Iosco County Medical Care Facility
Government - County
78 Beds
Independent
Data: November 2025
Trust Grade
70/100
#32 of 422 in MI
Photo by Tim Condo
Last Inspection: November 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Iosco County Medical Care Facility has a Trust Grade of B, indicating it is a good choice, but not without some concerns. It ranks #32 out of 422 nursing homes in Michigan, placing it in the top half, and is the best option among three facilities in Iosco County. The facility is improving, with issues decreasing from 13 in 2023 to 7 in 2024, but it still reported serious incidents, such as failing to prevent pressure ulcers for residents and not ensuring proper supervision, leading to potential injuries. Staffing is strong with a 5/5 rating and a turnover rate of 35%, which is lower than the state average. There have been no fines recorded, suggesting good compliance with regulations, but the RN coverage is only average, which may impact the quality of care.
- Trust Score
- B
- In Michigan
- #32/422
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 35% turnover. Near Michigan's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Michigan facilities.
- Skilled Nurses ✓ Good
- Each resident gets 54 minutes of Registered Nurse (RN) attention daily — more than average for Michigan. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 28 deficiencies on record. Higher than average. Multiple issues found across inspections.
70/100
Top 7%
Needs review
13 → 7 violations
★★★★★
5.0
Overall Rating
★★★★★
5.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2023: 13 issues
2024: 7 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (35%)
13 points below Michigan average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
Staff Turnover: 35%
11pts below Michigan avg (46%)
Typical for the industry
The Ugly 28 deficiencies on record
2 actual harm
Nov 2024
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
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 issue a beneficiary notice (ABN/Nomnic) for one reside...
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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 issue a beneficiary notice (ABN/Nomnic) for one resident (Resident #155) of three residents reviewed for beneficiary notices to eligible resident/representative in writing of the items and services which are/are not covered under Medicaid or by the facility's per diem rate, including the cost of those items and services, resulting in the potential for financial hardship when changing to hospice services.
Findings include:
The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
Resident #155:
Beneficiary Notification
An interview and record review was conducted on 11/18/24 at 02:42 PM with Social Work Designee G to review the ABN/NOMNIC forms issued to residents. Review of Resident #155's ABN/NOMNIC notification forms revealed them to be unsigned by the resident or representative. Social work designee G revealed that Resident #155 admitted on [DATE] and then switched to hospice services on 9/13/2024 but stayed in the facility. Review of the ABN/NOMNIC forms were not signed/not issued at the time of the care level switch. Social work designee G did not know why the forms were not signed. and referred the writer to the billing office manager. Social work designee G revealed that she had documented notes, but that the notes did not state why the forms were not signed.
An interview and record review on 11/19/24 at 01:03 PM with [NAME] staff H revealed that she types up the ABN/NOMNIC forms but does not get them signed. [NAME] staff H revealed that the forms were not signed because of the family choice of hospice. Resident #155 went right to hospice services here within the facility and there was no window of time to get the forms signed.
On 11/19/24 at 12:11 PM this writer Requested the facility ABN/NOMIC policy. No ABN/NOMIC policy was received.
An interview on 11/20/24 at 12:09 PM with the Nursing Home Administrator (NHA) revealed that the facility had no ABN/NOMNIC policy. The NHA stated that she did type up a policy, but it will not be ready for 2 more weeks.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #50:
An observation and interview on 11/18/24 at 12:03 PM with Resident #50 revealed that her call light takes a long t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #50:
An observation and interview on 11/18/24 at 12:03 PM with Resident #50 revealed that her call light takes a long time to get someone to her room to assist her to the bathroom and with her bathing.
Record review of Resident #50's Progress notes from admittance date of 10/29/2024 through 11/19/2024 revealed an elderly female admitted with post-surgical hip repair for rehab services.
Record review of Resident #50's care plan for: Activity of Daily Living (ADL) self-care deficit related to deconditioning from recent hospitalization for right hip fracture with closed reduction (repair). Interventions included: Toileting- assist of 2 staff members to use toilet, Transfers- assist of 2 staff members with pivot transfer and front wheeled walker (FWW). Bathing- assist of one staff member participation with bathing.
Record review of Resident #50's [NAME] (resident care guide) noted assist of one staff member with bathing. There was no indication of what days to bathe and if the resident preferred showers or bed baths.
An interview on 11/19/24 at 12:03 PM with Certified Nurse Assistant (CNA) J shower assistant revealed that resident showers are to be twice a week. CNA J stated that she does get pulled to the floor and may miss some showers. Resident #50 in room [ROOM NUMBER] was a Tuesdays and Fridays shower. CNA J reviewed Shower task and admission date of Resident #50 as 10/29/2024 and the resident has been at the facility 21 days and has 3 documented showers. CNA J explained that if a resident is washed up in the bathroom, CNA's can document in the progress note, but it disappears after 24 hours. CNA's use to have paper shower sheets, but those went away this year, So CNA's no longer have written document just the disappearing progress note. It doesn't stay there very long.
Based on observation, interview and record review, the facility failed to update care plans for 2 residents (Resident's #19 and #50) of a sample of 16 resident's reviewed for care plans, resulting in delayed nursing interventions, showers not given and proper wound care given for a pressure ulcer not done.
Findings Include:
Resident #19:
Review of the face Sheet, diagnosis sheet, orders, nurse's notes and physician progress note's dated 9/24 through 11/24, revealed Resident #19 was 73 years-old, had a guardian in place, admitted to the facility on [DATE], dependent on staff for all Activities of Daily Living/ADL's, and resided on the Woodlands unit (locked Dementia unit). The resident's diagnosis included, cognitive impairment, severe depression, Dementia, Parkinsonism, pressure ulcer stage II on coccyx, heart disease, stroke with weakness of left side, Aphasia (difficulty with communication) and Dysphagia (swallowing impairment).
Review of the facility Brief Interview for Mental Status (BIMS) dated 11/7/24, revealed the resident had a BIMS of 2, severe cognitive decline.
Review of the facility nursing progress note dated 11/12/24, stated This nurse (Wound Nurse K) assessed what was documented as a stage II pressure ulcer on resident's coccyx. Upon assessment resident was noted to have an area of blanchable erythema (reddened) measuring 4.0cm (L) x 4.0cm (W). In the center of the erythema is an area of MASD (macerated) measuring 2.2cm (L) x 1.0. (W) x 0.1cm (D). The area presented as white, wrinkled macerated skin. ROHO cushion (pressure reduction cushion) placed in wheelchair.
Review of the physician order dated 11/12/24, stated Cleanse MASD (macerated area) on coccyx with wound wash, pat dry, and cover with Optifoam 3 x 3 Q (every) 3 days and PRN (as needed) if soiled.
Observation of wound care was done on 11/19/24 at 2:50 p.m. During the dressing change, Resident #19 had a stage II pressure ulcer to his lower coccyx area that was red on the outside and a light pink to white in the center.
Review done on 11/18/24, of the resident's facility potential for impairment to skin integrity r/t (related) limited mobility related to CVA (stroke) care plan dated 4/3/24, revealed no actual pressure ulcer care plan was in place nor any up-dates of an actual pressure ulcer was found.
During an interview done on 11/19/24 at 3:03 p.m., Rehab Manager D said a communication between nursing and rehab, is what generates a care plan or a care plan change and she had none for the resident regarding pressure ulcer or preventive skin management.
During an interview done on 11/19/24 at 12:03 p.m., Shower Aide/Nursing Assistant J revealed the facility had no longer used shower sheets to document any reddened areas or unusual skin concerns (pressure ulcers) noted during a shower. When the previous Director of Nursing discontinued the shower sheets, nothing was put in their place for communication to nursing of abnormal skin areas on resident's. Shower Aide J stated, We no longer have shower sheets; no communication of any abnormal skin areas was being told to nursing for skin assessment to be done.
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 Activities of Daily Living (ADL), including ba...
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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 Activities of Daily Living (ADL), including bathing/showering for one resident (Resident #50) of 13 residents reviewed for ADL's, resulting in missed bathing/showers and the potential for feelings of embarrassment.
Findings include:
Resident #50:
The clinical record of Resident #50's OBRA admission assessment dated [DATE] revealed under section GG: Functional abilities- substantial/maximal assist, helper does more than half the effort for task: toileting, shower/bathing, personal hygiene.
Record review of Resident #50's Progress notes from the admittance date of 10/29/2024 through 11/19/2024 revealed an elderly female admitted with post-surgical hip repair for rehab services.
Record review of Resident #50's care plan for: Activity of Daily Living (ADL) self-care deficit related to deconditioning from recent hospitalization for right hip fracture with closed reduction (repair). Interventions included: Toileting- assist of 2 staff members to use toilet, Transfers- assist of 2 staff members with pivot transfer and front wheeled walker (FWW). Bathing- assist of one staff member participation with bathing.
Record review of Resident #50's [NAME] (resident care guide) noted assist of one staff member with bathing. There was no indication of what days to bathe and if the resident preferred showers or bed baths.
An interview on 11/19/24 at 12:03 PM with Certified Nurse Assistant (CNA) J shower assistant revealed that resident showers are to be twice a week. CNA J stated that she does get pulled to the floor and may miss some showers. Resident #50 in room [ROOM NUMBER] was a Tuesdays and Fridays shower. CNA J reviewed Shower task and admission date of Resident #50 as 10/29/2024 and the resident has been at the facility 21 days and has 3 documented showers. CNA J explained that if a resident is washed up in the bathroom, CNA's can document in the progress note, but it disappears after 24 hours. CNA's use to have paper shower sheets, but those went away this year, So CNA's no longer have written document just the disappearing progress note. It doesn't stay there very long.
Record review of Resident #50's Shower Task documentation for a 30-day look back revealed Question #3: Bathing support provided how resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower: there were only three dates of showers given in the 30 days look back period. 10/30/2024, 11/4/2024 and 11/11/2024.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility 1) Failed to prevent and implement preventive measures to avoid ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility 1) Failed to prevent and implement preventive measures to avoid a pressure ulcer and 2) Failed to timely identify a pressure ulcer, for 1 resident (Resident #19) of 3 residents reviewed for pressure ulcers, resulting in a Stage II pressure ulcer on the coccyx, pain, increased potential for infection, antibiotic usage and hospitalization.
Findings Include:
Resident #19:
Observation of wound care was done on 11/19/24 at 2:50 p.m. During the dressing change, Resident #19 complained of discomfort and pain when the pressure ulcer was cleaned and dressed. The resident had a Stage II pressure ulcer to his lower coccyx area that was red on the outside and a light pink to white in the center. At this time the dressing was coming off due to loose stool. When the nurse cleaned him up, he complained of pain.
Review of the face Sheet, diagnosis sheet, orders, nurse's notes and physician progress note's dated 9/24 through 11/24, revealed Resident #19 was 73 years-old, had a guardian in place, admitted to the facility on [DATE], dependent on staff for all Activities of Daily Living/ADL's, and resided on the Woodlands unit (locked Dementia unit). The resident's diagnoses included, cognitive impairment, severe depression, Dementia, Parkinsonism, pressure ulcer stage II on coccyx, heart disease, stroke with weakness of left side, Aphasia (difficulty with communication) and Dysphagia (swallowing impairment).
Review of the facility Brief Interview for Mental Status (BIMS) dated 11/7/24, revealed the resident had a BIMS of 2, severe cognitive decline.
During an interview done on 11/19/24 at 10:23 a.m., Wound Nurse, RN K stated On 11/12/24, this pressure ulcer was identified. I saw a reddened area about a week ago (no documentation was found of area). It's (a wheelchair cushion) something he should of had prior (before the development of a pressure ulcer), it (the pressure ulcer) could have been prevented.
Review of the facility nursing progress note dated 11/12/24, stated This nurse (Wound Nurse K) assessed what was documented as a Stage II pressure ulcer on resident's coccyx. Upon assessment resident was noted to have an area of blanchable erythema (reddened) measuring 4.0cm (L) x 4.0cm (W). In the center of the erythema is an area of MASD (macerated) measuring 2.2cm (L) x 1.0. (W) x 0.1cm (D). The area presented as white, wrinkled macerated skin. ROHO cushion (pressure reduction cushion) placed in wheelchair.
Review of the physician order dated 11/12/24, stated Cleanse MASD (maserated area) on coccyx with wound wash, pat dry, and cover with Optifoam 3 x 3 Q (every) 3 days and PRN (as needed) if soiled.
Review of facility nursing progress note dated 11/14/24, stated Resident noted to have a Stage II pressure ulcer to coccyx area.
Review of the physician progress note dated 11/14/24, stated Patient is seen for newly acquired Stage II pressure ulceration to the coccyx.
Review of the facility Skin/Wound assessment dated [DATE], 1 of 3 pages, had no documentation of a coccyx wound; just a scabbed area on the top of the resident's head. No facility Skin/Wound assessment dated [DATE] or 11/13/24, regarding the resident's pressure ulcer, was given to this surveyor upon request.
Review of the facility nursing progress note dated 11/14/24, stated Action: Treatment is to cleanse wound (coccyx pressure ulcer) with wound wash and cover with Optifoam BID (twice a day) and PRN (as needed). Response: Resident noted to have poor diet. Air mattress and Roho cushion in w/c (wheelchair) have been put into place for pressure relief. Staff to lay resident down after meals, reposition often and be prompt with brief changes. The first time an air mattress was documented as being used for the resident, after development of the pressure ulcer.
During an interview done on 11/20/24 at 8:07 a.m., the MDS Coordinator, RN E stated On 11/9/24 there was an order for an open area, the Stage II pressure ulcer was identified on 11/9/24, an order given for a dressing and a skin assessment was done. It also should have been put in the wound binder for the wound nurse (on 11/9/24). The care plan was up-dated on 11/12/24, but no documentation of it being an actual care plan (no care plan for actual pressure ulcer was done, only potential). I think they should of put actual impairment (skin impairment care plan) on the 9th (11/9/24), the care plan was not up-dated until today (11/20/24), I just did it. This surveyor requested MDS Coordinator E get the wound binder; no documentation of any pressure ulcer for the resident of concern was found.
Review of the resident's facility potential for impairment to skin integrity r/t (related) limited mobility related to CVA (stroke) care plan dated 4/3/24, revealed a Roho cushion intervention was added onto this care plan on 11/12/24. No actual pressure ulcer care was found.
During an interview done on 11/19/24 at 3:03 p.m., Rehab Manager D revealed she had no communication from therapy to nursing or from nursing to therapy regarding a pressure reduction cushion for the resident's wheelchair. Rehab Manager D said a communication between nursing and rehab, is what generates a care plan or a care plan change.
Review of the facility Therapy Communication forms dated 9/16/24 and 10/22/24 (only two available upon request), revealed no documentation of an air mattress or of a cushion for the wheelchair, preventive measures. The facility note dated 11/14/24, was the first documentation of an air mattress and Roho cushion (pressure reduction cushion) being used for the resident.
Review of physician order dated 9/9/24, stated Skilled PT tx (treatment) includes: W/C (wheelchair) Management/Training (includes placing a pressure reduction cushion put on the wheelchair if resident at risk for skin breakdown). No documentation of any type of wheelchair cushion was found prior to 11/14/24 on the potential for wound/skin pressure ulcer care plan dated 4/3/24.
During an interview done on 11/19/24 at 12:03 p.m., Shower Aide/Nursing Assistant J revealed the facility had no longer used shower sheets to document any reddened areas or unusual skin concerns (pressure ulcers) noted during a shower. When the previous Director of Nursing discontinued the shower sheets, nothing was put in their place for communication to nursing of abnormal skin areas on resident's. Shower Aide J stated, We no longer have shower sheets; no communication of any abnormal skin areas was being told to nursing for skin assessment to be done. The resident's pressure ulcer was not identified until it was staged as a stage II pressure ulcer.
Review of the facility Nurse's education and meeting dated 10/25/24, revealed slides going over pressure ulcer preventive measures and wound care. This surveyor requested a pressure ulcer preventive policy during the survey (11/18/24 to 11/20/24), none was received.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain supervision of two residents (Resident #19 an...
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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 supervision of two residents (Resident #19 and Resident #37), of two residents reviewed for falls, resulting in Resident #19 and Resident #37 to have recurrent/repeated falls causing Resident #37 to have a head injury, pain and transfer to the emergency room and the potential for continuous falls and injuries.
Findings include:
Resident #37:
Record review of Resident #37's Minimum Data Set (MDS) assessment dated [DATE] revealed an elderly male with medical diagnosis included: Cancer, hypertension, Gastroesophageal reflux disease, benign prostatic hyperplasia, arthritis, dementia, anxiety, depression and glaucoma. Section I: Health conditions- noted falls of two or more since prior assessment.
Observation on 11/19/24 at 08:05 AM with Licensed Practical Nurse (LPN) L during medication administration in the secured dementia unit of Resident #37 revealed left upper brow facial bruising with a small laceration. LPN L stated that Resident #37 had sustained a fall over the weekend and went out to the hospital for treatment. LPN L revealed that Resident #37 was on Ativan (Antianxiety medication) cream three times daily was out of stock per the pharmacy, so Resident #37 was ordered Ativan 1mg oral three times daily. LPN L stated that the oral Ativan snowed (sleepy/lethargic). Observation of Resident #37's medication pass revealed the resident took oral medication crushed in pudding.
Record review of Resident #37 incident reports from August 2024 through November 2024 revealed:
On 8/2/2024 at 2:20 PM Resident #37 misjudged sitting in recliner and sat on floor. Predisposing factors included: confusion, impaired memory, wandering, ambulating without assist, and poor safety awareness. No injuries noted.
Record review of Resident #37's incident report dated 8/25/2024 at 7:10 PM revealed that the resident was in the common area and tried to sit on the small end table between the two recliner chairs. The resident misjudged the distance and sat on the floor in front of the table. Predisposing factors included: poor safety awareness. No injuries noted.
In a record review of Resident #37's incident report dated 8/31/2024 at 7:50 AM Resident #37 was found by staff sitting on the floor in resident's room. Resident #37 complained of hip and knee pain with pain score of 6 expressed by facial expression, ridged, fist clenched, knees pulled up, pulling or pushing away, striking out and unable to console.
Record review of Resident #37's incident report dated 9/12/2024 at 6:10 PM when staff heard loud noise and approached the dining area Resident #37 was on his buttocks next to dining chair. Predisposing factors included: confusion and ambulating without assist. No injuries noted.
Record review of Resident #37's incident report dated 9/29/2024 at 9:50 AM Resident #37 was found on the floor in resident room on hands and knees with blankets between legs attempting to get up. Predisposing factors included: confusion, impaired memory, improper footwear, and poor safety awareness. No injuries noted.
Record review of Resident #37's incident report dated 11/17/2024 at 2:15 AM Resident was found on floor with large golf ball size hematoma to left side of forehead with scant amount of blood. Resident tired and groggy still and mumbled incoherent responses when asked what happened. Resident had removed his socks. Resident sent to emergency room for evaluation. Predisposing factors included: confusion, impaired memory, drowsy, improper footwear, ambulating without assist, wanderer and poor safety awareness. Facility fall investigation noted that the resident #37 was incontinent/wet. Medications given in the previous 8 hours included: Anti-anxiety, cardiovascular, and anti-psychotic medications. Investigation noted that the Resident #37 was receiving Ativan 1 mg tablet due to pharmacy unable to prepare the gel/cream formula. Record review of Resident #37's 'Neurological Record' dated 11/17/2024 instructions: Complete form and describe any neurological problems on the reverse. Perform initial, then every 15 minutes, then every hour times 4 hours, then every 8 hours times 24 hours. The Neurological record stopped documenting neurological checks after six hours.
