 reviewed/revised 10/26/23 revealed, Tracheostomy care will be provided according to the physician's orders, comprehensive assessment, and individualized care plan .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure medications were available and provided timely for one resident (R230) of one whose medications were reviewed resulting in expressio...
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Based on interview and record review, the facility failed to ensure medications were available and provided timely for one resident (R230) of one whose medications were reviewed resulting in expression of poorly controlled pain. Findings include:
On 01/30/24 at 12:28 PM, R230 reported that they had entered the facility on a Friday afternoon and and through a series of room changes due to uncooperative roommates ended up in the cold lobby until they received a room late in the morning the next day. R230 reported that during their first four days they did not receive any pain medication and reported rib and leg pain. It was also reported they were to have oxygen at night and it had not been set up. R230 further noted the bed in the room was in need of repair. R230 reported a nurse noted they had to cover two nursing units which were not close together and was not seen by a member of the medical staff until that following Monday. R230 noted they were also on heart medication.
A review of the medical record for R230 revealed, R230 was admitted into the facility on Friday 01/19/24. Diagnoses included Chronic Pain Syndrome, Arthritis and Diabetes.
A review of the physician orders documented the oxycodone was ordered with a start date of 01/19/24.
A review of the Medication Administration Record (MAR) for January 2024 revealed, R230's Phentermine 37.5 milligrams daily (for weight loss) was not charted as given until 01/23/24 with three doses missed; The carvedilol 3.125 milligrams twice daily (blood pressure medication on the hospital discharge list) was not charted as given or ordered until 01/25/24; and the Percocet/oxycodone (narcotic pain medication) 10/325 milligrams every six hours was not provided until 01/23/24. A pain level was not documented on the MAR until 01/23/24. A review of the Delivery Manifests from the facility pharmacy documented delivery of the oxycodone and Phentermine on 01/23/24.
On 02/01/24 at 3:39 PM, the Director of Nursing (DON) was asked about medication and pharmacy orders for new admissions, The DON reported medications ordered in the evening on a Friday would not arrive until the following day or the day after and that a controlled substance (like oxycodone) would require a script or physician request to be taken from the back up supply. The timing would depend on the physician's response to the need for a script. A review of the facility Inventory on Hand back up supply list documented oxycodone 10/325 milligrams and carvedilol were on the list.
A review of the facility policy titled, Provider Pharmacy Requirements dated 08-2020 revealed, Regular and reliable pharmaceutical service is available to provide residents with prescription and non-prescription medications .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a 14-day stop date on an anti-anxiety medication for two ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a 14-day stop date on an anti-anxiety medication for two (R26, and R135) of seven residents reviewed. Findings include:
R26
Review of the facility record for R26 revealed an admission date of 05/14/23 with diagnoses that included Chronic Osteomyelitis, Chronic Obstructive Pulmonary Disease and Generalized Anxiety Disorder. The Minimum Data Set (MDS) dated [DATE] indicated R26 required total to maximum assistance with activities of daily living and the presence of moderate cognitive impairment.
On 2/1/24 review of R26's active physician orders revealed an order dated 12/27/23 for Ativan Oral Tablet 0.5 milligram (MG): Give one tablet by mouth every six hours as needed for anxiety.
Additional review of R26's record revealed no documentation of justification for continuing the Ativan order.
R135
A review of R135's medical record revealed that they were admitted into the facility on 7/13/23 with diagnoses of Hemiplegia and Hemiparesis, Dysphagia, Depression, Anxiety, and Diabetes. Further review revealed that the resident was cognitively intact and required 1-2-person assistance for Activities of Daily Living.
Further review of R135's medical record revealed the following active order dated for 12/15/23:
Ativan (Lorazepam) Oral Tablet 0.5 Milligram (MG). Give 1 tablet by mouth every 8 hours as needed (PRN) for Anxiety.
A review of R135's December Medication Administration Record (MAR) revealed that the resident received the PRN medication on the following dates: 12/23/23 (twice), 12/25/24, 12/27/23, 12/29/23 (twice), 12/31/23. Further review of R135's January Medication Administration Record revealed the resident received the PRN medication on the following dates: 1/2/24, 1/12/24 (twice), 1/13/24, 1/14/24, 1/18/24 (twice), 1/19/24, 1/25/24, 1/26/24 (twice), 1/27/24 (twice), 1/28/24 (twice), 1/29/24 (twice).
A review of R135's comprehensive care plan did not reveal a care plan for the resident's use of anti-anxiety medications. In addition, there was no documentation indicating the continued use of the medication.
On 02/01/24 at 3:29 PM, the facility Director of Nursing (DON) reported that the expectation is that PRN (as needed) psychotropic medication orders should have a 14 day stop date and should either be discharged on the stop date or justification of continuing the medication documented in the progress notes.
Review of the facility policy Medication-Psychotropic dated 10/30/23 includes the following entry:
.8. PRN orders for 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 (i.e. 14 days). a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to store/label/discard expired medications for (a) one (500/600 unit) of three medication storage rooms, (b) two (200 unit and 7...
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Based on observation, interview, and record review, the facility failed to store/label/discard expired medications for (a) one (500/600 unit) of three medication storage rooms, (b) two (200 unit and 700 unit) of four medication carts reviewed and (c) two of two refrigerators reviewed for medication storage. Findings include:
On 1/30/24 at 11:13 AM, the 500/600 medication storage room was inspected with Unit Manager, Registered Nurse (RN) H and the results were the following:
-A vial of Lantus (Diabetes insulin) 100 ml (milliliter)/unit with no name on it was observed in the medication cupboard in the medication storage room;
-A bottle of Guaifensin (Expectorant medication) 400 mg (milligrams) with an expiration date of 11/23 was also observed.
RN H was interviewed about the expired vial of insulin in the cupboard and stated, It should be refrigerated. RN H was further interviewed about the expired medication and did not directly answer the question.
On 1/31/24 at 1:25 PM, the 200 unit medication cart was inspected with RN I present and the results were the following:
-Two inhalers were not labeled with resident identifying information on the inhaler. RN I was interviewed about the labeling of the inhaler and stated, It should be labeled.
On 2/1/24 at 2:30 PM, the DON (Director of Nursing) was interviewed about their expectations regarding labeling, storing, and discarding of expired medications. The DON indicated that medications should be clearly labled and expired medications should be discarded.
On 01/31/24 at 1:42 PM, an observation of the 700 unit medication cart with Licensed Practical Nurse (LPN) E revealed on bottle of liquid iron that was opened and had an expiration date of 09/2022. One insulin vial was not dated when opened on the vial.
On 1/30/24 at 9:15 AM, in the 200 unit refrigerator which is utilized for the storage of resident food items brought in from the outside, there were 3 resident medications ( Levemir, Humulin and Vancomycin) stored with the food items. At that time, Nurse M confirmed that medications should not have been stored in the food refrigerator.
On 1/30/24 at 9:25 AM, in the 400 unit resident food refrigerator, there were 4 vials of influenza vaccine stored with the food. There was a sign on the front of the refrigerator that stated Food only.
On 2/1/24 at 10:45 AM, a facility policy regarding medication labeling, storage, and discarding of expired medications was requested and not received prior to exit from the facility
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This ciation pertains to Intake: MI00141406 and MI00141058.
Based on observation, interview, and record review the Facilty faile...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This ciation pertains to Intake: MI00141406 and MI00141058.
Based on observation, interview, and record review the Facilty failed to ensure that resident call lights were functioning properly for one resident (R79 ) of five residents reviewed for call lights, resulting in feelings of frustration. Findings include:
On [DATE] at 9:20 AM, during an initial tour of the facility R79 was interviewed regarding their level of satisfaction with the care and services they were receiving at the facility. R79 expressed frustration related to long call light wait times. R79 indicated that they currently needed their pillows adjusted and R79 activated their call light while the Surveyor was present in their room. A small red light went on next to R79's bed when the call light was activated.
On [DATE] at 9:21 AM until 9:40 AM, multiple staff members were observed to walk back and forth in the hallway passing R79's room without answering the resident's call light.
On [DATE] at 9:41 AM, the Surveyor exited R79's room and observed that the light outside of the room was not activated and an observation of the call light screen by the nurses station revealed no observation of the resident's call light being on and/or activated.
On [DATE] at 9:45 AM, unit Licensed Practical Nurse (LPN) K was interviewed regarding R79's call light and stated, I need to put a ticket in to maintenance.
An electronic medical record (EMR) reviewed revealed that R79 was admitted to the facility on [DATE] with diagnosis that included Atrial Fibrillation (Abnormal heart rhythm). R79's most recent minimum data set assessment (MDS) revealed that the resident had a severely impaired cognition and required extensive to minimum one person assistance for all activities of daily living (ADLs) other than eating.
On [DATE] at 2:39 PM, Maintenance Director (MD) J was interviewed regarding call light maintenance and the call light not working for R79's room. MD J indicated that no (Electronic repair request system)request had been submitted. MD J was asked if the maintenance department was responsible for monitoring the call light system to ensure proper operation of call lights within the facility. MD J stated, That's on us. MD J was asked to provide call light inspection/monitoring logs/reports/documentation. MD J was unable to provide any of the requested call light inspection/monitoring information.
On [DATE] at 1:00 PM, the Administrator (NHA) was interviewed regarding their expectations for maintenance of the facility including inspection of call lights. The NHA indicated that MD J was new and the NHA acknowledged that MD J needed additional training.
Review of a facility policy titled Call Lights Accessibility and Timely Response Date Reviewed/Revised: [DATE] was reviewed and stated the following, Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside .to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Conditions: 5) Staff will report problems with a call light or call system immediately to the supervisor and/or maintenance director and provide immediate or alternative solutions until the problem can be remedied .
Review of a facility policy titled Preventative Maintenance Program Date Reviewed/Revised: [DATE] was reviewed and stated the following, Policy: A preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents .Policy Explanation And Compliance Guidelines: 1) The Maintenance Director is responsible for developing, and maintaining a schedule of maintenance service to ensure the building .equipment are maintained in a safe and operable manner.
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 F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00141058.
Based on observation, Interview, and record review, the facility failed to ensure that foo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00141058.
Based on observation, Interview, and record review, the facility failed to ensure that food was served in a palatable manner and at the preferred temperature for three residents (R167, R230, and R279) of six residents reviewed for food palatability and twelve anonymous group members, resulting in dissatisfaction during meals. Findings include:
R167
On 1/30/24 at 11:32 AM, during an initial tour of the facility R167 was interviewed regarding food palatability at the facility and stated, The food is cold and doesn't taste good.
On 1/30/24 at 2:00 PM, a review of R167's electronic medical record (EMR) revealed that R167 was admitted to the facility on [DATE] with diagnoses that included Fracture of ribs and Quadriplegia (Paralysis of all four limbs). R167's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R167 had an intact cognition.
R279
On 1/30/24 at 11:56 AM, during an initial tour of the facility R279 was interviewed regarding food palatability at the facility and stated, The food sucks.
On 1/30/24 at 2:15 PM, R279's EMR was reviewed at revealed that R279 was admitted to the facility on [DATE] with diagnoses that included Acute poliomyelitis right ankle/foot (Infection of the bone) and Type 2 diabetes. R279's most recent MDS assessment dated [DATE] revealed that R279 had an intact cognition.
On 1/31/24 at 8:47 AM, a random food tray was pulled from a random food cart and temperature tested by Dietary manager (DM) D. The results were the following: Biscuits and gravy: 116.5 Degrees Fahrenheit; Hash browns: 105.9 Degrees Fahrenheit; Milk: 45.5 Degrees Fahrenheit. DM D was interviewed regarding their expectations for hot and cold food temperatures and stated, We want the hot food hot and the cold food cold. DM D tasted the Biscuits and gravy per request and stated. It tastes good.
On 1/31/24 at 8:55 AM, the food was taste tested by the Surveyor and the following was observed/revealed: The meal was carbohydrate heavy with limited protein. The Biscuits and gravy were luke warm and the biscuit tasted dry. The hash browns were luke warm and difficult to chew. A resident on the back half of the 400 unit was observed to return the hash browns provided.
On 1/31/24 at 2:30 PM, twelve of fifteen anonymous group members indicated that they were consistently dissatisfied with the taste, temperature and quantity (not enough food) of their meals.
On 01/30/24 at 12:08 PM, the lunch trays were observed to be on the 200 unit on an open and uninsulated cart.
On 01/30/24 at 12:17 PM, a resident who requested to remain anonymous reported that the food was sometimes cold when it should have been warm and that the pureed white bread was like eating wet bread.
On 01/30/24 at 12:28 PM, R230 reported on some food issues, R230 presented pictures of food from the weekend. One picture from Sunday revealed greens beans and macaroni and cheese on a plate. R230 reported no meat was served though a chicken patty had been on the menu. R230 also had a picture of two sandwiches on a plate which appeared as two slices of bread with nothing in between. The next picture showed the sandwich open and a circular dollop of chicken salad (per the resident and on the menu) in the middle of the bread. It had not been spread out to the edges. R230 further reported having had gravy on items instead of on the side as it was too salty. R230 reported they felt the portions sizes could be larger.
On 01/30/24 at 12:55 PM, a resident on the 200 hall who requested anonymity reported sometimes it takes awhile to get an answer on things and the kitchen has issues with the food. The resident did not think the food was healthy. The resident also reported the other night they ran out of meat. The resident reported the food ticket indicated one cup of mac and cheese but it was only a half a cup and served with some green beans and a slice of white bread. The resident further reported all the food smells the same and breakfast could have more variety of eggs. The resident also noted dietary staff had come down but they still do not always get what is printed on ticket. When asked about the quality, the resident reported the hearty vegetable soup had no solids in the soup and was more like cream of chicken color; the banana parfait was nothing but banana pudding; and the apple crisp had not crispy topping.
On 02/01/24 at 12:31 PM, Dietary Staff G was asked about the lack of chicken or any meat for the meal and reported that the supplier had shorted the order leaving the facility without enough chicken to serve all the residents and therefore increased the portion size of the macaroni and cheese to replace the chicken as the main entree. Staff G noted the chicken salad was served on Saturday. Staff G was asked about staff training for the sandwich prep and reported the spreads whether chicken salad or peanut butter and jelly should reach the edge of the bread. Staff G also noted there is a staff person who is supposed to verify the items on the tray match the food preferences on the ticket.
On 02/01/24 at 1:00 PM, during the quality assurance (QA) review the Administrator was asked about the food concerns and reported that food concerns had come to QA in December 2023 and all the resident's food preferences were reviewed. Issues related to quantity and quality were reported to have been reviewed. Concerns included palatability, appearance, taste and texture. The administrator further reported assigned staff round on residents daily and weekly with specific questions to discern any care concerns face to face.
On 2/1/24 at 10:45 AM, a facility policy regarding food palatability and temperature was requested and not received by exit from the facility.
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 the ventilation covers in a clean manner, failed to maintain the ice machine rooms in a sanitary manner, and failed ...
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Based on observation, interview, and record review, the facility failed to maintain the ventilation covers in a clean manner, failed to maintain the ice machine rooms in a sanitary manner, and failed to ensure resident food items were labeled, dated and discarded when expired. This deficient practice had the potential to affect all residents that consume food. Findings include:
On 1/30/24 at 8:55 AM, the ceiling/wall ventilation covers located by the dish machine, by the steam table, and near the ice machine, were observed with a buildup of dust. When queried, Dietary Manager D stated that Maintenance was responsible for cleaning the vents.
On 1/30/24 at 9:15 AM, in the 200 unit refrigerator utilized for the storage of resident food items brought in from the outside, there were 2 undated food containers. When queried, Dietary Manager D confirmed the food items should have been dated, and further stated that the resident refrigerators were monitored by nursing staff.
On 1/30/24 at 9:25 AM, in the 500/600 unit resident refrigerator, there was a container with moldy noodles dated 1/7-1/13, a container of pasta dated 12/19/23, an undated container of lasagna, a container of cupcakes dated 1/7-1/13, an undated container of pasta, a large container of undated chili, and an opened, undated package of bologna.
On 1/30/24 at 9:30 AM, in the 700/800 unit resident refrigerator, there was an undated container of pasta salad, a container of ham salad dated 1/18-1/22, and a container of fried chicken dated 1/20.
Review of the facility's policy Use and Storage of Food Brought in by Family or Visitors dated 01/01/22 noted: 2. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated.b. The prepared food must be consumed by the resident within 3 days. c. If not consumed within 3 days, food will be thrown away by facility staff .
On 1/30/24 at 9:45 AM, the water supply line for the ice machine located near the kitchen, was observed to be leaking, leaving standing water on the floor.
On 1/30/24 at 11:00 AM, the ice machine room located near the 500/600 units was observed with standing water on the floor. The water had leaked out into the hallway, leaving a large, wet stain on the carpet in the hallway. The floor sink located located next to the ice machine was observed with black mold surrounding the drain.
Dec 2023
7 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
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 MI00141632, MI00138084, and MI00137973.
Based on interview the facility failed to ensure the responsib...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00141632, MI00138084, and MI00137973.
Based on interview the facility failed to ensure the responsible party was informed of a change in condition for one of two residents (R918) reviewed for a change in condition, resulting in lack of knowledge about a decline and or change in the resident's condition and the potential for a delay in advanced treatment. Findings include:
A review of the record for R918 revealed the resident was admitted into the facility on [DATE] and discharged on 12/13/23. Diagnoses included Sepsis, Bacteremia (systemic infection), Gastroenteritis (Stomach/Bowel inflammation/infection), Ascites (build up of fluid in the abdomen) and Dependence on Dialysis.
A skilled nursing note dated 12/13/23 indicated R918 was alert to name and place but not to time and date.
A review of a progress note by Licensed Practical Nurse (LPN) J dated 12/13/2023 at 7:12 AM revealed, .resident had a large projectile emesis at approx 0400. vitals are stable. resident has had no further episodes will continue to monitor.
A review of a progress note by LPN N dated 12/13/2023 at 7:32 AM revealed, .resident had a large projectile emesis at approx 0400. vitals are stable. resident has had no further episodes will continue to monitor.
A review of a progress note by LPN N dated 12/13/2023 at 12:52 PM, revealed, .during wound rounds writer reported that wound site to ABD (abdomen) was observed undressed and bleeding, wound nurse reported to unit manger and writer, unit manager stated (spouse) known that resident picks at site and is always messing with it, writer educated resident on the importance of keeping the site clean and dry to reduce risk of infection and to heal . Documentation of spouse notification was not documented in this note.
A review of a progress note by LPN N dated 12/13/2023 at 6:12 PM, revealed, .wife brought in food for resident for dinner, (spouse) stated (name of R918) took one bite of everything and that was pretty much it, (R918) had sepsis in the hospital that (sic) is still recovering from . resident went to dialysis for 2 hours and is expected to go again tomorrow, resident does appear restless, weak, and (tired) .
A review of a progress note by LPN J dated 12/13/2023 at 9:09 PM revealed, .writer arrived on 7p-7a shift and was given report that resident is having loose dark stools. while making my rounds residents (spouse) informed me (they were) concerned with (their spouse's) health and suggested (R918) be sent out to hospital. contacted supervisor who contacted Director of Nursing (DON) and receive instructions to send resident to hospital .
On 12/19/23 at 9:26 AM, a call to the spouse of R918 was made. The spouse reported they had arrived at the facility around 5:30 PM on 12/13/23 and that was when they first heard about the emesis at 4:00 AM and that there had been some blood. The spouse was concerned because later they noted blood in the stool during incontinence care and possibly R918 could have been sent out to the hospital sooner.
On 12/19/23 at 1:41 PM, LPN N was interviewed and reported, Midnights told me (R918) had emesis, but did not say it was bloody. LPN further reported R918 was always tired and the blood pressure was high. LPN N commented on the spouse trying to get R918 to eat and R918 only had a couple bites. LPN N also confirmed there was blood in the brief when R918 was changed and they did not receive a call from physician about the emesis.
On 12/18/23 at 3:49 PM, the DON was asked to review the progress note related to the emesis on the morning of 12/13/23. The DON confirmed that the note did not document that the residents spouse or family member was notified and that the notification should be documented in the progress note. The DON further reported that the family would not generally be called as/if the resident was their own responsible party.
A review of the facility policy titled, Notification of Changes dated 10/30/2020 revealed, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident ' s physician; and notifies, consistent with his or her authority, resident ' s representative when there is a change requiring notification. Definitions: Life-Threatening Conditions: Examples - Heart Attack or Stroke. Clinical Complications: Examples - Development of stage 2 pressure injury, recurrent episodes of delirium, recurrent UTIs or onset of depression. Need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (such as adverse drug reaction), or commence a new form of treatment to deal with a problem (for example, the use of any medical procedure, or therapy that has not been used on that resident before . Compliance Guidelines:
The facility must inform the resident, consult with the resident ' s physician and /or notify the resident ' s family member or legal representative when there is a change requiring such notification. For changes of condition the facility may use: 1. SBAR® (Situation, Background, Assessment, and Recommendation) process for assessment, documentation and report to the practitioner 2. Care Paths for the INTERACT®(Interventions to Reduce Acute Care Transfers) program 3. Sepsis protocols. Circumstances requiring notification include:
1. Accidents a. Resulting in injury. b. Potential to require physician intervention. 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or
b. Clinical complications. 3. Circumstances that require a need to alter treatment. This may include: a. New treatment. b. Discontinuation of current treatment due to: i. Adverse consequences. ii. Acute condition. iii. Exacerbation of a chronic condition . Additional considerations: 1. Competent individuals: a. The facility must still contact the resident's physician and notify resident ' s representative, if known. b. A family that wishes to be informed would designate a member to receive calls. c. When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident.
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00138087.
Based on observation, interview, and record review the facility failed to ensure appropria...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00138087.
Based on observation, interview, and record review the facility failed to ensure appropriate interventions were implemented and documented to prevent falls for one of three residents (R903) whose falls were reviewed. Findings include:
On 12/18/23 at 9:53 AM and on 12/19/23 at 7:48 AM R903 was observed to be standing in the doorway of the bathroom.
On 12/19/23 at 10:58 AM, the therapy treatment notes for R903 were reviewed with the Therapy Director. It was reported that the root cause for many of R903's falls a lack of safety awareness, not calling for help and not able to follow safety instructions given even with in context reminders such as remembering to lock the wheelchair before standing. The Therapy Director reported R903 could stand by themselves, but should not.
A review of the record for R903 revealed that R903 was admitted into the facility on [DATE]. Diagnoses include Syncope (fainting) and Collapse, Hemiplegia (weakness on one side), Mild Cognitive Impairment and Fall. The Minimum Data Set, dated [DATE] indicated intact cognition while not able to recall the day of the week. Mobility device was a wheelchair. Sit to stand was documented as substantial/maximal assistance helper does more than half the effort. Toilet transfer was documented as dependent.
The care plan dated 07/05/23 documented, .has chronic pain related to history of fracture and falls .has an alteration in neurological status (hemiplegia-paralysis of one side) related to cerebrovascular disease . The care plan dated 07/13/23 documented, .had an actual fall. Resident refuses care and is able to make needs known and refuses to use call light and ask for assistance with toileting .behaviors of non-compliance (are) leading to increased falls . Revision 12/06/23.
A review of the records for R903 documented 13 falls afternoon and evening falls since 07/01/23. Two witnessed and 11 unwitnessed falls.
The incident reports revealed:
A fall 07/01/23 in the resident room resident was using a urinal and the wheelchair fell backward when attempted to sit down. Bleeding was noted from a laceration on the head and resident was sent out due to being on a blood anticoagulant. A condom catheter at night was initiated 07/05/23.
A fall on 07/09/23 at 6:34 PM in the resident's room documented the resident was found lying on the floor near the bed. The resident was trying to plug in their phone. Resident belongings were placed in reach.
A fall on 7/09/23 at 7:18 PM was documented. The incident report was not received.
A fall on 08/06/23 documented the resident was found on the floor next to the bed. When the resident was asked what they were trying to do they replied, I don't know. Patient advised to wait for staff assistance.
An unwitnessed fall on 09/06/23 in the resident room, documented R903 was found on their knees next to the bed. It also noted the resident had attempted to stand and use the urinal. An intervention initiated 9/22/23 and revised 12/12/23 indicated nursing to offer toileting approximately every two hours.
An unwitnessed fall on 09/20/23 in the resident room documented R903 was observed sitting on the floor on buttocks. It was noted that R903 was trying to stand up and fell. Mental status at the time of fall was not indicated.
A fall on 10/04/23 documented R903 was found on the floor of the bathroom with their pants down. R922 reported they were trying to wipe themself. The intervention dated for 10/05/23 was Resident is standby assist while being toileted.
A fall on 10/26/23 documented R903 was found on their buttocks in the threshold of the bathroom. R903 was trying to pull their pants up. The intervention dated 10/27/23 was resident to ask staff for assistance not other residents.
A fall on 11/01/23 documented R903 was found on the floor on their buttocks and was trying to pull their pants up. The intervention dated 11/02/23 indicated the resident will be placed on toileting program.
A fall on 11/06/23 documented R903 was found on the floor in room bleeding from the head and was sent to the hospital. An intervention dated 11/07/23 documented therapy to eval for increased weakness.
A fall on 11/26/23 documented a fall during a visitor's attempt to help the resident stand and use the urinal.
A fall on 11/27/23 documented R903 was found on the floor in their room and reported R903 had attempted to stand and use the urinal. Resident responded I don't know when asked why they did not call for assistance. An intervention dated 11/28/23 indicated to keep the urinal in reach and encourage to call for staff assistance when standing to urinate.
A fall on 12/05/23 documented R903 was lowered to floor when they left the common area, returned to their room and attempted to stand and retrieve a phone charger. An intervention dated 12/06/23 indicated a Psych Consult was ordered.
A review of the 7 day bladder documentation for December 2023 revealed missing checks for various times: on 12/1 four were missing on the night shift, on 12/3 four were missing on the day shift, on 12/5 four checks on the midnight shift were documented as not applicable and four on the day shift were not documented, on 12/6 one at 6 AM was not documented, on 12/9 six checks were not documented on the afternoon and midnight shift, on 12/10 two were not documented on the afternoon shift, on 12/11 four checks were not documented on the day shift, on 12/14 four checks were not documented on the afternoon and night shift, on 12/15 eight checks were not documented on the midnight shift and day shift, and on 12/16 and 12/17 four checks were not recorded.