In an interview and record review on 11/20/24 at 08:34 AM, Registered Nurse (RN) M reviewed the Medication Administration Record of Resident #37, who was receiving cream Ativan 1mg topical and on 11/14/2024 the order was discontinued. Resident #37 was started on Ativan 1 mg tablet oral. RN M revealed that Resident #37 had a history of falls, and he does have 4 falls in the last 2 months. There should have been a continued neurological assessment for 24 hours with the 11/17/2024 fall with head injury.
Record review of Resident #37's hospital emergency room evaluation discharge instructions included diagnosis of: head injury, scalp hematoma, traumatic brain injury. Resident #37 was returned to the facility.
Record review of fall program policy on 11/20/24 09:39 AM with Registered Nurse (RN) M revealed that the policy 'Catch a Falling Star Program' dated 1/23/2024 revealed that the facility was committed to the reduction of falls among residents using a systematic, multidisciplinary team approach. This program serves as an alert to all staff, including clinical and non-clinical staff. The yellow sticker star is a signal to all staff to be observant and to intervene if resident is displaying any unsafe behaviors.
Record review of facility 'Fall Prevention & Follow-up' policy dated 12/21/2023 revealed each resident will be assessed for the risk of falls. Appropriate interventions are identified, care planned and follow up done to monitor effectiveness. Residents are assessed for fall risk upon admission, quarterly, with any significant change and with each fall. (4.) Post fall assessment may include: c) Neuro checks (head injury or unwitnessed fall). (5.) If head injury or unwitnessed fall: initiate neurological checks: initial, then every 15 minutes for 1 hour (5 assessments), every 1 hour for 4 hours (4 assessments) and every 8 hours for 24 hours (3 assessments).
Resident #19:
Review of the face Sheet, diagnosis sheet, orders, nurse's notes and physician progress note's dated 9/24 through 11/24, revealed Resident #19 was 73 years-old, had a guardian in place, admitted to the facility on [DATE], dependent on staff for all Activities of Daily Living/ADL's, and resided on the Woodlands unit (locked Dementia unit). The resident's diagnosis included, cognitive impairment, severe depression, Dementia, Parkinsonism, pressure ulcer stage II on coccyx, heart disease, stroke with weakness of left side, Aphasia (difficulty with communication) and Dysphagia (swallowing impairment).
Review of the facility Brief Interview for Mental Status (BIMS) dated 11/7/24, revealed the resident had a BIMS of 2, severe cognitive decline.
Review of the physician order dated 10/16/24, revealed Resident #19 was ordered Ativan (for anxiety) oral tablet 0.5 mg, Give 1 tablet by mouth three times a day. This medication is scheduled as a regularly scheduled med to be given 3 times per day.
Review of the physician order dated 9/24/24, revealed Resident #19 was ordered Ativan oral tablet 0.5 mg, give 1 tablet by mouth every 6 hours as needed for agitation. The resident was getting a total of 1.5 mg of Ativan daily regularly scheduled, with the likelihood for getting a total of 2.0 mg Ativan as needed with no stop date (every 14 day's this medication is required to be re-ordered with explanation or stopped. This would be a total (both as needed and regularly scheduled) of 3.5 mg a day of Ativan given per order.
Review of the resident's facility fall's dated 5/10/24 through 11/20/24, revealed he had fallen a total of x 7 times.
Resident #19's Falls:
1. On 5/10/24
2. On 5/31/24
3. On 7/7/24
4. On 7/10/24
5. On 7/25/24
6. On 11/15/24
7. On 11/20/24
Review of the resident's Anti-Anxiety care plan dated 9/30/24, stated I am taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips and legs.
Review of the resident's Falls care plan dated 4/2/24, stated Anticipate and meet my needs, visualize resident while in dining room at all time. The resident fell in the dining room on .
During an interview done on 11/19/24 at approximately 2:00 p.m., Medical Director C said he ordered Resident #19's Ativan, he was aware of the dose.
During an interview done on 11/20/24 at 11:18 a.m., the Director of Nursing and this surveyor reviewed Resident #19's orders, and the Ativan order had not been changed and no note from Physician C was found to justify the continuing of Ativan PRN/as needed. The Director of Nursing changed the order and stated it was not changed until today (11/20/24). We will be having a manager on that unit, that will help out.
Review of the facility Fall Prevention & Follow-up policy dated 12/21/23, revealed all fall investigations will include interviews with resident's and staff, vital signs, pain, injuries occurred, fall assessment, medication review (includes Ativan), psychiatric and cognitive factors, history of other fall, and causative factors. This information generates care plan interventions and safety precautions.
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 ensure that one resident (Resident #19) remain free fr...
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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 one resident (Resident #19) remain free from unnecessary medications (Ativan) and to obtain consent for antidepressant use for one resident (Resident #26) of two residents reviewed for Ativan usage, resulting in Resident #19 receiving Ativan medication as needed with no stop date and Resident #26 receiving antidepressant medications with no consent.
Findings include:
Record review of the facility 'Psychotropic Medications' policy dated 12/21/2023 revealed residents receiving ant-psychotic medications with black box warnings will be provided with education regarding the significant risk of serious or even life-threatening adverse effects of the medication. A signed informed consent will be obtained for all ant-psychotic medications use in the facility. The attending physician or psychiatrist will provide an individualized risk vs benefits analysis for each resident receiving anti-psychotic medications. Specific conditions listed: Mood disorders (e.g., mania, bipolar disorder, depression ) All residents receiving newly prescribed psychotropic medications PRN (as needed) will be evaluated by provider within 14 days to evaluate need to continuation, or discontinuation of medication.
Record review of the 'Nursing 2017 Drug Handbook' page 1454-1455, Identified Trazadone Hydrochloride therapeutic classification: antidepressant.
Resident #26:
Record review of Resident #26's physician orders on 11/20/24 at 07:55 AM revealed medications of Prozac and Trazadone were ordered on 10/29/2024.
Record review of Resident #26's October 2024 Medication Administration Record (MAR) revealed that anti-depressant medications of Prozac and Trazadone were administered starting on 10/29/2024.
In an interview on 11/20/24 at 08:05 AM, social service designee G revealed that Resident #26 admitted on [DATE] from hospital, referral paperwork comes prior to resident arrival. Resident #26 Started Prozac and Trazadone (antidepressants) on 10/29/2024 was administered and the written consent was obtained November 13th. Social services designee G stated that she asks the nurses to get consents signed before the first dose is administered.
An interview and record review on 11/20/24 at 08:11 AM with the interim Director of Nursing (DON) M revealed that the nurses get the consent prior to administering the medications. It's in the policy to get a consent. Record review of the Psychotropic medication policy was reviewed.
Resident #19:
Review of the face Sheet, diagnosis sheet, orders, nurse's notes and physician progress note's dated 9/24 through 11/24, revealed Resident #19 was 73 years-old, had a guardian in place, admitted to the facility on [DATE], dependent on staff for all Activities of Daily Living/ADL's, and resided on the Woodlands unit (locked Dementia unit). The resident's diagnosis included, cognitive impairment, severe depression, Dementia, Parkinsonism, pressure ulcer stage II on coccyx, heart disease, stroke with weakness of left side, Aphasia (difficulty with communication) and Dysphagia (swallowing impairment).
Review of the facility Brief Interview for Mental Status (BIMS) dated 11/7/24, revealed the resident had a BIMS of 2, severe cognitive decline.
Review of the physician order dated 10/16/24, revealed Resident #19 was ordered Ativan (for anxiety) oral tablet 0.5 mg, Give 1 tablet by mouth three times a day. This medication is scheduled as a regularly scheduled med to be given 3 times per day.
Review of the physician order dated 9/24/24, revealed Resident #19 was ordered Ativan oral tablet 0.5 mg, give 1 tablet by mouth every 6 hours as needed for agitation. The resident was getting a total of 1.5 mg of Ativan daily regularly scheduled, with the likelihood for getting a total of 2.0 mg Ativan as needed with no stop date (every 14 day's this medication is required to be re-ordered with explanation or stopped. This would be a total (both as needed and regularly scheduled) of 3.5 mg a day of Ativan given per order.
Review of Resident #19's Medication Administration Sheet dated 11/24, revealed he had received the Ativan three times a day regularly scheduled and a total of x 20 Ativan doses as ordered on 9/24/24, as needed.
Review of the resident's facility fall's dated 5/10/24 through 11/20/24, revealed he had a total of x 7 falls.
Review of the resident's Anti-Anxiety care plan dated 9/30/24, stated I am taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips and legs.
During an interview done on 11/19/24 at approximately 2:00 p.m., Medical Director C said he ordered Resident #19's Ativan, he was aware of the dose.
During an interview done on 11/20/24 at 11:18 a.m., the Director of Nursing and this surveyor reviewed Resident #19's orders, and the Ativan order had not been changed and no note from Physician C was found to justify the continuing of Ativan PRN/as needed. The Director of Nursing changed the order and stated it was not changed until today (11/20/24).
Record review of the facility 'Psychotropic Medications' policy dated 12/21/23, revealed the physician will provide an individualized risk vs benefits analysis for each resident receiving anti-psychotic medications (including Ativan). Residents receiving newly prescribed psychotropic medications PRN (as needed) will be evaluated by provider within 14 days to evaluate need to continuation, or discontinuation of medication.
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 follow policies and procedures for medication labeling...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow policies and procedures for medication labeling and storage in 3 of 3 medication carts reviewed, resulting in opened and undated multi-dose medications, and an unclean and sanitary medication cart with the potential of administration of ineffective medications and the spread of infection.
Findings include:
Observation and interview on 11/18/24 at 08:59 AM of the East/West unit medication cart with Licensed Practical Nurse (LPN) N revealed that her morning medication pass was completed. Observation of the top drawer of the medication cart revealed a clear plastic medication dose cup with Pre-setup probiotics capsules sitting in the drawer with no label. LPN N stated that the probiotics are kept in the refrigerator in the medication room and that she put the 6 capsules in the cup so she would not have to go back to the med room to retrieve a capsule.
Observation and interview on 11/18/24 at 09:48 AM with Registered Nurse (RN) O of the North sub-acute unit medication cart revealed multiple medications that were opened with no open or expiration dates noted. RN O revealed that Medications need to be dated when opened, so that the medication does not over run the expected date of opening.
Observations revealed:
Resident #15- Breo Ellipta 100mcg/25mcq multi-dose powder inhaler not dated on box or bottle of when opened or when expires. Fluticasone propionate 50mcg nasal spray opened and not dated on the box or bottle. Albuterol sulfate 2.5mg/3ml multi-dose vial for nebulizer noted 23 vials left in box with no date on foil packet wrap or on the box.
New admission resident in room [ROOM NUMBER]-Rocklantan 0.02%/0.005% ophthalmic solution eye drops in 2.5ml bottle and box not dated. Brimonidine tartrate 0.2% eye drop not dated on bottle or box.
Resident #156- Albuterol sulfate 2.5 mg/3 ml multi-dose vials for nebulizer noted 21 vials left in box no date on foil packet wrap or box.
Resident #26- Albuterol HFA 90 mcg inhaler opened not dated on inhaler or box.
Resident #20- Fluticasone Propionate 50mcg nasal spray not dated on bottle or box.
Resident #13- Timolol Maleate 0.5% eye drop opened used with no date on bottle or box.
Observation and interview on 11/18/24 at 10:45 AM of the secured dementia unit medication cart with Licensed Practical Nurse (LPN) P revealed:
Resident #21- Potassium chloride 20 meq powder packets in box with individual packets with no open date on the box.
Resident #37- Latanoprost 0.005% eye drops for Glaucoma, labeled with pharmacy label to discard six weeks after opening, opened 11/6/2024, no discard or use by date on bottle or box. Timolol maleate 0.5% eye drop expires tomorrow.
Observation of the medication cart 1st drawer revealed paper debris and a loose tan round tablet found in the bottom of the medication cart drawer. Observation of the narcotic secured drawer revealed four small white pieces of a tablet found in the back of the drawer. LPN P stated that the night shift clean the medication carts, and the Registered Nurse/staff educator is to review medication carts also.
Record review of the facility 'Medication storage' policy dated 10/2/2024 revealed the facility will store medications and biological's in a manner which maintains the integrity of the medications and ensures the safety of the residents. The medication carts are to be kept clean and free of clutter.
Record review of the pharmacy services 'General Dose Preparation and Medication Administration' dated 4/30/2024 revealed the policy set forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to facility policy regarding medication administration and should comply with applicable law and the State Operations Manual (SOM) when administering medications. Procedure: (2.10) Facility staff should enter the date opened on the label of medications with shortened expiration dates. (2.10.1) Facility staff may enter the expiration date based on date opened on the label of the medications with shortened expiration dates.
Observation and record review of the medication refrigerator temperature logs observed on 11/19/2024 and on 11/20/2024 revealed there to be two medication refrigerators located within main nursing unit station and another in the main hallway toward the outside of the dementia care units. Record review of medication refrigerator temperature logs for 6 months from May 2024 through November 2024 revealed that the May 2024 log had a month and year but no location. June 2024 medication Refrigerator temperature logs could not be found. July 2024 Refrigerator temperature log had a date but no location. There were no August 2024 medication Refrigerator temperature logs could not be found.
Nov 2023
11 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement and operationalize a comprehensive skin man...
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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 and operationalize a comprehensive skin management program and implement meaningful and timely interventions to prevent pressure ulcer (wounds caused by pressure) development for two residents (Resident #9 and Resident #24) of four residents reviewed, resulting in inconsistent, inaccurate, and unclear wound documentation and assessment, lack of implementation of meaningful, timely, and revised, interventions, care coordination, Resident #9 developing a Stage 3 (full thickness tissue loss with exposed subcutaneous tissue), Resident #24 developing Stage 2 (partial thickness tissue loss presenting as an open ulcer) and unstageable pressure ulcers (unknown depth), and the likelihood for lack of timely and accurate identification of pressure ulcers, additional pressure ulcer development, infection, unnecessary pain, and decline in overall health status.
Findings include:
Resident #9:
Review of facility provided CMS-802 Resident Matrix Form dated 11/15/23 revealed Resident #9 had a stage 3 facility acquired pressure ulcer.
On 11/16/23 at 9:19 AM, Resident #9 was observed sitting in a wheelchair in the activity/dining room of the facility. When queried, Resident #9 indicated they had been sitting in their wheelchair for a while but was unable to provide a specific timeframe.
An interview was completed with Certified Nursing Assistant (CNA) I on 11/16/23 at 9:23 AM. When queried regarding Resident #9's skin, CNA I replied, (Resident #9 has a) pressure sore on their buttocks.
Record review revealed Resident #9 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebral infarction (stroke), pain, epilepsy, diabetes mellitus, heart disease, and pressure ulcer. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required moderate to substantial assistance to complete Activities of Daily Living (ADL) with the exception of eating. The MDS further revealed the Resident had three stage two pressure ulcers.
On 11/16/23 at 12:39 PM, an observation of Resident #9's room was completed. A foot cradle was observed sitting on the floor in the Resident's room. A passing staff member in the hallway was asked Resident #9's location and directed this surveyor to the central/dining room area of the facility.
Resident #9 was observed sitting in the same position in their wheelchair as previous observation.
At 1:13 PM on 11/16/23, Resident #9 remained in the same position in their wheelchair in the central/dining area of the facility.
Review of Resident #9's care plans in the Electronic Medical Record (EMR) revealed a care plan entitled, I have a pressure ulcer to my coccyx. I have a bunion on my left second toe that has been inflamed and aggravated in the past (Initiated: 8/27/20; Revised: 8/1/23). The care plan included the following interventions:
- Encourage ordered treatment. I refuse treatment at times, please educate me on the risks of refusing treatment (Initiated: 8/1/23)
- Follow facility policies/protocols for the prevention of skin breakdown (Initiated and Revised: 8/27/20)
- I have an air mattress on my bed set to my comfort level (Initiated: 8/1/23; Revised: 8/23/23)
- Roho cushion in wheelchair, please ensure is properly inflated . (Initiated: 8/1/23)
The care plan included the discontinued intervention, Resolved: Foot cradle on my bed (Initiated: 2/3/22; Revised: 5/24/22)
Review of Resident #9's current health care provider orders revealed the following:
- Cleanse L inner ankle wound with wound cleanser, pat dry, apply Medihoney & cover with optilock and wrap with kerlix. Secure with tape every day shift (Start Date: 11/16/23)
- Cleanse wound on Right upper gluteal cleft with soap and water or wound cleanser, pat dry, apply Santyl cover with ABD (large dressing) and and secure every day shift for wound care (Start Date: 10/25/23)
On 11/17/23 at 1:47 PM, an interview was conducted with Licensed Practical Nurse (LPN) F. When asked if the facility had a wound care and/or treatment nurse, LPN F indicated the facility had one nurse who completed wound care measurements but revealed treatments are completed by the resident's assigned nurse for the day/shift. When queried regarding observation of Resident #9's wound care treatment, LPN F replied Already done and indicated Resident #9 likes their treatment completed really early before they get out of bed for breakfast. With further inquiry regarding the Resident's wounds, LPN F revealed the Resident had wounds on their coccyx and the back of their left ankle. When asked if the wounds were pressure ulcers, LPN F confirmed they were. LPN F then stated that the left ankle pressure ulcer was fairly new, within two weeks. When queried regarding the appearance of the pressure ulcers, LPN F stated the left ankle wound had eschar (dead black or brown colored tissue) covering the wound bed.
On 11/17/23 at 2:07 PM, Resident #9 was observed in their room with multiple visitors. The Resident was sitting in the same position in their wheelchair in their room.
On 11/17/23 at 4:26 PM, an interview was conducted with the Director of Nursing (DON), Infection Control (IC) Registered Nurse (RN) D, and Education RN B. When queried regarding the wound care program in the facility, the DON stated, We have an LPN who does wound care measurements and treatments. When asked if floor nursing staff also complete ordered wound care treatments, the DON confirmed treatments are completed by assigned floor nurses. When queried when Resident #9's pressure ulcers were first identified, the DON, RN D, and RN B revealed they were not sure and would need to review the Resident's individual assessment documentation in the EMR. When asked if the facility had a way to monitor and tract wound progression, measurements, and treatments without having to access and review each individual assessment, the DON replied, (Wound Care LPN C) keeps a paper list. The list was requested for review and the DON exited the room. RN D and RN B were asked how many pressure ulcers Resident #9 had, what interventions were in place to prevent pressure ulcer development, and treatments/treatment changes implemented, RN D verbalized they understood the importance of the information but revealed they were unable to provide the information without opening each individual assessment. The DON returned to the room at this time with written wound care tracking forms dated 9/13/23, 9/24/23, 10/8/23, 10/27/23, and 11/9/23. Review of documentation on the form for Resident #9 detailed the following:
- 9/13/23: No documentation for Resident #9
- 9/24/23: Patient: (Resident #9). Wound Type: Stage 2 Pressure Wounds. Location: Right buttocks (1) 5 cm (centimeters) X 3 cm, black scab, Right buttocks (2) 1 cm X 1 cm, shallow/gran base, Gluteal fold (3) 1.5 cm X 1 cm, shallow/gran base Acquired . Deteriorating . Treatment: Cleanse with soap and water- apply magic butt cream. Change treatment prescription .
- 10/8/23: Patient: (Resident #9). Wound Type: Stage 3, Stage 2 Pressure Wounds. Location: Right buttocks 6 cm X 5 cm, Right buttocks 1.75 cm X 1 cm, Gluteal fold 2 cm X 0.5 cm . Acquired . Deteriorating . Treatment: Cleanse with soap and water- apply magic butt cream .
- 10/27/23: Patient: (Resident #9). Wound Type: Stage 3 Pressure Injury. Location: Right buttocks: 5.5 cm X 4 cm, Gluteal Cleft: 2 cm X 1 cm, Gluteal Cleft/Right Buttocks: 0.5 X 0.5 cm . Acquired . Improving . Treatment: Santyl (topical debridement treatment) - cover with gauze .
- 11/9/23: Patient: (Resident #9). Wound Type: Stage 3 Pressure Wounds. Location: Right Buttocks- 5 cm (centimeters) X 2 cm X 1.5 cm, Gluteal Cleft- 2 cm X 1 cm . Acquired . Improving . Treatment: Santyl .
Review of documentation in Resident #9's EMR revealed the following:
- 6/15/23: Skin/wound Assessment . Is Resident skin intact: Yes . Notes: Reddened bump/corn on 2nd toe right foot Is resident experiencing pain related to wound? (Blank) . Care Plan Updated? (Blank) . Provider Notified or Updated? (Blank) Dietary Notified or Updated? (Blank) . Resident or Responsible Party Notified . (Blank) .
Note: There was no documentation of follow up, interventions, and/or treatment/care noted.
- 6/22/23: Skin/wound Assessment . Is Resident skin intact: No . Site: Coccyx . Pressure . Length: 3.5 cm . Width: 1.5 cm . Stage 2 . Site: Other (not specified) . Pressure . Length: 1.5 cm . Width: 1.5 cm . Stage 2 . Wound Bed: Granulation Tissue . Dressing and Wound Care: Optifoam (adhesive foam dressing used for pressure ulcers) . Treatment Progress: (Blank) . Continue Treatment: Yes . Is resident experiencing pain related to wound: Yes . Care Plan Updated: (Blank) . Provider Notified or Updated? (Blank) Dietary Notified or Updated? (Blank) . Resident or Responsible Party Notified . (Blank) .
- 6/29/23: Skin/wound Assessment . Is Resident skin intact: No . Site . Coccyx . Pressure . Length: 3.5 cm . Width: 1.5 cm . Stage 2 . Site: Other (not specified) . Pressure . Length: 1.5 cm . Width: 1.5 cm . Stage 2 . Wound Bed: Granulation Tissue . Dressing and Wound Care: Optifoam (adhesive foam dressing used for pressure ulcers) . Treatment Progress: Unchanged . Continue Treatment: Yes . Is resident experiencing pain related to wound: Yes . Care Plan Updated: (Blank) . Provider Notified or Updated? (Blank) Dietary Notified or Updated? (Blank) . Resident or Responsible Party Notified . (Blank) .
- 7/6/23: Skin/wound Assessment . Is Resident skin intact: Yes .
- 7/13/23: Skin/wound Assessment . Is Resident skin intact: No . Notes: Resident has .2 x. 3 to rt. inner upper buttocks. Optifoam applied .
Note: No further description of the wound was present in the assessment.
- 7/20/23: Skin/wound Assessment . Is Resident skin intact: No . Notes: Open are to rt inner buttocks 0.5 x 0.5 cm. Optifoam dressing in place . Note:
Note: No further description of the wound was present in the assessment.
- 7/27/23: Skin/wound Assessment . Is Resident skin intact: No . Site: Left buttocks . Pressure . Length: 0.5 cm . Width: 0.5 cm . Wound Bed (Blank) . Dressing and Wound Care: (Blank) . Treatment Progress: (Blank) . Is resident experiencing pain related to wound: (Blank) . Care Plan Updated: (Blank) . Provider Notified or Updated? (Blank) Dietary Notified or Updated? (Blank) . Resident or Responsible Party Notified . (Blank) .
Note: Pressure ulcer identified as being on the left.
- 8/3/23: Skin/wound Assessment . Is Resident skin intact: No . Notes: Resident continues with open area the size of .5 cm x 1 cm. on inner rt. Buttock, continue with z-paste (Zinc oxide paste used for skin maceration associated with moisture) .
Note: Pressure ulcer size increased and no additional treatment, intervention, and/or follow-up documentation were present.
- 8/10/23: Skin/wound Assessment . Is Resident skin intact: No . Notes: Resident has 2 open area to rt inner buttocks. Continue to use z-paste as ordered every shift. Area is looking better and healing . Site: Right inner buttocks . Pressure . Length: 0.7 cm . Width: 1.0 cm . Right inner buttocks . Pressure . Length: 0.5 cm . Width: 1.0 cm . Wound Bed (Blank) . Dressing and Wound Care: (Blank) . Treatment Progress: (Blank) . Is resident experiencing pain related to wound: (Blank) . Care Plan Updated: (Blank) . Provider Notified or Updated? (Blank) Dietary Notified or Updated? (Blank) . Resident or Responsible Party Notified . (Blank) .
Note: The assessment indicated the pressure ulcer was healing while detailing an additional pressure ulcer developed as well as an increase in wound size.
- 8/17/23: Skin/wound Assessment . Is Resident skin intact: No . Notes: Resident has 2 open areas on rt inner buttocks area. Cleaned, dried, and put a 4 by 4 optifoam dressing on area . Site: Right inner buttocks . Pressure . Length: 0.8 cm . Width: 1.0 cm . Stage 1 . Right inner buttocks . Pressure . Length: 0.7 cm . Width: 1.0 cm . Stage 1 . Treatment Progress: (Blank) . Is resident experiencing pain related to wound: (Blank) . Care Plan Updated: (Blank) . Provider Notified or Updated? (Blank) Dietary Notified or Updated? (Blank) . Resident or Responsible Party Notified . (Blank) .
- 8/22/23: Skin/wound Assessment . Is Resident skin intact: No . Notes: Continues with 2 small circular wounds on R gluteal cleft; wound care provided, measurements collected. Please see skin/wound note for further details . Site: Right gluteal cleft . pressure . Length: 0.75 cm . Width: 0.75 cm . Stage 2 . Other (Blank) . Pressure . Length: 1 cm . Width: 0.5 cm . Stage 2 . Dressing and Wound Care . Cleanse with soap and water, pat dry and apply Z-paste to wound area . Deteriorated . Continue Treatment: Yes . Care Plan Updated: (Blank) . Provider Notified or Updated: Yes . Dietary Notified or Updated? Yes .
- 8/22/23 at 1:55 PM: Skin/Wound Note . Resident's wound care/tx completed by this nurse today; resident continues with two (2) stage II pressure injuries to R gluteal cleft. Areas were cleansed with soap and water, then patted dry as ordered. Measurements collected, then z-paste (barrier) cream applied to wound area. Wounds measure: #1 - 0.75cm x 0.75cm, #2- 1cm x 0.5cm. Wound bed #1 is dry and crusty with wound bed #2 is pink/epithelial tissue, with no drainage present. Both wounds are oval/round shaped with smooth margins and are located vertically on R gluteal cleft .
- 8/28/23: Skin/wound Assessment . Is Resident skin intact: No . Two wounds present on R gluteal cleft; z-paste tx (treatment) continued at this time . Site . Right gluteal cleft . pressure . Length: 0.5 cm . Width: 0.5 cm . Stage 2 . Right gluteal cleft . Pressure . Length: 1 cm . Width: 0.5 cm . Stage 2 .
- 9/5/23: Skin/wound Assessment . Is Resident skin intact: No . Site: Gluteal . Pressure . Length: 0.5 cm . Width: 0.5 cm . Stage 2 . Gluteal cleft . Pressure . Length: 1 cm . Width: 0.5 cm . Stage 2 . Treatment Progress: Not Changed . Care Plan Updated: No .
- 9/6/23 at 11:00 AM: Skin/Wound Note . Resident's wound care completed by this nurse today; resident continues with pressure injuries on R gluteal fold. Wound at proximal most area is a small circular scab measuring 0.5cm x 0.5cm, distal most wound measures 1cm L x 0.5cm W, wound bed is immeasurable; wound bed is pink with irregular edges. No drainage noted .
On 9/11/23, Resident #9 was transferred to the hospital with a diagnosis of Urinary Tract Infection (UTI) with sepsis (life threatening condition resulting from infection). The Resident returned to the facility on 9/15/23.
- 9/18/23 at 8:56 AM: Skin/Wound Note . Late Entry . nurse was called to the shower room this AM to assess resident's skin; resident observed to have 3 Stage II pressure injuries on gluteal cleft and R gluteal cleft. The newest wound observed measures 1cm x 0.5cm. The distal most wound on R gluteal cleft now measures 3 cm x 2 cm with a crater-like center measuring 0.5 cm x 0.5 cm. This wound is surrounded by pink-purple- black colored skin, which is slightly raised and hardened. The proximal most wound on R gluteal cleft is unchanged and measures 1 cm x 1 cm. Barrier cream applied as ordered. This nurse spoke to resident and (family) about the importance of frequent position changes to prevent new or worsening pressure injuries . verbalized understanding. Resident currently has air mattress in place; will continue to encourage resident change positions frequently. Will update as appropriate.
- 9/22/23: Skin/wound Assessment . Is Resident skin intact: No . Notes: Three small circular openings on right buttocks. Magic butt cream applied.
Note: The assessment did not include wound measurements and/or any further documentation.
- 9/24/23 at 4:44 PM: Skin/Wound Note . Resident now has three (3) Stage II pressure injuries present on gluteal cleft and R buttocks. Gluteal cleft measures 1.5 cm x 1 cm and is shallow with bed of granulation tissue. Wounds to R buttock measure 5 cm x 3 cm with dark black scab, pink-irregular margins, surrounded by hardened tissue. Smaller wound to R buttock measures 1 cm x 1 cm with shallow appearance and bed of pink granulation tissue. This wound has deteriorated significantly since last assessed by this nurse .
- 9/26/23 at 11:34 PM: Skin/Wound Note . Late Entry . Wound on left upper gluteal appears larger than last observed. Wound bed hard w/ eschar noted. Two smaller open areas noted inside the gluteal folds. Wound bed granulated tissue noted. Noted to be dk (dark) pink around larger wound. No drainage . Cleansed w/ soap and water and applied magic butt as ordered .
- 9/27/23 at 11:40 PM: 'Skin/Wound Note . Resident continue to have eschar noted on right upper buttocks. 2 smaller open areas noted inside right gluteal fold. Pink noted around periwound on right gluteal. No drainage noted. Magic butt applied to areas after cleansed w/ soap and water .
- 9/28/23: Skin/wound Assessment . skin intact: No . Notes: Resident has open area to buttocks z-paste applied per orders .
Note: The assessment did not include wound measurements and/or any further documentation.
- 9/29/23 at 12:43 PM: Skin/Wound Note . Resident's wound care and tx completed . largest wound on R buttock now measures 5cm x 3cm with black-yellow center of eschar tissue. Margins of this wound are bright pink and irregular. Appears scab like in center of this wound. Wound on gluteal fold is shallow and resembles shearing, irregular shape margins and measures 1 cm x 1 cm. The smaller wound present on R buttock measures 1 cm x 1.5 (cm). Moderate drainage from wound noted on resident's brief; resident will not tolerate dressing on wound on buttocks. These wounds have significantly deteriorated .
- 10/1/23 at 11:17 PM: Skin/Wound Note . The larger sore on right buttock-wound bed appears creamy yellow w/ small line of black noted. Peri wound is red. The second wound on right buttocks, wound bed granulated tissue noted. Third one barely open. Cleansed w/ soap and water and apply magic butt. Resident c/o (complain of) pain in area. This nurse encouraged resident to lay on right side but resident couldn't lay on right side and ended getting up in w/c (wheelchair) d/t (due to) resident stated it hurt too much to lay in bed.
- 10/3/23 at 3:17 AM: Skin/Wound Note . Larger sore on right buttocks-half yellow on left side and half brownish/red on right side of sore. Wound bed hard to touch. Distal to first wound is the second open-smaller in size. Wound bed pink. No drainage noted from both open sores. Both sores redden around periwound. Cleansed w/ soap and water then applied magic butt.
- 10/5/23: Skin/wound Assessment . skin intact: No . Site: Right Buttocks . Pressure . Length: 62 cm . Width: 33 cm . Depth: (Blank) . Stage: 3 . Sacrum . Pressure . Length: 7 cm . Width: 10 cm . Depth: (Blank) . Stage 2 . Sacrum . Pressure . Length: 10 cm . Width: 8 cm . Depth: (Blank) . Stage 2 . Wound Bed: Slough . Cleanse with soap and water, pat dry. Apply Z-paste . Deteriorated . Continue Treatment: Yes . Care Plan Updated: No .
- 10/7/23 at 12:52 AM: Skin/Wound Note . Larger wound on right gluteal-Light yellow slough noted on wound bed. The smaller wounds distal to above wound (right gluteal) and left of this wound on gluteal cleft smaller in size. Wound bed for smaller 2-pink wound bed. Red around all wounds. No drainage noted. Cleansed w/ soap and water and applied to all wounds per doctor's order.
- 10/12/23: Skin/wound Assessment . skin intact: No . Notes: Resident continues with treatment per orders. Wound care nurse will measure and tx (treat) on Friday Oct. 13th .
Note: No further wound documentation was included in the assessment.
- 10/13/23 at 12:28 PM: Skin/Wound Note . Resident wound care and tx (treatment) to Stage III pressure wounds to R buttock and gluteal cleft completed . The largest wound to R buttock measures 6.5 cm x 2.5 cm. A thick layer of yellow slough covering wound bed, undermining present. Wound margins are raised, irregular and bright pink. Unable to determine depth of wound d/t presence of slough. Smaller wound to R buttock measures 1.5cm x 1cm with light pink wound bed, smooth edges and no s/s of infection noted. Wound to gluteal cleft measures 2.5cm x 1cm with pink wound bed and smooth edges . Magic butt cream applied to wound beds. Wound continues to deteriorate; resident is non-compliant with frequent position changes to offload pressure from coccyx/sacrum area . Resident continues with air mattress but is reluctant to sleep in bed for reasonable amounts of time. Resident to continue with daily tx and weekly assessments . until wound has resolved. Resident has states that 'bottom is sore' .
- 10/22/23 at 11:49 AM: Skin/Wound Note . Resident's wound care and tx to R buttocks x 2 and gluteal cleft completed . No drsg to discard; however, small amount of frank red blood present on resident's brief . the largest wound to R buttock appears to be improving slightly. Small area of thick yellow slough present, covering a good portion of the L side of wound bed. R side of wound has undermining present with pink wound bed. The wound margins are uneven and are bright pink-red with inflammation . measures 6 cm x 3 cm x 0.5 cm . The second and smaller wound to R buttock measures 0.5 cm x 0.5 cm. This wound is shallow with a pink wound bed. The wound to gluteal cleft measures 0.5 cm x 1.5 cm, shallow with pink wound bed . buttocks were cleansed with soap and water, then gently patted dry. Magic butt cream applied as ordered. No s/s of infection present in regard to smaller wounds . Resident encouraged to make frequent position changes while in bed and in WC to offload pressure to sacrum/coccyx area to prevent further skin breakdown. Resident verbalized understanding .
- 10/26/23: Skin/wound Assessment . skin intact: No . Notes: Resident continues with a stage III and a stage II open area to rt. buttocks and gluteal fold. Continues with treatment per orders .
Note: No further wound documentation was included in the assessment.
- 10/27/23 at 1:51 PM: Skin/Wound Note . Resident's wound care and tx completed . did not have a dressing in place, moderate yellow-opaque drainage present on resident's brief. The wound was cleansed with soap and water . Large wound to R buttock measures 5.5 cm x 4 cm with 0.25 cm depth to top R corner of the wound. Wound bed is uneven with irregular, bright red (inflamed) margins. Wound bed partially covered with thick coating of slough. Peri-wound skin is pale, but blanchable. Smaller wound on R buttock measures 0.5 cm x 0.5 cm with shallow pink wound bed. This wound shows some improvement compared to last assessment . Wound to gluteal cleft measures 2 cm x 1 cm with shallow pink wound bed and smooth margins. Peri-wound skin to smaller wounds is also pale but blanchable. Santyl ointment applied to large wound on R buttock, then covered with super absorbent dressing., secured with tape. Magic butt cream applied smaller wounds; smaller wounds left open to air .
- 11/9/23: Skin/wound Assessment . skin intact: No . Notes: Resident continues with a stage II and a stage III wound to rt. buttocks/gluteal fold. Treatment in place as ordered .
Note: No further wound documentation was included in the assessment.
- 11/9/23 at 4:38 PM: Skin/Wound Note . Resident wound care and tx to Stage III pressure wounds to R buttock and gluteal cleft . No drsg present, moderate, yellow-tinged drainage noted on resident's brief. Wounds were cleansed with soap and water . patted dry. Wound to R buttock measures 5 cm x 2 cm x 1.5 cm. Wound has uneven margins, wound bed with less slough present than when last assessed . Wound bed is red, some granulation tissue present . Wound to gluteal cleft measures 2 cm x 1 cm with pink wound bed, smooth margins . Wound margins are no longer stiff or red with inflammation . some improvements . Santyl applied to wound bed on R buttock. Wound was then covered with small non-adherent bandage and secured with tape. Z-paste applied to wound on gluteal cleft; wound left open to air .
- 11/14/23: Skin/wound Assessment . skin intact: No . Notes: Noted open area to inner LLE (Left Lower Extremity) just above ankle. Noted 2 smaller open areas just below . Site: Inner LLE above ankle . open area . Length: 2.3 . Width: 1.5 . Left inner ankle . open area . Length: 0.8 . Width: 0.7 . Left inner ankle . open area-pinpoint . Exudate Type: Serous . Amount: Small . Wound Bed: Slough .
An interview was conducted with Wound Care LPN C on 11/21/23 at 11:21 AM. When queried regarding the frequency they are supposed to measure and assess wounds, per facility policy/procedure, LPN C replied, Weekly. LPN C was then asked why wound assessments were not completed weekly for Resident #9, LPN C revealed they have only been in the wound care nurse role for a couple of months and are not employed full time in the role. When asked to explain, LPN C explained they are employed full time at the facility but work as nurse on the floor. When queried if a collaborative nutritional consult was completed for Resident #9 related to their wounds, LPN C revealed they were unsure if the Resident was receiving nutritional supplementation for wound healing and/or of any dietary recommendations made. No further explanation was provided. LPN C was then queried where wound assessment and measurements are documented and revealed they use both the Skin/Wound assessment and Skin/Wound Note in the EMR. When asked where documentation is supposed to be completed per facility policy/procedure, LPN C revealed they were unsure. When queried if they received and/or completed any specialized training pertaining to wound care, LPN C stated, None. LPN C was asked the date Resident #9's pressure ulcers were first identified and indicated they would need to review the Resident's EMR. When queried, LPN C revealed they do not maintain documentation of the initial identification date for Resident wounds. LPN C was asked if all Resident #9's pressure ulcers were facility acquired and stated they were. A review of Resident #9's wound care documentation in the EMR was completed with LPN C at this time. When asked why there was no follow up documentation pertaining to the Resident's right foot second toe being intact with Reddened bump/corn on 6/15/23, LPN C reviewed the EMR and was unable to provide an explanation. When, LPN C confirmed follow up documentation and assessment should have been completed. LPN C was then queried regarding the blank areas of documentation on the assessment, if the skin was blanchable, and the cause of the redness but was unable to provide an answer. Resident #9's Skin/Wound . documentation was reviewed with LPN C at this time.