On 12/19/23 at 3:14 PM and 3:49 PM the Director of Nursing (DON) was asked about falls for R903 and noted there were interventions after every fall. The DON noted the spouse was involved, Psych was consulted, Therapy initiated, Xanax was prescribed for the history of anxiety and a toileting program was implemented. The DON report that they Truly don't know what to do. I can't think of anything else . Physical interventions did not work.
A review of the policy titled Comprehensive Care Plans dated 01/01/21 revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment (Minimum Data Set) .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00138118, MI00138025 and MI00137992.
Based on interview and record review the facility failed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00138118, MI00138025 and MI00137992.
Based on interview and record review the facility failed to provide activities of daily living care (ADLS) for dependent residents for one of seven residents (R905) reviewed for ADL care. Findings include:
On 12/18/23 at 9:00 AM, documentation was reviewed from a complaint received by the State Agency from [Hospital Representative] which indicated, [R905] had a strong foul odor to them .[R905] had to be cleaned up once they arrived to the [Emergency Room].
On 12/19/23 at 10:30 AM, a review of R905's electronic medical record (EMR)/shower documentation during their last stay at the facility from 10/26/23 through 11/28/23 revealed that R905 had no shower documentation observed in their record and no record of shower/bath refusals. Review of R905's EMR revealed that R905 was scheduled to receive their showers on, Thursday and Sunday day shift. Prefers showers.
Further review of R905's EMR revealed that R905 was most recently admitted to the facility on [DATE] with diagnoses that included Acute respiratory failure with hypoxia (Not enough oxygen in blood with too much carbon dioxide) and Morbid obesity. R905's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R905 had a moderately impaired cognition and was totally dependent to requiring extensive one to two person assistance for all ADLs. R905 was discharged from the facility and transferred to the hospital on [DATE].
On 12/19/23 at 12:36 PM, Certified Nursing Assistant (CNA) L was interviewed and asked about their ability to meet the ADL needs of the residents. CNA L indicated that occasionally it could be difficult.
On 12/19/23 at 12:40 PM, CNA M was interviewed and asked about their ability to meet the ADL needs of the residents. CNA M stated, Occasionally it can be challenging when we are not fully staffed.
On 12/19/23 at 12:50 PM, the Administrator (NHA) was interviewed regarding their expectations for providing showers/ADL care to residents. The NHA stated, The expectation is residents should be offered showers two days per week and as requested. The NHA was further interviewed about the shower documentation for R905 and indicated that there were changes to the documentation in the computer and the CNAs struggled with the new way to document.
On 12/19/23 at 1:07 PM, a facility policy titled Activities of Daily Living (ADLs) Date Reviewed/Revised: 01/01/22. Policy Explanation and Compliance Guideline: 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good .grooming and personal hygiene .
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 MI00141644.
Based on interview and record review, the facility failed to accurately assess and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00141644.
Based on interview and record review, the facility failed to accurately assess and document vital signs for one of one sampled resident (R919) reviewed for professional standards, resulting in inaccurate vital sign recording. Findings include:
A review of the Intake noted, On 12/15/2023 at 7:55pm [R919] was not breathing and without a pulse when the [Local] Fire Department arrived at the facility. [R919] had blood pooling on [their] back, lividity (bluish-purple discoloration of skin after death). [R919] was in rigor mortis and was cool to the touch and [R919] pupils were affixed .
A review of the Patient Care Report by the local ambulance service that arrived to pick R919 for their scheduled discharge noted, Call Demographics. Incident Location: (Nursing Home) . Reason for leaving Nursing Home: Discharge to home . Misc (miscellaneous) Call Info . Reason for Ambulance? Dead on Scene . Response Information. Complaint Reported by Dispatch: Sick Person. Response Mode to Scene: Priority 4 - Non-Emergency . Disposition. Incident/Patient Disposition: Dead at Scene-Resusce Attempt . Call Times: Received 12/15/23 09:43:27, Dispatched 12/15/23 19:23:22, En Route 12/15/23 19:25:26, At Scene 12/15/12 19:37:29, Pt (Patient) Contact 12/15/23 19:39:02 . Complaints: Primary Symptom: Death, Primary Impression: Obvious Death . Narrative: (name of ambulance) dispatched priority 4 for transport. Arrived on scent to find [R919] laying semi-Fowler's (head of bed up) in bed at nursing home. (name of ambulance) could not locate nurse, and upon checking on the patient (name of ambulance) noticed patient to be pulse less and apneic (temporarily stop breathing). Patients skin was cold to touch with non reactivity in both eyes. (name of ambulance) was told the patients code status was a full code so a backboard was placed under patient to begin compressions. (Name of ambulance) and nursing staff did 5 rounds of compressions and ventilations with oxygen at 15LPM (liters per minute). [Local] fire engine was next to respond on scene. Fire assisted with compressions with no success. Fire called the hospital and pronounced patient dead on scene at 20:10 per fire. (Name of ambulance) witnessed pronouncement and notified dispatch of the situation. No further interventions were done by (name of ambulance). End of call. document dated and signed 12/15/23.
A review of R919's Electronic Medical Record (EMR) revealed, [R919] was admitted to the facility on [DATE] with diagnoses of Fracture of Alveolus of Maxilla, Acute Respiratory Failure, Hypertension and discharged on 12/15/23.
A review of R919's EMR vitals tab noted, last entry documented 12/14/23 at 11:55, Blood Pressure 146/86 (sitting), 97.6 temp, Pulse 84, 18 breaths/min Respirations, No blood sugar, O2 96% signed Licensed Practical Nurse (LPN I).
A review of R919's Medication Administration Record (MAR) noted, December 2023. Order: Vital Signs two times a day for prophylaxis -Start Date: 11/29/2023.
12/1/23 and 12/2/23 at 0900 (9:00 AM) and at 2100 (9:00 PM). R919's vitals were documented as the exact same for the two days and two times. BP (Blood pressure): 143/83. Temp (Temperature): 97.5. Pulse: 98. Resp (Respiratory ): 18. O2 (oxygen) Sats: 97.
12/3/23 at 0900 and 2100 R919's vitals were recorded as the same at both times, BP: 114/80. Temp: 98.4. Pulse: 102. Resp: 16. O2 Sats: 96.
12/4/23 at 0900 BP: 154/92. Temp: 98.1. Pulse: 111, Resp: 16. O2 Sats: 97. At 2100 BP: 143/81, Temp: 97.8, Pulse: 83, Resp: 16, O2 Sats: 97.
12/5/23 BP: 124/77, Temp: 98.2, [NAME]: 84, Resp: 18, O2: 96. At 2100. BP: 141/72, Temp: 98, Pulse: 80, Resp: 16, O2 Sats: 96.
12/6/23 BP: 134/66, Temp: 97.7, Pulse: 70, Resp: 18, O2: 96. At 2100 BP: 124/64, Temp: 97.8, Pulse: 71, Resp: 16, O2 Sats: 96.
12/7/23 at 0900 and 2100, was record the same as previous day vitals. BP: 124/64, Temp: 97.8, Pulse: 71, Resp: 16, O2 Sats: 96.
12/8/23 at BP: 136/78, Temp: 98.8, Pulse: 76, Resp: 18, O2 Sats: 97. At 2100 BP: 122/77, Temp: 97.7, Pulse: 71, Resp: 18, O2 Sats: 97.
12/9/23 0900 N/A. at 2100 BP: 152/80, Temp: 97.8, Pulse: 100, Resp: 18, O2 Sats: 97.
12/10/23 (X) no documentation. At 2100, recorded as the previous day at 2100. BP: 152/80, Temp: 97.8, Pulse: 100, Resp: 18, O2 Sats: 97.
12/11/23 at 0900 BP: 157/180, Temp: 97.8, Pulse: 75, Resp: 19, O2 Sats: 94. at 2100 BP: 150/90, Temp: 98.0, Pulse: 75, Resp: 19, O2 Sats: 94.
12/12/23 at 0900 and 2100 vitals were recorded as the same, BP: 150/90, Temp: 98.0, Pulse: 75, Resp: 19, O2 Sats: 94.
12/13/23 at 0900 vitals were recorded as the same as the previous day at 0900. BP: 150/90, Temp: 98.0, Pulse: 75, Resp: 19, O2 Sats: 94. At 2100 BP: 150/90, Temp: 98, Pulse: 81, Resp: 18, O2 Sats: 96.
12/14/23 at 0900, 2100, and 12/15/23 at 0900 vitals were recorded as the exact BP: 146/86, Temp: 97.6, Pulse: 84, Resp: 18, O2 Sats: 96.
On 12/19/23 at 2:26 PM, LPN I was asked about R919's vitals that are recorded the same on multiple days. LPN I explained asking for assistance with taking vitals from the Certified Nursing Assistants (CNA), when busy. LPN I was asked if the CNA's were able to see the resident's previous vitals and stated, Yes. LPN I was asked the process for when the CNA's obtained vitals and stated, They write it down on a loose sheet of paper and then give it to me. LPN I was asked if they reviewed the vitals and if they noticed that the vitals were the exact same for days in a row. LPN I confirmed using the vitals that were provided by the CNA's. LPN I was asked about the EMR and if there was a way to duplicate the previous vitals and stated, Yes. There is a button that you can hit to say use previous vitals. LPN I was asked about using older vitals and stated, I wouldn't use anything over 15 minutes or 20 minutes old.
On 12/19/23 at 3:15 PM, the Director of Nursing (DON), was asked about the vitals being the same for multiple days, for R919 and explained, CNAs or Nurses can take the vitals, and they should be recorded in the vitals tab on the EMR versus the Medication Administration Record (MAR). The DON further explained, I will be educating the Nurses. I know it's repetitive work, but If you are giving a med within 5 minutes then no need to take vitals again. The DON was asked if they had concerns with R919's vitals record as the exact same for multiple days and explained, she did not because R919 was a stable resident and that vitals would have been taken prior to R919 leaving the facility. The DON was asked about the vital order and the expectations for that by the Nurses, the DON stated, They should be following the order.
A review of the facility's policy titled, Routine Resident Checks dated 10/30/2020, noted, Routine resident checks shall be made to assure that the resident ' s safety and well-being are maintained. Policy Explanation and Compliance Guidelines: 1. To ensure the safety and well-being of our residents, a resident check will be made at least every two (2) hours throughout each 24-hour shift by nursing service personnel. 2. Routine resident checks involve entering the resident ' s room to determine if the resident 's needs are being met, if there has been a change in the resident ' s condition, if the resident has any complaints, if the resident is sleeping, needs toileting assistance, etc. 3. Changes in the resident 's condition and medical needs that cannot be performed by the person conducting the routine check must be reported to the Nurse Supervisor/Charge Nurse at once.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00141632 and MI00138087.
Based on observation, interview, and record review the facility failed to e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00141632 and MI00138087.
Based on observation, interview, and record review the facility failed to ensure an air mattress was in place, and or reposition a resident timely and or document wound care as completed for three residents (R922, R904, R918) of three reviewed for pressure ulcer care, resulting in the potential for decreased wound healing. Findings include:
R922
On 12/18/231:15 R922 was observed to be in bed. R922 appeared to be on their back in bed despite a foam wedge on the left side. A visitor in the room reported they had been with the resident since around 11:30 AM and the staff had not repositioned R922. The visitor reported that the staff were attending to R922's wounds but the facility had yet to place the air mattress on R922's bed and the resident had been at the facility for two weeks since returning from the hospital. The visitor further noted R922 to be a long-term resident and that R922 had the mattress in their other room prior to discharge to the hospital. The visitor reported R922 had acquired wounds to the left buttock.
On 12/18/23 at 1:27 PM, the Wound care nurse reported a request for the air mattress was put into TELs (maintenance portal) this day. It had been noted that admissions could initiate the request on admission if a resident has a known wound. A review of the TELs report documented a request for an air mattress on 12/18/23. A TELs report for 12/06/23 was also noted, but this was related to the headboard and foot board.
On 12/18/23 at 1:57 PM, an observation of R922's wounds with the wound care nurse was completed. A single, large, padded dressing covered the buttocks and when removed the area under the dressing appeared reddened with dusky areas around the wound locations. This revealed three wound areas. A left gluteal fold (lower buttock/upper thigh) wound around the size of a golf ball with similar depth; An abrasion/skin tear around the size of a quarter, to the upper left buttock and a wound to on the right lower buttock around the diameter of a golf ball. The wound base on the right buttock wound was not visualized as the paste applied to the wound could not be cleaned off as this caused increased pain for R922. The left lower buttock wound appeared as a stage four (damage extends to the muscle, bone, or joints) and was a dusky pink color. The general redness around the wounds had diminished but remained at the end of the treatments. R922 was returned to a position with the wedge on the left side.
On 12/18/23 at 4:30 PM, R922 was interviewed related to the care and treatment received and reported that the staff were not always consistent with the turning. The foam wedge was observed to be o the left side of R922.
On 12/19/23 at 8:03 AM, R922 was observed to be in bed with their breakfast tray on the over the bed table. The foam wedge was on the left side.
A review of the record for R922 revealed R922 was re-admitted into the facility on [DATE]. Diagnoses included Osteomyelitis (bone infection) and Heart Disease. The Minimum Data Set, dated The self care performance deficit care plan dated 12/08/23 indicated R922 required one person assist for bed mobility with date initiated of 09/25/23. The .has impaired skin integrity related to stage four pressure ulcer to left gluteal fold . care plan documented the interventions Wedge to side, rotate periodically . initiated 12/14/23 and Pressure redistribution LAL (low air loss) Mattress to bed initiated 09/25/23. The care plan also noted the potential for refusal to be turned.
R904
A review of a complaint for R904 indicated R904 was stuck in a dialysis room for over 2 hours and then was in the chair for over 12 hours stuck in a upright position until a pressure sore developed on the right leg.
On 12/18/23 at 3:51 PM, the wound nurse was asked about the wounds for R904. The wound nurse reported R904 had wounds the buttocks, sacral (lower back/tailbone) and popliteal (behind knee) areas. The wound nurse also reported R904 had consistent complaints of pain with movement and wound care and did not always want to be touched. It was also reported that R904 had complaints about sitting in dialysis too long and would request shortened sessions. The wound nurse also noted the regular recliner was a tight fit for the resident and was changed out for a larger one.
On 12/19/23 at 11:27 AM, Nurse K was asked about R904 and reported R904 often reported that they waited hours to get returned to bed and confirmed there were times that R904 waited in dialysis up to two hours after dialysis was completed for facility staff to pick R904 up and return them to their room. Nurse K also noted R904 complained of pain and the recliner to be uncomfortable. It was noted that timely pick up up resident from the dialysis room was an ongoing issue.
A review of the record for R904 revealed R904 was admitted into the facility on
R918
On 12/19/23 a complaint related to R918 was reviewed and indicated concerns for the care and treatment of pressure sores and the development of new areas that were not there on admission.
A review of the record for R918 revealed R918 was admitted into the facility on [DATE] and discharged on 12/13/23. Diagnoses included Diabetes and Polyneuropathy (nerve damage causing weakness numbness and pain). A review of the Treatment Administration record for December 2023 revealed missing documentation for 9AM wound care treatments to the sacrum and hernia sites on 12/09/23 and 12/10/23. The morning medications were documented as given. The has impaired skin integrity care plan dated 12/07/23 documented, Administer treatments as ordered. A skilled note dated 12/13/23 indicated R918 was alert to name and place but not to time and date. A skin assessment dated [DATE] documented wounds to the coccyx (tailbone/sacral area) the hernia at the belly button, and redness to the buttocks.
On 12/18/23 at 3:49 PM the Director of Nursing was asked about the implementation of interventions and reported that planned interventions should be implemented, and the air mattress should have been in place.
A review of the facility Wound Treatment Management policy dated 10/30/2020, documented, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders . 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change .
A review of the facility policy titled Comprehensive Care Plans dated 01/1/2021, documented, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00140698.
Based on observation, interview, and record review, the facility failed to ensure ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00140698.
Based on observation, interview, and record review, the facility failed to ensure four (R903, R911, R921, and R923) of four residents reviewed for dietary services, received meals according to their preferences. Findings include:
A review of R921's medical record revealed, R921 was admitted to the facility on [DATE] with diagnosis of Acute Respiratory failure. A review of R921's [NAME] Data Set (MDS) assessment noted, R921 with an intact cognition.
On 12/18/23 at 10:17 AM, R921 was asked about the food at the facility and stated, I get a lot of pasta and I'm diabetic. I don't eat it because I know I can't have that many carbs. A lot of rice and ravioli. The broccoli is mushy and cold. R921 was asked if they are able to preview the menu and then select. R921 stated, No. R921 also stated, I'm allergic to nuts and tuna but I get them both on my tray. I had a care conference and said no bread, I keep getting it. R921 was observed to pointed out that the HS snack for last night was a graham cracker, the label on the graham cracker noted, [R921] allergy to all nuts, peanut oil, no salt. (Saturday 12/16 - h.s) Assorted yogurt Cup - 1 each.
A review of R921's care plan noted, Focus: [NAME] is at risk for altered nutritional status related to Chronic obstructive pulmonary disease (COPD), diabetes, diuretic use, food allergy/intolerance (Nuts, Peanut Oil), heart failure, obesity, takes psychotropic medication, therapeutic diet. Hx of impaired skin integrity. Desires gradual wt (weight) loss as medically feasible. Date Initiated: 10/10/2023. Goal: Resident will have adequate nutrition to meet nutritional needs and have no signs/symptoms of malnutrition. Date Initiated: 10/10/2023. Interventions: Provide meals/fluids based on resident food preferences and as ordered Date Initiated: 10/18/2023. Observe percentage of meal intake for changes in eating habits Date Initiated: 10/18/2023. Periodically obtain [NAME]'s weight, evaluate, and report to Dietitian, Physician/NP/PA, and responsible party of significant weight changes. Date Initiated: 10/10/2023.
On 12/18/23 at 11:47 AM, during the lunch meal preparation, the kitchen was observed with cold air blowing throughout the kitchen, plates stacked on the steam table and not in the plate warmer. Food was observed to sit uncovered for some time due to missing items that were not ready to be plated. The cook was asked for the temperature log and was unable to provide them. The cook stated that they took them but had not written them down because they had a marker and not a pin.
Meal ticket for lunch on 12/18/23 noted, [R921] Allergy to all Nuts, Peanut Oil. No Salt Packets; large Entrée Portions. Monday Lunch 12/18/23. 1 ½ Sandwich - Breaded Fish on a Bun. 2 Pkt Tarter Sauce, 2/3 Cup Potato wedges. 2 Pkt - ketchup. 1 Cup - Tossed Salad w/dressing. Please send ranch dressing. ½ square - Chocolate Cake w/ Peanut [NAME] Frosting. 8 oz ;Skim Milk, 6oz - Hot Tea. ALLERGIES: PEANUT, NUTS.
A review of R911's lunch tray and meal ticket noted, 1 EA (each) dinner roll/bread. R911 tray was observed without a dinner roll. R911 stated, This always happens. The food is also cold.
A test tray was pulled from unit 700. Meal ticket noted, 1/2 cup of buttered rice. The test tray was observed without rice and with mash potatoes.
On 12/18/23 at 3:58 PM, the Dietary Manager (DM Q) was as about the meal tickets not being followed and if they had sugar cookies, dinner rolls, and yogurt, and stated, Yes. We do. The DM Q was asked if the HS snacks label is supposed to match the item that is on it and stated, Yes. The label should be the item. The DM Q was asked about R921 being served an item with peanuts on it, when the meal ticket notes R921 allergic to peanuts. The DM Q did not response verbally and shook their head. The DM Q was asked about the observation of the temperatures of the food not being available at request and their expectations for taking the temperature of the food prior to meal services. DM Q stated, No one is served unless it's temp. I in-service them. The DM Q was asked about the observation of the plates not being in the warmer and stated, The plates were too hot, it burned me that is why I took them out of the warmer.
On 12/18/23 at 9:53 AM, R903 wheeled out of their room and reported that menus should be provide to resident daily so there is not so much wasted food.
On 12/18/23 at 1:30 PM, R923 was asked about the food and reported they had been trying to get eggs for breakfast and was trying to get a hold of the dietitian as they are also supposed to have a Glucerna (liquid supplement). R923 reported that the food is often cold and it was like the cooked it and then just left it out in the hallway. R923 also commented that the french toast casserole was just one piece of cold french toast. A review of the meals tickets did not show the ordered Glucerna.
On 12/18/23 at 3:28 PM a resident on the 700 unit whose chose to remain anonymous commented when asked about the food that meals were few and far between at the appropriate temperature and scrambled eggs are served almost continuously.
On 12/19/23 at 8:10 AM, R923 reported their breakfast was cold and include one slice of toast, some peanut butter and fruit (not eaten pineapple cubes) and oatmeal which R923 generally did not eat. R923 did report a staff went down to the kitchen and picked up some scrambled eggs and sausage and these temperatures were good.
A review of the facility's policy titled, Dining and Food Preferences dated, 5/2014 noted, Policy Statement: Individual dining, food, and food beverage preferences are identified for all residents/patients. Procedures: 1. The Diet Requisition form will notify the Dining Services department of food allergies up admission and prior to any meals served . 4. Food allergies, food intolerance, food dislikes, and food and fluid preferences will be entered into the residents profile in the menu management software system . 7. The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies & intolerances, and preferences .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00138084.
Based on observation, interview and record review the facility failed to ensure rooms were...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00138084.
Based on observation, interview and record review the facility failed to ensure rooms were cleaned appropriately and beds were in good condition for two room [ROOM NUMBER]-1 and 716-1 resulting in the potential for resident disatisfaction with their rooms and lingering debris on the floor. Findings include:
On 12/18/23 at 10:24 AM, 1:03 PM and 3:36 PM, room [ROOM NUMBER] was observed to have a metal fork under the center area of the bed. On 12/19/23 at 7:55 AM and 10:36 AM, the fork remained under the bed.
On 12/18/23 at 12:57 PM, in room [ROOM NUMBER] piles of different sized pieces of sheet rock and sheet rock dust were observed on the floor below vertical gouges in the sheetrock behind the head of the first bed. A visitor commented that it had been that way for months and had not been cleaned up. On 12/19/23 at 10:32 AM, it was noted that the sheet rock dust remained and two of the four wheels at the foot of the first bed were broken and the wheel trucks rested on the ground. This would have made the bed difficult to move.
On 12/19/23 at 1:07 PM, the enviromental services manager reported that the expectation was that the sheetrock and fork would have cleaned up during the routine daily cleaning.
A review of the Daily Patient Room Cleaning revised 6/2016, revealed, B. Do quick straighten up. C. Follow 5-Step room cleaning and courteous. 1) Empty trash. Get the trash out of all rooms first thing. Wipe basket - if necessary replace liner. 3) Spot clean. With a cloth & disinfectant spot clean all vertical surfaces. 4) Dust mop floor. Use dust mop to gather all trash & debris on floor. Sweep to the door; pick up with dust pan. 5) Damp mop floor working from back corner .
A review of the facility policy titled, Safe and Homelike Environment dated 07/28/2020 revealed, Policy: In accordance with residents ' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible .
Oct 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 MI00137875.
Based on interview and record review, the facility failed to obtain a stool (bowel ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00137875.
Based on interview and record review, the facility failed to obtain a stool (bowel movement) sample, initiate a new wound treatment timely, adequately document nursing assessment and monitor edema/swelling, affecting one resident (R003) of three reviewed for quality of care, resulting in decreased coordination of care and the potential for unmet care needs. Findings include:
A review of R003's record revealed the resident was admitted into the facility on 5/5/23 and discharged on 7/1/23. R003's medical diagnoses included Myocardial Infarction (Heart Attack), Diabetes, Lung Disease, Muscle Weakness, Dysphagia (difficulty swallowing), and Malignant Neoplasm Of Uterus and Colon (Cancer).
A review of R003's record revealed that the resident began having loose stools on 5/27/23 that persisted through 5/30/23. A Physician Progress note dated 5/30/23 indicated that a stool sample was to be collected to test for C. Diff (Clostridioides difficile - an infection of the large intestine that causes persistent diarrhea). The prescriber entered the order, Stool for c-diff, on 5/30/23. A dietary note dated 6/13/23 noted that the resident was experiencing frequent loose stools/persistent diarrhea per nursing. An attempt to collect the stool sample was not noted in the record until 6/14/23.
Additionally, a Skilled Wound Care note dated 5/8/23 indicated that the resident's skin had no open areas of concern and indicated the following, The patient has chronic skin condition on legs. The patient is also at risk for the development of a pressure injury due to the following risk factors: Diabetes and Limited Mobility.
A review of R003's progress notes revealed:
-6/21/2023 17:54 (5:54 PM) Nurses' Notes Text: Skin assessment was completed. Resident has two new open wounds on the sacrum (buttocks). No current drainage. no odor. Area cleaned with normal saline and dressing applied until further assessment can be completed by wound care team. No current complaints of pain.
A treatment order for R003's newly identified skin impairment was not initiated until 6/26/23. A wound assessment dated [DATE] described the skin impairment as, In-House Acquired, IAD (Incontinence Associated Dermatitis) [on the] Lateral Sacrum.
Further review of R003's orders revealed, X-ray left hand and wrist venous doppler us (ultrasound) r/t (related to) left hand and wrist edema one time only for 3 Days left extremity edema, Order Date: 06/07/2023. The ordered tests were completed with negative results, however, a nursing assessment(s) related to the identification and/or monitoring of the left extremity edema was not found in the record.
On 10/2/2023 at 12:04 PM, the Nursing Home Administrator (NHA) was asked to provide assessment documentation related to the X-ray and doppler ordered for R003 on 6/7/23. The results of the tests were the only documentation provided prior to survey exit. No nursing assessments were received. At 2:44 PM, the NHA indicated through interview that the lack of documented nursing assessments is an ongoing issue that the facility has been working on.
On 10/2/23 at 2:15 PM, the Director of Nursing (DON) was interviewed regarding R003. The DON was queried about the timeliness of the stool sample collection versus when it was ordered to rule out C. Diff. The DON stated it should have been collected the same day as the order. When queried regarding the lack of nursing documentation related to the diagnostics performed for R003's left extremity swelling, the DON acknowledged that she was unable to find any nursing assessments and would have expected there to be one. The DON also acknowledged that R003 having persistent loose stool would increase the likelihood of skin breakdown. The DON also indicated that the treatment order for R003's new skin impairment should have been initiated sooner than it was.
A review of the facility's policy/procedure titled, Wound Treatment Management, reviewed/
revised 1/1/2022, revealed, .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 .
A review of the facility's policy/procedure titled, Laboratory and Diagnostic Guidelines, reviewed/
revised 1/1/2022, revealed, .2. Routine laboratory or diagnostic test may be placed on a calendar or schedule, or other mechanism. The mechanism should allow for ease of the facility staff to recognize upcoming lab and diagnostic tests .All notifications, attempts at notifications, and response should be noted in the resident ' s medical record. 13. Results should also be reported to the resident and/or responsible party, including any new orders .
Jun 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
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 M100135612.
Based on interview and record review, the facility failed to ensure one (R701) of f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake M100135612.
Based on interview and record review, the facility failed to ensure one (R701) of five residents was free from verbal aggression from a staff member, resulting in resident dissatisfaction with care and the resident being hesitant to request assistance from that staff member. Findings include:
Review of the facility record for R701 revealed an original admission date of 05/21/19 with diagnoses that included Muscle Wasting and Atrophy, Asthma, Depression, Anxiety Disorder and Bipolar Disorder. The Minimum Data Set (MDS) assessment dated [DATE] included the Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition.
On 06/20/23 at 10:26 AM, R701 was interviewed regarding the alleged incident and reported that Licensed Practical Nurse (LPN) A was their nurse on the night shift for 2 consecutive nights on the weekend. R701 reported that they were used to receiving their evening medication around 9 or 10 (PM) and when it became later than 10 PM they asked LPN A about their medication. R701 reported that LPN A responded Go back to your room and you'll get it when I get around to it. R701 reported that they heard other residents ask LPN A about their medication and they heard LPN A say shut up, you're all getting on my nerves in a raised voice. R701 reported that R713 called the DON (Director of Nursing) to report that they had not received their medication. R701 reported they overheard another nurse come to tell LPN A that the DON had been called and that LPN A stated I don't give a (explicitive) who they call in a manner that was easily overheard. When asked if they had interacted with LPN A since that weekend R701 reported that they had not and that they were told that LPN A had been escorted out of the building by the police about a month ago.
On 06/20/23 at 10:40 AM, R712, who shares a room with R701, reported that they were present during the alleged incident and that they could substantiate R701's statements and added (LPN A) was very rude. When asked if they heard LPN A cursing R712 responded yes. Review of R712's BIMS assessment dated [DATE] revealed a score of 15/15 indicating intact cognition.
On 06/20/23 at 10:55 AM, R713 (whose room is across the hall from R701/R712) reported that they were present during the alleged incident and could substantiate what R701 and R712 reported. R713 reported that they did hear LPN A cursing and added (LPN A) told me directly to shut up. Review of R713's BIMS assessment dated [DATE] revealed a score of 15/15 indicating intact cognition.
Review of the human resources file for LPN A revealed that they were terminated in May 2023 with the termination reason documented as insubordination.
On 06/20/23 at 4:11 PM, the Facility Adminstrator (NHA) was queried regarding about LPN A's termination. The NHA reported that the termination was related to a situation regarding insubordination.
Review of the facility policy Abuse, Neglect and Exploitation dated 10/24/22 includes in the Definitions section the entry Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes desparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.
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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00135307.
Based on interview and record review the facility failed to update a care plan foll...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00135307.
Based on interview and record review the facility failed to update a care plan following a fall for one resident (R708) of two residents reviewed for falls, resulting in a lack of fall interventions to prevent falls and the potential for injuries to occur related to falls. Findings include:
On 6/20/23 at 9:00 AM, a review of R708's electronic medical record (EMR) revealed that R708 was admitted to the facility on [DATE] with diagnoses that included End stage renal disease and Hypertension. A review of R708's most recent Minimum Data Set (MDS)assessment (MDS) dated [DATE] revealed that R708 had a severely impaired cognition and required extensive assistance for all activities of daily living (ADLs) other than eating.
On 6/20/23 at 9:21 AM, R708's fall incident and accident reports (I/As) were reviewed and indicated that R708 had fallen at the facility on 3/5/23 and 3/9/23. The I/A regarding R708's fall on 3/5/23 indicated the following, A. Event Information 1. Date of fall: 03/05/2023 .12. What was resident doing prior to fall? Sitting in w/c (Wheelchair) .D. Physical Evaluation 1. Any injury or suspected injury? b. No.
On 6/20/23 at 9:37 AM, a review of R708's fall care plan revealed that no fall intervention had been added to the care plan following R708's fall on 3/5/23.
On 6/20/23 at 12:20 PM, the Administrator (NHA) was interviewed regarding their expectations for interventions being added to a care plan following a resident fall. The NHA stated, Typically yes, an intervention should be added to a resident's care plan following a fall.
A facility policy titled Comprehensive Care Plans Date Reviewed/Revised: 06/30/2022 was reviewed and stated the following, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing, and mental and psychosocial needs .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake M100136136.
Based on interview and record review, the facility failed to provide/document show...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake M100136136.
Based on interview and record review, the facility failed to provide/document showers/bathing at the standard of care frequency of twice weekly for one (R703) resident of five reviewed for showers/bathing resulting in resident and family dissatisfaction with care. Findings include:
On 06/20/23 at 9:51 AM, R703 reported that they had not been receiving regular showers and stated I've had two showers in the last four weeks.
Review of the facility record for R703 revealed an admission date of 04/19/23 with diagnoses that included Diabetes Mellitus, Lumbar Disc Degeneration and Low Back Pain. Minimum Data Set (MDS) assessment dated [DATE] indicated R703 required Moderate assistance for bathing. The Brief Interview for Mental Status (BIMS) assessment score of 15 indicated intact cognition.
Review of R703's showering/bathing task completion record of the previous 30 days revealed documentation of bathing on 06/01/23 only. No other days were included or addressed in this record. R703's Progress Notes were reviewed and there was no documentation of bathing or bathing refusal.
On 6/20/23 at 4:05 PM, certified Nurse Assistant (CNA) N reported that resident bathing is documented in the task checklist and that the standard bathing frequency is two times weekly.
On 06/20/23 at 4:12 PM, the Facility Administrator (NHA) reported that the expectation regarding bathing frequency is twice weekly and as needed. The NHA reported that the facility was not able to provide further documentation of R703's bathing.
Apr 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 MI00135577.
Based on interview and record review the facility failed to ensure that adequate st...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00135577.
Based on interview and record review the facility failed to ensure that adequate staff supervision was provided to one resident (R700) of three residents reviewed for supervision, resulting in the potential for accidents to occur. Findings include:
On 4/26/23 at 8:30 AM, a State of Michigan (SOM) Intake document was reviewed which indicated the following, On 3/7/23 at 4:17 AM, EMS (Emergency Medical Services) was dispatched to (name of facility) based on a call received from a resident. When EMS arrived the facility did not answer their phone and upon entry into the facility, EMS was unable to locate any staff. EMS proceeded to the resident's room and resident indicated that they had to use the bathroom and had attempted for over an hour to contact staff through use of their call light with no response. EMS offered to transport resident to the hospital and took resident out of the facility and into the ambulance. EMS made one last check inside the facility and located staff members by an office close to the resident's room. The nurse indicated that they were unaware of the resident's call light being on. The nurse was informed that the resident was being transported to the hospital.
On 4/26/23 at 12:49 PM, R700's electronic medical record (EMR) was reviewed and revealed the following, 3/7/2023 06:32 (6:32 AM) Nurses' Notes Note Text: At approx 4:40 am approached by EMS [Emergency Medical Services] that states they are here for resident. Resident called 911 and states no one would take them to the bathroom and it had been about an hour. Resident call light not on at time of incident. MD [Medical Director], DON [Director of Nursing] notified.
On 4/26/23 at 1:03 PM, EMS report incident #2023-00003152 dated 3/7/23 4:28 AM, was reviewed and revealed the following, Dispatched to Medilodge for a [Patient] needing help getting out of bed .PT (patient) lying in bed stated Uncomfortable called 911 needing to use bathroom has been using call light for Past hour, possibly two. No staff response per patient. FD (Fire Department) was unable to locate any staff. Dispatch called the facility and got no answer. Pt requested transport to hospital because they aren't getting the care they need. PT was secured to the stretcher and loaded into the ambulance without incident. FD went back into the facility to make one more effort to notify the facility that one of their pts was being transported. FD located several staff members sitting together in an office. LPN [Licensed Practical Nurse] was advised that her pt (patient) was being transported. Pt transported to [Hospital]. Enroute pt indicated it is a common problem to be left without assistance for hours despite calling for help using the facility provided call button.
On 4/26/23 at 1:30 PM an interview was conducted with night nurse supervisor, LPN H regarding the incident which occurred involving R700 early in the morning of 3/7/23. Nurse H stated, I heard something about it. I was working on another unit. Nurse H indicated that LPN G was aware and familiar with the incident involving R700.
On 4/26/23 at 2:00 PM, R700 was interviewed regarding the incident which occurred during the early morning hours of 3/7/23. R700 stated, I called 911 (Emergency services) because I had my call light on for four hours waiting for staff to come and change my brief and nobody came. R700 indicated that EMS arrived in their room and transported them to the hospital. R700 expressed dissatisfaction with call light wait times and lack of staff supervision related to their care needs.
On 2:13 PM, a review of R700's EMR revealed that R700 was admitted to the facility on [DATE] with diagnoses that included, Lymphocytic colitis (Inflammation of large intestine) and Muscle weakness. R700's most recent Minimum data set assessment (MDS) dated [DATE] revealed that R700 had a moderately impaired cognition and required extensive one person assistance for toileting.
On 4/26/23 at 2:25 PM, Maintenance Director (MD) I was interviewed regarding how the front door operates after the receptionist leaves for the evening. MD I indicated that a receptionist is present at the front desk by the front door from 7:00 AM to 11:00 PM. At 11:00 PM the front door is locked and alarmed via a timer. Law enforcement, EMS, and the Fire department are able to open the front door either by use of their equipment or by use of a Key located in a lock box outside the building. MD I tested the front door alarm and the alarm worked properly.
On 4/26/23 at 4:39 PM, LPN G was interviewed by phone regarding the incident which occurred involving R700 on 3/7/23. LPN G indicated difficulty recalling R700 and/or the incident which occurred on 3/7/23. LPN G stated, I think that was the one where the resident had to go to the toilet and called EMS. I didn't even know EMS was in the building until they came to the nurse's office. LPN G was asked if they heard an alarm go off when EMS entered the building. LPN G stated, No, we cannot hear the alarm in the back of the building.
On 4/26/23 at 4:53 PM, a phone interview was conducted with the Director of Nursing (DON) and the Administrator (NHA). The DON and NHA were asked what their expectations were for midnight staff regarding monitoring and supervision of facility residents. Both the DON and NHA indicated that nursing and Certified nursing assistants (CNAs) should be doing hourly rounding throughout the building and monitoring/supervising all residents. The DON and NHA were asked what their expectations were for staff responding to alarms in the building. Both the DON and NHA indicated that staff should identify the location of the alarm and respond accordingly. The DON stated, Call light expectation is to respond within fifteen minutes if possible.
On 4/26/23 at 4:55 PM, a facility policy regarding staff supervision of residents was requested and was not received by survey exit.
On 4/26/23 at 5:00 PM, a facility policy titled Call Light Accessibility and Timely Response Date Reviewed/Revised: 1/1/2022 was reviewed and stated the following, Policy: Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines: 7. All staff members who see or hear an activated call light are responsible for responding .
Mar 2023
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00134739.
Based on interview and record review, the facility failed to update the care plan ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00134739.
Based on interview and record review, the facility failed to update the care plan following a fall for one resident (R717) out of two reviewed for falls, resulting in the potential for increased falls with injury. Findings include:
A review of the medical record revealed that R717 admitted into the facility on 1/21/2023 with the following medical diagnoses, Muscle Weakness and Unsteadiness on feet. A review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental status score of 14/15 indicating an intact cognition. R717 also required one person supervision with bed mobility and set up help with transfers.
A review of the progress notes revealed the following,
Date:1/23/2023 19:35 (7:00 PM). Writer observed resident face down on the floor in front of dining room. Other residents saw [R717] that [R717] fell forward from the wheelchair .transferred to [hospital] .
Date: 1/26/2023 16:23 (4:00 PM) .[Family Member] stated that [R717] has a history of falls and does not know if [R717] obtained fracture form the fall at home or from the fall at facility.
A review of the care plan revealed that the fall care plan had not been updated with any new interventions following R717 returning from the hospital.
On 3/21/2023 at 12:08 PM, an interview was conducted with the Director of Nursing (DON) regarding a fall intervention for R717. The DON stated that they would have to look further into why an intervention was not put in place upon return.
No further information was provided prior to exit.
A review of a facility policy titled, Fall Prevention Program revealed the following, 6. When any resident experiences a fall, the facility will: .e. Review the resident's care plan and update as indicated.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
This citation pertains to Intakes: MI00134462, MI00134954, and MI00134634.
Based on observation, interview, and record review, the facility failed to meet the care needs of a resident (R722) out of fi...
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This citation pertains to Intakes: MI00134462, MI00134954, and MI00134634.
Based on observation, interview, and record review, the facility failed to meet the care needs of a resident (R722) out of five reviewed for Activities of Daily Living, resulting in dissatisfaction with care, risk of infection, and feelings of frustration. Findings include:
On 3/21/2023 at 9:10 AM, the light for R722 was observed to be activated. The call light board situated at the nurse's station noted that the call light had been activated since 9:02 AM.
On 3/21/2023 at 9:20 AM, the light for R722 was still activated. R722 stated that they activated their light because their colostomy had needed to be emptied, but now it had burst and needed to be changed. R722 stated he had an abdomen wound and did not want it to get infected. R77 was observed to have a dressing on their abdomen, the dressing was noted to have feces on it.
On 3/21/2023 at 9:26 AM, R722's light was observed to still be activated. Staff members were observed to walk past the room with the light activated.
On 3/21/2023 at 9:33 AM, a certified nursing assistant (CNA) was observed going into R722's room and deactivating the call light.
On 3/21/2023 at 9:54 AM, an interview was conducted with R722. R722 stated that although their call light was off, they were still waiting for their bag to be changed. R722 stated that the CNA did come in and cleaned them up a little and placed a towel under their colostomy, but their dressing was still soiled, and the bag was still leaking.
A review of the medical record revealed that R722 was admitted into the facility on 2/10/2023 with the following diagnoses, Ventral Hernia with Obstruction and Incisional Hernia without Obstruction or Gangrene. A review of the Minimum Data Set assessment revealed that R722 had intact cognition and required one-person extensive assistance with bed mobility and transfers.
On 3/21/2023 at 10:54AM, R722 was observed up in his wheelchair dressed.
On 3/21/2023 at 3:08 PM, an interview was conducted with Nursing Home Administrator (NHA) regarding their expectation on answering call lights. The NHA stated that they expect for a call light to be answered within 15-20 minutes and that anyone can answer a call light.
A review of a facility policy titled, Call Lights: Accessibility and Timely Response noted the following, 7. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.
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 MI00134468.
Based on observation, interview, and record review, the facility failed to administ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00134468.
Based on observation, interview, and record review, the facility failed to administer medications in a timely manner following admission into the facility (R720) from a total sample of 23, resulting in a delay in appropriate treatment.
Findings include:
Resident 720 (R720)
A review of an Intake called into the State Agency noted the following, [R720] was admitted to [Facility Name] .during the early evening of 1/12/2023. I had visited[R720] late in the afternoon on 1/13/2023 and [R720] had not received any of [their] medications. On that date I was told that [R720] would not be receiving any of [their] medications (cardiac meds, endocrine, anticoagulant) until the following day, 1/14/2023 By the time [R720] received any medication I estimate it had been about 30 hours since [their] prior dose.
A review of the medical record revealed that R720 admitted into the facility on 1/12/2023 at 7:48 PM, with the following diagnoses, Pulmonary Hypertension and Polymyalgia Rheumatica. A review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 9/15 indicating impaired cognition. R720 also required extensive one to two persons assist with bed mobility and transfers.
A review of the Medication Administration Record (MAR) revealed that R720 did not receive any medications on 1/12/2023 and did not receive medication scheduled for 1/13/2023 at 9:00 PM.
A review of the vital sign results revealed that the only documented set of vitals were recorded on 1/13/2023 at 4:42 PM. R720's blood pressure appeared to be elevated at 146/97 (average blood pressure 120/80).
On 3/21/2023 at 12:08 PM, an interview was conducted with the Director of Nursing (DON) regarding the admission process with R720 and why they received their medications so late. The DON stated that they would have to look into it.
No further information was provided prior to the end of survey.
A review of a facility policy titled, Medication Administration, did not address the admission process.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00134897.
Based on interview and record review, the facility failed to implement a low air lo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00134897.
Based on interview and record review, the facility failed to implement a low air loss specialty bed mattress for one resident (R718) of one resident reviewed for wound care, resulting in the development of a new wound and a non healing of a pressure ulcer.
Findings Include:
A review of an Intake called into the State Agency noted the following, Within a week of [R718] being there [R718] developed bed sores due to not being rotated (turned and repositioned) .When first getting there[R718] stay was in [room number]. [R718] was supposed to have a rotating mattress that [they] should have been on their first day. Two weeks being in the facility [R718] moved to [room number] and was then put on the rotating mattress that [they] should have been on [their] first day.
A review of the medical record revealed that R718 admitted into the facility on 1/11/2023 with the following diagnoses, Muscle Weakness and Encounter for attention Tracheostomy (tube inserted into the throat to assist with breathing). A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 0/15 indicating an impaired cognition. R718 also required total two-person dependence with bed mobility and transfers.
Further review of the progress notes noted the following notes,
Date:1/11/2023 15:59 [3:59 PM]. Progress Note-Admission- .Peg (percutaneous endoscopic gastrostomy ) tube in abdomen (to assist with food, water and medications), remainder or skin intact.
Date:1/11/2023 16:00 [4:00 PM] Progress Note-Admission- .Writer completed follow up skin assessment. Trach and Peg in place, no other skin issues at this time.
Further review of the wound care notes revealed the following,
Date of Service: 1/16/2023. Reason For Visit: to evaluate this patient for wounds located on the left heel and right heel .Wound Location: Left Heel. Etiology: Pressure injury/ulcer-Wound Stage: Deep Tissue Pressure Injury . Wound Location: Right Heel. Etiology: Pressure injury/ulcer-Wound Stage: Deep Tissue Pressure Injury .Assessment and Plan: Offloading: Continue offloading turn per facility protocol. A low air loss mattress is recommended.
Date of Service:1/23/2023. Reason for Visit: Consultation and evaluation of wounds on the left heel, right heel, right buttock, and left buttock. Change in Patient Health: New wounds on Buttocks . Wound Location: Left Heel. Etiology: Pressure injury/ulcer-Wound Stage: Unstageable Pressure Injury. Wound Location: Right Heel. Etiology: Pressure injury/ulcer-Wound Stage: Unstageable Pressure Injury. Wound Location: Right Buttock. Etiology: Pressure injury/ulcer-Wound Stage: 3 (full thickness skin loss)-Pressure Injury. Wound Location: Left Buttock. Etiology: Open Lesion.
Date of Service:1/30/2023. Reason for Visit: Consultation and evaluation of wounds on the left heel, right heel, right buttock, and left buttock. Change in Patient Health: New wounds on Buttocks . Wound Location: Left Heel. Etiology: Pressure injury/ulcer-Wound Stage: Unstageable Pressure Injury. Wound Location: Right Heel. Etiology: Pressure injury/ulcer-Wound Stage: Unstageable Pressure Injury. Wound Location: Right Buttock. Etiology: Pressure injury/ulcer-Wound Stage: 3-Pressure Injury. Wound Location: Left Buttock. Etiology: Open Lesion.
Date of Service:2/06/2023. Reason for Visit: Consultation and evaluation of wounds on the left heel, right heel, right buttock, and left buttock. Change in Patient Health: New wounds on Buttocks . Wound Location: Left Heel. Etiology: Pressure injury/ulcer-Wound Stage: Unstageable Pressure Injury. Wound Location: Right Heel. Etiology: Pressure injury/ulcer-Wound Stage: Unstageable Pressure Injury. Wound Location: Right Buttock. Etiology: Pressure injury/ulcer-Wound Stage: 3-Pressure Injury. Wound Location: Left Buttock. Etiology: Open Lesion.
On 3/21/2023 at 12:08 PM, an interview was conducted with the Director of Nursing (DON) regarding R718 wounds. The DON stated that they believe the heels were on admission and the buttocks developed in the facility. The DON stated that R718 was supposed to be on a air mattress, but they were having problems with their TELS system (maintenance system) and there was a delay with it being applied.
A review of a facility policy titled, Pressure Injury Prevention and Management noted the following, Policy: This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries.
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
Pharmacy Services
(Tag F0755)
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 medications were available for administration for one residen...
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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 medications were available for administration for one resident (R712) of three reviewed for medications and pharmacy services resulting in an as needed pain medication not available for administration.
On 03/21/23 at 9:39 AM, R712 was asked about medications concerns and reported that their as needed liquid morphine was not available for a number of days in February and had received various excuses why it had not been available. This included the need for a new script from the physician.
A review of the record for R712 revealed R712 was admitted into the facility on [DATE]. Diagnoses included Lymphoma, Chronic Fatigue and Anxiety. A physician order dated 11/23/22, for Morphine Sulfate (Concentrate) Solution 10 milligrams (mg)/.05 milliliters (ml). Give 20 mg by mouth every two hours as needed for pain. 1 ml.
The nursing care plan .has chronic pain related to disease diagnosis .initiated 02/21/19, revised 03/28/22 revealed, Administer pain medications as ordered.
A review of the January 2023 and February 2023 Medication Administration Records (MAR) documented daily as needed administration of the Morphine sulfate liquid except for the periods from 01/31/23 through 02/06/23 and 02/19/23 through 02/22/23.
A review of the back up pharmacy medication on hand documented the liquid morphine was available.
The Controlled Substance Records for the morphine sulfate liquid indicated zero milliliters left on 01/29/23. This record indicated the order was written 01/07/23 and received at the facility 01/08/23. The next Controlled Substance Record for the morphine sulfate liquid was dated 02/07/23. This record indicated the order was written 02/07/23 and received at the facility 02/07/23. An amount remaining of zero was documented on 02/17/23. Further review of the Controlled Substance Record documented six removals of one milliliter as compared to the February 2023 MAR which documented four administrations on 02/17/23 and one on 01/18/23. Additional discrepancies were noted for entries on 02/16/23 (four removals and three administrations) and 02/15/23 (four removals and three administrations) and on 02/14/23 (two removals and four administrations).
On 03/21/23 at 1:40 PM the Director of Nursing (DON) reported they were not aware of a concern for the morphine sulfate liquid not having been available for R712.
A request for the date and times the medication was ordered was requested and a timeline from the pharmacy was received and documented, 01.07.23 - 30 mL delivered (ordered 1 mL Q2H prn [every 2 hours as needed]). This depleted the prescription. A pending order form was faxed to the prescriber. 01.27.23 - Refill requested in (electronic medical record), but there was no quantity remaining on the prescription. 02.02.23 - Faxed prescription received from prescriber for 1 mL Q12H prn. Because this did not match the previous order and order on file in PCC, a clarification was generated. Pharmacy was not able to reach the facility on 6 attempts.
On 2/7 at 9:16 am, pharmacy reached (Nurse C) who said they would contact the prescriber. 02.07.23 - Electronic prescription received for 1 mL Q2H prn. 60 mL delivered same day. 02.21.23 - Electronic prescription received for 1 mL Q2H prn. 30 mL delivered on 2/22.
A review of the facility policy titled, Medication Orders revised 01/01/22 revealed, This facility shall use uniform guidelines for ordering of medication .
A review of the facility policy titled Medication Administration revised 01/01/22 revealed, .17. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR. 18. If medication is a controlled substance, sign narcotic book.
19. Report and document any adverse side effects or refusals. 20. Correct any discrepancies and report to nurse manager .
Oct 2022
26 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #131:
On 10/19/22 at 10:28 AM, R131 was observed in bed awake. R131 explained that they had a vision impairment and cou...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #131:
On 10/19/22 at 10:28 AM, R131 was observed in bed awake. R131 explained that they had a vision impairment and could not see very well. R131 was asked if they had sustained any injuries as they were observed with a sling on their right arm. R131 explained that they had fallen from their bed, causing injury to their shoulder which was in pain.
A review of R131's medical record revealed that they were admitted into the facility on 4/23/21, with a readmission of 9/21/22 with diagnoses that included Dementia, Respiratory Failure and Diabetes. Further review of the resident's medical record revealed a Minimum Data Set assessment (MDS) dated for 9/27/22 revealing a Brief Interview for Mental Status score of 13/15 indicating an intake cognition, and revealed that the resident required extensive assistance of 2-persons for Activities of Daily Living including transfers and bed mobility.
Further review of R131's medical record revealed the following progress notes:
9/19/2022 11:54 (11:54 am) Nurses' Notes. Around 11:30 am. Writer was called to the resident's room by the CNA (Certified Nurse Assistant), The CNA stated that the resident fell on the floor while providing care. Resident observed lying on the floor, on [their] back, parallel to [their] bed. Resident was crying and complaining of severe pain to [their] R (right) arm and shoulder. Resident unable to move R arm, Round, lump on the R outer humerus noted, C/O (complaint of) pain when palpated. Observed small bump on the back of [their] head .Resident is currently on blood thinner. Writer notified [physician], received order to send resident to the ER (emergency room), 911
9/20/2022 10:29 (10:29 am) IDT-Interdisciplinary Progress Note. To prevent further falls. IDT advised to have 2 person assist while taking care of the resident.