When queried if the Health Care Provider had been notified of the Resident's stage two pressure ulcers in June 2023 when first documented, LPN C designated the assessments did not specify. When asked why the location of the second identified pressure ulcer was not specified, LPN C stated they had not completed the assessment and were not able to say. When asked if the wounds were of the right or the left (per 7/22/23 assessment), LPN C reviewed the documentation and indicated Resident #9's pressure ulcers had always been on the right as far as they were aware. When asked why pressure ulcers were documented as stage one on 8/17/23 after being identified as stage two, LPN C did not provide an explanation. LPN C was then asked to clarify Resident #9's wound locations and total numbers on their buttocks/gluteal cleft due to documentation being unclear. LPN C responded that Resident #9 had three facility acquired pressure ulcers in close proximately on the right buttocks/gluteal cleft. When asked if the facility utilized photographs for wounds, LPN C replied, No. When queried if Resident #9's pressure ulcers had deteriorated from a stage two facility acquired to a stage three with tunneling and undermining, LPN C confirmed the pressure ulcers had worsened. LPN C was then asked why treatments were not changed/modified timely when the pressure ulcers were not healing and/or deteriorating/worsening. LPN C was unable to provide an explanation but confirmed treatments were not modified based upon assessment of the wounds. When queried regarding turning and repositioning, LPN C verbalized Resident #9 likes to be up in their chair all day. When asked if the Resident is able to move/reposition themselves in their wheelchair, LPN C indicated the Resident was able to move a little in their chair. When asked if assistance to reposition was provided, LPN C did not respond. When queried if wheelchair positioning devices and/or a reclining/different type of chair for pressure reduction had been attempted/implemented, LPN C revealed there had not been any new interventions implemented/attempted recently. LPN C was then queried if Resident #9 had developed a new pressure ulcer on their left ankle within the prior two weeks as indicated by their assigned floor nurse. LPN C confirmed Resident #9 had developed a new wound and stated they are unable to identify and classify wound types due to being an LPN. When asked who determines wound types if they are unable to do so as the facility Wound Care nurse, LPN C indicated the Health Care Provider makes that determination. When queried if they had assessed the wound, LPN C stated they had and stated they documented in a progress note.
Record review revealed the following note in Resident #9's EMR:
- 11/18/23 at 3:11 PM: Skin/Wound Note . Wound care and tx to Stage III pressure wound to R (right) buttock and gluteal cleft and wound care to inner L ankle venous stasis ulcers completed . Kerlix and drsg present on L inner ankle completely saturated with serosanguineous drainage . There are two separate areas with wounds present on the L inner ankle and bridge of L foot (cluster of 3 small open areas). Area to inner L ankle is macerated with thick patches of yellow/white slough to wound bed. Wound margins are irregular, red and inflamed. This wound measures 3.5 cm x 2.5 cm. Cluster of 3 small open areas on bridge of L foot was cleansed with wound cleanser . The 3 areas are circular with more [TRUNCATED]
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
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice Statement (DPS) Two:
Based on observation, interview and record review, the facility failed to follow and im...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice Statement (DPS) Two:
Based on observation, interview and record review, the facility failed to follow and implement appropriate interventions and ensure the safety and supervision for two residents (Resident#32 and Resident #36), resulting in unsupervised wandering into other residents bathroom, a forehead bruise, and undocumented neurological status.
Findings include:
Resident #32:
On 11/15/23, at 10:03 AM, Resident #32 was in the main dining area eating their breakfast. There was a bruise noted to their forehead approximately 2 inches by 2 inches. Resident #32 was nonverbal when asked where their forehead bruise came from.
On 11/15/23, at 12:59 PM, Resident #32 was resting in a recliner in the common area with a four wheeled walker next to her.
On 11/16/23, at 9:06 AM, CNA M was interviewed regarding Resident #32's forehead bruise. CNA M was asked what happened and CNA M stated, we think she hit her head on her bedside table.
On 11/17/23, at 8:30 AM, a record review of Resident #32's electronic medical record revealed a readmission on 10/092023 with diagnoses that include Dementia, Anemia and delusional disorder. Resident #32 had severely impaired cognition and resided on the locked dementia unit.
A review of the 11/9/2023 Practitioner Documentation Note Text: Patient is seen for new noted ecchymosis. Discussed case with nursing at length . ECCHYMOSIS TO MID FOREHEAD . Plan: Patient counseled and encouraged. No changes to plan of care.
A review of the progress notes revealed 11/8/2023 . Incident Note . On 11/3/23 Resident noted to have a bruise in the center of her forehead, originally measurement of 20 x 25 cm (Nurse will be educated on measuring), area is 2 cm (centimeters) x (by) 3 cm, fading green/yellow color. Unknow how bruise occurred, Resident is not fearful at the time this Nurse was talking with her. Resident did have an outing with her Son during the day on 11/3/23. Nurses to do skin assessment upon returning from all outings. Will monitor as needed. There was no neurological assessment noted in the record for the bruising. A review of the progress notes for 11/3/2023 revealed 11/3/2023 18:27 (6:27 PM) . Resident was observed with a 20 x 25 cm light colored bruise to her forehead. Resident had no knowledge of it, and denies pain. There was no notation reporting the bruise to the abuse coordinator as an injury of unknown origin or notification to the physician and the family.
A review of the incident report provided by the facility revealed: Bruising . Incident Location: Unknown . Resident was observed with a small bruise to her forehead . Resident unable to give Description . Resident did not know what happened or that she had a bruise . Mobility: Ambulatory without assistance . Witnesses . No Witnesses found . Agencies/People Notified . No notifications found .
On 11/17/23, at 8:57 AM, The Director of Nursing (DON) was interviewed regarding Resident #32's forehead bruise and how did they injury their head. The DON explained that the resident may have fallen while out with their son and that an intervention was placed to assess the resident's skin upon return from family outings. The DON was asked if they had called the son to inquire if the resident fell or hit their head while out in their care and the DON stated, no, I don't think so. The DON was asked if the facility completed an investigation on the bruise/injury of unknown origin and the DON explained that the resident can be resistive to care and at times will barricade themselves in their room but denied reporting the bruise as an injury of unknown origin. The DON was again asked if the facility hypothesized, summarized, investigated or reported the injury of unknown origin and the DON stated, no.
On 11/21/23, at 12:15 PM, the DON was questioned if the facility had assessed the neurological status of the resident once the forehead bruise was recognized and the DON stated, No but the nurse was educated.
A review of the facility provided RESIDENT ABUSE POLICY & PROCEDURE 12-18-17 policy revealed . The Administrator / DON will ensure all alleged violations involving abuse, neglect, exploitation, mistreatment, including injuries of unknown sources . are reported immediately, but not less than 2 hours after the allegation is made, to the appropriate state agency .
A review of the Abuse, Neglect Exploitation & Misappropriation of Resident Property 5-11-2022 policy revealed . It is the Facility's policy to investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property, including Injuries of Unknown Source, in accordance with this policy . DEFINITIONS . Injury of Unknown Source. An injury is classified as an Injury of Unknown Source when both the following conditions are met: The source of the injury was not observed by an person, or the source of the injury could not be explained by the resident; AND The injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point int time, or the incident of injuries over time.
Resident #36:
On 11/15/23, at 2:35 PM, Resident #36 was sitting on the side of their bed. The resident was dressed although had white socks with no grippers and no shoes on. There was an 8-inch x 11 inch sign next to their bathroom that stated, please leave bathroom light on. The bathroom light was off and the door to the bathroom was missing. The resident quickly stood up said they I need to find the bathroom and ambulated out of their room. Resident #36 ambulated out into the hallway, turned right, and headed towards another resident's room. Resident #36 entered room [ROOM NUMBER], walked into their bathroom and closed the door. The facility staff was unaware. This surveyor walked to the nurses' station where the door and window faced the center of the main hallway out of view of the 200 hall and asked if Resident #36 is allowed to use other resident's restroom. Nurse N stated, oh no as they hustled to room [ROOM NUMBER]. Nurse N entered room [ROOM NUMBER], opened up the bathroom door and Resident #36 stated, shut the door I'm trying to pee. Nurse N waited for the resident to finish, walked Resident #36 back to their room. Resident #36 sat down on their bed. Nurse N was asked if Resident #36 had gripper socks on and Nurse N stated, no. Nurse N left out of the room as they were assigned at the other end of the building in the locked dementia unit.
On 11/15/23, at 2:52 PM, a staff member was noted on the 200-hall putting a hoyer lift in the utility room. CNA O was inquired why Resident #36 did not have a door on their bathroom and CNA O stated, so he can find the bathroom easier. CNA O was asked what the sign was for that said leave the light on and CNA O stated, so he knows it's his bathroom. The light was off. Resident #36 was asked if he knew what the sign was and Resident #36 stated, oh, it's my sisters. She put it up there. It's not mine.
On 11/16/2023, at 11:00 AM, a record review of Resident #36's electronic medical record revealed an admission on [DATE] with diagnoses that included Alzheimer's Disease, Dementia and Osteoarthritis. Resident #36 had severely impaired cognition and required assistance with Activities of Daily Living (ADL').
A review of the care plan I am at risk for falls r/t (related to) new environment and I ambulate independently without assistive device Date Initiated: 05/30/2023 . Interventions Anticipate and meet my needs . Follow facility fall protocol .
A review the care plan ELOPEMENT: I am an elopement risk/wanderer AEB (as evidenced by) Disoriented to place, Impaired safety awareness Date Initiated: 06/01/2023 Revision on: 06/01/2023 . My safety will be maintained through the review date . Interventions . Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Date Initiated: 06/01/2023 .
A review of the care plan I have an ADL Self Care Performance Deficit r/t Alzheimer's Date Initiated: 05/16/2023 Revision on 05/18/2023 . Interventions TOILET USE: I require set up assistance for toilet use. Please encourage me to change my pull-up when it is soiled. I may need queuing to find the bathroom at times. I have the bathroom door removed for easier access to toilet. Date Initiated: 05/18/2023 Revision on: 10/03/2023 .
The care plans did not mention the resident often wanders into other resident's bathrooms.
On 11/16/23, at 3:45 PM, Resident #36 was observed ambulating out of the dining room. Resident #36 passed by the Social Worker's office towards the main entrance. Social Worker (SW) L stood up and asked Resident #36 where he was going and the resident stated, I need to urinate.
On 11/16/23, at 3:50 PM, SW L was asked if they knew why Resident #36 didn't have a bathroom door and SW L stated, the son suggested it as that was worked at home. SW L stated, they tried a restroom sign on the outside of his door but that didn't work.
Deficient Practice Statement (DPS) One:
This Citation Pertains to Intake Number: MI00139609.
Based on observation, interview, and record review, the facility failed to implement and operationalize policies and procedures to ensure appropriate supervision to prevent falls for one resident (Resident #24) of two residents reviewed, resulting in Resident #24 (R24) being left unattended in the Activity Room, falling, and suffering a right hip fracture, unnecessary pain, and the likelihood for decline in overall health status.
Findings include:
Resident #24:
Record review revealed Resident #24 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia, overactive bladder, weakness, and displaced femur fracture necessitating surgical intervention following a fall in the facility. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required moderate to total assistance to complete Activities of Daily Living (ADLS) with the exception of supervision with eating.
On 11/16/23 at 1:09 PM, Resident #24 was observed eating in the dining area of the locked dementia unit of the facility. Resident #24 was observed to have a purple/green colored bruise around their left eye. A heel boot (pressure reduction device) was in place on their right lower extremity. An interview was attempted to be completed at this time. When spoke to, Resident #24 made eye contact and smiled but did not provide meaningful responses to questions when asked.
Certified Nursing Assistant (CNA) P was interviewed on 11/16/23 at 1:05 PM. When queried regarding Resident #24's boot, CNA P explained that Resident #24 developed a pressure ulcer (wound caused by pressure) on their right heel after returning to the facility following hospitalization. CNA P was asked why Resident #24 was hospitalized and revealed the Resident fell in the facility and fractured their hip. With further inquiry, CNA P said that before Resident #24 fell on 8/20/23, Resident #24 was much more mobile, using a walker with one person assist. CNA P stated, (Resident #24) was able to ambulate and transfer using a walker before the fall with fracture. When queried regarding the Resident's black eye, CNA P revealed it was from a more recent fall.
An interview was completed with Nurse Q on 11/16/23 at 1:20 PM. When queried regarding Resident #24's fall on 8/20/23, Nurse Q indicated they did not recall the fall but verbalized that Resident #24's ambulation status before the fall on 8/20/23 was one assist with a walker.
Activities Director U was interviewed on 11/16/23 at 1:41 PM regarding Resident #24's fall on 8/20/23. Activities Director U revealed that Resident 24's fall happened in the dementia unit activity room on 8/20/23. After the activity was done, Activities Director U described leaving Resident #24 in the activity room while they escorted a different resident back to their room. Activities Director U they were the only staff member present in the activity room and stated, No other staff was designated to watch other residents when I left the room. Activity Director
U continued, Usually, (Resident #24) does not get up when sitting in their chair. Activities Director U further commented, (Resident #24) must have decided to follow me to go to their room. Activities Director U described finding Resident #24 on the floor in the activity room after returning from taking the other resident back to their room. When asked, Activities Director U confirmed the fall was unwitnessed and they found the Resident.
Housekeeper R was interviewed on 11/16/23 at 2:00 PM. Housekeeper R remembered the day of Resident #24's fall in the activity room of the locked unit of the facility. Housekeeper R described they were assigned to work in the locked dementia unit on 8/20/23. When asked what had occurred, Housekeeper R revealed the activity room in the locked unit had a door between the two rooms (the activity room and the dining room). Housekeeper R recalled that when in the dining room, the door blocks anyone from seeing the residents in the activity room. Housekeeping R verbalized they were not in the activity room when the fall occurred. When queried, Housekeeper R denied being asked to watch the residents in the activity room. Housekeeper R further stated, I was unaware of what happened and left for lunch, and upon my return from lunch, I heard that Resident #24 had fallen.
Review of Resident #24's Electronic Medical Record (EMR) revealed a care plan entitled, I have had an actual fall with right hip fracture. I have poor comprehension related to cognition (Initiated and Revised: 8/25/23). The care plan included the interventions:
- Follow ordered transfer and ambulation orders (Initiated: 8/25/23)
- I am on the falling star program indicated by a yellow star on my door and yellow rope on my walker (Initiated: 8/25/23)
- Orient me as able to my surroundings, make sure my needs are met and call light in reach. Check on me frequently (Initiated and Revised: 8/25/23)
- Resolved: Non-ambulatory (Initiated: 8/25/23; Revised and Resolved: 10/4/23)
Note: Resident #24 did not have a care plan for fall prevention prior to their fall on 8/20/23.
A second care plan entitled, I have an ADL Self Care Performance Deficit r/t (related to) Dementia (Initiated: 4/25/23). The care plan included the interventions and historical data:
- Ambulation: I require two (2) assist with gait belt (Initiated: 4/25/23; Revised: 11/8/23)
Review of historical care plan data revealed the following changes: On 4/25/23, Resident #24 was independent with ambulation with no device. On 8/15/23, the Resident's care plan detailed they required assist of 1 with a 4-wheel walker for ambulation. The care plan was modified again on 8/20/23 to detail, I need assist of 1 with a 4-wheel walker for ambulation. Please keep walker in front of me when left unattended.
Review of hospital documentation revealed Resident #24 was transferred from the facility to the local hospital and then transferred to a tertiary hospital where they had a surgical repair completed for their right displaced intertrochanteric femur fracture.
Review of Resident #24's documentation in the EMR revealed the following:
- 8/17/23 at 3:59 PM: Medicare Note . Resident being treated . for decline in ADL's .
- 8/20/23 at 11:52 AM: Health Status Note . CNA notified writer res was on the floor, writer entered room observed this res sitting on right hip holding upper body up with Right arm and bilateral legs were bent at the knee and on left side of trunk of body, res was able to move all extremities while sitting on the floor, pupils equal and reactive, hand grasps strong and equal, staff assisted res off the floor, as res began to walk res started to guard hip and give signs of pain, res assisted into stationary chair . Contacted . (Physician) at 1104 am, ambulance at 1105, and report given .
- 8/20/23 at 12:04 PM: Health Status Note . res did have irregular shaped nickel sized blood blister to right hand btwn (between) thumb and first finger .
- 8/24/23 at 4:09 PM: Health Status Note . Res arrived via ambulance and admitted to room . res is alert to self only . drsg (dressing) in place . res is noted with pain during assessment .
Minimum Data Set Registered Nurse (RN) S was interviewed on 11/20/23 at 1:30 PM. When queried regarding Resident #24's level of assistant needed for ambulation at the time of their fall on 8/20/23, RN S explained the Resident ambulated with a rolling walker and one person assist. RN S was asked if Resident #24 was at risk for falls prior to falling and fracture their femur on 8/20/23 and revealed the Resident was deemed a moderate Fall Risk at that time due to their cognition, prescribed medications, and use of an assistive device when ambulating. RN S was asked if Resident #24 had a fall risk care plan in place prior to their fall on 8/20/23 and stated there was no fall care plan. When asked why, RN S did not have a response. When asked if Resident #24 had other falls in the facility, RN S indicated the recently fell again on 11/12/23. When queried the facility policy/procedure pertaining to fall risk assessment determination, RN S revealed an assessment is utilized in the EMR and Resident #24 is currently assessed as being a moderate risk for falls.
Review of Resident #24's Fall Risk Assessment documentation revealed the Resident was assessed as a moderate fall risk on 4/19/23, 7/23/23, 8/20/23, and 8/24/23. The Resident was assessed as a high risk for falls on 11/11/23.
The Director of Nursing (DON) was interviewed on 11/21/23 at 3:00 PM. The DON was queried regarding Resident #24 being assessed as a moderate risk for falls prior to their fall with fracture on 8/20/23 and not having a fall risk care plan in place. The DON confirmed Resident #24 should have had a fall risk care plan in place. When asked what occurred when Resident #24 fell on 8/20/23, the DON revealed Resident #24 was left alone and unattended in the activity with their walker not in reach. When queried if the fall was a result of lack of supervision and staff assistance, the DON validated it was. No further explanation was provided.
Review of facility policy/procedure entitled, Fall Prevention & Follow-up (Reviewed/Revised: 8/11/23) detailed, Our mission is the reduction of falls through a systematic, multidisciplinary team approach. The falling star identification program identifies residents at high risk for falls . Each resident will be assessed for the risk of falls. Appropriate interventions are identified, care planned, and follow up done to monitor effectiveness. Residents are assessed for fall risk upon admission, quarterly, with any. significant change and with each fall. If a resident falls or is lowered to the floor, the resident is not moved until a licensed nurse is notified and a full assessment is done .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure respectful treatment of residents for one resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure respectful treatment of residents for one resident (Resident #7) of one resident reviewed resulting in Resident verbalization of not receiving timely care, and verbalization of emotional distress and feelings of frustration.
Findings include:
Resident #7:
Record review revealed Resident #7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included pain, weakness, asthma, Peripheral Vascular Disease (PVD), and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to complete all Activities of Daily Living (ADL) with the exception of eating and locomotion.
On 11/15/23 at 12:12 PM, Resident #7 was observed sitting in a wheelchair in their room and an interview was completed. Resident #7 was guarding their right side and had tears in their eyes. When queried if they were having pain, Resident #7 stated, Yes. Resident #7 then stated, I leaned over the side of my wheelchair to pick up my phone. My side hit the wheelchair and I hurt myself. Resident #7 was asked when that happened and reviewed the incident occurred early in morning yesterday. When queried if they had informed their nurse, Resident #7 confirmed they had and stated, The nurse said I make stuff up. When queried if their nurse told them that, Resident #7 stated, They don't take me seriously. Resident #7 did not provide a response when asked the name of the nursing staff. Resident #7 was asked the location of the pain and pointed to their right flank/ribs. When asked to rate their pain on a scale of zero to 10 with 10 being the worst pain imaginable, Resident #7 stated, Six. Resident #7 was asked if they had seen their Health Care Provider, received any testing, and/or medication for their pain and revealed they had not. When queried if their assigned nurse today was aware of the incident and their pain, Resident #7 indicated they were but reiterated they did not take them seriously. When asked how it makes them feel when they do not feel that staff are taking them seriously, Resident #7 stated, Bad, like I don't matter.
An interview was completed with Licensed Practical Nurse (LPN) T on 11/15/23 at 12:30 PM. When queried if they were aware of Resident #7's pain in their right ribs/flank, LPN T indicated they were. When queried regarding assessment and treatment for the pain, LPN T revealed they had given Resident #7 their scheduled dose of Tylenol. LPN T was then asked if the pain in their right flank/ribs was new for Resident #7 but did not provide a response. When queried why Resident #7 received scheduled Tylenol, LPN T indicated it was for their arthritis. With further inquiry, LPN T revealed they had not assessed the Resident for injury and had not reassessed their pain level after administering the Tylenol during morning medication pass.
An interview was conducted with the facility Administrator on 11/17/23 at 11:13 AM. When queried regarding Resident #7's verbalization of feeling that nursing staff do not take them seriously, the Administrator stated, That is not okay. When queried if they were aware Resident #7 informed staff they injured themselves and were experiencing pain, the Administrator revealed they were not. After relaying Resident #7's statements regarding what had occurred and their feelings to the Administrator, the Administrator stated there are multiple system concerns involved and indicated they would address.
On 11/17/23 at 1:22 PM, a follow up interview was completed with the facility Administrator. The Administrator revealed they spoke with Resident #7, validated the concerns, and would work to address the issues.
A facility policy/procedure related to Dignity was requested on 11/16/23 at 12:21 PM but not received by the conclusion of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNEC) for one resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNEC) for one resident (Resident #24) of three residents reviewed for Beneficiary Notices, resulting in the resident and/or the representative not being informed of the right to appeal and the potential for undue emotional and financial hardships.
Findings include:
Resident #24:
Record review revealed Resident #24 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia, weakness, and a fall with femur fracture. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required substantial to total assistance to complete Activities of Daily Living (ADL).
During record review on 11/17/23 at 11:04 am, the facility was asked to provide a NOMNEC letter for Resident (R) #24. Upon request the facility did not provide a NOMNEC letter for Resident #24's discharge from service in November 2023. Per facility provided beneficiary notice documentation, No Notice of Medicare Non-Coverage available for (R#24) with last covered day 11/06/2023.
An interview with facility Staff E was completed on 11/17/23 at 11:30 am. When asked, Staff E relayed they did not have the NOMNEC letter available for Resident #24's 11/6/23 discharge date . When further queried, Staff E confirmed R#24's representative was not provided a NOMNEC letter. When asked the date R#24's services were discontinued, Staff E indicated R#24's is currently receiving services via private pay as of 11/7/23.
According to the Facility's admission Packet: Grievances and Appeals (page no. 12) (Revised: 11/2017): You can appeal any decision about your services and supports that your agency makes. This includes denying a service that you asked for and reducing, suspending, or terminating services that you already have. When the waiver agency makes these decisions, they must send you a letter called an adverse benefit determination. This letter contains information about the changes or decision made, you can also ask for an appeal . If you would like your services to continue without any changes when you ask for an appeal, you must ask for the appeal before the effective date of the action (usually 12 days after the date on the letter). When you do this, your services will not change until after a decision is made about your appeal .
On 11/17/23 at 11:45 am, the Administrator was made aware that R#24 did not receive a NOMNEC letter for discontinuation of services on 11/6/23. The Administrator did not provide further explanation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to operationalize their Abuse policy and investigate and report an injury of unknown origin to the State Agency for one resident ...
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Based on observation, interview and record review, the facility failed to operationalize their Abuse policy and investigate and report an injury of unknown origin to the State Agency for one resident (Resident #32), resulting in a forehead bruise going uninvestigated as to its origin with the likelihood of other injuries of unknown source going unreported and investigated.
Findings include:
Resident #32:
On 11/15/23, at 10:03 AM, Resident #32 was in the main dining area eating their breakfast. There was a bruise noted to their forehead approximately 2 inches by 2 inches. Resident #32 was nonverbal when asked where their forehead bruise came from.
On 11/15/23, at 12:59 PM, Resident #32 was resting in a recliner in the common area with a four wheeled walker next to her.
On 11/16/23, at 9:06 AM, CNA M was interviewed regarding Resident #32's forehead bruise. CNA M was asked what happened and CNA M stated, we think she hit her head on her bedside table.
On 11/17/23, at 8:30 AM, a record review of Resident #32's electronic medical record revealed a readmission on 10/092023 with diagnoses that include Dementia, Anemia and delusional disorder. Resident #32 had severely impaired cognition and resided on the locked dementia unit.
A review of the 11/9/2023 Practitioner Documentation Note Text: Patient is seen for new noted ecchymosis. Discussed case with nursing at length . ECCHYMOSIS TO MID FOREHEAD . Plan: Patient counseled and encouraged. No changes to plan of care.
A review of the progress notes revealed 11/8/2023 . Incident Note . On 11/3/23 Resident noted to have a bruise in the center of her forehead, originally measurement of 20 x 25 cm (Nurse will be educated on measuring), area is 2 cm (centimeters) x (by) 3 cm, fading green/yellow color. Unknown how bruise occurred, Resident is not fearful at the time this Nurse was talking with her. Resident did have an outing with her Son during the day on 11/3/23. Nurses to do skin assessment upon returning from all outings. Will monitor as needed. There was no neurological assessment noted in the record for the bruising. A review of the progress notes for 11/3/2023 revealed 11/3/2023 18:27 (6:27 PM) . Resident was observed with a 20 x 25 cm light colored bruise to her forehead. Resident had no knowledge of it, and denies pain. There was no notation reporting the bruise to the abuse coordinator as an injury of unknown origin or notification to the physician and the family.
A review of the incident report provided by the facility revealed: Bruising . Incident Location: Unknown . Resident was observed with a small bruise to her forehead . Resident unable to give Description . Resident did not know what happened or that she had a bruise . Mobility: Ambulatory without assistance . Witnesses . No Witnesses found . Agencies/People Notified . No notifications found .
On 11/17/23, at 8:57 AM, The Director of Nursing (DON) was interviewed regarding Resident #32's forehead bruise and how did they injury their head. The DON explained that the resident may have fallen while out with their son and that an intervention was placed to assess the resident's skin upon return from family outings. The DON was asked if they had called the son to inquire if the resident fell or hit their head while out in their care and the DON stated, no, I don't think so. The DON was asked if the facility completed an investigation on the bruise/injury of unknown origin and the DON explained that the resident can be resistive to care and at times will barricade themselves in their room but denied reporting the bruise as an injury of unknown origin. The DON was again asked if the facility hypothesized, summarized, investigated or reported the injury of unknown origin and the DON stated, no.
On 11/21/23, at 12:15 PM, the DON was questioned if the facility had assessed the neurological status of the resident once the forehead bruise was recognized and the DON stated, No but the nurse was educated.
A review of the facility provided RESIDENT ABUSE POLICY & PROCEDURE 12-18-17 policy revealed . The Administrator / DON will ensure all alleged violations involving abuse, neglect, exploitation, mistreatment, including injuries of unknown sources . are reported immediately, but not less than 2 hours after the allegation is made, to the appropriate state agency .
A review of the Abuse, Neglect Exploitation & Misappropriation of Resident Property 5-11-2022 policy revealed . It is the Facility's policy to investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property, including Injuries of Unknown Source, in accordance with this policy . DEFINITIONS . Injury of Unknown Source. An injury is classified as an Injury of Unknown Source when both the following conditions are met: The source of the injury was not observed by an person, or the source of the injury could not be explained by the resident; AND The injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incident of injuries over time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement and operationalize policies and procedures for care coord...
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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 and operationalize policies and procedures for care coordination with Hospice services for one resident (Resident #9) of one resident reviewed resulting in lack of timely availability of Hospice documentation, lack of documented communication, and the likelihood for uncoordinated and unmet needs.
Findings include:
Resident #9:
On 11/16/23 at 9:19 AM, Resident #9 was observed sitting in a wheelchair in the activity/dining room of the facility. An interview was completed at this time. When queried regarding their care at the facility, Resident #9 verbalized they were receiving Hospice services and did not understand why.
An interview was completed with Social Services Staff L on 11/16/23 at 9:27 AM. When queried if Resident #9 is receiving Hospice Services, Staff L stated, Yes, (Resident #9) is on hospice. Staff L indicated the Resident had a major decline and signed up for Hospice after returning to the facility following hospitalization. Staff L verbalized they would speak to Resident #9 regarding Hospice services.
Record review revealed Resident #9 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebral infarction (stroke), pain, epilepsy, diabetes mellitus, heart disease, and pressure ulcer. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required moderate to substantial assistance to complete Activities of Daily Living (ADL) with the exception of eating.
Review of documentation in Resident #9's Electronic Medical Record (EMR) revealed a Health Status Note dated 9/20/23 at 1:45 PM which detailed, . Hospice here on this day and resident admitted . family present .
Review of Resident #9's Health Care Provider orders in the EMR revealed the Resident did not have an order for Hospice services.
Review of facility provided CMS-802 form dated 11/15/23 for Resident #9 did not indicate the Resident was receiving Hospice services.
On 11/17/23 at 1:47 PM, an interview was completed with Licensed Practical Nurse (LPN) F. When queried regarding coordination of care with Hospice for Resident #9, LPN F revealed they did not know when the Hospice nurse was scheduled to come to the facility. LPN F was asked how they communicate with Hospice regarding the Resident's plan of care and/or any changes and revealed the Hospice nurse will let staff know if there is something to change. When queried if Hospice staff complete a form or provide documentation to facility nursing staff, LPN F revealed they communicate verbally when in the facility and staff have to pass information to each other in shift-to-shift report. With further inquiry, LPN F indicated Hospice staff document in their own system and send the documentation to the facility later. The documentation received from the Hospice provider is then scanned into the Resident's medical record.
An interview was completed with Certified Nursing Assistant (CNA) A on 11/17/23 at 2:10 PM. When queried if Hospice staff provide/assist Residents who are on Hospice with showers, CNA A revealed they do. When asked how they know when Hospice staff will be in the facility to provide care, CNA A revealed they generally know the day but do not know the time. CNA A was asked when Resident #9's Hospice provider comes to the facility to provide care, CNA A replied, Showers on Monday and Friday by the Hospice Aide.
Review of scanned documentation in Resident #9's EMR revealed the most recent Hospice documentation was dated 9/28/23.
Review of Resident #9's care plans revealed a care plan entitled, Hospice: I utilize hospice services r/t (related to) terminal prognosis of heart disease (Initiated: 9/25/23; Revised: 11/16/23). The care plan included the interventions:
- Assess resident coping strategies and respect resident wishes (Initiated: 9/25/23)
- Consult with physician and Social Services to have Hospice care for resident in the facility (Initiated: 9/25/23)
- Encourage resident to express feelings, listen with non-judgmental acceptance, compassion (Initiated: 9/25/23)
- Encourage support system of family and friends (Initiated: 9/25/23)
- Keep the environment quiet and calm. Keep linens clean, dry and wrinkle free. Keep lighting low and familiar objects near (Initiated: 9/25/23)
An interview was completed with the Director of Nursing (DON) on 11/17/23 at 2:20 PM. When queried regarding coordination of care with Hospice and lack of recent Hospice documentation in Resident #9's EMR, the DON stated, They (Hospice) send the documentation over monthly. When queried how the facility knows if there are changes in the plan of care, the DON replied, (Hospice staff) verbally tells the (facility) nurse. When queried if facility staff document a progress and/or communication note after speaking with Hospice providers, the DON replied, No. The DON was then asked how effective care coordination is completed without documentation of the care provided and did not provide an explanation.
Upon request for a facility policy/procedure related to care coordination with Hospice, the facility provided the Hospice Services Contract. The contract did not detail specific methods of communication and/or timeliness of documentation receipt for Hospice visits.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive pain mana...
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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 and operationalize a comprehensive pain management program for one (#7) of one Resident reviewed for pain, resulting in lack of assessment, monitoring, and management of pain following an injury, Resident #7 experiencing unaddressed/untreated pain for greater than 24 hours, and the likelihood for ongoing pain and psychosocial distress.
Findings include:
Resident #7:
On 11/15/23 at 12:12 PM, Resident #7 was observed sitting in a wheelchair in their room. An interview was completed at this time. Resident #7 had visible tears in their eyes and was guarding their right side. When queried if they were having pain, Resident #7 stated, Yes. When asked if the pain was new, Resident #7 revealed the pain started early yesterday. Resident #7 stated, I leaned over the side of my wheelchair to pick up my phone. My side hit the wheelchair and I hurt myself. Resident #7 was asked if they had informed facility nursing staff. Resident #7 confirmed they had and stated, The nurse said I make stuff up. When asked if the nursing staff who they had informed what occurred and of their pain said that to them, Resident #7 replied, They don't take me seriously. When queried the location of their pain, Resident #7 pointed to their right flank/ribs. Resident #7 was then asked to rate their pain on a scale of zero to 10 with 10 being the worst pain imaginable, and stated, Six. When queried if the area had been assessed by facility nursing staff, the health care provider, and if any testing had been completed, Resident #7 revealed the only thing that had been done was that the nursing staff member whom they first told looked at their side. Resident #7 then revealed that staff member had told them there was no bruising and nothing was wrong. Resident #7 verbalized frustration related to the pain and lack of perceived staff concern. When queried if they had received any medications and/or non-pharmacologic interventions to help with the pain, Resident #7 responded they had not received anything other than their normal medications. When queried if their assigned nurse today was aware of the incident and their pain, Resident #7 indicated they were, but reiterated facility nursing staff did not take them seriously and accused them of making things up. When asked, Resident #7 stated that it makes them feel Bad, like I don't matter when they are having a concern and staff do not take them seriously.
An interview was completed with Licensed Practical Nurse (LPN) T on 11/15/23 at 12:30 PM. When queried if they were aware of Resident #7's pain, LPN T indicated they were. When queried regarding assessment and treatment, LPN T revealed they had given Resident #7 their scheduled dose of Tylenol during morning medication pass. When queried why Resident #7 received scheduled Tylenol, LPN T revealed it is for the Resident's arthritis pain. When queried if they had reassessed Resident #7's pain following Tylenol administration, LPN T revealed they had not. When queried if Resident #7 had received any testing and/or additional assessment related to their verbalization of having pain after hurting themselves, LPN T revealed they were unaware of any new/additional interventions. When queried if they had assessed Resident #7 for injury related to their pain, LPN T revealed they did not. When queried regarding assessment and identification of non-verbal signs and systems of pain, LPT T revealed they did not notice any concerns. With further inquiry regarding Resident #7's self-reported injury and pain, LPN T was unable to provide further explanation.
Record review revealed Resident #7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included pain, weakness, asthma, Peripheral Vascular Disease (PVD), and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to complete all Activities of Daily Living (ADLs) with the exception of eating and locomotion.
Review of Resident #7's Electronic Medical Record (EMR) revealed a care plan entitled, I have pain r/t (related to) diabetic neuropathy, osteoarthritis, headaches, peptic ulcers, right hip pain, right shoulder pain, left arm pain, and low back pain (Initiated: 9/21/22; Revised: 10/15/23). The care plan included the interventions:
- I am able to call for assistance when in pain, ask for medication, tell you how much pain is experienced, tell you what increase or alleviates pain (Initiated and Revised: 9/21/22)
- Administer pain medication as per orders (Initiated and Revised: 9/21/22)
- Anticipate my need for pain relief and respond immediately to any complaint of pain (Initiated and Revised: 9/21/22)
- Monitor/record pain characteristics PRN (as needed): Quality . Severity (1 to 10 scale); Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors (Initiated and Revised: 9/21/22)
- Monitor/record/report to Nurse any s/sx of non-verbal pain: Changes in breathing . Vocalizations . Mood/behavior . Eyes . Face . Body . (Initiated: 9/21/22)
Review of Progress Note documentation in Resident #7's EMR revealed no documentation from 11/10/23 to 11/14/23. There was one Health Status note on 11/15/23 at 1:57 PM which detailed, Into res room for c/o (complaints of) r (right) side/rib pain . Reports pain when moves. On scale 1-10 reports 4. R side noted to be clear without redness or swelling. Will call doctor to report pain at this time. Res noted to receive scheduled Tylenol at this time.
Review of Resident #7's pain level documentation revealed documentation that the Resident complained of pain at three out of 10 on 11/14/23 during the day shift. This was the first documentation of any pain since 11/8/23.
Review of Resident #7's Medication Administration Record (MAR) and health care provider orders revealed the Resident did not have an as needed (PRN) pain medication available. Resident #7 did have following medications for pain:
- Tylenol Extra Strength Tablet 500 mg (milligrams) . 2 tablet by mouth two times a day for pain (Start Date: 12/14/22)
- Voltaren Gel 1 % (topical pain relief) . Apply to L (left) elbow, R (right) shoulder, L back topically every day and evening shift related to primary osteoarthritis, unspecified site . (Start Date: 4/12/23)
On 11/16/23 at 1:29 PM, an interview was completed with the Director of Nursing (DON). When queried regarding Resident #7's complaints of rights sided flank/rib pain after hitting their side on their wheelchair, the DON stated, I know they called the Doctor yesterday. When queried why the Physician was not contacted immediately following the injury and when the pain started, the DON was unable to provide an explanation.
An interview was conducted with the facility Administrator on 11/17/23 at 11:13 AM. The Administrator was asked if they had received an Incident and Accident (I and A) and/or Concern report for Resident #7 related to injuring themselves when bending over to reach for their phone in their wheelchair and indicated they had not. When queried regarding Resident #7's verbalization of feeling that nursing staff do not take them seriously and no documentation related to assessment of injury and complaints of new pain for over 24 hours, the Administrator indicated that was not acceptable practice in the facility and stated, That is not okay.