Further review of R131's medical record revealed that the resident was admitted to the local hospital on 9/19/22 with a final impression of, Other displaced fracture of upper end of right humerus, initial encounter for closed fracture.
Further review of R131's medical record revealed the following care plan, Focus: [R131] is at risk for falls related to: impaired mobility, and weakness. Date Initiated: 04/23/2021. Revision on: 02/16/2022. Interventions: Be sure [R131's] call light is within reach and encourage [them] to use it for assistance as needed. Date Initiated: 04/23/2021. Revision on: 08/22/2022. Bed in low position when not providing care. Date Initiated: 04/23/2021. Revision on: 08/22/2022. Ensure [R131] is positioned in center of bed. Date Initiated: 08/06/2021. Revision on: 08/22/2022.
Further review of R131's medical record revealed a Minimum Data Set assessment dated for 8/11/22, prior to R131's fall, that they required extensive assistance of 2-persons for bed mobility and transfers.
On 10/21/22 at 9:05 AM, CNA P was interviewed regarding the fall of R131. CNA P explained that she was cleaning R131 by themselves. CNA P explained that R131 was lying in their right side, facing away from her. CNA P explained that she turned around to grab a towel, and at that time R131 rolled out of the bed onto the floor. CNA P explained that she went and obtained a nurse, and R131 was sent out to the hospital. CNA P explained that she was unaware that R131 was a 2-person assist, and later received training on how to check a resident's transfer/bed mobility status in the computer system.
A review of the facility policy titled Fall Prevention Program dated 10/30/2022 revealed the following: Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls.
Based on observation, interview and record review, the facility failed to position a resident safely during care for two residents (Resident #102 and Resident #131) of four residents reviewed for falls, resulting in hospitalization, unnecessary prolonged pain and decreased range of motion resulting from injury.
Findings include:
Resident #102
On 10/18/2022 at 12:01 PM, Resident #102 was lying in bed in a hospital gown. Resident #102 was asked about getting out of bed and stated they had a broken hip and rubbed their left hip with their right hand. Resident #102 was further queried about their hip and explained that an unknown Certified Nurse Assistant/CNA had been changing them while in bed and had let go of them, causing the Resident to fall out of bed on the floor. Resident #102 further stated that their hip was indeed broke and had not been operated on but was unsure why. Resident #102 was asked about the pain experienced and stated, It hurts! They give me medication to help with the pain.
A record review of the Minimum Data Set (MDS) assessments revealed the Resident was most recently admitted to the facility on [DATE] with the diagnoses of Displaced Intertrochanteric Fracture of Left Femur (hip fracture) and Diabetes Mellitus. Resident #102 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognition, and needed extensive, two-person assistance with bed mobility and transfers.
A record review of the progress notes for Resident #102 revealed the following:
9/25/2022 15:10 (03:10 PM) Progress Note-General Note Text: At approximately 1:55 PM CENA (Certified Educated Nurse Assistant) staff was assisting the resident with brief change and was rolling resident over to clean (their) backside up and (Resident #102) rolled out of bed .Resident has complaint of left hip pain of 10 at time of assessment. No changes in mental status fro (sic) baseline, unable to perform range of motion to left lower extremity related to pain. Received orders to send to ER (emergency Room) for eval (evaluation). Guardian .called and message left.
10/6/2022 15:13 (02:13 PM) Nurses' Notes Note Text .Refused .shower or bed bath stating .is in to (sic) much pain. Refused to have .skin assessed .states that the bed .is in is to small to move (Resident #102) to much due to fear of falling. Looking into larger mattress.
10/7/2022 09:15 (AM) Transcribed NP/PA Progress Note .Chief Complaint / Nature of Presenting Problem: Pain control History Of Present Illness: Resident is a [AGE] year old female that is being seen today for follow up on her pain control after sustaining (sic) a fall that resulted in a closed trochanteric fx (fracture) of .L femur. (Resident #102) saw ortho in hospital, (Resident #102) and guardian declined surgical repair .has received .abduction pillow to assist with turns as well. Upon exam .is lying in bed. States .is still having some pain but it has improved with increase of Tramadol to TID (three times a day). She also has Tylenol PRN (as needed) Q6H (every six hours) PRN .
10/10/2022 15:27 (03:27 PM) Transcribed NP/PA Progress Note Late Entry .Chief Complaint / Nature of Presenting Problem: pain. History Of Present Illness: Resident . is being seen for follow-up on .pain control after sustaining a fall that resulted in a closed trochanteric fracture of .left femur. Upon exam (Resident #102) is lying (on) back in bed tearful and anxious .states that .pain is better controlled on .current dose of Tramadol 50 mg 3 times daily. Psych consult ordered for increased tearfulness and anxious mood .new abrasions from fall to R (Right) elbow, R thigh, bruising to l arm and L hip .
10/14/2022 06:10 (AM) Transcribed NP/PA (Nurse Practitioner/Physician Assistant) Progress Note Late Entry: Note Text: PATIENT: Medications reviewed, please see MARS (Medication Administration Records). Resident is a [AGE] year-old female that is being seen for follow-up on .pain control, decreased appetite, and depressed mood. Resident was recently put on Tramadol 50 mg (milligrams) every 4 hours for pain. (Resident #102) states that .pain has improved significantly and that the current dose is adequate for .(pain) control. (Resident #102) also recently triggered for a weight loss and decreased appetite. Per facility charting resident is eating about 50% of .meals .states that .appetite is improving .Previously resident was having an increase in depressed mood anxiety and tearfulness. Psych services was consulted. (Resident #102) was put back on .Remeron (an antidepressant) 30 mg once daily at bedtime .PHYSICAL EXAM .General: Chronically ill, debilitated, obese, and bedbound .patient laying back in bed resting wearing gown, abduction pillow (large foam device used to keep legs apart) between legs, appears in no acute distress .abduction pillow in place decreased ROM (range of motion) to LLE (left lower extremity), NWB (non-weight bearing) LLE, Hoyer lift (mechanical lift used to transfer resident) .
10/20/22 11:56 AM, Resident lying in bed awake. Explained that when (Resident #102) gets changed, the aid went to grab .left leg, she (the CNA) swung it around so that (Resident #102) could be held at the edge of the bed, (Resident 102's) body weight flung over and .fell to the ground and [NAME] .(left) hip. states that the aid was alone during the brief change. States .is in pain, usually between 7-10 (out of 1-10 pain scale, 10 being the worst pain). Explained that .cries out in pain when .is changed. Explained .takes Tramadol for pain which helps but is not strong enough.
A review of the October 2022 MAR for Resident #102 revealed the Resident had pain rated from three to nine (1-10 pain scale) daily.
A review of the Care Plan for Resident #102 revealed the following:
Focus-[Resident #102] has an ADL (activity of daily living) self-care performance deficit r/T (related to) CVA (Cerebral Vascular Accident/stroke) with LT (left) Hemiplegia (paralysis). Date Initiated: 01/06/2017 .
Goals-[Resident #102] will maintain current level of function in ADLs through the review date .
Interventions . BED MOBILITY: [Resident #102] requires two assist with turning and repositioning in bed . ADLS . requires 2 person assistance with ADLS
Date Initiated: 10/14/2020 .
A record review of the incident report dated 09/25/2022 for Resident #102 revealed the following:
.Nursing Description: Resident was being assisted with brief change and rolled out of bed while CENA staff was rolling .to clean .backside .
CNA statement: I was rolling (Resident #102) over to clean (Resident #102) up and (they) rolled out of bed.
On 10/21/2022 at 08:54 AM, Resident #18 was in bed awake. Resident #18 was asked about allowing staff to change their brief since 09/25/2022 and stated, I am not letting anyone get in their brief (to change them) again!
On 10/21/2022 at 10:41 AM, the Director of Nursing (DON) was asked about Resident #102 rolling out of bed on 09/25/2022. The DON explained that he was new to the facility and referred this Surveyor to the Corporate Nurse (Corporate RN J).
On 10/21/2022 at 11:12 AM, the Nursing Home Administrator (NHA) was queried about Resident #102 rolling out of bed on 09/25/2022. The NHA also referred this Surveyor to Corporate RN J.
On 10/21/2022 at 12:12 PM, Corporate RN was interviewed in regard to Resident #102's incident on 09/25/2022. The Corporate RN J confirmed that on 09/25/2022, Resident #102 was assisted with a brief change with one CNA, the CNA attempted to grab the Resident's right leg and the leg along with the Resident's body weight flung over the bed on top of the CNA, causing her to be injured as well. According to Corporate RN J, the CNA ended up going to urgent care as a result of her injuries and was suspended from their current job duties. Corporate RN J further explained that because the CNA was hurt, she was involved in the investigation and the CNA would not be allowed to keep her job. Corporate RN J was asked if the CNA had mentioned why she had attempted to move the Resident without help and explained that the CNA had given a reason.
On 10/21/2022 at 02:22 PM, the NHA was queried in regard to CNA's knowing how many persons should be helping with care for Residents and explained that the level of care needed for Resident care was in the [NAME] (a computer system) and that the CNA's have access to and document on the computer program. The NHA was asked about the CNA performing bed mobility care to Resident #102 on 09/25/2022 without assistance from another staff member and explained that the CNA felt she could handle the Resident alone.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
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 nurse remained at the bedside during medicat...
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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 nurse remained at the bedside during medication administration for one resident (R919) of five reviewed for medications, resulting in the resident self-administering medication without an assessment or nurse oversight, and the potential for medication mismanagement. Findings include:
On 1/11/2023 at 10:20 AM, Registered Nurse (RN) A was observed walking out of R919's room and down the hallway back to the medication cart. Upon entering R919's room, the resident was observed sitting up in their wheelchair with a medication cup in front of them that contained 3 small pills. R919 took one of the pills with a sip of water and when asked about it, stated, The nurse just left .She watched while I took the big ones and I can take these small ones myself. R919 was queried regarding what the pills were or what they were for, however, the resident did not know.
On 1/11/2023 at 11:22 AM, the Director of Nursing (DON) was interviewed and queried if R919 had been assessed to self-administer medications. The DON indicated that R919 had not been assessed for that to his knowledge. When queried regarding the expectation of nursing staff during bedside medication administration, the DON stated that nurses should observe residents take and swallow all medications given to them before leaving the room. The DON added that nurses should not leave the room before a resident finishes taking their medication and should not be leaving pills at the bedside.
A review of R919's medical record did not reveal an assessment for medication self-administration. A review of R919's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident is cognitively intact, requires supervision to limited assistance from staff for activities of daily living, and has medical diagnoses that include Heart Disease, Hypertension, Dysphagia, Muscle Weakness, Schizophrenia, Anxiety, and Bipolar Disorder.
A review of the facility's policy/procedure titled, Medication - Resident Self-Administration of, reviewed/revised 01/01/2022, revealed, .A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely .The results of the interdisciplinary team assessment are recorded in the resident's medical record .
A review of the facility's policy/procedure titled, Medication Storage, reviewed/revised 01/01/2022, revealed, .During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0577
(Tag F0577)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to inform residents, families, and visitors of the location of the survey results for eight confidential residents who attended ...
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Based on observation, interview, and record review, the facility failed to inform residents, families, and visitors of the location of the survey results for eight confidential residents who attended a confidential group meeting, resulting in the potential for residents, families, and visitors to be uninformed of the facility's deficient practices.
Findings include:
On 10/19/22 at 3:25 PM, a confidential group meeting was conducted with eight confidential group residents. The group was interviewed and asked about the location of the state survey results and all eight members of the group indicated that they were unaware of the location of the state survey results.
On 10/21/22 at 8:30 AM, a tour of the facility revealed no observed state survey results in the facility.
On 10/21/22 at 8:38 AM, Front desk receptionist B was interviewed regarding the location of the state survey results and stated, I don't know. I'm new here.
On 10/21/22 at 8:40 AM, Assistant Business office manager C was interviewed regarding the location of the state survey results and indicated, I'm not sure. I'm fairly new. Assistant Business office manager C was observed to be looking for the state survey results.
On 10/21/22 at 8:45 AM, the Assistant Administrator (ANHA) A was interviewed regarding the location of the state survey results and was observed to start looking for them. NHA A stated, I know it's supposed to be in plain sight.
On 10/21/22 at 8:48 AM, the Surveyor located a binder containing the state survey results. The binder was observed to be towards the back of a shelf with no label on the shelf indicating that the state survey results were located there.
A facility policy related to the location of the state survey results was not received from the facility by the conclusion 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 numbers: MI00129858, MI00131062, and MI00131427
Based on observation, interview, and record rev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to intake numbers: MI00129858, MI00131062, and MI00131427
Based on observation, interview, and record review the facility failed to monitor and prevent resident-to-resident abuse for two of eight residents (R47 and R138) reviewed for abuse, resulting in a vulnerable resident (R47) being yelled at and slapped in the face, by another resident (R51), resulting in, the potential for injury, pain, mental anguish, and psychosocial harm, and a vulnerable resident (R138) being hit in the forehead by another resident (R414), experiencing a hematoma to their forehead, pain to their right thumb, and the likelihood of mental anguish, and psychosocial harm, utilizing the reasonable person concept.
Findings include:
Resident #47 (R47) and Resident #51 (R51):
On [DATE] at 10:41 AM, A facility reported incident (FRI) report was reviewed and indicated the following, [R47] yelled at and slapped by [R51] . The incident was alleged to have occurred on the Memory care unit on [DATE].
On [DATE] at 11:03 AM, R47 was interviewed regarding the incident involving R51 and stated, [R51] hit me multiple times, I blocked their hits with my arm. R47 denied any injuries from the incident, and when asked how they felt about the incident, stated, I thought oh no not again.
On [DATE] at 9:45 AM, Nurse F was interviewed regarding the incident involving R47 and R51. Nurse F indicated that they had no recollection of the incident. Nurse F stated, [R51] is a fighter.
On [DATE] at 3:05 PM, R51 was met in their room and interviewed about the incident involving themselves and R47. R51 had no recollection of the incident and was unable to answer any questions.
On [DATE] at 3:15 PM, Certified Nurse Assistant (CNA) G was interviewed regarding the incident involving R47 and R51 and stated, I don't remember, I'm sorry.
On [DATE] at 3:19 PM, Memory Care Unit Nurse Manager (UNM) E was interviewed regarding the incident involving R47 and R51. UNM E indicated that during the date when the incident occurred they were working on the 300 unit of the facility. UNM E stated, I was working on the 300 unit during the month of July and am not aware of this incident.
On [DATE] at 4:27 PM, a review of R47's electronic medical record (EMR) revealed that R47 was originally admitted to the facility on [DATE] with diagnoses that included Schizoaffective disorder, Bipolar type and Type two diabetes. R47's most recent minimum data set assessment (MDS) dated [DATE] revealed that R47 had a moderately impaired cognition and required one person assistance with all activities of daily living (ADLs) other than eating.
On [DATE] at 4:41 PM, a review of R51's EMR revealed that R51 was originally admitted to the facility on [DATE] with diagnoses that included Unspecified dementia and Muscle weakness. R51's most recent MDS dated [DATE] revealed that R51 had a severely impaired cognition and required one to two person assistance/supervision with all activities of daily living (ADLs).
Resident #138 (R138) and Resident #414 (R414)
On [DATE] at 3:03 PM, a review of a progress note dated [DATE] in R138's EMR revealed the following, Nurses notes .Note Text: Around 10:40 AM, Writer heard [R138] yelling, 'Help me.' Writer ran to [R138's] room. Writer observed [R138] lying on the bed and [R414] was sitting on the side of the bed hitting [R138's] face with their fist. [R138] was observed trying to cover their face with their hands. Writer immediately separated both residents, Writer redirected [R414] back to their room. Staff was with [R414] while writer was doing assessment to [R138] .Notified NP (Nurse Practitioner) .911 (Emergency number) was called and EMS (Emergency Medical Service) arrived .took [R138] to [Hospital] .
On [DATE] at 10:43 AM, Surveyor attempted to meet with R138 for an interview regarding the incident involving themselves and R414, Surveyor was informed by Nurse F that R138 had recently been sent to the hospital and was not at the facility.
On [DATE] at 10:45 AM, Nurse F was interviewed about the incident involving R138 and R414. Nurse F indicated that they were unaware of the incident.
On [DATE] at 12:35 PM, a phone interview was conducted with Nurse H regarding the incident involving R138 and R414. Nurse H stated, I heard [R138] screaming, I went in [R138's] room and observed [R414] hitting [R138] in the face while [R414] was sitting on the side of [R138's] bed and [R138] was lying down. I separated the residents and assessed [R138]. [R138] had a bump and redness on their forehead and were complaining about pain to their thumb. I contacted the doctor and was advised to send [R138] to the hospital by EMS.
On [DATE] at 3:25 PM, Memory Care Unit Nurse Manager (UNM) E was interviewed regarding the incident involving R318 and R414 on [DATE]. UNM E indicated that they were unaware of the incident on [DATE] and stated, I'm usually on a medication cart, I don't know what's going on because I'm not on the unit.
On [DATE] at 4:18 PM, R138's EMR was reviewed and revealed that R138 was originally admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and Major depressive disorder. R138's most recent MDS dated [DATE] revealed that R138 had a severely impaired cognition and required limited assistance of one person with all ADLs other than eating. R138 was discharged from the facility on [DATE] and sent to the hospital following a fall.
On [DATE] at 4:24 PM, R414's EMR was reviewed and revealed that R414 was originally admitted to the facility on [DATE] with diagnoses that included Unspecified psychosis and Unspecified dementia. R414's most recent MDS dated [DATE] revealed that R414 had a severely impaired cognition and required limited assistance of one person with all ADLs other than eating. R414 expired at the facility on [DATE].
On [DATE] at 2:12 PM, the Administrator (NHA) was interviewed regarding their expectations for preventing resident abuse and monitoring of residents. The NHA stated, Staff should report any concerns to me. I expect all CNAs to monitor and be cognizant of the resident's location. All nurses should be supervising their assigned CNAs.
On [DATE] at 2:45 PM, a facility policy titled Abuse .Date Implemented: [DATE] Date Reviewed/Revised: [DATE] stated the following, Policy: It is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse .Definitions: Abuse means the willful infliction of injury .with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, causes physical harm, pain or mental anguish. It includes .physical abuse. Willful means the individual must have acted deliberately .Physical abuse includes .hitting, slapping, punching .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident was made aware of a facility's bed-hold and ...
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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 that a resident was made aware of a facility's bed-hold and reserve bed payment policy before and upon transfer to a hospital for one resident (R146) of three residents reviewed for hospitalizations, resulting in the potential for denial of readmission or the unexpected incurrence of financial liability.
Findings include:
Resident #146:
A review of R146's Minimum Data Set (MDS) assessment dated [DATE] and medical record revealed that the resident was initially admitted into the facility on 6/22/22, most recently re-admitted on [DATE], and sent to the hospital twice - on 9/15/22 and 10/3/22. Further review revealed that the resident is moderately cognitively impaired, requires supervision to extensive assistance from staff for activities of daily living (ADLs), and has medical diagnoses including, but not limited to, Acute Respiratory Failure with Hypoxia, End Stage Renal Disease, COVID-19, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, Muscle Weakness, Dysphagia, Dysphonia, Cognitive Communication Deficit, Tracheostomy Status, Gastrostomy Status, Hypertension, Dependence on Renal Dialysis, Major Depressive Disorder, and Seizures. The resident's medical record also indicated that R146 was their own responsible party.
A review of R146's progress notes and scanned documents revealed no mention of the resident being provided information regarding the facility's bed hold policy for either hospitalization on 9/15/22 nor 10/3/22.
On 10/20/22 at 1:48 PM, bed hold information for R146 was requested from the facility.
On 10/20/22 at 1:53 PM, the Nursing Home Administrator (NHA) indicated she did not have bed hold information for R146's most recent hospitalization, and no further information was provided.
On 10/21/22 at 3:10 PM, the NHA and Director of Nursing (DON) were interviewed. When queried regarding bed holds, the NHA stated that bed hold information should have been provided to R146 and documented upon transfer to the hospital.
A review of the facility's policy/procedure titled, Bed Hold Prior to Transfer, reviewed/revised 2/1/22, revealed, It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold policies prior to transferring a resident to the hospital .The facility will provide written information about these policies to residents and/or resident representatives prior to and upon transfer for such absences .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R131:
On 10/19/22 at 10:28 AM, R131 was observed in bed awake. R131 explained that they had a vision impairment and could not se...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R131:
On 10/19/22 at 10:28 AM, R131 was observed in bed awake. R131 explained that they had a vision impairment and could not see very well, and further explained that they had a catheter that was irritating them, and making them uncomfortable. R131 further indicated that they didn't want the catheter anymore.
A review of R131's medical record revealed that they were admitted into the facility on 4/23/21 with diagnoses that included Dementia, Respiratory Failure and Diabetes, and had recently readmitted to the facility on [DATE]. Further review of the medical record revealed a Minimum Data Set assessment dated for 9/27/22 revealing a Brief Interview for Mental Status score of 13/15 indicating an intake cognition, and that R131 required extensive assistance of 2 persons for Activities of Daily Living.
Further review of R131's medical record revealed that the resident did not have a catheter care plan in place although a physician ordered the following on 9/26/22, Maintain indwelling catheter 16 fr (French) every shift for Neuromuscular dysfunction of bladder.
On 10/21/22 at 3:14 PM, the Director of Nursing (DON) was asked whether a care plan for a new catheter should be implemented for a resident, in which the DON explained that a care plan should be implemented.
A review of the facility's Comprehensive Care Plan policy revealed the following, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment (Minimum Data Set) . The comprehensive care plan will describe, at a minimum the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being .
Based on observation, interview and record review the facility failed to ensure that residents' comprehensive care plans included a care plan for a colostomy for R6 and a urinary catheter for R131 resulting in the potential for unmet care needs.
Findings include:
Resident R6:
On 10/19/22 at 12:02 PM, R6 was asked about the care received at the facility and reported they had an ostomy bag and had trouble getting the proper bag while at the facility. R6 reported that they used a special order bag. R6 reported they felt that it had been all straightened out with the insurance and medical supply company but had worried they would have to use a bag that did not fit properly and would leak. R6 also reported they were comfortable taking care of their own ostomy and had supplies available bedside.
A review of the facility record for R6 revealed R6 was admitted into the facility 03/30/22. Diagnoses included Colostomy Status and Diabetes. A review of the care plan initiated 03/30/22 and with a last update 10/10/22 revealed no care plan related to the ostomy nor interventions and no specific Diabetes care plan. The at risk for nutritional declines care plan initiated 04/19/22 and revised 10/11/22 documented the Diabetes diagnosis but did not provide a reference to the ostomy status or specific interventions for the ostomy and diabetes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to revise a fall care plan for one sampled resident (R131) of two residents reviewed for accidents following a fall with an inju...
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Based on observation, interview, and record review, the facility failed to revise a fall care plan for one sampled resident (R131) of two residents reviewed for accidents following a fall with an injury resulting in, the potential for unmet care needs and additional falls.
Findings include:
Resident #131:
On 10/19/22 at 10:28 AM, R131 was observed in bed awake. R131 explained that they had a vision impairment and could not see very well. R131 was asked if they had sustained any injuries as they were observed with a sling on their right arm. R131 explained that they had fallen from their bed, causing hospitalization and injury to their shoulder which was in pain.
A review of R131's medical record revealed that they were admitted into the facility on 4/23/21, with a readmission date of 9/21/22 with diagnoses that included Dementia, Respiratory Failure and Diabetes. Further review of the resident's medical record revealed a Minimum Data Set assessment (MDS) dated for 9/27/22 revealing a Brief Interview for Mental Status score of 13/15 indicating an intake cognition, and revealing that R131 required extensive assistance for Activities of Daily Living.
Further review of R131's medical record revealed the following progress notes:
9/19/2022 11:54 (11:54 am) Nurses' Notes. Around 11:30 am. Writer was called to the resident's room by the CNA (Certified Nurse Assistant), The CNA stated that the resident fell on the floor while providing care. Resident observed lying on the floor, on [their] back, parallel to [their] bed. Resident was crying and complaining of severe pain to [their] R (right) arm and shoulder. Resident unable to move R arm, Round, lump on the R outer humerus noted, C/O (complaint of) pain when palpated. Observed small bump on the back of [their] head .Resident is currently on blood thinner. Writer notified [physician], received order to send resident to the ER (emergency room), 911
Further review of R131's medical record revealed that the resident was admitted to the local hospital on 9/19/22 with a final impression of, Other displaced fracture of upper end of right humerus, initial encounter for closed fracture.
Further review of R131's medical record revealed the following fall care plan had not been revised following R131's fall on 9/19/22, Focus: [R131] is at risk for falls related to: impaired mobility, and weakness. Date Initiated: 04/23/2021. Revision on: 02/16/2022. Interventions: Be sure [R131's] call light is within reach and encourage [them] to use it for assistance as needed. Date Initiated: 04/23/2021. Revision on: 08/22/2022. Bed in low position when not providing care. Date Initiated: 04/23/2021. Revision on: 08/22/2022. Ensure [R131] is positioned in center of bed. Date Initiated: 08/06/2021. Revision on: 08/22/2022.
On 10/21/22 at 3:14 PM, the Director of Nursing (DON) was asked about his expectation for care plan revisions, and he explained that the care plan should reflect the patient's current condition.
A review of the facility's Comprehensive Care Plan policy revealed the following, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment (Minimum Data Set) . The comprehensive care plan will describe, at a minimum the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being .
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
This Citation pertains to Intake Number MI00128863.
Based on observation, interview and record review, the facility failed to reposition a dependent resident per professional standards of care for one...
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This Citation pertains to Intake Number MI00128863.
Based on observation, interview and record review, the facility failed to reposition a dependent resident per professional standards of care for one sampled resident (R119) of two residents reviewed, resulting in unmet care needs, the potential for falls, and skin breakdown.
Findings include:
Resident #119:
On 10/19/22 at 11:55 AM, R119 was observed in bed asleep on their back. Due to R119's cognition, they were unable to be interviewed.
A review of R119's medical record revealed that they were admitted into the facility on 1/6/17 with diagnoses that included Cerebral Palsy, Dysphagia, and Other Intestinal Obstruction. Further review revealed a Minimum Data Set assessment dated for 9/15/22 revealing that the resident is severely cognitively impaired, and was totally dependent on facility staff for Activities of Daily Living (ADLs).