Review of facility provided policy/procedure entitled, Pain Assessment (Reviewed/Revised: 10/12/23) revealed, The purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family and members of the health care team . Procedure: 1. Ask the resident if he/she is experiencing any pain. Note the location of pain and the level of pain using the pain assessment tool identified by facility protocol. 2. Assess pain including onset and duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying signs and symptoms. 3. Determine appropriate type of pain medication as ordered by the physician. 4. Pharmacological interventions: a) Tylenol, per standing order, may be used to treat mild to moderate pain and chronic pain. b) Class II medications may be used for more severe pain. 5. If no pain medication is ordered, obtain an order from physician and medicate the resident as the physician ordered. 6. Do follow-up assessment within 2 hours after administration of medication. 7. Non-pharmacological interventions: a) Evaluate effectiveness of non-pharmacologic interventions (i.e., repositioning, turning lights off, warm cloth, etc.). b) These may be used alone or in combination with pharmacological interventions. c) Examples include, but are not limited to, massage, application of warm/cool, ROM, change of position, music, ambulation, activities, room temperature, distraction, relocation, and imagery. 8. If pain is not relieved, give further medication as ordered. If there are no orders, notify the physician and obtain an order. Documentation: The person performing this procedure should record the following information in the resident's electronic medical record: 1. Assessment of pain.2. All assessment data obtained during the procedure including location of pain, level of pain using the pain scale, and type of pain relief used. 3. EMR will trigger a reminder in 1 hour for reassessment of pain and the resident's response to the pain relief used. 4. Monitor side effects and document if present. 5. If the resident refused the procedure, the reason(s) why and the intervention taken .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive and resident cen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive and resident centered dementia plan of care for one (#29) of one Resident reviewed resulting in lack of thorough assessment of Resident #29's physical, mental, and psychosocial needs, lack implementation of individualized interventions and adequate supervision to prevent elopement, the Resident experiencing multiple falls following initiation of psychoactive medication, and the likelihood for injury and psychosocial distress utilizing the reasonable person concept. Findings include:
On 11/15/23 at 9:53 AM, Resident #29 was observed sitting in a chair across from the nurses' station in a chair. A tab motion alarm was observed on the Resident. Resident #29 was pleasantly confused but did not provide meaningful and appropriate responses when asked questions.
Record Review revealed Resident #29 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease, wandering, anxiety, depression, heart failure, and multiple falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required supervision to moderate assistance to complete hygiene Activities of Daily Living (ADLs) and was independent with eating and mobility. The MDS further revealed the Resident rejected care one to three days and displayed wandering behaviors daily.
Review of Resident #29's EMR revealed the following care plans and interventions:
Care Plan: Cognition- I have impaired cognitive function/dementia or impaired thought processes r/t (related to) Alzheimer's (Initiated and Revised: 1/3/23). The care plan included the interventions:
- Administer meds as ordered (Initiated Revised: 1/3/23)
- Engage me in simple, structured activities that avoid overly demanding tasks (Initiated and Revised: 1/3/23)
- Keep my routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion (Initiated and Revised: 1/3/23)
- Use task segmentation to support short term memory deficits (Initiated and Revised: 1/3/23)
Care Plan: Behaviors: I have a behavior problem r/t dx. of Alzheimer's disease Initiated and Revised: 10/31/23) was present in Resident #29's EMR. This care plan included the interventions:
- Intervention 1: I tend to have increased behaviors starting around 3pm. Please engage me in physical activity prior to this time (Initiated: 10/31/23)
- Intervention 2: Please provide me a low-stim environment at first sign of overstimulation. If safety is a concern, please only have the necessary number of staff as I can become overwhelmed with too many people (Initiated: 10/31/23)
- Intervention 3: I have increased behaviors after my (spouse) leaves the facility. Please provide me with companionship, reassurance and/or meaningful activities if I am still seeking stimulation (Initiated: 10/31/23)
Care Plan: Antipsychotic: I use antipsychotic medication, Risperdal (Initiated and Revised: 12/27/22). Care plan interventions included the following:
- Administer medications as ordered. Monitor/document for side effects and effectiveness (Initiated: 12/27/22)
- Consult with pharmacy, MD to consider dosage reduction when clinically appropriate (Initiated: 12/27/22)
- Discuss with MD, family re ongoing need for use of medication (Initiated: 12/27/22)
- Educate me, the resident, family and caregivers about risks, benefits and the side effects and/or toxic symptoms of Risperdal via informed consent form (Initiated: 12/27/22; Revised: 6/28/23)
Care Plan: Antidepressant: I use antidepressant medication Zoloft r/t Depression (Initiated and Revised: 12/27/22) was present in Resident #29's EMR. Care plan interventions included the following:
- Educate me, the resident, family and caregivers about risks, benefits and the side effects and/or toxic symptoms of Zoloft via informed consent form (Initiated: 12/27/22; Revised: 6/28/23)
- Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness . (Initiated: 12/27/22)
- Monitor/document/report to MD prn ongoing s/sx (signs/symptoms) of depression unaltered by antidepressant meds .(Initiated: 12/27/22)
Care Plan: Anti-Anxiety: use anti-anxiety medications Xanax r/t anxiety disorder (Initiated and Revised: 11/9/23). The care plan included the interventions:
- Educate me, family and caregivers about risks, benefits and the side effects and/or toxic symptoms of Xanax via informed consent (Initiated and Revised: 11/9/23)
- Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness . (Initiated: 11/9/23)
- I am taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips and legs. Monitor for safety (Initiated and Revised: 11/9/23)
Review of Resident #29's Health Care Provider Orders revealed Resident #29 was not receiving Xanax but was receiving Sertraline (antidepressant medication), Risperdal (atypical antipsychotic medication), and Ativan (antianxiety medication) scheduled three times a day as well as PRN. Further review revealed the PRN order for Ativan did not include a stop date and/or duration. The order detailed, Ativan (psychoactive medication used to treat anxiety) Oral Tablet 0.5 mg (milligram) . Give 1 tablet by mouth every 4 hours as needed for anxiety/agitation (Start Date: 10/24/23).
Review of Resident #29's Health Care Provider Orders and Medication Administration Record (MAR) in the Electronic Medical Record (EMR) revealed the Resident was receiving the following psychoactive medications:
- Sertraline (Zoloft- antidepressant medication) Oral Tablet 150 milligrams daily related to Major Depressive Disorder. The medication dosage was originally ordered on 6/8/23 and had resumed following hospitalization.
- Risperdal (atypical antipsychotic medication) Oral Tablet 0.25 mg twice daily related to Major Depressive Disorder (Start Date: 9/2/23). From 12/23/22 to 8/29/23, Resident #29 was taking Risperdal 0.25 mg once a day related to irritability with mood disorder. Resident #29 was hospitalized from [DATE] to 9/2/23 and the medication dosage was increased upon their readmission to the facility.
- Ativan (antianxiety medication) Tablet 0.5 mg three times a day for agitation / combative (Start Date: 10/20/23).
- Ativan Oral Tablet 0.5 mg one tablet every 4 hours as needed (PRN) for anxiety/agitation (Start Date: 10/24/23).
Review of Resident #29's Documentation Survey Report for October 2023 included Behavior documentation three times a day. Review of documentation revealed the Resident displayed behaviors eight times on 10/1/23, 10/3/23, 10/6/23, 10/15/23, 10/18/23, 10/20/23, 10/22/23, and 10/29/23. There were 36 blank sections where documentation was not completed and 49 areas of documentation indicating the Resident displayed no behaviors.
Review of Resident #29's Documentation Survey Report for November 2023 included Behavior documentation three times a day. Review from 11/1/23 to 11/19/23 revealed documentation of behaviors five times on 11/2/23, 11/11/23, 11/13/23, 11/14/23, and 11/18/23. There were 23 areas where documentation blank and not completed, and 29 areas of documentation indicating the Resident did not display any behaviors.
Per Resident #29's Medication Administration Records (MARs) for October and November 2023, the Resident received PRN Ativan 23 times from 10/25/23 to 11/20/23.
Review of Facility Reported Incident (FRI) documentation revealed Resident #29 exited the facility, without staff knowledge, and walked 0.68 miles from the facility prior to being located by a non-facility staff member on 6/15/23.
Further review of Resident #29's Electronic Medical Record (EMR) revealed the Resident had three unwitnessed falls on 10/23/23, 10/25/23, and 10/26/23 following the initiation of the Ativan. The EMR did not reflect assessment and implementation of resident centered non-pharmacological interventions prior to psychoactive medication initiation.
Review of Resident #29's EMR revealed one Social Service Assessment was completed on 12/29/22. The assessment detailed the Resident worked with photography, was in the service, and enjoyed religious services, reading/writing, and socializing. An assessment was not completed when the Resident was readmitted to the facility.
An interview was conducted with Social Services Staff L on 11/21/23 at 12:29 PM. When queried regarding dementia care program in the facility, Staff L indicated staff receive dementia training. When queried regarding care and interventions for Resident #29, Staff L stated, Well, they are on the care plan. Resident #29's care plan was reviewed with Staff L at this time. Staff L was then asked what activities are meaningful to the Resident, what they did for work, and what they enjoyed and verbalized they did not know. The Social Services Assessment was reviewed with Staff L at this time. When asked if an assessment should have been completed when the Resident was readmitted , Staff L did not respond. When queried how the activities identified in the assessment dated [DATE] were incorporated into the Resident's dementia care plan to ensure the Resident was able to reach their highest practicable level of well-being, Staff L was unable to provide an explanation. When queried regarding their role with psychoactive medications, Staff L revealed they coordinate with the nursing staff and Health Care Provider. When queried why their Risperdal dosage was increased when they were readmitted from the hospital, Staff L revealed they were unsure. When queried why Resident #29 was started on Ativan, Staff L indicated it was related to behaviors. When asked what the behaviors were as there was minimal documentation of behaviors on the Survey Report and what non-pharmacological interventions were attempted prior to Ativan, Staff L was unable to provide an explanation.
An interview was conducted with the Director of Nursing (DON) on 11/21/23 at 1:02 PM. When queried regarding dementia care in the facility, the DON revealed four staff were currently getting educated as part of a grant. When asked why Resident #29 was not in the designated dementia unit of the facility, the DON revealed there is one male Resident in the unit who will urinate on other residents. The DON revealed Resident #29 had been in the dementia unit previously but was moved to a regular unit when that resident had urinated on them. When queried regarding Resident #29's psychoactive medications and lack of resident centered interventions, the DON indicated they would need to review the EMR. When asked about the increase in Resident #29's falls following the initiation of Ativan, the DON confirmed a correlation. When queried regarding a comprehensive dementia program, the DON revealed they hope to get the other dementia area opened and to be able to move Resident #29 into a locked unit. The DON verbalized understanding related to the lack of personalized interventions and indicated they are going to review it.
A policy/procedure related to dementia management was requested but not received by the conclusion of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician orders and monitor a thyroid replacement hormone m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician orders and monitor a thyroid replacement hormone medication (Levothyroxine) for a dementia Resident #23, resulting in missed lab tests (TSH TF4 TF3) that measure the thyroid medication, increased efficacy, with the likelihood of signs of symptoms of too much medication going unnoticed and unassessed. Findings include.
On 11/15/23, at 12:54 PM, Resident #23 was sitting at the dining table in the common area with their arms crossed looking around at other residents laughing.
On 11/16/23, at 1:00 PM, a record review of Resident #23's electronic medical record revealed an admission on [DATE] with diagnoses that included Hypothyroidism, Dementia and mood disturbance. Resident #23 had severely impaired cognition and required assistance with all Activities of Daily Living.
A review of the care plan I have hypothyroidism r/t (related to) dx (diagnosis) of hypothyroidism Date Initiated: 07/29/2019 revealed Goal I will be complianct with thyroid replacement therapy and take around 8pm everyday. Date Initiated: 07/29/2019 Revision on: 07/29/2019 Target Date: 01/29/2024 Interventions Give thyroid replacement therapy as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 07/29/2019 Obtain and monitor lab/diagnostic work as ordered, Report results to MD and follow up as indicated. Date Initiated: 07/29/2019
A review of Physician orders revealed Levothyroxine Sodium Oral Tablet 112 MCG (micrograms) Give 1 tablet by mouth . Start Date 02/28/2023 20:00 (8:00PM) . TSH level every six months . Start Date: 7/22/2021 .
A review of the TSH lab results revealed a result on 02/24/2023 TSH 4.27 There was a hand written order on the lab result that revealed an arrow up/increase 112 mcg re (check) 2 MO (month) . TSH FT4 FT3 (thyroid labs) . There was no lab result noted in the record for the month of April. The next TSH lab result was noted to be on 07/21/2023 which revealed TSH 0.10 L (low) there was a hand written note on the lab result page that read Res has been spitting meds out as of recently There were no results noted for the lab order of the FT4 and the FT3 that were ordered on 02/24/2023.
On 11/17/23, at 8:49 AM, the Director of Nursing (DON) was queried regarding Resident #23 and their thyroid lab results. The DON was asked why the resident didn't get their labs drawn as ordered for the month of April, 23 and the DON stated, we missed it and they had called the physician the night prior for a stat lab draw the TSH. The DON was asked to provide the lab result for Resident #23 prior to exit.
On 11/21/23, at 11:06 AM, a further record review of Resident #23's progress notes revealed the following:
11/16/2023 17:28 (5:28) . this nurse called on (physician) and informed him of resident TSH result on 0/21/2023 was 0.10 and we have not rechecked since that time. (physician) gave this nurse order to draw TSH level. Order placed in computer at this time.
11/17/2023 0010 (12:10 AM) Lab for TSH obtained from RAC (right antecubital) without difficulty, no further bleeding, no s/s (signs and symptoms) of pain or discomfort noted, lab awaiting transport to (hospital lab)
11/17/2023 11:43 . Resident has a TSH level of 0.06, (physician) notified and gave order to decrease Levothyroxine to 100 mcg QD (every day) and recheck TSH, T3 and T4 in one month.
According to the American Thyroid Association, If your TSH level is low, your thyroid hormone dose is excessive and should be reduced. In most patients on thyroxine replacement, the goal TSH level is between 0.5 to 2.5 .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure food temperatures were obtained in a sanitary manner for the 36 of 47 residents, resulting in cross-contamination of th...
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Based on observation, interview and record review, the facility failed to ensure food temperatures were obtained in a sanitary manner for the 36 of 47 residents, resulting in cross-contamination of the thermometer and food items with the likelihood of Gastrointestinal upset or illness. Findings include.
On 11/15/2023, at 12:30 PM, an observation of [NAME] K in the main dining room for the lunch meal service/food temping was conducting. [NAME] K took the digital thermometer and placed into the mashed potatoes. After obtaining the temperature, [NAME] K removed the thermometer and wiped it with a pink wash cloth. [NAME] K continued to obtain temperature of the remaining food items and wiping off the thermometer with the pink wash cloth in between each item. Certified Dietary Manager (CDM) J walked up and was asked if that's how the facility normally cleaned the thermometer in between food items and CDM J stated, no, we're supposed to use alcohol pads. CDM J stated, they would go get some and left the dining room.
On 11/15/23, at 3:28 PM, CDM J offered that [NAME] K had left for the day. CDM J was asked if they normally use the pink rag to clean the thermometer and CDM J said, no and she's getting written up. CDM J was asked how many residents were served from the main dining room during lunch and CDM J stated, every resident minus the Dementia unit.
On 11/16/23, at 1:13 PM, [NAME] K was asked how they could ensure the pink rag they used the day prior to clean the thermometer was clean and [NAME] K stated, I change them out but normally use alcohol swabs.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure PRN (as needed) anti-psychotic medications were ordered with...
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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 PRN (as needed) anti-psychotic medications were ordered with a 14 day stop date, complete and document Gradual Dose Reductions (GDR) and psychoactive medications were not ordered per family request for Residents (#9,14, 29, 36), resulting in PRN unassessed antipsychotics for longer than 14 days. Findings inlcude
On 11/16/23, at 4:02 PM, a record review of Resident #14's electronic medical record revealed an admission 9/27/2019 with diagnoses that included Heart Failure, Schizoaffective Disorder and epilepsy. Resident #14 had severely impaired cognition, required extensive assistance with all Activities of Daily Living and received hospice services.
A review Medication Administration Record for 11/1/2023 - 11/30/203 revealed the following:
LORazepam Oral Tablet 0.5 MG (milligrams) Give 1 tablet by mouth every 4 hours as needed for anxiety -Start Date- 09/10/2023 The resident received 28 doses from the 11/1 through 11/16.
ABHR 1/25/1/10 mg/ml apply 1ml topically to inner wrist or back every 4 hours as needed for Anxiety/Agitation -Start Date- 10/18/2023 The resident received 28 dose from 11/1 through 11/16. The two medications did not have a stop date and were ordered as Indefinite. ABHR gel consists of Lorazepam, Benadryl, haldol and metoclopramide.
On 11/16/23, at 4:03 PM, Social Worker (SW) L was interviewed regarding the PRN psychotropic medications for Resident #14 and why there wasn't a 14 day stop date. SW L assured that the physician was aware.
Resident #36
On 11/16/2023, at 11:00 AM, a record review of Resident #36's electronic medical record revealed an admission on [DATE] with diagnoses that included Alzheimer's Disease, Dementia and Osteoarthritis. Resident #36 had severely impaired cognition and required assistance with Activities of Daily Living (ADL').
A review of the Medication Administration Record for 11/1/2023 - 11/30/2023 revealed Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for anxiety/agitation -Start Date- 08/01/2023 There was no stop date and the resident had received the PRN antipsychotic medication 17 times in 20 days.
A review of the physician's orders revealed an order placed on 11/21/2023 that read Review use of Ativan with practitioner . Start Date 12/5/2023 .
Resident #9
On 11/16/23 at 9:19 AM, Resident #9 was observed sitting in a wheelchair in the activity/dining room of the facility. When queried regarding their medications, Resident #9 was unable to recall what medications they receive at the facility.
Record review revealed Resident #9 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebral infarction (stroke), pain, epilepsy, diabetes mellitus, heart disease, and pressure ulcer. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required moderate to substantial assistance to complete Activities of Daily Living (ADLs) with the exception of eating. The MDS further revealed the Resident had three stage two pressure ulcers.
Review of Resident #9's Health Care Provider Orders and Medication Administration Record (MAR) revealed the following PRN order:
- Ativan Oral Tablet 0.5 mg (milligrams) . Give 1 tablet by mouth every 4 hours as needed for anxiety/restlessness related to Anxiety disorder, Unspecified (Start Date: 10/11/23).
Review of the Medication Administration Records (MARs) for October and November 2023 revealed Resident #9 had received doses of PRN Ativan.
Resident #29
On 11/15/23 at 9:53 AM, Resident #29 was observed sitting in a chair across from the nurses' station in a chair. A tab motion alarm was observed on the Resident. Resident #29 was pleasantly confused but did not provide meaningful and appropriate responses when asked questions.
Record Review revealed Resident #29 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease, wandering, anxiety, depression, heart failure, and multiple falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required supervision to partial assistance to complete hygiene activities.
Review of Resident #29's Electronic Medical Record (EMR) revealed a care plan entitled, Anti-Anxiety: use anti-anxiety medications Xanax (antianxiety medication) r/t (related to) anxiety disorder (Initiated and Revised: 11/9/23). The care plan included the interventions:
- Educate me, family and caregivers about risks, benefits and the side effects and/or toxic symptoms of Xanax via informed consent (Initiated and Revised: 11/9/23)
- Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness . (Initiated: 11/9/23)
- I am taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips and legs. Monitor for safety (Initiated and Revised: 11/9/23)
Review of Resident #29's Health Care Provider Orders revealed Resident #29 was not receiving Xanax but was receiving Sertraline (antidepressant medication), Risperdal (atypical antipsychotic medication), and Ativan (antianxiety medication) scheduled three times a day as well as PRN. Further review revealed the PRN order for Ativan did not include a stop date and/or duration. The order detailed, Ativan (psychoactive medication used to treat anxiety) Oral Tablet 0.5 mg (milligram) . Give 1 tablet by mouth every 4 hours as needed for anxiety/agitation (Start Date: 10/24/23).
A review of Resident #29's Medication Administration Records (MARs) for October and November 2023 revealed the Resident received PRN Ativan 23 times from 10/25/23 to 11/20/23.
An interview was completed with the facility Administrator on 11/21/23 at 1:45 PM. When queried if PRN psychoactive medication should have a 14 day stop date, the Administrator confirmed they should. When asked why Resident #9 and Resident #29 had PRN Ativan orders without a stop date, the Administrator did not provide an explanation but indicated they would address the concern.
On 11/21/23 at 1:56 PM, an interview was completed with Physician H. When queried regarding facility policy/procedure related to PRN psychoactive medication orders and duration, Physician H stated, Initial order for 14 days or less. Physician H continued, After 14 days then we get a recommendation from pharmacy. When queried why Resident #29 had a PRN Ativan ordered on 10/24/23 with no stop date, Physician H indicated in should have a stop date. Physician H was informed of other Resident's receiving a PRN psychoactive medication without a 14 day stop date, including Resident #9, and stated, If you have some that didn't have it (stop date) then that's a mistake.
Review of facility provided policy/procedure entitled, Psychotropic Medications (Reviewed/Revised: 10/12/23) did not include information pertaining to PRN psychotropic medication use.
Aug 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure water flushing was completed per facility protocol from 01/2...
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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 water flushing was completed per facility protocol from 01/2023 through 06/2023, resulting in legionellosis positive environments in 2 residents' rooms (rooms [ROOM NUMBERS]-shower), the North Loops ice machine and the Activity kitchen, and 2) one resident (Resident #101) testing positive for legionellosis, and the high likelihood for residents, staff and visitors testing positive for the bacteria and resident death.
Findings Include:
Resident #101:
Review of the Faces Sheet, care plans dated 4/28/23 to 6/1/23, and hospital records revealed Resident #101 was admitted to the facility on [DATE], 76 years-old, confused, had a feeding tube and dependent on staff for activities of daily living. The resident's diagnosis included, chronic lung disease, weakness, Parkinson's disease, chronic kidney disease, Dementia, and anxiety.
Review of the facility nursing notes dated 6/1/23, revealed Resident #101 was transferred to the hospital due to shortness of breath.
Review of the hospital notes dated 6/7/23, revealed the resident was admitted to the ER (emergency room) on 6/1/23, for respiratory failure and altered level of consciousness. Review of the hospital lab dated 6/3/23, revealed the resident was positive for Legionella in her sputum and urine. The resident wishes were to be DNR (do not resuscitate) and was put on Hospice services. The resident's hospital diagnoses at discharge were, sepsis, acute respiratory failure and pneumonia due to other gram-negative bacteria (Legionella ).
Review of the resident's Certificate of Death dated 6/12/23, revealed the cause of death was aspiration pneumonia/sepsis.
During an interview done on 8/8/23 at 8:25 a.m., the Director of Maintenance A stated we didn't document flushing (the flushing of standing/pooled water from water sources) before this happened. We did have it in the water management program (facility policy said to flush water sources), but we didn't document that we did it. We were flushing the fountain (outside) and in the colder months we would do the facility, random areas, and rooms. I was off and no one else did it (flushed water sources), I didn't tell anyone to do it.
No documentation was given to this surveyor per request dated 1/23 through 6/1/23, regarding the flushing of water sources in the facility, until after the resident was transferred to the hospital.
During an interview done on 8/8/23 at 9:30 a.m., the Director of Housekeeping B stated We were not flushing before (prior to 6/1/23), now we are flushing on Tuesday's and Thursdays.
During an interview done on 8/8/23 at 10:10 a.m., the Director of Nursing said she was not aware that resident rooms and the facility had not been flushing the water sources and stated, I didn't know they didn't document it (flushing water sources) before.
Review of the facility water management program revealed unused/stagnate water sources were to be flushed weekly.
Jan 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
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00133681.
Based on interview and record review, the facility 1) Failed to document a s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00133681.
Based on interview and record review, the facility 1) Failed to document a stop and watch and significant change, 2) Failed to ensure a complete Neurological assessment, and 3) Failed to ensure 15-minute checks were implemented, after a fall with injury (head injury which lead to subdural hemorrhage, brain bleed), for one resident (Resident #101) of 3 residents reviewed for falls, resulting in a craniotomy (surgery to remove partial skull bone due to brain hemmorragh) with a second surgical intervention of decompressive hemiectomy (partial skull removal due to pressure on the brain).
Findings Include:
Resident #101:
Review of the Face Sheet, Minimum Data Set (MDS-assessment tool dated 11/22), nurses and physician notes dated 11/22 through [DATE], and hospital notes dated [DATE] through [DATE], revealed Resident #101 was [AGE] years old, alert, a full code, and admitted to the facility after a fall at home with a hip fracture for rehabilitation on [DATE]. The resident's diagnosis included, cardiomyopathy, gastroesophageal reflux, prostate cancer, diabetes, hypertension, coronary artery disease, hypothyroidism, arthritis, sleep apnea, and anxiety with a history of coronary bypass graft, abdominal aortic aneurysm repair with stent, and having a pacemaker placed in 2021.
Review of the facility Fall Risk assessment dated [DATE], reported the resident was a new admission, unable to independently come to a standing position, he had loss of balance while standing, required hands-on assistance for transfers, had decreased muscle coordination and used short discontinuous steps and/or shuffling. The resident's medications included antihistamines, antihypertensives and narcotics, which all increase the risk for falls.
Review of the facility Physical Therapy Evaluation & Plan of Treatment dated [DATE], reported He requires a significant amount of assistance for all mobility because of his pain level and decreased leg strength.
Review of the facility Fall Investigation Report dated [DATE], reported he had self-transferred, fell in the bathroom, pulled himself up using the sink and put himself back in bed after he had fallen. The root cause of the resident's fall was documented as self-transferring, did not use call light. The facility intervention after the resident's fall was to put a sign on his bedside table reminding him to ask for help.
Review of the facility Fall Care Plan dated [DATE], revealed documentation that a sign to remind the resident to call for assistance was already posted in his room; no new intervention after his fall on [DATE], was put in place.
The resident fell at the facility (on [DATE]) and did not report the fall to staff until the end of the day. The resident informed staff that he had fallen in the bathroom and hit head. The resident was transferred to the hospital on [DATE], after complaints of a severe headache where he had a total of two brain surgeries due to a brain bleed. The residents condition progressively worsened due to the brain bleed and numerous co-morbidities, leading to Resident #101 expiring at the hospital.
Review of the facility Nursing Home to Hospital Transfer Form dated [DATE], reported the reason for transfer was Pain (uncontrolled).
Review of the facility Progress notes dated [DATE], reported at 8:39 a.m. the resident complained of right sided headache and the pain was increasing. At 9:27 a.m., the resident complained again of increasing pain to the right front of his head; at this time an order to transfer was obtained.
Review of the residents facility electronic record revealed no documentation of a Stop and Watch (alert after a change in condition to monitor resident) or Change of Condition (an acute change of condition) being completed.
Review of the facility Change of Condition Acute policy dated [DATE], reported When interacting with residents, staff is to note any changes in the resident. These include; sudden onset or increase in pain (example: headache). Staff is to report any changes noted to the licensed nurse assigned to the resident on that shift. Stop and Watch Alert should be completed. If the nurse's assessment (at any time) has a change of condition (including an increase in headache), the nurse completes an assessment Interact Change of Condition Assessment in Electronic Charting.
Review of the facility Incident Report dated [DATE], reported Resident reported to staff on [DATE] that he experienced a fall in his bathroom while self-transferring early this morning; small abrasion to back of scalp and small skin tear noted to left forearm. [DATE] at approximately 8-9 AM resident complaining of headache and more agitated than normal. Resident states no history of headache; 11:20 AM, nurse receives report from ER that resident has sizeable subdural hematoma and is being transferred to another hospital.
Review of the hospital records dated [DATE], reported (Resident #101) was recovering at (the facility), and sustained a fall on [DATE], but (Resident #101) did not seek care at the time (the resident did not inform staff of his fall at this time). On [DATE], (Resident #101) developed significant headache which led to evaluation at (the hospital emergency room) where head CT (cat scan) showed subdural hemorrhage (brain bleed).
Review of the hospital CT dated [DATE], reported right subdural hematoma (right brain bleed). The resident underwent two surgeries to relieve the pressure on the brain ([DATE] and on [DATE]).
Review of the hospital Operative Report dated [DATE], reported Preoperative Diagnosis: Intracranial hemorrhage with brain compression. Procedure: Right decompression hemicraniectomy with intraparenchymal hematoma evacuation.
Review of the Hospital Course dated [DATE], reported on [DATE], (Resident #101) underwent right craniotomy for subdural hematoma evacuation (removal of blood on brain). On [DATE], exam worsened, and head CT showed worsening intracranial contusions, especially in the occipital (eye) area and that expanded significantly midline shift that did not respond to medical therapy. On [DATE], (Resident #101) underwent right decompressive hemicraniectomy with hematoma evacuation. The resident had deteriorating respiratory status on [DATE] and expired on [DATE].
Review of Resident #101's Certificate of Death dated [DATE], reported the resident expired on [DATE], from complications of blunt force head injuries w/subdural hemorrhage; contributing to his death were his numerous co-morbidities.
Review of the facility Neurological Record dated [DATE] through [DATE], reported neuro assessments except for on [DATE] and [DATE], which was found to have five blank spaces (neurological assessments were not documented as completed).
During a phone interview done on [DATE] at 8:52 a.m., Nurse, LPN B stated He was on neuro's after a fall. I did checks on her pupils and his tongue. My bad; usually they (facility management) tell me to fix it.
During a phone interview done on [DATE] at 8:42 a.m., Nurse, LPN D stated When he told us he fell and hit his head, after he said this, we put 15-minute checks on him. We don't typically document that; I should of charted more.
Review of the resident's entire facility record revealed no documentation of any 15-minute checks being done.
During an interview done on [DATE] at approximately 11:00 a.m., the Director of Nursing confirmed no documentation of 15-minute checks were found and said they should have documented them if they did them. When a 15-minute policy was requested, the DON said the facility did not have one. The DON was not able to produce any documentation of a Stop and Watch Alert or of a Change of Condition being done by nursing staff regarding the changes including headache and increased headache complaints by Resident #101.
During a phone interview done on [DATE] at 10:03 a.m., Physician, Medical Director, MD E said the residents fall and numerous co-morbidies was the cause of his death.
Aug 2022
8 deficiencies
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 and record review the facility failed to care plan and implement bi-later upper arm dressings for one resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review the facility failed to care plan and implement bi-later upper arm dressings for one resident (Resident #25) resulting in Resident #25 to have bilateral upper arm dressings applied with no physician order or care plan interventions, the potential lack of dressing changes and prolong illness or health decline.
Findings include:
Record review of facility 'Care Planning' policy dated 1/20/2022, revealed each resident will have a care plan developed and maintained by the interdisciplinary team, in coordination with the resident and the family/representative. The interdisciplinary Team includes, but is not limited to, representative from nursing, activities, social services, dietary, and therapy services. The individualized care plan includes measurable objectives and timetables established to meet the resident's medical, nursing, mental, social, and psychological needs
Resident #25:
Observations on 08/15/22 at 09:04 AM during the initial tour of the survey revealed Resident #25 was seated up in her room in a wheelchair with a sleeveless green silk night gown on. observed with bilateral upper arm dressings/wraps in place with no dates noted on dressings. Resident makes eye contact but did not know why the dressings were in place. Licensed Practical Nurse (LPN) Q was notified that the state surveyor requested to see Resident #25's bilateral upper arms dressing changes. LPN Q stated that she would notify surveyor.
Record review on 08/16/22 at 3:13 PM of Resident #25's electronic medical records revealed physician orders revealed no treatment to the bilateral upper arms. Record review of the electronic Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for August 2022 identified that Tubi-gripes to be placed on bilateral lower extremities in AM related to swelling and weeping every day shift. The treatment was noted to be signed out as performed all three days of survey although the State surveyor did not see the Tubi-Gripes implemented. There were no treatment order for the bilateral upper arm dressings found.
Record review of Resident #25's care plans pages 1-15, revealed focus of pressure ulcer/skin care plan noted potential for pressure ulcer development related to immobility and age process, has blisters to right shin and right great toe due to edema and immobility. Interventions did not identify and problem area of bilateral upper arms with dressings.
Observation and interview on 08/17/22 at 12:10 PM with the Nursing Home Administrator (NHA) was taken to room [ROOM NUMBER] to observe Resident #25 with bilateral upper arm dressings seated up in wheelchair in her room. Licensed Practical Nurse (LPN) Q came into the room and stated that she just changed the dressing, Observation revealed that there was no date of dressing change or initials noted. NHA notified that there were no physician orders for dressings to bilateral arms.
Observation and interview on 08/17/22 at 12:18 PM with Registered Nurse (RN) D MDS assessment nurse, was brought into the all-purpose room to perform a record review with the state surveyor in the electronic record of Resident #25 for an order for bilateral upper arm dressing changes. None found in electronic record. RN D and state surveyor walked to the nursing care unit and Resident #25 was up in wheelchair in hallway. Resident #25 was being pushed in wheelchair by Certified Nurse Assistant (CNA) V. Observed with bilateral upper arm dressings from upper shoulder arms to mid forearms with no dates or initials noted, no tube grippies (compression wraps) noted to lower extremities, no dressing to lower extremities noted.
The State surveyor was in the facility for three days and LPN Q was notified of need to observe Resident #25's bilateral upper arm dressing changes. LPN Q performed dressing changes without notifying the state surveyor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1) Obtain a physician's order for Resident #25's bila...
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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: 1) Obtain a physician's order for Resident #25's bilateral dressing changes and 2.) Have nursing staff properly date and initial dressings changes for Resident #25, resulting in the lack of implementation of interventions for dressing changes, lack of clear documentation, monitoring, and care coordination of dressings with a likelihood for decline in overall health status.
Findings include:
Record review of facility 'Dressing Change-Clean' policy dated 1/28/2022, revealed that the facility ensures that licensed nurses are competent to perform clean dressing changes to protect the wound, prevent irritation, prevent infection/spread of infection . Procedure: (17.) Date and initial dressing . Care plan: 1.) Identify condition requiring application of a dressing. (2.) Establish a measurable goal and date for resolution of the condition. (3.) Develop a plan to treat the condition. Observe and monitor elder's response to treatment. Prevention measure, safety measures and resident education. Observation and reporting of complications.
Record review of facility 'Skin Assessment' policy dated 1/28/2022, revealed the purpose of the procedure was to provide guidelines for the assessment or resident skin and identification of risk of developing pressure ulcers or other skin concern . (7.) Completion of the skin check is documented in the electronic medical record in the nurse's notes or other appropriate folder. Documentation: The following information for a pressure area or wound should be recorded in a resident's electronic medical record.
Resident #25:
Observations on 08/15/22 at 09:04 AM during the initial tour of the survey revealed Resident #25 was seated up in her room in a wheelchair with a sleeveless green silk night gown on. observed with bilateral upper arm dressings/wraps in place with no dates noted on dressings. Resident makes eye contact but did not know why the dressings were in place. Licensed Practical Nurse (LPN) Q was notified that the state surveyor requested to see Resident #25's bilateral upper arms dressing changes. LPN Q stated that she would notify surveyor.
Record review on 08/16/22 at 3:13 PM of Resident #25's electronic medical records revealed physician orders revealed no treatment to the bilateral upper arms. Record review of the electronic Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for August 2022 identified that Tubi-gripes to be placed on bilateral lower extremities in AM related to swelling and weeping every dayshift. The treatment was noted to be signed out as performed all three days of survey although the State surveyor did not see the Tubi-Gripes implemented. There were no treatment order for the bilateral upper arm dressings found.
Observation and interview on 08/17/22 at 12:10 PM with the Nursing Home Administrator (NHA) was taken to room [ROOM NUMBER] to observe Resident #25 with bilateral upper arm dressings seated up in wheelchair in her room. Licensed Practical Nurse (LPN) Q came into the room and stated that she just changed the dressing, Observation revealed that there was no date of dressing change or initials noted. NHA notified that there were no physician orders for dressings to bilateral arms.
Observation and interview on 08/17/22 at 12:18 PM with Registered Nurse (RN) D MDS assessment nurse, was brought into the all-purpose room to perform a record review with the state surveyor in the electronic record of Resident #25 for an order for bilateral upper arm dressing changes. None found in electronic record. RN D and state surveyor walked to the nursing care unit and Resident #25 was up in wheelchair in hallway. Resident #25 was being pushed in wheelchair by Certified Nurse Assistant (CNA) V. Observed with bilateral upper arm dressings from upper shoulder arms to mid forearms with no dates or initials noted, no tube gripes (compression wraps) noted to lower extremities, no dressing to lower extremities noted.
The State surveyor was in the facility for three days and LPN Q was notified of need to observe Resident #25's bilateral upper arm dressing changes. LPN Q performed dressing changes without notifying the state surveyor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to 1) Ensure that staff reconnected a fall prevention personal alarm after disconnecting it, 2) Ensure that a complete investigat...
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Based on observation, interview and record review, the facility failed to 1) Ensure that staff reconnected a fall prevention personal alarm after disconnecting it, 2) Ensure that a complete investigation was conducted for a resident for each fall, and 3) Ensure that staff documented and implemented fall care plan interventions for 1 resident (Resident #18) of 12 resident's reviewed for falls, who had a history of falls, resulting in the high likelihood for a severe injury from a fall, hospitalization, and pain.
Findings Include:
Resident #18:
Review of the Face Sheet, Minimum Data Set (MDS, resident assessment tool) dated 6/10/22, nurse's notes dated 5/22 through 8/15/22, current Physician orders dated 7/12/18 through 7/29/22, revealed Resident # 18 was 89 years-old, was severely cognitively impaired with a Power of Attorney in place, and required total staff assist with all Activities of daily Living. The resident's diagnosis included, Parkinson's Disease, Physical Debility, Dementia, Anxiety Disorder, Dizziness, Diabetes, Hypertension, and Wandering. Resident #18 had a history of falls, was confused, had poor balance, incontinent, unaware of safety needs and had periods of dizziness; the resident was at high risk for falls.
Review of Resident #18's Fall care plan dated 10/18/16 with up-dated through 5/20/22, revealed to ensure the residents safety they were to have a bed and wheelchair alarm, anticipate and meet needs, follow the fall protocol, have a recurved mattress on her bed, decrease clutter in her room and have adequate lighting, ensure proper footwear and glasses were on when up, frequently toilet her (every 2 hours), place a floor mat next to her bed and when she was not in bed, ensure staff could visualize her at all times.
Observation of Resident #18 was done on 8/17/22 at 10:40 a.m., on the Woodland Unit. The resident was sitting in her wheelchair near the table. This surveyor requested staff (Nursing Assistants/CNA's M & N) lift her up so visualization of a gripper pad could be confirmed, staff lifted her then sat her back down and did not connect her personal alarm to her clothing to alert staff if she started to get out of the wheelchair.