Further review of R119's medical record revealed the following care plan, Focus: [R131] has contractures to bilateral upper extremities r/T (related to) history of CP (Cerebral Palsy). Cognitive loss resulting in the need for assist with mobility and ADL's. Date Initiated: 09/19/2019. Interventions: Avoid keeping [R131] in one position for any extended length of time. Date Initiated: 09/19/2019. Revision on: 03/10/2022. [R131] has risk of pressure ulcer development to right outer ankle, and coccyx/buttocks r/T hx (history) of pressure ulcer, Disease process dx (diagnoses) of cerebral palsy, hydrocephalus, muscle weakness, Immobility, Nutritional deficits. Date Initiated: 10/15/2021. Revision on: 09/16/2022. Interventions: Yellow dot program. Date Initiated: 01/26/2022. Revision on: 09/16/2022.
On 10/20/22 at 8:32 AM, R119 was observed lying on their right side, head facing toward the door. R119 remained in this same position at 10:38 AM, 11:51 AM, 1:26 PM, and 2:54 PM.
10/21/22 at 3:14 PM, the Director of Nursing (DON) was asked about the yellow dot program, and he indicated that residents on the program are supposed to be turned and repositioned every 2 hours, which is his expectation.
A review of the facility's Turning and Repositioning policy revealed the following, 1. All residents at risk of, or with existing pressure injuries, will be turned and repositioned unless it is contraindicated due to a medical condition. In this case, small shifts in repositioning will be employed. 3 .The facility has established routine turning an repositioning scheduled consisting of every 2-4 hours .
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** This Citation pertains to Intake Numbers MI00130784, MI00131011, MI00130203, and MI00131281.
Based on observation, interview and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Numbers MI00130784, MI00131011, MI00130203, and MI00131281.
Based on observation, interview and record review, the facility failed to document completed wound care treatments for three residents (Resident #18, #264 and #367) of eight residents reviewed for pressure ulcers (an injury from prolonged pressure of the bony prominence of the skin), resulting in the likelihood of continued prolonged wound healing.
Findings include:
Resident #18
On 10/18/2022 at 09:04 AM, Resident #18 was observed laying in bed on a specialty bed with their feet and lower legs propped on a pillow. Resident #18 was unable to answer questions appropriately.
A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #18 was most recently admitted to the facility on [DATE] with the diagnosis of Acute Respiratory Failure and Cerebral Vascular Accident. Resident #18 had a moderately impaired cognition and needed extensive, two-person assistance with bed mobility and transfers.
A record review of the physician orders for Resident #18 revealed the following:
Left heel: apply betadine to wound, let dry every day shift initiated 09/20/2022.
Right heel; apply betadine to heel and let dry every night shift initiated 10/10/2022.
On 10/21/2022 at 01:57 PM, an observation of the wounds of Resident #18's bilateral heels were made with Wound Nurse K. According to Wound Nurse K, Resident #18 had bilateral heel boots ordered to offload pressure to the heels. Wound Nurse K removed each heel dressing, revealing a hard, black area over each heel. Wound Nurse K stated, It's eschar (nonviable dead skin tissue).
A record review of the October 2022 Treatment Administration Record (TAR) revealed that the treatment to the right and left heel were not documented as being completed for Resident #18 on 10/01-10/02/2022, 10/11/2022 and 10/14-10/15/2022.
Resident #367
A record review of the Progress Notes for Resident #367 revealed the following:
7/23/2022 00:01(12:01 AM) Nursing Evaluation Summary Note Text: Resident arrived to facility via ambulance. Resident alert but unable to communicate due to language barrier. Resident VSS (vital signs stable), no visible sign of distress. Resident has a right chest port, site CDI (clean, dry, intact). Resident has bilateral bruising on both upper extremities. NO edema in lower extremities. Heels boggy, toenails hard, feet elevated with pillow. Resident has colostomy on abdomen and a peg tube. Resident has a Foley catheter in place, wit yellow urine with sediment. Resident has sacral open pressure sore with drainage, and slough noted, dressing in place, open area on left and right buttock. Open area on left lateral knee. No s/s (signs and symptoms) of pain indicated upon assessment.
8/16/2022 15:18 (03:18 PM) Nurses' Notes Note Text: Wound/skin: New right lateral thigh .Unstageable wound noted to right lateral thigh. Wound orders initiated .Catheter anchor placed. LAL (low air loss) mattress, heel lift boots, wedge and yellow dot program in place.
8/24/2022 14:04 (02:04 PM) Nurses' Notes Note Text: Wound/skin: New DTI (deep tissue injury) noted to right heel, 1.9 x 1.7 x 0 cm (centimeter), 100% necrotic tissue, no exudate .Treatment orders initiated .LAL mattress, heel lift boots, roho cushion, positioning wedge and yellow dot program in place.
A record review of the MDS dated [DATE] revealed that Resident #367 was admitted to the facility on [DATE] with the diagnoses of Diabetes Mellitus and a Stage 4 Pressure Ulcer of the Sacral Region. Resident #368 had a moderately impaired cognition, and needed extensive assistance of transfers and bed mobility.
A record review of the August 2022 TAR for Resident #367 revealed the following:
Right medial foot wound-The treatment was not documented as being completed on 08/17/2022 and 08/19/2022-08/22/2022.
Left medial foot wound-The treatment was not documented as being completed on 08/17/2022, 08/19/2022-08/22/2022, 08/24/2022-08/25/2022 and 08/29/202
On 10/21/2022 at 03:27 PM, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) were interviewed in regard to the process of completing wound care from the order to the actual care itself. The NHA explained that there were two wound nurses that do rounds on Monday with the Doctor. The Wound nurses measure the wounds and document in the medical record. The NHA further explained that the nurses that are assigned the unit do the actual treatments and are to document the wound care has been completed in the TAR.
Resident R264
On 10/21/22 at 12:30 PM, Nurse K was asked about the care of R264 and reported R264 was resistant to care at times and did not want to wear the heel boots but would let the wound treatments be done. Nurse K reported they believed R264 knew at what was going on but not always and psych issues got in the way.
On 10/21/22 at 12:50 PM, Nurse U was asked about the care of R264 and reported R264 was so hard to take care of and combative. Nurse U reported the CNAs reported R264 was screaming, yelling and physically fighting and hit the aides when they tried to provide incontinence care and not taking medicine. Nurse U reported the rash to the buttocks was there the first time they cared for R264 and that it did require cream to be applied.
A review of the facility record for R264 revealed R264 was admitted into the facility on [DATE]. Diagnoses included Vascular Dementia with Behavioral Disturbance, Mood Disorder, Hemiplegia (paralysis of one side) and Anxiety Disorder. A review of the Minimum Data Set (MDS) assessment dated [DATE] indicated impaired cognition and the need for extensive assistance for bed mobility, transfer, dressing, toilet use, personal hygiene and bathing. Eating was documented as independent. The nursing care plan dated 09/19/16 documented R264 has and ADL self care performance deficit related to traumatic Brain Injury. (R264) often refuses showers .(revised 03/11/22) and resident has limited physical mobility . and impaired skin integrity related to psoriatic lesions (rash) to face and chest .keep nails trimmed as much as resident will allow .Revised 06/28/16 and 02/21/22 .
and .actual pressure ulcer development to left heel, left elbow, coccyx, right lower back related to decreased mobility (dated initiated 04/09/22, revised 04/22/22) .evaluate, monitor record wound healing . and .has impaired skin integrity in the form of [MASD] moisture associated skin dermatitis (rash) to left buttock, initiated 12/21/22 revised 03/11/22) . A review of the shower and bath documentation for January 2022 revealed not documentation of bathing provided or refused. A review of the Medication Administration records documented daily refusals of medications.
A review of the Treatment Administration Record (TAR) documentation revealed wound treatments were not documented (completed, not available, hospitalized or refused): For February 2022: On 2/8 for the left elbow, 2/16; 2/17; 2/23, 24, 25, 28 for the buttocks; 2/16,17 for the left heel, outer ankle, first toe and fifth toe; For March 2022: For the betadine treatment to all wounds on bilateral feet and ankles 3/14, 15, 16, 22/ 23, and 28 ; For the left ear and bilateral buttocks 3/5, 14, 15, 16; Right lateral ankle 3/23, 3/26; Left lateral ankle 3/30, 31; Left elbow and right medial ankle 3/14, 15, 16; For April 2022: Coccyx 4/17, 24, 26; Left Fifth toe and left/right lateral ankle and right lower back 4/21, 27, 30; Left elbow 4/15, 17; For May: Coccyx 5/3, 4, 5, 6, 7, 8, 14, 15, 17, 19, 20, 21; Left fifth toe, elbow, ankle, Right lateral ankle, right lateral foot and lower back (likely at hospital) 5/3-8; Lower back 5/17, 19, 22, 24, 25; Bilateral buttocks 5/15, 21, 22.
A review of the wound notes revealed an increase in the number of wounds without significant improvement of the existing ones. The wounds were identified by the wound consultant notes: Surgical Note: 01/31/2022, Early deep tissue injury (DTI), 100% Necrotic (dead or dying) Tissue, .7 (centimeters) cm x 1.0 cm x 0.1 cm, Left Elbow, Etiology: Trauma, Bilateral Buttocks etiology MASD lesion condition: Erythema, Erosions, Scales, This patient has wounds located at the left lateral heel and left elbow. The patient has a chronic wound which may or may not heal and may worsen because of chronic comorbidities, restricted mobility, thinning skin, and chronic waxing and waning wounds. 1/31/22 Appearance: Yelling and Swearing;
A wound consult note for 02/07/2022 documented: .wounds left lateral heel-DTI expected to breakdown 1.2 x .7 UTD (depth not known, base not visible), left elbow .8 x 1.1 x .2, left fifth toe 1 x 1.2 x UTD, left lateral malleolus, skin lesion bilateral buttocks. plan for protective dressings and offloading to prevent further breakdown. , 2/14 left) heel 3.5 x 2.2 x UTD, Left elbow 1.7 x 1.3. x .1, Left 5th toe 9 x 1.1 x utd, Buttocks MASD, Left first toe: 1.6 x 2.2 x UTD DTPI (deep tissue pressure injury), Left Ear: trauma .3 x .5 x .1; 2/28 Left lat heel 4.3 x 4.8 x utd, elbow 2.6 x 1.8 x utd, alginate with honey, Buttocks MASD, Barrier Cream; l lat mal 1.3 x. 6, left first toe 3.3 x 2.5, left ear .7 x .5 x utd, left lateral calf: PAD 2.8 x 3.1 R(ight) lat(eral) malleolus (ankle): 1.5 x .9 x utd betadine, R(right) Med(ial) Mal(leaolus): 3.7 x 1.6 x utd PAD (peripheral arterial disease) 70% necrosis, R lateral foot: two wounds with bridge 5.3 x .8 x utd, The patient has wounds found at the left lateral heel, left elbow, left 5th toe, left lateral malleolus, left first toe, left ear, left lateral calf, right lateral malleolus, right medial malleolus, and right lateral foot. I believe the overall prognosis for the patient is poor. Follow-up: follow up at an interval of 1 week. Offloading: continue offloading: turn per facility protocol. Continue low air loss .
A wound consult note for 3/7 documented: .Left Lateral Heel Etiology: PAD/Pressure - Wound Stage: Unstageable Pressure Injury, 6.2 x 5.6 x Utd , betadine, l elbow 3.1 x 2.4 x Utd, bil(ateral) buttocks masd, barrier cream, 5th toe 1.1 x .5 x utd, Left Lateral Malleolus, PAD .9 x 2.1 x utd, Left First Toe PAD 1.1 x 2.4 x utd, L ear triple ABX (antibiotic), Left Lateral Calf 3.5 x 1.6 x Utd, Right Lateral Malleolus 3.4 x 2.0 x Utd, Right Medial Malleolus 2.3 x 2.1 x Utd, collagen, Right Lateral Foot, 1.5 x 2.8 Right Medial Foot 1.6 x 3.6 x utd, 100% eschar (non viable tissue), This patient has wounds at the left lateral heel, left elbow, left 5th toe, left lateral malleolus, left first toe, left ear, left lateral calf, right lateral malleolus, right medial malleolus, right lateral foot, and right medial foot. This patient has diagnoses including (but not limited to): Traumatic Brain Injury, Dementia, Hemiplegia, Muscle weakness, Hypertension, and Hyperlipidemia, etc., which might lead to further degradation or wound chronicity, hindering wound healing. The patient also has the following risk factors: Cognitive Impairment, Dementia, and Limited Mobility that could contribute to the worsening of the pressure injury .
A wound consult note for 5/23/22 documented, .Reason for visit: Consultation for wounds found at the left lateral heel, left elbow, left 5th toe, left lateral malleolus, left lateral calf, right lateral malleolus, right medial malleolus, right lateral foot, right medial foot, right lower back, coccyx, and left intercostal, MENTAL Status: A&O (alert and oriented) x 1, Coccyx Etiology: Pressure injury/ulcer - Wound Stage: 4 - Pressure Injury Dressing used: Calcium Alginate with Honey, Bordered Foam Wound Description: Undermining comments: 1.9 cm from 4-11 (o'clock) Exudate (drainage): Moderate, Serosanguineous Tissue types by percentage: 20% Slough, 80% Granulation, 0% Necrotic Tissue, 0% Hypergranulation Tissue, 0% Eschar, 0% Epithelial Tissue Size, Wound Length (cm ),Width (cm ) Depth (cm ) 4.3 cm x 4.6 cm x 1.6 cm Wound Location: Left Intercostal (back) ETIOLOGY: Open lesion, left elbow in house acquired, right lower back in house acquired, Coccyx in house acquired, medial right foot in house acquired . R264 had 12 wounds total that were considered arterial or pressure related.
A noted by the primary physician on 4/28/22 documented, .Follow-up for R lateral malleolus infected pressure ulcer, completed a 14 day course of Keflex (antibiotic) on 4/22. Wounds remain stable, per wound care nurse, without signs of continued infection. Patient declines physical exam of wounds, does not want to be touched but will allow visual inspection without position change. Patient has remained afebrile. Denies N/V/D (nausea, vomiting, diarrhea) 4/28/2022 12:58
SOC-Skin Explain area(s) (new/existing/size/description/etc.): Coccyx stage IV - 4.4 x 3.7 x 1.4 cm, R lower back UTD- 1.6 x 2.5 x utd, R medial foot PAD- 4.8 x 1.8 x utd, R lateral foot PAD (3 areas)- 3.0 x 9.0 x utd, L calf lateral PAD (3 areas) - 17.3 x 2.1 x utd, R lateral ankle PAD- 3.6 x 3.0 x 0.3 cm, R medial ankle PAD- 1.3 x 1.0 x utd, L foot 5th toe PAD- 1.5 x 2.1 x utd, L lateral ankle PAD- 1.8 x 1.3 x utd, L elbow open lesion- 1.8 x 1.1 x 0.3 cm, L heel UTD- 5.6 x 6.1 x utd, Background/History: long-term, non-compliant with care, treatments, combative, TBI (traumatic brain injury), Contributing diagnoses: sepsis, vascular dementia, TBI, hemiplegia hemiparesis, mood disorder, muscle wasting, atrophy, psoriasis, anxiety disorder, seizures, PVD (periheral vascular disease), delirium, idiopathic progressive neuropathy, hyperlipidemia .
A review of photographs taken post discharge to the hospital of R264's wounds received related to a complaint about wound care revealed: on the coccyx/tailbone area (irregular round wound-with undermined/non-adhered edges), cicatrix/old wound areas to the coccyx, scabs to the fifth toe and between the fourth and fifth toe, dry scaly yellow skin to the feet, thin/muscle wasted lower legs, wounds to the top of the right foot, a facial rash. fingers of digits one to four on the right hand soiled with a brown and black substance and a urinary catheter
A review of the facility policy titled Pressure Ulcer/Skin Breakdown - Clinical Protocol implemented 10/30/2022 did not refer to the daily documentation for the completion of wound care.
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 assess for removal of a urinary catheter following ad...
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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 assess for removal of a urinary catheter following admission to the facility for one sampled resident (R131) of one resident reviewed for catheters, resulting in feelings of discomfort and resident frustration.
Findings include:
Resident #131:
On 10/19/22 at 10:28 AM, R131 was observed in bed awake. R131 explained that they had a vision impairment and could not see very well, and further explained that they had a catheter, that was irritating them, and that they no longer wanted because it made them uncomfortable.
A review of R131's medical record revealed that they were admitted into the facility on 4/23/21, with a readmission of 9/21/22 with diagnoses that included Dementia, Respiratory Failure and Diabetes. Further review of the resident's medical record revealed a Minimum Data Set assessment (MDS) dated for 9/27/22 revealing a Brief Interview for Mental Status score of 13/15 indicating an intake cognition, and revealed that the resident required extensive assistance for Activities of Daily Living.
Further review of the medical record revealed a physician ordered dated on 9/26/22 indicating the following, Maintain indwelling catheter 16 fr (French) every shift for Neuromuscular dysfunction of bladder.
On 10/20/22 at 1:30 PM, LPN (licensed practical nurse) N was asked if R131 had ever complained to them that their catheter was irritating them. LPN N explained that R131 recently had blood in their urine, and their physician put a hold on their [blood thinner] as a result. LPN N further explained that R131 is new to the unit and was not sure how long R131 has had the catheter in place.
On 10/20/22 at 2:15 PM, Unit Manager E for the unit R131 previously resided on was asked about the length of time R131 had their catheter. Unit Manager E indicated that the resident did not have a catheter in place prior to being sent out to the hospital for a fall on 9/19/22.
Further review of R131's medical record did not reveal any catheter assessments since their readmission on [DATE]
On 10/20/22 at 10:36 AM, documentation was requested from the facility regarding R131's catheter, specifically assessments, reason for the catheter, bladder scans, or voiding trials. The facility provided a progress note dated from 2021 with the diagnosis of neurogenic bladder circled in ink, and what appeared to be a physician note which lacked R131's identifying information, was undated, and indicated the following, status post recent urine retention status post recent Foley catheter. No other documentation was received by the end of survey.
On 10/21/22 at 3:14 PM, the Director of Nursing (DON) was asked about their expectation for assessing a resident with a catheter, and he explained that he would have to refer to the facility policy as he did not want to generalize being a new DON at the facility.
A review of the facility's Catherization policy revealed the following, .2. B. Residents who are admitted with an indwelling catheter, or residents who subsequently received an indwelling catheter, will be assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catherization is necessary. 4. Documentation to support decision making will be included in the medical record .b. Assessment of incontinence, including the type, frequency, duration, and complicating factors associated with incontinence 5. Indwelling urinary catheters will be used on a short-term basis, unless the resident's clinical condition warrants otherwise. The Interdisciplinary team, with the support and guidance from the physician, will assure the ongoing review, evaluation, and decision making regarding insertion, continuation, or removal of an indwelling catheter .
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 obtain weekly weights or complete Food Acceptance Repo...
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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 obtain weekly weights or complete Food Acceptance Reports (FAR) for two residents (Resident #113 and Resident #120) of nine residents reviewed for nutrition, resulting in the likelihood of continued weight loss.
Findings include:
Resident #120:
On 10/18/2022 at 10:43 AM, Resident #120 was observed lying in bed in a hospital gown. The Resident was pleasant, but unable to answer questions appropriately.
A record review of the MDS dated [DATE], revealed that Resident #120 was most recently admitted to the facility on [DATE] with the diagnosis of Anxiety. Resident #120 had a BIMS score of 11, indicating a moderately impaired cognition, and needed extensive assistance with transfers and bed mobility.
A record review of the Progress Notes for Resident #120 revealed the following:
04/29/2022 14:22 (02:22 PM) .Nutrition/Hydration Weight gain/loss; Hydration concern: Significant weight loss. 4/28: 150.4 lbs (pounds), 4/18: 148.8 lbs, 4/14: 146.4 lbs, 4/6: 148 lbs 3/30: 152.8 lbs, 3/23: 157.6 lbs .Interventions: 1. 120ml (milliliters) Med plus 2.0 QD(everyday) .started 4/7- good acceptance per resident. 2. Seen by dentist this week. 3. Lactaid milk with all meals. 4. Additional foods in place- extra sandwich at lunches .Weight is trending upward and stable x~3 weeks. Continue to monitor weight weekly. Continue with POC (plan of care). Thrush medication ending 5/2.
5/10/2022 11:21 (AM) Dietary Progress Notes Note Text: WEIGHT WARNING: Value: 143.4 (Lbs) .Resident triggers for significant weight change (-6.2%x 30 days)CBW (current body weight): 5/9: 143.4 lbs, 5/3: 148.6 lbs, 4/14: 146.4 lbs, 3/30: 152.8 lbs 3/4: 163.4 lbs, 2/16: 156 lbs. H/o (history of) weight fluctuations from ~ 140-165 x 180 days .120ml Med plus 2.0 QD to provide 240kcals (kilocalories), 10g (grams) protein. Observed resident at breakfast .consumed some milk and ~50% biscuit with jelly. Resident was asked if .needed assistance at meals and .declined at this time. Resident declined wanting any additional foods at this time. Observed residents hands shaking while trying to eat. Reviewed weight loss with IDT (Interdisciplinary Team)- tremors worsening- nursing to review POC with physician. Screening for therapy is in progress .Recommend increase supplement: 120ml Med plus 2.0 BID (480kcals, 20g protein) to promote weight maintenance .Continue to monitor weight weekly as able. Monitor weight, PO (by mouth)intake, labs and skin and provide nutrition recommendations PRN (as needed).
5/13/2022 14:22 (02:22 PM) .Nutrition/Hydration Weight gain/loss; Hydration concern: Significant weight loss. 5/9: 143.4 lbs, 5/3: 148.6 lbs, 4/28: 150.4 lbs, 4/18: 148.8lbs, 4/14: 146.4 lbs, 4/6: 148 lbs. Interventions: 1. 120ml Med plus 2.0 QD (240kcals, 10g protein) started 4/7- good acceptance per resident. Comments: Continue current interventions in place. Continue to monitor weight weekly. Continue with POC. DON (Director of Nursing) to see if teeth can be pulled - refer to dentist.
6/1/2022 15:05 (03:05 PM) Dietary Progress Notes Note Text: Resident seen for nutrition review .Diet order: regular diet, level 3 texture, regular fluid/thin consistency. 120ml med plus 2.0 BID (480kcals, 20g protein) for additional nutrition support and promote weight maintenance. PO intake is recorded as ~50% at most meals, some varied PO intake noted. At lunch resident ate 100% tuna salad sandwich, 100% side, 50% vegetable, 50% fruit. Spoke with resident .reported she tries to eat some at most meals. Reviewed preferences .reported good acceptance of supplements .Last weight: 5/9: 143.4 lbs .Recommend obtain updated weight to verify weight trend- awaiting monthly weight. Recommend continue with current POC. Will continue to monitor and provide nutritional recommendations PRN.
6/3/2022 11:56 (AM) .Nutrition/Hydration Weight gain/loss; Hydration concern: Significant weight loss. 6/1: 141.4lbs, 5/9: 143.4 lbs, 5/3: 148.6 lbs, 4/28: 150.4 lbs, 4/18: 148.8lbs, 4/14: 146.4 lbs, 4/6: 148lbs. Weight continues to trend downward .Interventions: 1. 120ml Med plus 2.0 BID (480kcals, 20g protein) started 4/7, increased on 5/10- good acceptance per resident. 2. Lactaid milk with all meals- good acceptance. 3. Additional foods in place- extra sandwich at lunches. 4. Followed by psych services every two weeks- medications adjusted. 5. Resident is followed by SLP- diet downgraded to regular diet, dysphagia advanced texture. 6. Labs ordered . Comments: RD (Registered Dietician) spoke with resident-PO intake remains varied, observed at lunch resident consumed 100% sandwich, 100% side, and 50% vegetable, 50% fruit. Resident reported good acceptance of supplements .reported .does need assistance as needed r/T (related to) tremors. Recommend obtain updated weight to verify weight trend. Continue current interventions in place. Nursing notified to provide assistance as needed.
6/16/2022 14:00 (02:00 PM) Dietary Progress Notes Note Text: WEIGHT WARNING:
Value: 138.2 .Resident continues to trigger for significant weight change (-16.6%x 90 days) . CBW: 6/13: 138.2lbs, 6/6: 141.4lbs, 5/9: 143.4 lbs, 5/3: 148.6 lbs, 4/6: 148.0lbs, 3/4:163.4 lbs. 2/2: 156 lbs, 1/6: 167.3lbs .Resident is now receiving hospice services starting 6/15 for comfort measures only .
Coordinated care with hospice services- nurse .Notified of resident cbw, supplements in place and diet order. (Hospice Nurse) recommended monthly weight monitoring and continue with current supplements as tolerated .
10/10/2022 15:42 (03:42 PM) Dietary Progress Notes Note Text: WEIGHT WARNING: Value: 116.9
Res wt (weight) triggers for significant (sic) loss of 9.9# x 30 days, 15.1# x 60 days, 29.5# x 180 days .Resident seen at bedside. Res states .appetite has been poor and .has not felt like eating much. Per FAR, intake varies from refusal to 100%, usually ~ 50%. Res states .enjoys the MedPlus and prefers the supplement to food as it is easier for her stomach to handle. Encouraged res to get more calories and protein from food - res was agreeable to additional snacks added to meal trays .
A record review of the weights of Resident #120 revealed the following:
10/4/2022
116.9 Lbs
09/12/2022
126.8 Lbs
09/02/2022
125.2 Lbs
08/06/2022 136.7 Lbs
07/06/2022
132.0 Lbs
06/13/2022
138.2 Lbs
06/06/2022
141.4 Lbs
05/09/2022
143.4 Lbs
05/03/2022
148.6 Lbs
04/28/2022
150.4 Lbs
04/18/2022
148.8 Lbs
On 10/21/2022 at 01:49 PM, Registered Dietician (RD) D was interviewed regarding the continued weight loss for Resident #120. RD D explained that the Resident gets and accepts a supplement from the nurses. RD D was queried regarding the lack of weekly weights in the medical record for the month of May, despite dietary recommendations to obtain weekly weights to monitor for weight loss. The RD D confirmed the weights were not done and stated, We were still able to assess and review Resident #120 based on observations at meal times.
A review of the facility policy titled Weight Monitoring, revised 01/01/2022 did not address the frequency of monitoring of weights of residents with weight loss.
A review of the facility policy titled Nutritional Management, revised 01/01/2022 stated the following: .Nursing staff shall obtain the resident's height and weight upon admission, and subsequently in accordance with facility policy .
Resident #113:
On 10/18/22 at 12:52 PM, R113 was observed in bed making sounds that were not able to be understood. There was no visible sign that R113 had their lunch. At that time an unidentified Certified Nursing Aide was asked if R113 had lunch and explained that R113 had lunch and that R113 is a one to one assist with meals.
A review of R113's medical record revealed, R113 was admitted to the facility on [DATE], with diagnosis of Stroke. R113's quarterly Minimum Data Set (MDS) assessment noted, an impaired cognition and the required extensive assistance for all other activities of daily living
A review of R113's care plan noted, Focus [R113] has potential for nutritional deficits r/T (related to) medical dx (diagnosis) including disorganized schizophrenia, adult failure to thrive, sequel of cerebral disease, dysphagia, PVD (posterior vitreous detachment), HTN (hypertension), GERD, anxiety, dementia. Mechanically-altered diet; Requires feeding assistance at meals. Has experienced significant weight loss/flux and supplements in place. Diuretic therapy may contribute to weight fluctuations. Date Initiated: 10/03/2017. Revision on: 09/12/2022. Goal: [R113] will maintain adequate nutritional status as evidenced by maintaining weight with weight gain as able and no s/sx (signs and symptoms) of malnutrition, and consuming meals daily through next review date. Date Initiated: 01/12/2019. Revision on: 06/23/2022. Intervention: Monitor FAR and record PO (by mouth) intake. Date Initiated: 04/05/2018. Revision on: 09/19/2022.
A review of R113's, 30 day look back of the FAR's in the electronic medical record was completed and revealed, NUTRITION Amount Eaten, the documentation was missing for either the entire meals for that day or not to have three meals per day. There were eight days not documented for meals and 17 days not documented for three meals of acceptance.
A review of R113's Quarterly Nutrition assessment dated, 9/12/22 noted, 1. Recommend strike out weight 9/9: 123lbs r/T reweight obtained ~5.5lbs weight change x 3 days. 2. Monitor weight weekly to monitor weight trend. 3. Continue with supplements in place to promote wound healing and weight maintenance.
4. Obtain updated labs- CMP. 5. Will continue to monitor and provide nutrition recommendations PRN (as needed).
On 10/21/22 at 1:53 PM, the Registered Dietician was asked about the note regarding a significant weight loss and stated, We believe that outlier. The RD explained that R113's weights were trending up and that they ordered labs and the results showed no concerns. The RD was asked about the inconsonant documentation of R113's FAR's and if they reviewed them. The RD explained that they should be completed and that they do review them.
A review of the facility's policy titled, Weight Monitoring dated 1/1/2022, noted Policy: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as useful body weight or desirable body weight range and electrolyte balance, I don't last their resident's clinical condition demonstrates that this is not possible or resident preference indicate otherwise .
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 implement tube feeding (artificial nutrition by means ...
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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 tube feeding (artificial nutrition by means of a tube inserted into the stomach through the abdominal wall) orders per physician's orders for one resident (Resident #18) of one resident reviewed for tube feeding, resulting in the likelihood of increased weight loss, malnutrition and an over all health decline.
Findings include:
Resident #18:
On 10/18/2022 at 09:02 AM, Resident #18 was observed lying in bed with their eyes closed. When spoken to, the Resident did not respond. There was a tube feeding pole next to the bed with the following tube feeding nutrition bag hanging up: Jevity 1.5 cal, with the date 10/18/2022 and time 6:30 amhand written on the bag. The bag was about 2/3 full and the machine was not on and the pump was not infusing.
On 10/19/2022 at 10:45 AM, Resident #18 was not in the room. The same Jevity tube feeding bag was hanging up on the tube feeding pole in the room. There was no additional fluid that appeared to be missing from the bag since yesterday (the bag was about 2/3 full).
A record review of the Physician Orders for Resident #18 revealed the following tube feeding order:
two times a day Nepro @60 ml/hr (milliters per hour) x 16 hours or until 960 ml administrated, to provide 1728 kcals (calories), 78g (grams) protein, 69 8ml free water. Ordered 10/18/2022.
The previous tube feeding order stated as follows: Jevity 1.5 Cal @80cc/hr x14 hours (0800-1800) (08:00 am-06:00 PM). This order was discontinued on 10/18/2022.
On 10/21/2022 at 12:01 PM, Resident #18 was observed lying in their geri chair in the room. There was no tube feeding bag on the tube feeding pole or pump.
A record review of the Progress Notes for Resident #18 revealed the following:
10/12/2022 16:43 (04:43 PM) Dietary Progress Notes Note Text: WEIGHT WARNING:
Value: 138.7
Vital Date: 2022-10-12 06:41:00.0
-7.5% change [ 8.8% , 13.3 ]
-10.0% change [ 11.1% , 17.3 ]
Resident continues to trigger for weight change (-8.8%x 60 days, -11.2%x 180 days)
EN (enteral/tube feeding) order: Jevity 1.5 @80ml/hr x 14 hrs to provide 1120 ml formula, 1680 Kcals, 71 g protein, 851 ml free water with Auto flush @35 ml/ hr x 14 hrs total daily water 1341 ml .Recommend d/c (discontinue) current EN order.
Recommend Nepro .
On 10/21/2022 at 12:20 PM, Wound Care Nurse K was asked when the resident's tube feeding formula gets hooked up. Wound Care Nurse K was covering the unit and looked in the MAR to clarify when the tube feeding formula should be infusing and stated, I can't tell (what time to hang the tube feeding). It (the tube feeding infusing time) usually tells you when they (the tube feeding formula) get hooked up and when they get taken down.
On 10/21/2022 at 12:23 PM, Registered Dietician (RD) D was interviewed regarding the tube feeding order for Resident #18. RD D was notified of the Surveyor's observation on 10/18/2022 and 10/19/2022 and no observations of any tube feeding formula being infused. The RD D explained that she would follow up with the above observations. RD D was also asked to clarify when the tube feeding formula should be hung up.
On 10/21/2022 at 01:47 PM, RD D approached this Surveyor and stated, (Resident #18) an order for the Nephro to be up at 6 PM, and down by 10 am. RD D was asked why there has not been any Nephro solution hung up for Resident #18 but did not respond. RD D was asked if the facility has Nephro available and stated, We do have it (Nephro tube feeding solution) in the building.
On 10/21/2022 at 01:56 PM, Resident #18 was in their room in bed. Wound Care Nurse K was in the room. A full bag of Nephro tube feeding solution was now infusing. Wound Care Nurse K stated, (Resident #18) wasn't in here (in the room), so I thought I would hang it up since I thought the (new) order said to hang it (the Nephro) up at ten. But was it (the Nephro) supposed to come down at ten?
A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #18 was most recently admitted to the facility on [DATE] with the diagnosis of Acute Respiratory Failure and Cerebral Vascular Accident. Resident #18 had a moderately impaired cognition and needed extensive, two person assistance with bed mobility and transfers.
A record review of the Medication Administration Record (MAR) for October 2022 revealed that Resident #18's tube feeding order changed from Jevity to Nephro formula on 10/18/2022. The MAR revealed no documentation of receiving any tube feeding formula on 10/18/2022 and 10/19/2022.
On 10/18/2022, there was a 0 marked for the 18:00 (06:00 PM) off, and a 9 (other/see note) for 10/19/2022 10:00 (AM) for on.
On 10/21/2022 at 03:29 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were interviewed regarding Resident #18 having a bag of Jevity tube feeding solution in their room, with no observations of any formula infusing. The NHA explained that the RD places the order in the system and it is up to the nurses to carry out the order. The DON further explained that the nurse should be verifying that the orders have the tube feeding solutions and time on the MAR.
A record review of the facility policy titled Feeding Tubes, revised 06/30/2022 revealed the following: .7. Feeding tubes will be utilized according to physician orders .11. Direction for staff regarding nutritional products and meeting the resident's nutritional needs will be provided to include .e. Ensuring that the administration of enteral nutrition is consistent with and follows the practitioner's orders .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide timely respiratory care, including tracheosto...
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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 timely respiratory care, including tracheostomy care and tracheal suctioning, for one resident (Resident #146) of one resident reviewed for tracheostomy care, resulting in the potential for impaired breathing, infection, and/or respiratory distress.
Findings include:
Resident #146:
A review of R146's Minimum Data Set (MDS) assessment dated [DATE] and medical record revealed that the resident was initially admitted into the facility on 6/22/22, most recently re-admitted on [DATE], and sent to the hospital twice - on 9/15/22 and 10/3/22. Further review revealed that the resident is moderately cognitively impaired, requires supervision to extensive assistance from staff for activities of daily living (ADLs), and has medical diagnoses including, but not limited to, Acute Respiratory Failure with Hypoxia, End Stage Renal Disease, COVID-19, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, Muscle Weakness, Dysphagia, Dysphonia, Cognitive Communication Deficit, Tracheostomy Status, Gastrostomy Status, Hypertension, Dependence on Renal Dialysis, Major Depressive Disorder, and Seizures.
A review of R146's physician orders revealed the following order:
- Trach Change. Trach brand: UN75M Trach size: 6 one time a day every 3 month(s) starting on the 20th for 1 day(s) for Routine Trach Care.
Review of the administration record for this order on 10/21/22 revealed that it had not been documented as carried out.
On 10/21/22 at 12:16 PM, this surveyor was waiting to interview R146, as they had been unavailable the previous day due to being at dialysis. R146 came out of the bathroom and ambulated toward their bed. R146 was observed to have thick, cloudy white trach secretions coming out of their tracheostomy tube, secretions on their chest, and secretions in their hair. R146 was also currently in isolation due to testing positive for COVID-19 on 10/13/22. R146's breathing was noted to be very congested at this time. R146 attempted to talk to this surveyor, however, secretions continued to come out of the resident's tracheostomy tube. R146 was asked when they were last suctioned, to which they mouthed the word, Yesterday. R146 indicated they needed to be suctioned now and indicated that they felt as if they had a fever. The dressing for R146's tracheostomy site was noted to be soiled a brownish color. R146 was asked how their breathing felt to which they motioned, So-so, with their hand.
Registered Nurse (RN) E came into the room briefly and was queried about R146 needing to be suctioned. R146 was coughing at this time with a copious amount of secretions pouring out of their tracheostomy tube. RN E was visibly flustered and explained that she was normally the unit manager for the 300 unit but was now working the floor on the COVID-positive unit. RN E appeared very upset and stated that she had 31 patients to take care of, and that the current staffing situation on the unit was Not a good set-up. When queried again regarding R146's need to be suctioned, RN E stated she had checked the resident's oxygen saturation approximately a half hour ago and it was 89%. RN E further stated that she knows the resident needs suctioning but added, I have meds due, residents are calling to have the door unlocked to go out and smoke .it's too much, it's not an ideal setup. RN E was unable to locate all the necessary supplies for suctioning and trach care and when queried, was unable to provide information as to why R146's trach was not changed yesterday per the order, because she was not the nurse who worked on the floor yesterday.
RN E left the room to go gather supplies. R146 was asked if their breathing was asked if their breathing was okay to which the resident shook their head, No. Thick secretions continued to be present in and slowly drain out of the resident's tracheostomy tube.
On 10/21/22 at 12:34 PM, R146 was still waiting to be suctioned. The resident was not in acute distress at this time.
On 10/21/22 at 12:37 PM, RN E entered back into the room with Certified Nursing Assistant (CNA) O and supplies to suction the resident. The suction canister in the resident's room appeared to be half full but not dated. At 12:44 PM, RN E removed the soiled dressing around the resident's tracheostomy tube. R146's right chest central venous catheter (CVC) site dressing was noted to be soiled with trach secretions and was a brownish color. R146's thick, cloudy trach secretions continued to drain and bubble from the tube. RN E was then about to start suctioning R146's tracheostomy when she was queried regarding the resident's vital signs, which had not yet been obtained. The resident's heart rate was noted to be 71 with an oxygen saturation of 93% (both within normal range).
R146's care plan was reviewed and noted to not have a focus area related specifically to their tracheostomy status.
On 10/21/22 at 3:10 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were interviewed. The NHA and DON indicated that staff education regarding tracheostomy care was given prior to their arrival to the facility (Inservice sheets indicated education was provided in December of 2021). When queried regarding the provision of suctioning, tracheostomy care and monitoring of trach residents, the NHA and DON both indicated they would expect a tracheostomy resident - especially if positive for COVID-19 - to be frequently monitored, provided suctioning and trach care as needed and per order, as well as have their trach changed per order.
A review of the facility's policy/procedure titled, Tracheostomy Care-Suctioning Procedure, reviewed/revised 1/1/22 revealed, Tracheal suctioning is performed by a licensed nurse to clean the throat and upper respiratory tract of secretions that may block the airway .
CONCERN
(D)
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 Number MI00129065.
Based on interview and record review the facility failed to consistently com...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00129065.
Based on interview and record review the facility failed to consistently compete dialysis pretreatment, for one resident (Resident #313) of four residents reviewed for dialysis.
Findings include:
The allegation listed on the intake alleged Details: It was alleged staff failed to administer the resident's dialysis treatments as ordered.
Resident #313:
A review of the closed record for R313 noted, R313 was admitted to the facility on [DATE] with diagnosis of End Stage Renal Disease and discharge on [DATE]. R313's Minimum Data Set (MDS) noted, R313 with an intact cognition 15 and required extensive assistance of one staff for activities of daily living.
6/27/2022 18:42 Nurses Note Text: Resident unable to get dialysis today due to malfunctioned access port. Appointment made by the dialysis nurse for resident to go to the dialysis access center. Resident to be picked up on Wednesday 6/29/22 at 6 am for appointment.
A review of R313's scanned dialysis pre/post treatment forms noted that the pretreatment sections were not completed prior to R313's dialysis treatment. The post treatment from the dialysis center were completed. The run time for treatment was noted to be completed as scheduled.
The forms were reviewed from 5/22/22 to 7/1/22 and noted the following without the pretreatment side completed. 5/22/22, 5/25/22, 5/30/22, 6/10/22, 6/29/22. 5/27/22 6/1/22 and 6/3/22, were fully completed.
A review of R313's care plan noted, Focus The resident needs dialysis hemodialysis r/T (related to) Renal failure Date Initiated: 06/01/2022. Revision on: 06/01/2022. Goal: The resident will have no s/sx (signs or symptoms) of complications from dialysis through the review date. Date Initiated: 06/01/2022. Revision on: 06/01/2022. Intervention: Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis three times weekly MON, WED, and FRI Date Initiated: 06/01/2022 Revision on: 06/01/2022. Monitor VITAL SIGNS daily, pre and post dialysis, and PRN (as needed) notify MD (medical doctor) of significant abnormalities. Date Initiated: 06/01/2022 Revision on: 06/01/2022.
On 10/21/22 at 3:30 PM, the Nursing Home Administrator was asked the facility's expectation regarding the completion of the dialysis pretreatment section and stated, To be completed to policy.
A review of the facility's policy titled., Care Planning Dialysis Special Needs dated, 01/01/2022 noted, Policy: this policy. Will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the residents goals and preference, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving dialysis . 3. Interventions will include, but not limited to: a. Documentation and monitoring of complications, b. Pre- and post- weights, Assessing, observing, and documenting care of access sites, as applicable . f. Vital signs . 4. Nursing staff will provide a repot to the dialysis provider regarding the resident's condition and treatment provisions each dialysis treatment day, and as needed .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pain medication per order for one resident (R912) of five r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pain medication per order for one resident (R912) of five reviewed for medications, resulting in the potential for ineffective pain management. Findings include:
On 1/10/2023 at 1:25 PM, R912 approached the State Agency (SA) with concerns about living in the facility. R912 stated they were, Sick of this place, and that approximately three weeks ago in December, the facility was, Out of, the resident's scheduled Percocet (opioid pain medication, used for moderate to severe pain) for two days. R912 explained that they take the medication around the clock and added that they have lung cancer.
A review of R912's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was most recently re-admitted into the facility on 8/2/2022 with medical diagnoses of Hypertension, Diabetes, Depression, Cellulitis, and Muscle Weakness. Further review revealed that the resident is cognitively intact and requires supervision to limited assistance from staff for activities of daily living. A review of R912's care plan revealed, The resident prefers to have pain controlled medications. Date Initiated: 06/17/2022.
A review of R912's Medication Administration Record (MAR) for December 2022 revealed the following active medication order:
-Percocet Tablet 10-325 MG .Give 1 tablet by mouth every 4 hours for pain -Start Date- 11/24/2022.
Further review revealed that the scheduled 1200, 1600 (4 PM), and 2000 (8 PM) doses on 12/24/2022 and the scheduled 0000 (midnight), 0400 (AM), 0800 (AM), 1200, and 1600 doses on 12/25/2022 were not administered to the resident. To summarize, R912 did not receive eight consecutive doses of their scheduled opioid pain medication over the course of two days. The corresponding progress notes in R912's medical record revealed that nursing staff was waiting for pharmacy to deliver the medication.
On 1/11/2023 at 10:40 AM, the Director of Nursing (DON) was interviewed and queried regarding R912's missing doses of Percocet on 12/24/22 and 12/25/22. The DON stated that he would not expect the resident to have missed any doses unless the resident refused to take them, and indicated he would look further into the matter.
On 1/11/2023 at 12:00 PM, the DON was again interviewed and indicated he did not have an answer as to why R912 missed consecutive doses of their scheduled pain medication. The DON explained there was no documentation found that the resident refused the medication and stated that staff should have been able to administer from the back-up supply while awaiting a delivery from pharmacy. The DON stated, Not sure why that didn't happen.
A Pharmacy Services policy was requested from the facility on 1/11/2023 at 1:01 PM, however only policies related to medication self-administration, medication storage, and medication regimen reviews were provided in return. These policies were reviewed but did not address missing doses of medication nor ordering medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to fully follow-up on an identified Medication Regimen Review (MRR) co...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to fully follow-up on an identified Medication Regimen Review (MRR) concern for one resident (Resident #146) of five residents reviewed for unnecessary medications, resulting in the potential for adverse side effects.
Findings include:
Resident #146:
A review of R146's Minimum Data Set (MDS) assessment dated [DATE] and medical record revealed that the resident was initially admitted into the facility on 6/22/22, most recently re-admitted on [DATE], and sent to the hospital twice - on 9/15/22 and 10/3/22. Further review revealed that the resident is moderately cognitively impaired, requires supervision to extensive assistance from staff for activities of daily living (ADLs), and has medical diagnoses including, but not limited to, Acute Respiratory Failure with Hypoxia, End Stage Renal Disease, COVID-19, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, Muscle Weakness, Dysphagia, Dysphonia, Cognitive Communication Deficit, Tracheostomy Status, Gastrostomy Status, Hypertension, Dependence on Renal Dialysis, Major Depressive Disorder, and Seizures.
A review of R146's recent medication regimen reviews (MRR) revealed the following:
-MRR Date: 6/23/2022 .This resident is receiving risperidone and metoclopramide, which may cause tardive dyskinesia and other movement disorders. Please complete an AIMS assessment to monitor for extrapyramidal side effects, and consider scheduling a psychiatry consult to assess risperidone use. No follow-through documentation was noted.
-MRR Date: 9/24/2022 .This resident is receiving metoclopramide, which may cause tardive dyskinesia and other movement disorders. Please complete an AIMS assessment to monitor for extrapyramidal side effects. No follow-through documentation was noted.
A review of R146's progress notes revealed the following:
-9/27/2022 11:12 (AM) .Last AIMS completed (admission/quarterly/change): Done on admission .
-10/14/2022 13:29 (1:29 PM) .Last AIMS completed (admission/quarterly/change): In process .
No full AIMS assessment was found upon review of R146's record.
On 10/20/22 at 3:00 PM, the facility was asked to provide all AIMS assessments for R146.
On 10/21/22 at 9:21 AM, the Nursing Home Administrator (NHA) stated via email that she was unable to locate any AIMS assessments for R146.
On 10/21/2022 at 10:35 AM, the NHA sent further email correspondence which read, No AIMS assessment was due on this resident because [they are] not on any antipsychotics, [they are] on an anti-depressant.
On 10/21/22 at 3:10 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were interviewed. When queried regarding the expected response to an MRR concern from pharmacy, the DON stated he would have to refer to the facility's policy.
A review of the facility's policy/procedure titled, Addressing Medication Regimen Review Irregularities, reviewed/revised, 1/1/22, revealed, .The pharmacist must report any irregularities to the attending physician, the facility's medical director and director of nursing, and the reports must be acted upon .The attending physician must document in the resident medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to place a stop date for as needed (PRN) medications for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to place a stop date for as needed (PRN) medications for four residents (Resident #102, Resident #120, Resident #264 and Resident #266) of five residents reviewed for unnecessary medications, resulting in the prolonged use of psychotropic medications.
Findings include:
Resident #102:
On 10/20/2022 at 11:59 AM, Resident #102 was lying in bed awake. Resident #102 was queried about the care received in the facility and stated that the were on one milligram of Xanax (an antianxiety medication) but had not received it for a few days and they felt anxious (because of not receiving it).
A record review of the Minimum Data Set (MDS) assessments revealed the Resident was most recently admitted to the facility on [DATE] with the diagnoses of Displaced Intertrochanteric Fracture of Left Femur (hip fracture) and Diabetes Mellitus. Resident #102 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognition, and needed extensive, two-person assistance with bed mobility and transfers.
A record review of the Physician Orders revealed the following order:
Xanax 1 milligram (mg) every eight hours as needed, ordered 09/29/2022. There was no stop date to indicate when to stop using the medication.
Resident #120:
On 10/19/2022 at 01:17 PM, Resident #120 was resting quietly in bed with their eyes closed.
A review of the Physician Orders revealed the following order for Resident #120:
Ativan 1 mg every four hours as needed, ordered 06/27/2022.
A record review of the MDS dated [DATE], revealed that Resident #120 was most recently admitted to the facility on [DATE] with the diagnosis of Anxiety. Resident #120 had a BIMS score of 11, indicating a moderately impaired cognition, and needed extensive assistance with transfers and bed mobility.
On 10/21/2022 at 08:51 AM, Resident #120 was observed in bed resting with their eyes closed.
On 10/21/2022 at 09:27 AM, the Social Worker (SW) L was interviewed regarding the process on ordering psychotropic medications. SW L stated, The nurses are supposed to put the orders in. We (Social Workers) cannot put orders in. SW L was asked about as needed psychotropic medication having a stop date and stated, The nurses are supposed to be putting a 14 day stop date on those (orders).
On 10/21/2022 at 03:30 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were interviewed regarding psychotropic medications. The NHA explained that the behavior health team writes the orders but was not sure about putting the stop date in the order.
Resident Resident #266 and Resident #264:
On 10/18/22 at 11:24 AM, R266 was observed to be hunched down in their bed with the head of the bed up 30-45 degrees. R266 reported they were tired of sitting in the same spot and it was difficult to move on their own.
On 10/19/22 at 9:43 AM, a medication pass observation was completed with Nurse U for R266. A review of the medication orders for R266 revealed a physician order for Ativan/Lorazepam 0.5 milligrams every fours as needed. The order did not have a 14 day review/stop date.
A review of the record for R266 revealed R266 was admitted into the facility on [DATE]. Diagnoses included COVID 19, Debility and Anemia.
A review of the facility record for R264 revealed R264 was admitted into the facility on [DATE]. Diagnoses included Vascular Dementia with Behavioral Disturbance, Mood Disorder, Hemiplegia (paralysis of one side) and Anxiety Disorder.
A review of the medication orders for R264 revealed an order dated 01/18/22 which documented, Inject 1 milligram (mg) intramuscularly every 24 hours as needed for anxiety related to mood disorder due to known physiological condition. The order did not include a 14 day stop date.
On 10/21/22 at 12:06 PM, a review of the orders for R266 and R264 was completed with the social workers. It was confirmed the orders for Ativan as needed should have a 14 day stop date.
A review of the facility policy titled Medication-Psychotropic revised 01/01/2022, revealed the following: .1. A psychotropic drug is any drug that effects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressant, anti-anxiety, and hypnotics .8. PRN orders for psychotropic drugs shall be used only when the medication is necessary to treat the diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days) .
CONCERN
(D)
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, interview and record review, the facility failed to store medications safely for two residents (Resident #...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store medications safely for two residents (Resident #70 and Resident #364), resulting in random medication being found in Resident rooms with the likelihood of unsafe, self administration of medication.
Findings include:
Resident #364:
On 10/18/2022 09:44 AM, during the initial tour, Resident #364 was observed dressed and groomed sitting on the edge of their bed. The Resident was alert and oriented and had clear speech. There were three red pills in a cup on the bedside table. The pills were red with black writing on them. The Surveyor asked Resident #364 about the pills and stated, The nurse gave me those last night, I didn't take them. I don't know what they are.
On 10/18/2022 at 10:02 AM, Nurse A was observed at the medication cart outside of Resident #364's room and was queried about the medications at Resident #364's bed side. Nurse A came in the room and immediately removed pills without answering the Surveyors questions. The Nurse was asked to follow up on what or who the pills were for but never did.
On 10/19/2022 at 01:28 PM, an observation of Resident #364's medication in the medication cart revealed no prescribed red pills that was found in the room of Resident #364.
A review of the facility policy titled Medication Storage dated 01/01/2022 revealed the following: .a. All drugs and biological's will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls .c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage/area.
Based on observation, interview, and record review the facility failed to ensure medication were secured in a locked medication cart and properly labeled, for two residents (R20 and R364) reviewed for medication. Findings included:
On 10/18/22 at 10:40 AM, R20 was observed in bed lying down on their back. R20 was a question about their stay at the facility and did not respond. The roommate stated that R20 does not talk a lot. Observed on the floor between the window and R20's bed was a plastic bag with medication. The bag was observed to have an eye dropper that was labeled, Brimobidine 0.2% ophth q8hrs along with R20's name and other information on it. A review of R20's medical record noted, an physician orders for the same medication.
On 10/18/22 at 10:40 AM, the assigned Nurse (Nurse M) was asked to review the medication that was observed on the floor of R20's room and explained they were not sure how this was left in the room.
A review of R20's medical record noted, R20 was admitted to the facility on [DATE] with diagnosis of Medically Complex Conditions. A review of R20's Minimum Data Set (MDS) revealed R20 with an impaired cognition and required two staff for assistance with activities of daily living.
Based on observation, interview and record review the facility failed to ensure insulin was dated when opened for two of four medications carts reviewed resulting in the potential for decreased efficacy of the medication. Findings include:
On 10/19/22 at 7:57 AM, the 600 unit medication cart was reviewed with Nurse M. During the medication pass observation a Novolog/aspart insulin pen was used to administer the insulin, The insulin pen was dated for 08/25/22. Additional review of the insulin revealed a second Novolog pen dated for 09/05/22, a vial of Lantus/Glargine insulin not dated when opened and an opened vial of aspart insulin dated 09/14/22. Nurse M confirmed the insulin's are dated when opened and good for 28 days.
On 10/19/22 at 9:43 AM, the 800 unit medication cart was reviewed with Nurse U. A vial of Lispro/Humalog insulin had not been dated when opened.
A review of the package insert information at Drugs.com revealed: .Insulin Lispro Injection prefilled pens should be stored at room temperature, below 86°F (30°C) and must be used within 28 days or be discarded .Storing opened (in use) Lantus: Store the vial in a refrigerator or at room temperature and use within 28 days .Storing opened (in use) Novolog: Store the vial in a refrigerator or at room temperature and use within 28 days .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure that three confidential group residents were offered bedtime snacks of eight residents reviewed for snacks, resulting in feelings of ...
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Based on interview and record review the facility failed to ensure that three confidential group residents were offered bedtime snacks of eight residents reviewed for snacks, resulting in feelings of dissatisfaction and the potential for feelings of hunger.
Findings include:
On 10/18/22 at 3:08 PM, a review of resident council meeting notes for the months of July 2022 through October 2022 revealed that residents had concerns with bedtime snacks not consistently being brought to all units of the facility and Not offered to each room or passed out.
On 10/19/22 at 3:25 PM, a confidential group meeting was held with eight confidential group residents. Three members of the group indicated that bedtime snacks were not being offered and/or distributed to them. One of the three residents who mentioned bedtime snacks, indicated that they were not able to get a banana for their bedtime snack.
On 10/20/22 at 11:23 PM, a review of bedtime snack documentation for the past thirty days in the three confidential residents' electronic medical record (EMR) revealed that two of the residents had no bedtime snacks documented as being offered to them and one of the residents had documentation of being offered a bedtime snack on three out of a possible thirty days.
On 10/21/22 at 1:42 PM, Registered Dietician (RD) D was interviewed regarding their expectations for residents being provided bedtime snacks. RD D stated, The kitchen provides snacks and delivers them to the units. Nursing is supposed to pass the snacks out.
On 10/21/22 at 1:58 PM, the Administrator (NHA) was interviewed about their expectations for offering bedtime snacks to residents and stated, It's a work in progress. Dietary is bringing the snacks to the units now and we are working on offering and documenting that bedtime snacks are being offered to the residents. I'm hoping that the new Director of Nursing (DON) can help me with this.
On 10/21/22 at 2:26 PM, a facility policy titled Frequency of Meals Date Implemented: 07/31/2020 Date Reviewed/Revised: 01/01/2022 was reviewed and stated the following, 4. For those residents who desire to eat at non-traditional times or outside of scheduled meal service times .suitable, nourishing .snacks will be provided .5. Nutritious snacks .fruit shall be available on the nursing units .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
This Citation pertains in part to Intake Numbers MI00128992 and MI00129791.
Based on observation, interview and record review, the facility failed to clearly identify/label an isolated room, and faile...
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This Citation pertains in part to Intake Numbers MI00128992 and MI00129791.
Based on observation, interview and record review, the facility failed to clearly identify/label an isolated room, and failed to don Personal Protective Equipment (PPE) correctly in the Covid units (designated units housing residents with the Coronavirus), resulting in the likelihood of continued spread of the Coronavirus.
Findings include:
On 10/18/2022 at 01:28 PM, after touring a long term care unit, this Surveyor began to tour the Presumptive/Under Investigation (PUI) unit just down the hall way. Upon entering, there was a cart with various PPE in it. There was red tape on the floor after passing a row of rooms. About 10 feet from the previous line of tape, was another red taped line. An Unidentified Nurse was at a medication cart and was queried as to which residents were in isolation. According to the Nurse, the Unit housed PUI residents in the front, but towards the back of the unit, were residents that had tested positive for the Coronavirus. The Nurse also explained that the residents that were in transmission based isolation precautions (TBP) would have isolation signs on the doors prior to entering the rooms.
On 10/18/2022 at 01:34 PM, this Surveyor entered the first room following the first line of tape. There were two blue visitation signs randomly placed on the door, the door was open. Inside the room, there were two residents, one was sleeping, while one was up dressed and groomed in their wheelchair. The Confidential Resident was alert and oriented and was queried about the care received in the facility. According to the Confidential Resident, they were abruptly told to change rooms because they had tested positive recently with the Coronavirus. The Confidential Resident was asked when they tested positive and stated, Yesterday, but I just feel like I have allergies.
On 10/18/2022 at 01:39 PM, this Surveyor completed hand hygiene and exited the room. The Unidentified Nurse was still at the medication cart and was queried as to which rooms were to be in isolation. The Nurse explained that they were not aware that the Confidential Resident was in isolation because they (the Resident) were new to the unit.
On 10/20/2022 at 08:48 AM, while entering the hallway with the PUI unit, the first few rooms indicated the residents were not in isolation. After the first few rooms, there was one newly taped red line on the floor, indicating the start of the PUI unit. The doors following the taped line had an isolation sign illustrating what PPE to wear upon entering the room. There was a donning station prior to entering the rooms.
On 10/20/2022 at 02:12 PM, the Infection Control Preventionist (ICP) was queried in regard to the PUI unit having residents on it that were positive with the Coronavirus. According to the ICP, their original Covid unit was full and they needed to place some of their residents that had tested positive somewhere so they expanded their PUI unit. The ICP was queried as to what staff are to wear when entering rooms with positive residents and explained that staff should be wearing a N 95 mask, face/eye covering, gloves and gown. The ICP was made aware of this Surveyor's occurrence of entering a room on 10/18/2022 with positive residents without PPE on related to no proper signage on the door. The ICP stated, The residents that tested positive should have signs on their door. The ICP further explained that they (the facility) had identified the staff were not always properly donning the correct PPE and did do some inservicing this month regarding PPE use.
FACILITY
Infection Control
On 10/18/22 at 10:10 AM, during a care observation with R150 with two CNAs, the CNAs were observed to remove and don gloves without hand hygiene between the glove changes.
On 10/18/22 and on 10/19/22 Nurse W was observed on the COVID isolation unit wearing a surgical style mask. An N 95 was to be worn on the unit.
On 10/19/22 at 10:57 AM, R54 and R79 were interviewed about the care at the facility. R54 reported they had tested for COVID a week ago Thursday and R79 did not and was moved out to the 600 unit. R79 reported they subsequently tested positive and moved back into the room with R54. R79 reported the roommate they had on 600 then tested positive and was moved to the isolation unit.
On 10/21/22 at 6:15 AM, Nurse X was observed to exit the 700 isolation unit in their PPE and enter the nursing office and return to the 700 unit. It was unknown if the nurse had been in any room on the isolation unit.
A review of the Infection Surveillance policy revised 01/01/22 revealed, A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. It's purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections .
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 maintain a dignified existence throughout the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a dignified existence throughout the facility and for a confidential group (Resident Council) of 13 residents as well as failed to meet the needs/requests of a resident (R921) in a timely manner, resulting in diminished quality of life, and resident feelings of frustration, dissatisfaction, and decreased self-worth. Findings include:
On 1/10/2023 at 2:00 PM, the regularly scheduled Resident Council meeting was observed, facilitated by the Activities Director (AD). The AD queried the group regarding customer service concerns. Two group members indicated that the dietary staff serving food at meals in the East dining room do not make them feel welcome, and as a result, they eat in their respective rooms. The group members indicated they would like to eat in the dining room but don't because of staff's attitude.
On 1/10/2023 at approximately 2:30 PM, the AD ended her facilitation of the meeting and exited so that the confidential group members (13 total) could speak with the State Agency (SA). When queried regarding concerns at the facility, the group members agreed overall that the staff at the facility, Could use more training. The group members elaborated with the following:
-One group member stated that she, Constantly hears residents calling out for aides, for help . and although it may be the same residents calling out over and over, she has witnessed staff stand in the hallway and make fun of the residents instead of going to help them.
-Group members stated they, Don't know who people (staff, etc.) are, because they do not wear name tags, and that staff does not tell the residents who they are when they enter their rooms. One member added, I tell them, if you can't tell me what your name is, get out of here!
-One group member stated, It seems like you get on their nerves when you go to them (staff) about a problem, and indicated she felt that Administrative staff seemed, Unapproachable. The member also stated she felt that staff plays, Favorites, with residents.
-One group member stated, They get all my money and they're not even doing anything for me. I get mad, then I don't act nice! .They don't even know how to comb my wig. They tell me it's not my place to tell them how to do it .They all got a nasty attitude and don't work together.
-Group members stated they had previously witnessed staff sleeping in various parts of the facility. One member stated they saw a staff member sleeping in the activity room located between the 700 and 800 unit, and another member stated they witnessed another staff member sleeping in one of the dialysis chairs.
-One member stated, I have learned to have no expectations, that way, I am not disappointed.
-One member stated that she needs to call out, Hello, to get some help to her room. The member added, They just don't answer the call light.
-One member stated that staff always checks on his roommate but never checks up on him. He stated, They just assume I can do everything by myself. Last night I had to change my own bed (due to incontinence) because no one came to check on me.
-The Group overall agreed that many of the nurse aides (CNAs) at the facility, Lack respect and courtesy .
-One member stated that staff at night time is loud, chattering, in the hallways, and added, They don't care about us trying to get some rest at all. Other group members agreed.
-One member stated that her negative experiences at the facility, Far outweigh, the positive.
On 1/10/2023 at 3:19 PM, three female staff members were observed standing in the common area between the 500/600 unit (near a wall desk unit). Two of the staff members were wearing black scrubs and one was wearing a blue top with black scrub pants. Two of the staff were on their cell phones and talking with each other about their schedules. Two residents in wheelchairs were noted in their vicinity at this time. Two call lights were noted to be on at this time as well - one was on in the 500 hallway and one was on in the 600 hallway. None of the staff were observed to be wearing name tags.
On 1/11/23 at 9:07 AM, the call light for R921 was observed to be activated above the resident's door. R921's room was observed to be the farthest room from the nurses' station on the 400 unit, all the way at the end of the hall. R921 was also observed to be under transmission-based precautions, with signage on the door and personal protective equipment (PPE) outside of the room. Record review at this time revealed that the resident was under contact/droplet precautions due to being positive for COVID-19 (infectious respiratory virus) and was currently the only resident occupying the room. R921 was observed sitting up in bed and was noted to have a tracheostomy and feeding tube. R921 was asked from the doorway if they had been waiting a while for someone to come help them. R921 was unable to speak and began making frustrated motions with their arms and face. R921 was attempting to reach their bedside table but was unable to.
On 1/11/2023 at 9:12 AM, Certified Nursing Assistant (CNA) J went to the doorway of R921 to see what the resident needed. CNA J told the resident it would be a second and began putting on PPE to enter the room. When asked if she was the assigned aide for R921, CNA J indicated that she was not, and just came to answer the call light. CNA J indicated the resident's assigned aide was likely collecting breakfast trays.
On 1/11/2023 at 9:18 AM, the call light screen at the 400 unit nurses' station was observed with the following: 1/11/2023, Bed 2 Alarm, 8:20 AM, and was colored yellow. Licensed Practical Nurse (LPN) B was nearby and queried at this time if a call light was colored yellow on the screen, if that meant it was active, and if the time noted was the time the call light was activated. LPN B seemed unsure but looked down the hallway and noted that R921's call light was on. LPN B then asked Unit Clerk D about it, who confirmed that yellow on the screen means an active call light and that 8:20 AM was the time that R921's call light had been turned on. A review of R921's record revealed that R921 was in Bed 2.
On 1/11/2023 at 9:25 AM, R921's yellow section on the call light screen was now gone, and the resident's call light was now observed to be off in the hallway above the door.
A review of R921's record revealed that the resident was initially admitted into the facility on [DATE] and most recently re-admitted into the facility on 1/9/2023 as a hospice patient with laryngeal carcinoma as well as positive for COVID-19.
On 1/11/2023 at 9:30 AM, LPN G was observed walking down the hallway with no visible name tag on. When queried where it was, LPN G stated, It probably fell off.
On 1/11/2023 at 9:37 AM, Unit Manager LPN C was observed near the 400 unit nurses' station with no visible name tag.
On 1/11/2023 at 9:38 AM, a female staff member outside of the 300 unit, filling an ice cooler, was observed with no name tag on.
On 1/11/2023 at 9:39 AM, CNA K was observed on the 300 unit (locked memory care unit) with no visible name tag on. Registered Nurse (RN) L was observed on the 300 unit to have her name embroidered on her scrubs, however, a female staff in dark blue scrubs working with her had no visible name tag on.
On 1/11/2023 at 10:17 AM, a female staff member with a blue top on was observed with no visible name tag. The staff member was in front of the 400 unit nurses' station talking to a male resident. At 10:40 AM, the female staff member (CNA F) was observed with a piece of tape on her shirt with her name and title written on it.
On 1/11/2023 at 10:25 AM, multiple residents from the confidential group meeting were observed facilitating their own exercise program in the East dining room. Activities Aide M was present at one of the nearby tables in the dining room with the group but was noted to be disengaged with the residents and using her cell phone. Activites Aide M quickly put her cell phone down when she saw this surveyor.
On 1/11/2023 at 10:40 AM, the Director of Nursing (DON) was interviewed and queried regarding staff wearing visible name tags while in the facility. The DON stated the facility had a town hall meeting this morning and part of that included identifying the staff who have name tags and those who need them. The DON stated, Staff are aware they need a name tag so colleagues, residents, family can identify them. The DON elaborated and stated that it is important to be able to identify those who give good service, and those who give service the facility does not expect.
When queried regarding staff being on their cell phones in front of residents, the DON stated, In front of residents should never happen. The DON stated that staff shouldn't have their cell phones out unless they are in a designated break area, which does not include the nurses' station. The DON acknowledge this is an ongoing issue and that the facility is considering bringing back a walkie talkie system to eliminate the need for phones altogether. The DON concluded, You can go to the break area and look at your phone but not when in patient care areas .Not acceptable.
When queried regarding expectation for answering call lights, the DON indicated that, Ideally, call lights would be answered immediately, but the expectation is that they are answered within 20 minutes. The DON stated, Beyond 20 minutes is a problem.
When queried if he was aware of any residents who feel as though staff at the facility have an attitude, the DON stated that this is something he has identified and heard from residents. The DON explained that he has heard residents state that they feel like staff can see standoff-ish, as though they don't have time to help, and as if they have something more important to do than their job. The DON stated, That is not acceptable here. [Everyone] is aware of this .and the expectation is, This is our community now.
When queried regarding any staff being found sleeping on the job, the DON acknowledge that, Several staff members, had been found sleeping on the job and were immediately terminated. The DON added, The problem previously was that no one was providing oversight of staff. Standards were not established, but now they are. The DON concluded by stating that the facility was now fully staffed with nurse managers, as they had not been previously.
On 1/11/2023 at 11:28 AM, the Assistant Nursing Home Administrator was observed walking down the hallway near the East dining room with no visible name tag. When queried about it, he stated he left it on his desk and would go get it.
On 1/11/2023 at 11:30 AM, LPN G was observed at his medication cart with no visible name tag.
On 1/11/2023 at 12:07 PM, the Nursing Home Administrator (NHA) was queried regarding call light wait times. The NHA stated that something is, Always in process, when it comes to call lights, and it has been emphasized to staff that anyone/everyone can answer a resident's call light when it is on. The NHA stated that right now, the goal is to get a call light answered within 20 minutes.
When queried if any concerns related to staff's attitudes had been brought to her attention, the NHA indicated she only knew of one issue with a dietary aide that was being addressed. The NHA indicated the facility is in the, Middle of doing another customer service education.
When queried regarding staff being seen without visible name tags, the NHA stated the tags are, On order.
A review of the facility's policy/procedure titled, Resident Rights, reviewed/revised 01/01/2022, revealed, Employees shall treat all residents with kindness, respect, and dignity .Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Numbers MI00128992, MI00128912, MI00129438, MI00129052, MI00129058, MI00129073, MI00129662, MI0...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Numbers MI00128992, MI00128912, MI00129438, MI00129052, MI00129058, MI00129073, MI00129662, MI00130203, MI00130641, MI00130889, MI00131755 and MI00131852.
Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff were available, affecting multiple resident units and residents (R146, R54, R79, R6, R263) and potentially affecting all residents residing in the facility, resulting in late medication administration, dissatisfaction with the care provided and unmet care needs.
Findings include:
A review of multiple complaints submitted to the State Agency included the following allegations:
-It was alleged the facility failed to have a nurse on duty, resulting in residents not getting their meds.
-It was alleged the facility is not adequately staffed to ensure residents are provided with proper care.
-It was alleged the facility failed to administer medications as ordered.
-It was alleged the facility is short staffed.
On 10/20/22 at 12:16 PM, Registered Nurse (RN) K, the facility's wound care nurse, was noted to be working as a floor nurse on the 700 unit (COVID-19 positive isolation unit). RN K was quickly moving to respond to multiple resident and staff requests and prepare medications. When queried regarding staffing on the unit for this (day) shift, RN K stated it was her, two Certified Nursing Assistants (CNAs), and one CNA on orientation. RN K indicated that she was responsible for passing medications to, obtaining vitals on, and completing COVID-19 assessments on 32 COVID-19 positive patients. Upon review, it was noted that RN K was still passing 9 AM scheduled medications as lunch trays were being passed out on the unit. Multiple medications were showing as late in the system. RN K confirmed she still had not finished passing morning medications and named 10 residents that had not yet received their medicine. RN K indicated she was doing her best to meet the needs of the residents but stated, It's a lot.
On 10/21/22 at 12:16 PM, this surveyor was waiting to interview R146, as they had been unavailable the previous day due to being at dialysis. R146 came out of the bathroom and ambulated toward their bed. R146 was observed to have thick, cloudy white trach secretions coming out of their tracheostomy tube, secretions on their chest, and secretions in their hair. R146 was also currently in isolation on the 700 unit due to testing positive for COVID-19 on 10/13/22. R146's breathing was noted to be very congested at this time. R146 attempted to talk to this surveyor, however, secretions continued to come out of the resident's tracheostomy tube. R146 was asked when they were last suctioned, to which they mouthed the word, Yesterday. R146 indicated they needed to be suctioned now and indicated that they felt as if they had a fever. The dressing for R146's tracheostomy site was noted to be soiled a brownish color. R146 was asked how their breathing felt to which they motioned, So-so, with their hand.
Registered Nurse (RN) E came into the room briefly and was queried about R146 needing to be suctioned. R146 was coughing at this time with a copious amount of secretions pouring out of their tracheostomy tube. RN E was visibly flustered and explained that she was normally the unit manager for the 300 unit but was now working the floor on the COVID-positive unit (700). RN E appeared very upset and stated that she had 31 patients to take care of, and that the current staffing situation on the unit was Not a good set-up. When queried again regarding R146's need to be suctioned, RN E stated she had checked the resident's oxygen saturation approximately a half hour ago and it was 89%. RN E further stated that she knows the resident needs suctioning but added, I have meds due, residents are calling to have the door unlocked to go out and smoke .it's too much, it's not an ideal setup.
On 10/21/22 at 1:25 PM, the Nursing Home Administrator (NHA) was interviewed for the Quality Assurance (QA) task review. The NHA was queried regarding knowledge of staffing challenges at the facility. The NHA stated that staffing is a challenge, For everyone at this point .We have orientation every week .recruiting .Hired three nurses last week and I think five scheduled for next week .Nurses have been more of a (hiring) challenge than CNAs at this point .All that matters is that the resident's get what they need, but you do see managers (working) on the floor today. The NHA did indicated that she aware of some residents having concerns related to medications being passed late.
On 10/19/22 at 10:57 AM, R54 and R79 were interviewed about the care at the facility. The chief concern was that the facility was insufficiently staffed as they did not get their medication on time. R79 indicated this usually happens at night and once had to wait until after noon the next day to get something other than Tylenol. R54 commented they had been on a different unit up until a few months ago and the call light concern was the same. It was not answered in a timely fashion. When this is brought to the aides and other staff attention, R54 and R79 agreed staff pass the buck for blame. R54 also commented on missing clothing items since July and a lack of follow up for concerns from the administration though R54 had given them a list. On 10/21/22 at 3:15 PM, the assistant administrator was asked about the missing items and reported that the missing items were not on the inventory sheet and therefore could not be reimbursed. The assistant administrator reported staff had notified R54 of the result but they would have staff follow up with R54.
On 10/19/22 at 12:02 PM, R6 was queried about the care at the facility and reported that at times the staffing was lousy, but I guess that is common now. The roommate reported it may take a few hours to get a towel or a blanket. R6 reported they felt staff were shorthanded and ignoring the call light and tries not to put it on unless they absolutely have to. R6 commented they had come down with COVID a week ago and was in a different room and the staff never unpacked their belongings.
On 10/20/22 at 11:36 AM, Certified Nurse Assistant (CNA) T CNA was observed to turn around a resident who wished to exit the isolation area. CNA T reported that they had told the ADON a couple of hours before that the resident wanted to speak with someone about getting out of isolation as they had spent the required amount of time on the unit. CNA T called the ADON on the phone and was told again that they would be down. The ADON was not observed to visit the resident, but a medical staff did enter the unit and appear to speak with the resident. The resident was observed outside the next day.
On 10/21/22 at 6:16 AM, Nurse V was asked about any improvements in staffing levels and reported that it had improved but in just the last week and a half.
On 10/21/22 at 12:30 PM, Nurse K was asked about staffing and the use of 911 for non-emergent resident care needs. Nurse K recalled an in-service 6 months ago, about if non emergent first call doctor, then let the administrator and Director of Nursing (DON) know. Nurse K was not aware of any resident who called 911 because of care needs not being met.
On 10/21/22 at 12:50 PM, Nurse U was asked about the use of 911 by staff and residents and reported calling 911 when the non-emergency transportation was going to be 4-5 hours or if family or the resident were insistent. Nurse K did recount and incident where a resident called 911 because they did not receive their medication and one about the need for suctioning.
On 10/21/22 at 1:13 PM, Nurse Consultant J was asked if they were aware of any concerns or complaints about the appropriate use of the 911 service vs non-emergency transportation by the facility and residents and reported they were not. It was reported that the conversation may include how to better manage residents and use the caring partners to develop other interventions so 911 is not needed. Nurse J reported nurse judgement and the doctor requests are also taken into account, along with the behavior of the resident for calls to 911. Nurse J was aware of the behaviors by R263 which could trigger a 911 call.
A review of a complaint related to appropriate and sufficient staffing revealed a concern for the need to call 911 related to behaviors exhibited by R263. The complaint indicated 911 was called six times in two months for R263 and had been at the facility multiple times in a day due to mismanaged residents and residents calling 911 because they can't get timely help from staff. Concerns per the complainant were not acted on appropriately or timely. Non-emergency incidents identified by the complainant included routine non critical abnormal labs, dialysis ports that needed cleaning and resident's calling 911 because they can't get help then found to be sleeping. They also noted the use off 911 when long wait times are received for transportation of residents or are called for staff convenience. A review of the record for R263 revealed: On 10/09/22 behaviors noted, not cooperative with staff direction, 911 called and transported to hospital; On 09/27/22 and order from the doctor to send resident to the hospital for aggressive behaviors to staff; On 08/28/22 police were called and resident was sent to hospital and returned in less than 24 hours; On 08/20/22 aggressive behaviors noted transferred by EMS with police present. On (09/06/22, 09/13/22, 09/20/22 and 09/21/22) behaviors were documented and R263 was able to be redirected and stayed at facility.
The complainant documented the following:
On 10/05/22 a resident in room [ROOM NUMBER] called 911 because staff had not responded to them all day and was in pain. It was noted that the facility was called and the phone not answered. It was noted that when 911 arrived the call light was observed to be activated along with others on the wing. Staff were not present on the wing and it took another five minutes before staff presented at the resident's room.
On 10/15/22 a resident in room [ROOM NUMBER] called 911 because they had been trying to get a hold of staff for three hours and had body aches. The facility was called and staff reported going to check on the resident. Two minutes after the first call the same resident complained of difficulty in breathing, chest pain and body aches. It was documented that upon assessment the resident denied chest pain or difficulty in breathing and complained only of body aches and abdominal pain since the day before. The resident stated that staff did not care and had not checked them for hours and wanted out of the facility. The resident left with 911. It was reported that in talking with the nurse for the resident, the nurse stated they were understaffed for the floor.
On 06/21/22 911 was called for abnormal labs that had been drawn a day prior. No patient complaints were reported no distress was observed and vital signs were stable. No report was received from the staff other than being handed the lab value report.
On 01/21/22 a resident in room [ROOM NUMBER] stated the only reason they had called 911 on their own because they had been pushing their red button and yelling for the nurses for over an hour. The roommate confirmed their story and said they had been hitting the button also to try and help get someone to assist the resident. Several nurses there denied blame and the name of the Director of Nursing was provided for contact.
A review of the facility's policy/procedure titled, Nursing Services and Sufficient Staff, reviewed/revised 1/1/22, revealed, It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment .Providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to resident's needs .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #514
Food
10/21/22 12:39 PM
Complaint substantiated for food.
A review of multiple complaints submitted to the State A...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #514
Food
10/21/22 12:39 PM
Complaint substantiated for food.
A review of multiple complaints submitted to the State Agency included allegations regarding poor quality and insufficient amount of food served at the facility.
On 10/19/22 at 11:14 AM, during an interview regarding living at the facility, R107 stated that the food frequently gets delivered cold. R107 stated, They just leave the cart sitting in the hallway. People pick off of it, off other's trays .I got a hamburger with no burger, just a bun. If you complain to the kitchen they say they will send more food and they never do.
On 10/20/22 at 10:13 AM, during an interview regarding living at the facility, R133 stated, The food is awful, awful, awful. It's always cold. My coffee is always cold.
On 10/20/22 at 10:19 AM, during an interview regarding living at the facility, R35 stated, The food is sh*tty but it is what it is. It's cold. It's not good. I usually order out.
On 10/20/22 at 12:39 PM, R30 was observed eating lunch in their room. Upon entering, R30 stated, I wish they would put something on this because it's so dry. I don't know if I can eat this! I have false teeth! R30 began laughing and added, It's just so hard to chew! A plain, pale, skinless, bland looking piece of chicken was observed on R30's lunch tray as they tried to cut into it.
Resident #70
Food
This Citation pertains to Intake Numbers MI00129438, MI00130074, MI00130203,and MI00131852.
Based on observation, interview and record review the facility failed to ensure food preferences were honored and food was served at preferred temperatures for seven residents (R6, R30, R35, R54, R79, R107, R133) of 35 residents reviewed for food palatability, resulting in dissatisfaction with the meals provided.
Findings include:
On 10/18/22 at 9:24 AM, an tray cart open on all sides and covered with a light weight clear plastic was dropped in the hallway of the 800 unit. Housekeeping was on the hall for cleaning of residents' rooms.
On 10/18/22 at 11:51 AM, a resident of room [ROOM NUMBER] reported that their breakfast was cold except for the oatmeal and was provided coffee not tea.
On 10/18/22 at 12:43 PM, the meal tray cart was brought onto the 800 unit, two staff were observed to distribute the meal trays. The open meal cart was covered with clear plastic like that used for disposable trash can liners. The food items were served in white foam clam shells and plastic utensils. A male resident walked down the hall and complained to the staff that the pasta sauce should have meat in it.
On 10/18/22 at 1:08 PM, the last tray had been passed from the meal cart. Food items in the foam clamshell were tested for flavor and temperature. The penne pasta noodles were firm served with a scant amount of sauce which was runny like water under the pasta. This was on the menu as Baked Ziti. It did not appear baked and did not have any cheese on it or meat within. The asparagus was hard and came as two stalks about three or four inches long and the diameter of a quarter. The asparagus could not be cut all the way through with the plastic knife provided or pierced with the plastic fork. The pieces were stringy when attempted to be cut. The garlic bread was bland. The temperature of the food was lukewarm in the mouth, not cold and not hot.
On 10/19/22 at 10:57 AM, R54 and R79 were interviewed about the care at the facility. R54 and R79 had concerns about not receiving what food had been ordered or the poor food quality provided. They also agreed that on weekends dinner meals may not come until 7:30 PM or 8 PM. The vegetables were described as mush, the chicken had been served undercooked, the quesadilla was too hard, toast was only toasted on one side and french fries were served still partially frozen or cold. Pictures of the items were observed when presented by R79. The chicken appeared flattened and pale. R79 reported the rim of the tomato slice was all they received on a sandwich, the drinking glasses had a cloudy film on them, and desserts are served uncovered. A picture of the cloudy glass was observed. R54 reported they had filled out papers and keeps getting what they don't like on their tray.
On 10/19/22 at 12:02 PM, R6 was asked about the food and reported they are given what they can eat but the facility did a lot better when served in the dining room. R6 commented they try to tell them not to send salad and it is sent anyway.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 10/18/22 at 9:28 AM during an initial tour of the facility's Memory care unit it was observed that the carpet in the unit was...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 10/18/22 at 9:28 AM during an initial tour of the facility's Memory care unit it was observed that the carpet in the unit was dirty and stained. There was a large hole on the bottom of the wall by the baseboard. room [ROOM NUMBER] was observed to have a surgical mask and a plastic drink lid on the floor.
On 10/18 /22 at 9:45 AM, the Memory Care Unit Nurse Manager (UNM) E was interviewed regarding environmental observations on the unit and stated, It's not the way I like it. UNM E indicated that the facility had a shortage of housekeeping staff due to COVID.
On 10/18/22 at 4:27 PM, a phone interview was conducted with Resident Representative (RR) I regarding care at the facility for their family member. RR I indicated that their family member's room was Dirty, the carpet on the unit was Disgusting and the bathroom door in their family member's room was Hard to open.
On 10/18/22 at 10:44 AM, the overbed table in room [ROOM NUMBER] bed two was observed to be open and without a light bulb. Nurse M was observed to pull the string to turn on the light and then noticed that it was not working. Nurse M explained that they had forgot the light was not working and that the facility ordered a part around June to fix it.
On 10/18/22 at 10:58 AM, room [ROOM NUMBER]-A, overbed light was observed to be without a chain string and instead had clear garbage bags that hung in its place.
On 10/18/22 at 11:00 AM, room [ROOM NUMBER] entry electrical outlet was observed to be without a covering and the entry light did not turn on when switched to the on position. The resident in room [ROOM NUMBER]-B also showed picture of their previous room that showed multiple flies on different surfaces in room and also stated that the air conditioning unit leak water and smelled of mildew.
On 10/18/22 at 1:15 PM, room [ROOM NUMBER]-A bed was observed to have flies on top of the bed.
On 10/18/22 at 9:48 AM, in room [ROOM NUMBER]-2, a quarter to half dollar size gouge was observed in the wall behind the headboard. A pile of white sheetrock dust was on the ground where the wall meets the floor.
On 10/18/22 at 11:44 AM, Housekeeper S was asked about the darker black soiled spots on the carpet in resident rooms and reported they notify floor care for carpet concerns and they will clean it.
On 10/18/22 at 11:51 AM, in room [ROOM NUMBER]-2 the wall outlet cover was missing from the outlet behind the head board and was observed under the bed. The cover had one of the corners broken off. The foot board was missing from the end of the bed and leaned against the wall away from the bed.
On 10/18/22 at 1:08 PM, the carpet in the atrium outside the 700 unit had two irregularly shaped volleyball sized black areas of soil. These were closer to room [ROOM NUMBER].
On 10/19/22 at 7:33 AM, a pungent urine odor was noted in the hallway outside room [ROOM NUMBER].
On 10/19/22 at 7:36 AM, the 800 hall smelled like old musty carpet.
On 10/19/22 at 7:53 AM, the left end of the cover for the base board heater at the end of the 600 unit hung down to the floor.
On 10/20/22 at 7:59 AM and 10:51 AM, on the 800 hall, quarter size piece of white paper and two snow pea sized, lint or fiber clumps were observed on the rug at the right side of the base board heater.
This Citation pertains to Intake Numbers MI00129791, MI00130074, MI00130203, and MI00131755.
Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment, as evidenced by soiled carpeting, odors, dusty ceiling vents and PTAC filters, soiled shower rooms, holes in the walls, broken window blinds, and unsafe hot water temperatures. This deficient practice had the potential to affect all 162 residents in the facility.
Findings include:
On 10/19/22 during an environmental tour with Maintenance Director Q between 9:15 AM- 11:00 AM, the following items were observed:
In the 800 hall shower room, there was a black, spotty mold-like substance on the ceiling, a dusty ceiling vent cover, a non-functioning ceiling light fixture in the first shower stall, and missing baseboard tiles.
In the 800 hall soiled utility room, there was a free standing, unsecured oxygen cylinder stored directly on the floor. Maintenance Supervisor stated, That's not where that goes.
room [ROOM NUMBER]: There were missing panes on the window blinds, leaving gaps which did not provide full visual privacy for the resident from outside.
In the 500/600 ice machine room, the drain line for the ice machine was observed to empty into a floor mop sink. The surface of the floor mop sink was covered with a black, mildew like substance.
The hand rail in the hallway outside room [ROOM NUMBER] was missing an end cap, leaving a sharp, exposed edge.
There was a dusty ceiling vent cover observed in the 500 hall shower room.
room [ROOM NUMBER]: The toilet was not secured to the floor, and could be easily moved from side to side. There was standing water on the floor, and a black mold-like substance covering the floor tiles surrounding the toilet.
room [ROOM NUMBER]: The PTAC (packaged terminal air conditioner) unit filters were coated with dust.
room [ROOM NUMBER]: The footboard on the bed was loose, and there was a large gap between the mattress and the footboard. In addition, the PTAC filters were coated with dust.
room [ROOM NUMBER]: There were baseboard tiles missing in the bathroom, leaving a large exposed hole in the wall. The soap dispenser had fallen off the wall onto the floor, the PTAC filters were dusty, and there were missing panes on the window blinds.
The hot water temperatures were measured, and the following temperatures were recorded:
room [ROOM NUMBER] 124 degrees Fahrenheit
room [ROOM NUMBER] 124 degrees Fahrenheit
room [ROOM NUMBER] 124 degrees Fahrenheit
room [ROOM NUMBER] 124 degrees Fahrenheit
room [ROOM NUMBER] 124 degrees Fahrenheit
room [ROOM NUMBER] 125 degrees Fahrenheit
room [ROOM NUMBER] 127 degrees Fahrenheit
room [ROOM NUMBER] 133 degrees Fahrenheit
room [ROOM NUMBER] 128 degrees Fahrenheit
room [ROOM NUMBER] 134 degrees Fahrenheit
room [ROOM NUMBER] 128 degrees Fahrenheit
room [ROOM NUMBER] 124 degrees Fahrenheit
room [ROOM NUMBER] 127 degrees Fahrenheit
Maintenance Director Q stated that the hot water temperatures should not be over 120 degrees Fahrenheit. Maintenance Director Q stated that he checks the water temperatures weekly. Maintenance Director Q stated that an outside company had been in last week to complete some work on the boilers, and that they must have turned up the temperature. The mixing valves for the hot water tanks were observed with Maintenance Director Q, and the valve for the 400 and 600 units was observed to be set at 125 degrees Fahrenheit. Maintenance Director Q stated, It got bumped up.
room [ROOM NUMBER]: On 10/19/22 at 11:46 AM, R 31 was interviewed and indicated that he currently resides in room [ROOM NUMBER]. R 31 stated that the air conditioning unit had been leaking water into the carpet when in use. The air conditioning unit in room [ROOM NUMBER] was observed to be covered in dust and debris. R 31 stated that the facility was supposed to replace the unit but never did. Pieces of discolored, warped wood were observed underneath the unit. The carpet directly underneath the unit was observed to be darkened compared to the rest of the room (as if it had been wet). R 31 stated, This place is the pits.
Review of a Pest Control Service Report dated 8/2/22 noted: .Inspected room [ROOM NUMBER] 4 fruit flies and gnats. Leaking air conditioning has soaked rug .Also advise thorough cleaning of carpets.
On 10/21/22 at 1:25 PM, the Nursing Home Administrator (NHA) was interviewed for the Quality Assurance (QA) task review. The NHA was asked if she provides oversight for the Housekeeping/Maintenance of the facility, or if she does any routine inspections herself. The NHA responded, Yes, to both. The NHA indicated that she and the Assistant NHA (ANHA) have been working to address multiple environmental concerns throughout the building since they started (end of July 2022). The NHA stated that deep cleaning of resident rooms in addition to the regular cleaning schedule as well as ordering a new floor care machine were among the tasks that were initiated to address the environment. The NHA further indicated that they are trying to identify what each room needs in the building by reviewing them one-by-one, and that they are working with department heads to, Get it (environment) back to where it should be.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R131
On 10/19/22 at 10:28 AM, R131 was observed in bed awake. R131 explained that they had a vision impairment and could not see...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R131
On 10/19/22 at 10:28 AM, R131 was observed in bed awake. R131 explained that they had a vision impairment and could not see very well. R131 remained in bed the entire survey with their hair observed as unkempt, and long hair observed on their chin.
A review of R131's medical record revealed that they were admitted into the facility on 4/23/21, with a readmission of 9/21/22 with diagnoses that included Dementia, Respiratory Failure and Diabetes. Further review of the resident's medical record revealed a Minimum Data Set assessment (MDS) dated for 9/27/22 revealing a Brief Interview for Mental Status score of 13/15 indicating an intake cognition, and required extensive assistance for Activities of Daily Living.
Further review of R131's medical record revealed that the resident had no documented showers within the last 30 days.
A review of the facility Activities of Daily Living (ADLs) policy revised 01/01/22 revealed, .3. 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 .
Resident #133
A review of R133's Minimum Data Set (MDS) assessment dated [DATE] and medical record revealed that the resident was initially admitted into the facility on 3/1/16 and most recently re-admitted on [DATE]. Further review revealed that the resident is cognitively intact, requires extensive assistance from staff for activities of daily living (ADLs), and has medical diagnoses including, but not limited to, Muscle Weakness, Osteoarthritis, Bipolar Disorder, Paraplegia, Epilepsy, Adjustment Disorder With Mixed Anxiety And Depressed Mood, Spinal Stenosis, COVID-19, Contractures, Osteomyelitis, and Pressure Ulcer Of Unspecified Buttock, Stage 4.
On 10/19/22 at 10:29 AM, R133 was interviewed in their room. R133 was observed lying in bed wearing a hospital-type gown. The resident was queried regarding care received at the facility and stated that they are supposed to get a shower twice a week. R133 stated that they had not been in the shower room in at least a month. R133 stated, They give me a so-called 'bed bath.' Depending on who gives it sometimes it's just a wet washcloth on my arm and they think it's a bed bath.
A review of the Point Of Care (POC - where tasks, typically carried out by nurse aides, are documented) shower documentation for R133 revealed only one shower documented as given to the resident on 10/5/22 over the last 30 days. The task indicated that the resident's preferred shower days were Wednesday and Saturday.
On 9/28/22, a progress note from the Nurse Practitioner indicated that the resident was observed on a shower chair, awaiting a shower. No other progress notes related to showers/bathing were found.
A review of R133's care plan revealed:
-[R133] requires assistance for ADL's due to weakness, decreased mobility total depended (sic). Date Initiated: 07/08/2016, Revision on: 02/15/2022.
-STAFF TO PROVIDE BATHING AND GROOMING NEEDS, Date Initiated: 07/09/2016, Revision on: 08/22/2022.
On 10/21/22 at 3:10 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were interviewed. When queried regarding provision of showers/baths, the NHA and DON indicated they expected them to be given per the plan of care and documented on the task list. If showers/baths were not given, the NHA and DON both indicated they would expect documentation in the record explaining why.
This Citation pertains to Intake Numbers: MI00128912, MI00129058, MI00129791, MI00130203, MI00130641, MI00130685, MI00130784, MI00130807, MI00130889, MI00131011 MI00131281, MI00131755, and MI00131852.
Based on observation, interview, and record review the facility failed to meet resident shower and/or personal hygiene needs and document resident showers being offered for twelve residents (R9, R20, R26, R47, R77, R83, R131, R133, R147, R150, R153, R155) of fifteen residents reviewed for activities of daily living (ADL) care, resulting in dissatisfaction and unmet care needs.
Findings include:
Resident #47 (R47)
On 10/21/22 at 12:10 PM, a thirty-day review of R47's shower documentation in their electronic medical record (EMR) revealed one shower being documented as having occurred for R47 on 10/2/22. No other showers were documented as having offered/received for R47 over the past thirty days.
On 10/21/22 at 12:41 PM, R47 was interviewed about their frequency of showers at the facility, and they indicated that they did not receive enough showers. R47 stated, I'm not happy about it.
On 10/21/22 at 2:06 PM, the Administrator (NHA) was interviewed about their expectations for residents receiving showers. The NHA stated, Staff should make sure they follow residents shower schedules and make sure showers are documented.
On 10/18/22 at 10:40 AM, R20 was observed in bed lying down on their back. R20 was a question about their stay at the facility and did not respond. The roommate stated that R20 does not talk a lot.
A review of R20's medical record noted, R20 was admitted to the facility on [DATE] with diagnosis of Medically Complex Conditions. A review of R20's Minimum Data Set (MDS) revealed R20 with an impaired cognition and required two staff for assistance with hygiene and other activities of daily living.
A review of R20's electronic medical record was made and revealed, Task: ADL - Bathing: Tuesday + (and) Saturday Afternoon Shift. In the last 30 days one shower was documented as given on 10/6/22 and bed baths on 9/27, 10/8, 10/11, and 10/18.
A review of R20's care plan noted, Intervention - Focus: [R20] needs activities of daily living assistance related to generalized weakness. Date Initiated: 07/17/2021. Revision on: 10/12/2022. Goal: [R20] will participate with [their] daily ADL's and reach [their] maximum potential by next review. Date Initiated: 07/17/202. Provide extensive assist with showers and skin assessments twice per week. Date Initiated: 07/23/2021.
On 10/21/22 at 3:13 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) was asked the facility's expectation for resident showers and explained, showers should be given by resident preference and at least two time per week. The NHA was asked the process if a shower is refused and explained refusals and reasons why not given are to be documented.
Resident R26
On 10/18/22 at 11:11 AM, R26 was observed to be in a lowered bed. R26 was covered with a top sheet that was soiled with what looked like spilled coffee stains. Additional food and liquid stains appeared on the bottom sheet at the left shoulder area of R26. A tan colored powder was spilled on the carpeted floor at the right side of the bed and it covered a curved area around 18 inches long and three to four inches wide and tapered at the ends. Additional food items were on the floor at the left side of the bed and on the over bed table. A cardboard box was on the mattress at the foot of the bed. A vague urine odor was noted. The origin of the odor was not determined. Both residents indicated they took themselves to the bathroom. On 10/19/22 at 7:40 AM, the powder had not been cleaned up, the soiled sheets remained and the urine odor remained. The task records for R26 titled ADL: Bathing Monday and Thursday days for the previous thirty days were reviewed and revealed showers were documented as refused on 09/26/22 and 10/13/22. On 10/17/22 a shower was documented as completed by center staff. No additional attempts for showers or baths were documented. No additional refusals were documented. The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition and R26 required no assistance for personal hygiene and limited assist for bathing related to transfer.
Resident R83
On 10/18/22 at 11:19 AM, R83 was observed to be seated in a wheelchair at the left side of their bed. R83 was dressed in a hospital style gown. The fingernails of both hands were yellowed and extended 1/8 to 1/4 inches beyond the tip of the fingers and thumbs. R83 reported they had asked for their fingernails to be trimmed and they had not been done. A review of the shower records indicated R83 had received three showers in the previous thirty days on 10/05, 10/10 and 10/14. R83 further reported a preference for more than one shower a week and asked why the Podiatrist could not cut their fingernails when they cut their toenails. Facility records indicated R83 was admitted into the facility on [DATE]. The MDS dated [DATE] indicated intact cognition and R83 required limited assistance of one person for personal hygiene.
Resident R150
On 10/18/22 at 9:48 AM, R150 was queried about their care experiences. R150 reported they had waited from 10 PM to 2:30 AM on Sunday to get put back to bed and at times will wait up to an hour and a half for staff to answer the call light. R150 further noted their roommate will call out at times for help and may put the call light on for them. R150 also reported they are to be out of bed daily, and it depends on who the aide is that day whether it happens or not. R150 did report they had a wound to the tailbone and that it was down to a pin prick. R150 was observed to be down in the bed with the breakfast tray at the level of their neck and R150 reached up from the sides to eat the items on the plate. R150 reported on query that would prefer to sit up higher and straighter when eating. A review of the MDS assessment dated [DATE] indicated intact cognition and the need for extensive assistance of one or two persons for bed mobility, transfer, dressing, toilet needs and personal hygiene, and total assistance for bathing and limited assistance and set up for eating.
Resident R155
On 10/18/22 at 12:55 PM, R155 was asked about the care provided at the facility and reported they would like a shower more often than once every two weeks. R155 was observed to have beard growth longer than an eighth of an inch and to have nails which extended beyond the tips of their fingers around an eighth of an inch or more. R155 reported they had asked to have them clipped whenever R155 sees staff. The white T-shirt worn by R155 had three orange (tomato sauce) dime sized spots on the abdomen area of the shirt. A review of the task documentation, ADL: Bathing Wednesday and Saturdays, Days, Shower if tolerates otherwise bed bath . for the previous thirty days documented a bath or shower on 10/05/22 and a shower on 10/15/22. No other bath or shower or refusal was documented.
On 10/19/22 at 7:45 AM, R155 was observed to be in bed with the head of the bed up 30-45 degrees. R155 was hunched down in the bed with their shoulders just above the break in the bed. R155 wore a white T-shirt and was covered with a blanket. At 1:27 PM, R155 reported no showers or bath had been done and had not been shaved.
On 10/20/22 11:42 AM, R155's soiled T-shirt had not been changed and on query about the stain reported they had additional T-shirts in the dresser and asked for one and was able to put it on. R155 also affirmed they would like their fingernails cut, hair washed and to be showered. A review of the facility record indicated R155 was admitted into the facility on [DATE]. A review of the MDS dated [DATE] indicated intact cognition, the need for supervision for bed mobility, transfer and dressing, and set up help only for bathing.
Resident R147 and resident R77
On 10/18/22 at 12:24 PM, R77 was asked about shower and reported they had not had a shower in a long time and thought it to be 8-9 days and felt they needed help to complete the shower. R77 also noted they had not been provided with a remote for the TV that works, and that the facility had brought in four of them. R77 was admitted into the facility on [DATE]. A review of the bathing task record for the previous thirty days for R77 documented showers on 10/05/22, 10/10/22 and 10/14/22. The MDS dated [DATE], indicated intact cognition and R77 was independent for personal hygiene and bathing. No other shower or bath or refusal was documented.
R147 was admitted into the facility on [DATE]. A review of the bathing task record for the previous thirty days for R147 indicated a shower or bath was documented on 10/04/22 and 10/07/22. No other shower or bath or refusal was documented. The MDS dated [DATE] indicated intact to moderately impaired cognition and the need for supervision and no set up for bathing.
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 dry storage area in a sanitary manner, failed to maintain the ice machine and the ice room flooring in a sanitar...
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Based on observation, interview, and record review, the facility failed to maintain the dry storage area in a sanitary manner, failed to maintain the ice machine and the ice room flooring in a sanitary manner, and failed to remove stagnant water from the floor and eliminate pest harborage conditions. These deficient practices had the potential to affect all residents that consume food from the kitchen.
Findings include:
On 10/18/22 between 9:00 AM-9:45 AM, during an initial tour of the kitchen with Dietary Manager (DM) R, the following items were observed:
There was a buildup of crumbs and food debris observed on the floor underneath the racks in the dry storage room. DM R stated they would get that cleaned up right away.
According to the 2013 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A Physical facilities shall be cleaned as often as necessary to keep them clean.
The ice scoop was observed to be stored inside ice bin, with the handle resting on the ice. DM R confirmed the ice scoop should not be stored inside the ice.
According to the 2013 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.
The flooring near the 2 compartment sink was observed with receding/missing grout, and stagnant standing water collected inside the wells between the tiles. In addition, there were cracked floor tiles near the dish machine, with standing water observed on the floor, and standing water observed on the floor underneath the table with the coffee maker. Small, black flies were seen flying throughout the kitchen area.
Review of a Pest Control Service Report dated 8/2/22 noted: Inspected kitchen for fruit fly issues .Also suggested sanitation in kitchen area .Multiple areas would improve fruit fly issue .
According to the 2013 FDA Food Code section 6-501.111 Controlling Pests, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: .2. (B) Routinely inspecting the PREMISES for evidence of pests; .4. (D) Eliminating harborage conditions.
The ice machine inside the ice room located next to the main kitchen, was observed with a water leak coming from the drainage line of the water filter. There was standing water on the floor, and mold was observed on the floor surrounding the floor drain. The drain pan from inside the ice machine had become detached, and was resting on the floor under the ice machine. The drain pan was observed with several inches of stagnant water, and was heavily soiled with a gray slimy material on the inside of the drain pan.
On 10/18/22 at 11:00 AM, Maintenance Director Q was queried about the soiled ice machine room, and stated that the ice machine has an auto clean function. Maintenance Director Q was shown the soiled flooring, the leaking drain line, and the soiled drain pan, and stated that he was unaware the drain pan had become detached. Maintenance Director Q stated he would repair the leaking drain line, but provided no explanation for the condition of the flooring in the ice machine room.
Review of the facility's policy Ice Storage dated 01/01/22 noted: Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice .2. Our facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions, and maintains a copy of the guidelines.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Michigan facilities.
Concerns
- • 79 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • Grade D (40/100). Below average facility with significant concerns.
Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Medilodge Of Sterling Heights's CMS Rating?
CMS assigns Medilodge of Sterling Heights 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 Medilodge Of Sterling Heights Staffed?
CMS rates Medilodge of Sterling Heights's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 52%, compared to the Michigan average of 46%.
What Have Inspectors Found at Medilodge Of Sterling Heights?
State health inspectors documented 79 deficiencies at Medilodge of Sterling Heights during 2022 to 2025. These included: 2 that caused actual resident harm and 77 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Medilodge Of Sterling Heights?
Medilodge of Sterling Heights 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 MEDILODGE, a chain that manages multiple nursing homes. With 248 certified beds and approximately 208 residents (about 84% occupancy), it is a large facility located in Sterling Heights, Michigan.
How Does Medilodge Of Sterling Heights Compare to Other Michigan Nursing Homes?
Compared to the 100 nursing homes in Michigan, Medilodge of Sterling Heights's overall rating (2 stars) is below the state average of 3.1, staff turnover (52%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Medilodge Of Sterling Heights?
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 Medilodge Of Sterling Heights Safe?
Based on CMS inspection data, Medilodge of Sterling Heights 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 Medilodge Of Sterling Heights Stick Around?
Medilodge of Sterling Heights has a staff turnover rate of 52%, which is 6 percentage points above the Michigan average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Medilodge Of Sterling Heights Ever Fined?
Medilodge of Sterling Heights has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Medilodge Of Sterling Heights on Any Federal Watch List?
Medilodge of Sterling Heights 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.