Review of the facility Fall Incident Report dated 4/27/22, revealed the resident had fallen; there was documentation that the residents personal alarm was not on at the time of her fall. Review of the facility Fall care plan dated 2/25/22, revealed the resident was to have a personal alarm connected to her wheelchair when up and a bed alarm in place.
Review of the facility Fall Incident Report dated 5/16/22, revealed the resident had fallen; no floor mat was drawn on the report in the drawing section indicating her floor mat had not been put down prior to her fall. Also, the Incident report and Investigation documented that the residents fall was unwitnessed. Review of the Fall care plan intervention dated 2/25/22, stated I require close supervision when I am not in bed; staff need to be nearby where they can visualize me.
Review of the facility Fall Incident Report dated 7/12/22, revealed the resident had fallen and hit her head and received 3 skin tears, with no investigation done by the facility, nor any added care plan fall preventive interventions done.
During an interview done on 8/16/22 at approximately 3:00 p.m., MDS Nurse, RN D revealed all resident falls had to have a full investigation done; she said she was unable to locate an investigation for the residents fall on 7/12/22.
During an interview done on 8/17/22 at 10:58 a.m., the Facility Education Nurse, RN L stated A fall education was on done on prevention (prevention of falls).
Review of the facility Fall Prevention & Follow-up policy dated 1/28/22, stated that the facility is strongly committed to the reduction of falls among our residents. Our mission is the reduction of falls through a systematic, multidisciplinary team approach. Appropriate interventions are identified, care planned, and follow up done to monitor effectiveness. Each resident fall was to have an investigation which begins at the time of the fall and includes: staff interviews, notification of family, responsible part, and physician. The facility was to complete Fall Investigation Tool with staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure that one resident (Resident #9) received appropriate care and confirm the placement of Enteral feeding prior to initiati...
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Based on observation, interview and record review the facility failed to ensure that one resident (Resident #9) received appropriate care and confirm the placement of Enteral feeding prior to initiating feeding, to prevent complications resulting in the likelihood for bloating, abdominal discomforts and respiratory distress, prolonged illness, or hospitalization.
Finding include:
Record review of the facility 'Enteral Nutrition (Tube Feeding)' policy dated 1/28/2022, revealed that the facility recognizes the necessity of providing a safe, sanitary, and effective means of providing enteral (tube fed) nutrition for those residents whose medical condition dictate use of means other than oral intake or those who require an adjunct to their oral intake . Procedure: (3.) Confirm placement of tube by auscultation and aspiration of gastric contents prior to initiating . (11.) For PEG tube (and other gastrostomy tubes), site care is done every shift. Cleanse site with soap and water and apply a small dressing if drainage present
Resident #9:
Record review of Resident #9's electronic medical record revealed medical diagnosis of traumatic brain injury, dementia, hypertension, lack of coordination, urinary incontinence, hemiplegia, dysphagia (requires tube feeding), poor verbal communication, and limited range of motion as some of the diagnosis.
Record review of Resident #9's care plans: Hydration-has the potential for nutritional problems related to dementia, poor dentation, hemiplegia, history of traumatic brain injury, swallowing problems related to dysphagia, requiring tube feeding. Interventions included: Staff to be informed of NPO (nothing by mouth) status, diet as prescribed NPO, Registered Dietitian to evaluate resident ad needed, tube feeding as ordered by doctor, weigh weekly on Wednesday. There were no interventions for nursing assessment of resident pre, post or during feeding tube administration for signs and symptoms of complications noted.
Observation and interview on 08/15/22 at 12:15 PM with Licensed Practical Nurse (LPN) Q of Resident #9's left lower abdomen peg tube site, revealed redness and drainage (noted on top of brief) with no split gauze dressing noted between the peg tube base ring and the resident's skin. Peg site is dirty with red rash. Feeding tubing is not hooked up, feeding tubing end is opened with no cap laid across the tube feeding machine open to air and touching side of machine. LPN Q stated that the resident went to the dental clinic in house and just came back. LPN Q with gloves on set the tubing open end in the residents lap and went into the bathroom to wet paper disposable cloth and wiped the peg tube site on abdomen to clean the site and then wipe the feeding tubing open end with the same paper cloth and hooked up the feeding at 65ml/hr. Observation of the feeding tube connection revealed that there was no auscultation of abdomen sound or aspiration of gastric contents check of placement after resident was at the dentist. Split gauze dressing applied to the peg tube site.
In an interview on 08/16/22 at 1:43 PM with Registered Nurse (RN) L staff development/Inservice director, was asked when hooking up a Tube feeding procedure- ensure that the resident is sitting up right, turn machine on, plug the end of the tube feed into the stomach, make sure that it is running properly and not stopped anywhere or plugged. Split gauze dressing is changed each shift, I would assess bowel sounds before and after hooking the tube feed up. It would be done with a stethoscope and the peg site cleaned.
In an interview on 08/17/22 at 10:37 AM Licensed Practical Nurse (LPN) B during the infection control task of the annual survey, LPN B described the way to hook up a tube feeding: anytime the tube feeding is being hooked up the abdomen should be checked for bowel sounds with a stethoscope, check for residual with a large syringe and check placement with air bolus prior to starting a feeding.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based observation, interview and record review, the facility failed to post in a prominent location for public viewing the actual hours worked by categories of nursing staff and the resident census fo...
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Based observation, interview and record review, the facility failed to post in a prominent location for public viewing the actual hours worked by categories of nursing staff and the resident census for each day, resulting in the public and the 38 residents residing in the facility being unaware of the nursing staff available to care for residents.
Findings include:
Record review of the 'Facility Assessment Tool' dated 2/28/2022 revealed that the facility identified different types of staff: Conventional Staffing- adequate labor pool to cover and staffing has no impact on cares being provided to residents. Contingency Staffing- Staff are routinely being asked to pick-up extra shifts and occasionally fill in other departments. Safe resident care is manageable, but with less-than-ideal staffing scenarios . Page 11. facility staffing needs are routinely evaluated by department managers and IDT (Inter Departmental Team) members from a variety of perspectives including but not limited to observation, work assignments, patient acuity, resident/family/staff feedback
Observation and interview on 08/16/22 at 02:17 PM of the main nursing station at the intersection of the 100/200 halls with Licensed Practical Nurse (LPN) Q at the Main nursing station for the required posting of staffing information for the day revealed there to be no publicly posted information found. LPN Q stated that she leaves the 'Facility Staffing Summary' form on the clip board in the nursing office. That's were yesterday's 8/15/22 remained. Registered Nurse L came into nursing office and staffing summary sheet was found on a brown clip board. The state surveyor asked about posting the staffing summary for public viewing and that the state surveyor did not see the posting public displayed on 8/15/22 or on 8/16/22.
Record review of the 'Facility Staffing Summary' on 8/16/2022 at approximately 2:20 PM, revealed that the form was only filled out for the 6:00 Am to 2:00 PM shift. The daily 24 hours for the afternoon and evening shifts were not filled out.
In an observation and interview on 08/17/22 at 08:56 AM with Licensed Practical Nurse (LPN) Q at the Main nursing station of all bulletin boards, white boards and glass display case with no posted public staffing information noted. Observation of the main nursing station desk, LPN Q stated that the staffing census is on the clip board in the nursing office, walked into the nursing office and on the clip board under other papers the 'Facility Staffing Summary' staffing census was found. Not posted in public place for public viewing.
In an observation and interview on 08/17/22 at 10:30 AM while finishing the infection control surveillance tour ended and the Licensed Practical Nurse (LPN) B walked through the main nursing station area 100/200 hallways the state surveyor asked about public posting of nursing census posting. Observation of walls revealed no postings and LPN B stated that it should be posted on the bulletin board and pointed to an empty spot on the bulletin board outside the nursing office.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow infection control standards of care to 1) Ensur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow infection control standards of care to 1) Ensure that Covid unit room doors were closed and there was proper containment receptacles with lids to contain used Personal Protective Equipment (PPE), 2) Prevent a Covid Unit nurse from eating while on the Covid Unit, 3) Prevent cross contamination regarding a feeding tube for Resident #9 and ensure an effective Infection Control program for all 38 Residents residing within the facility, resulting in the likelihood for the spread of organisms and/or resident harm or prolonged illness.
Findings include:
There was no certified Infection Preventionist in the facility during the annual survey due to a personal issue at the time of the survey.
Record review of the 'Facility Assessment' form dated 2/28/2022, revealed on page 16 section 3.11 The facility in-service Director/Infection Control Nurse oversees the infection control program and reporting. The facility attempts to follow the McGeer's Criteria for infection surveillance, identification, treatment, and prevention. Monthly infection control reports try to indicate numbers, types, and patterns of infections, if present, throughout the facility. The results are used to guide future opportunities for education to staff and patients both, as well as gauge the effectiveness of treatment .
Record review of the facility 'Infection Prevention & Control Program' policy dated 1/8/2020 revealed that the facility had an infection prevention and Control Committee of interdisciplinary in nature and has as its responsibilities the monitoring of the infection prevention & control program for all resident care and staff support departments . Orientation/Education: targeted in-service is done upon request and in specific areas for issues identified through surveillance activities . It is the responsibility of the infection prevention practitioner to present/schedule infection control in-services in conjunction with the in-service director. It is the responsibility of the department managers to guarantee attendance of his/her employees.
Infection Control Task:
Observation and interview was conducted on 08/17/22 at 9:00 AM with Licensed Practical Nurse (LPN) B, filling in for Registered Nurse/Director of Nursing (RN/DON), during a walking tour of facility. On the 100/200 hallways with isolation residents in rooms with open top trash containers noted in isolation rooms. room [ROOM NUMBER] on the 200-211 hallway, Resident #34 was in isolation and the trash basket with no covering top has been out in the hallway for three days, LPN B pushed down the gowns overflowing the basket and placed the basket into the resident room doorway. LPN B stated that none of trash baskets have a a lid. Room# 220 unsampled resident on the 212 to 223 hallway was in isolation precautions with open lid trash can noted. Room#106 Resident #38 in the 100 hallway isolation precautions on the 100 hall with open lid trash can in hallway with yellow isolation gowns and purple gloves noted. Observation of the wood railing outside of room [ROOM NUMBER] noted a used facial mask. Earlier in the week the state surveyor observed housekeeping to have a small plastic bag taped open to the hallway railing with a used N-95 mask in bag open to the air on the top. The state surveyor stated that on 8/16/22 observation of the Covid unit linen removal with housekeeper Supervisor X removed her N-95 mask and placed into the bag and stated that to decrease waste of mask she leaves her mask hanging on the side of the railing and placed the used mask in the taped-up bag and put on a blue surgical mask and walked away. Used N-95 mask? LPN B stated that the used mask needs to be a paper bag that does not hold moisture, the one on the railing I threw away and washed my hands. We have enough mask that they don't have to save mask. no mask policy just general PPE usage.
Observation and interview was conducted on 08/17/22 at 9:25 AM of the Covid Unit with three positive residents residing with doors wide open to rooms. Licensed Practical Nurse (LPN) P was in room [ROOM NUMBER] with gown and mask below the nose, no gloves observed as she had arms full of linens stripped from the resident's bed and walked out of the room across the hall with linens not bagged. The walking tour continued to the Covid unit nursing desk with resident doors wide open, the nursing desk room was also wide open to the nursing desk room revealed a full plate of food (scrambled eggs, bacon) not covered in the open and a large fountain pop on the desk in the Covid unit. LPN B stated that the nurse should not be eating in the Covid unit but did not dispose of the meal.
Observation on 08/17/22 at 10:30 AM as the tour ended and the nurse LPN B walked through the main nursing station area 100/200 hallways intersection the state surveyor asked about public posting of nursing census posting. Observations of walls revealed no postings and LPN B stated that it should be posted on the bulletin board in public view.
Record review of infection control records with LPN B post walk through tour revealed the facility to be a Covid positive building with 3 positive residents/ 2 positive housekeepers and 4 other staff members total of 6 positive staff currently after facility started the Covid unit. Spreading of Covid between staff and residents? LPN B was not sure how.
Record review and interview on 08/17/22 at 10:45 AM with LPN B of OUTBREAK info: the current outbreak started on 8/8/22 with positive residents and the facility opened the 300 halls as the Covid unit. The outbreak Started with unsampled resident in room [ROOM NUMBER], who had sign & symptoms of cough and runny nose and the facility tested her and she was negative first on 8/7/22, then retested on [DATE] she was positive. The unsampled resident was sent to the hospital and since passed away. Tested rest of residents on 8/8/22 with three positive residents noted.
record review of Covid vaccines and boosters- the facility had a Covid clinic in April 2022 100% vaccinated and only 5 resident decline boosters. Total of 38 residents are all vaccinated with 2 shots and 5 residents refuse boosters.
Record review during the Infection Control Task of infection control meeting notes for the month of June 2022 revealed: there was a spike of 5 Urinary Tract's (UTI's) as an increase from the previous month. The monthly report noted that 2 of the residents had the same microorganism. One Resident resided in Room#206 on the west hall and the second resident resided in Room#217 on the East Hall, both residents were noted to have the same microorganism and the same care givers. The state surveyor asked for staff education for UTI's or peri care? where Audits implemented?
In an interview and record review on 08/17/22 at 10:52 AM with the Staffing Education/In-Service Director revealed that she does attend the infection control meetings and was not aware of the increase in June 2022 Urinary Tract Infection rate, (5 UTI's). She stated that there was no staff education related to the increase in UTI's or peri-care for Certified Nurse Assistance's or nurses provided. If she was aware she would have implemented an education.
The State Surveyor request for the Infection Control Preventionist certificate of accredited course completion received the former Registered Nurse certificate who left the facility employment on 8/5/2022. There was not another certificate presented at the time of survey.
Resident #9 Tube Feeding cross contamination observation:
Observation and interview on 08/15/22 at 12:15 PM with Licensed Practical Nurse (LPN) Q of Resident #9's left lower abdomen peg tube site, revealed redness and drainage (noted on top of brief) with no split gauze dressing noted between the peg tube base ring and the resident's skin. Peg site is dirty with red rash. Feeding tubing is not hooked up, feeding tubing end is opened with no cap laid across the tube feeding machine open to air and touching side of machine. LPN Q stated that the resident went to the dental clinic in house and just came back. LPN Q with gloves on set the tubing open end in the residents lap and went into the bathroom to wet paper disposable cloth and wiped the peg tube site on abdomen to clean the site and then wipe the feeding tubing open end with the same paper cloth and hooked up the feeding at 65ml/hr. Observation of the feeding tube connection revealed that there was no auscultation of abdomen sound or aspiration of gastric contents check of placement after resident was at the dentist. Split gauze dressing applied to the peg tube site
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Dining Observation
Observation on 08/15/22 at 12:00 PM of the noon meal in the main dining room. Residents are gathering in room. One resident to a table is all that the facility allows. Observed 7 re...
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Dining Observation
Observation on 08/15/22 at 12:00 PM of the noon meal in the main dining room. Residents are gathering in room. One resident to a table is all that the facility allows. Observed 7 residents in the room. Resident #4, Resident #11, Resident #25, and 4 other off sampled residents noted in dining room. No beverages are passed. Observation of the room noted that there was no coffee, juice or even water available to residents. music was started in CD player. Staff of Certified Nurse Assistant (CNA) Y and restorative CNA C. Waited till 12:30 PM posted mealtime, no meals or food in dining room, still no beverages available. At 12:50 PM observed hot box of green plastic past the dining room to the 100/300 hall. Observed 300 hall meals on paper plates and disposable service wear. At 12:55 PM observed second hot box past the dining room to the 200 halls meals past by staff to rooms. Main dining room residents asking staff were their meals? At 1:05 PM Main dining room trays to the dining room only CNA Y to pass trays. Beverages on meal trays noted . Sign Posted on Dining room doors noted lunch served at 12:30 PM, residents not happy about late meal
Based on observation, interview and record review, the facility failed to ensure that dignity was maintained by 1) Not ensuring the food was hot when served, 2) Not ensuring enough staff to feed residents in a dignified manner, and 3) Making residents wait an excessive time for their food trays, for 17 residents (Residents: #2, #4, #5, #10, #11, #12, #13, #14, #16, #18, #20, #24,#25, #27, #29, #36, #40, 3 residents from Main Ding Room and 14 residents from Woodland/locked Unit) observed for dining , resulting in the likelihood for decreased self-esteem, anger with aggressive behaviors, weight loss and verbalizations of being hungry and wanting to eat.
Findings Include:
Observation was made on 8/15/22 at 12:00 p.m., of the noon meal on the Woodland (locked Dementia Unit). There were a census of 14 residents (Residents #2, #5, #10, #12, #13, #14, #16, #18, #20, #24, #27, #29,#36 and #40) on the unit at the time. At this time on the Woodland unit, there were a total of 6 residents (Residents #10, #12, #13, #18, #20 and #27) who required assistance with feeding and/or encouragement with eating. There were 2 residents (Resident #5 & #27) who only eat in their rooms and require frequent observation and encouragement during meal times. The food trays were to be on the Woodland unit at 12:00 p.m.; the trays did not arrive on the unit until 12:34 p.m. This was a 34 minute delay in delivering the residents food on the Woodland unit. Several residents were observed getting up off their chairs and walking around, getting up-set because they wanted to eat, yelling at staff and walking into their rooms out of sight. At this time there were only 2 staff members working on the Woodland unit (Nurse, LPN B and Nursing Assistant/CNA Z). Both Nurse B and CNA Z were observed running around on the unit trying to get the residents to calm down and to sit down at the tables. When the trays came, CNA Z was observed feeding 3 residents at one time and Nurse B was going between the no assist side of the dining area to the room were 2 residents were eating by themselves (Residents #5 & #27). Resident were getting up from the table, walking around, and yelling at each other and staff; they were very distracted. The 2 staff members were trying to get everyone fed at the same time.
During an interview done on 8/15/22 at 11:50 a.m., Nurse, RN K said the food trays were supposed to be on the unit at 12:00 p.m., noon. Nurse K said usually they have 3 staff on the unit to assist with feeding and care, however lately they did not have enough staff to feed all the residents at the same time, and some had to wait to be feed (the food was cold when feed to the residents, hamburgers was served). Nurse K said it was very difficult to feed 4 residents who required feeding assist and 4 residents who required encouragement at the same time, along with monitoring the rest of the units residents for safety concerns.
During an interview done on 8/15/22 at 12:45 p.m., CNA Z stated It's hard, you know they have to eat so you just do it. CNA Z was feeding Residents #12, #13 and #20 all at the same time. The residents were observed getting confused and angry at CNAZ because they had to wait for their next bit of food.
During an interview done on 8/15/22 at 2:42 p.m., Dietary Manager A was asked by this surveyor why the food trays were so late to be delivered (on 8/15/22 at the noon meal on the Woodland Unit), she stated Because we had hamburgers, it takes more time. We do get some complaints on cold foods. I have not in serviced staff in about 6 months (on dietary meal procedure).
During an interview done on 8/16/22 at 12:11 p.m., Nurse, RN D stated We are supposed to have 2 CNA's, we normally like to have 2. We tried to get 2 CNA's for 8/15/22 on days, but we couldn't.
Review of the facility Daily Census sheet dated 8/15/22, revealed only one CNA and one nurse was scheduled to work on the Woodland Unit, day shift.
During an interview done on 8/16/22 at 12:44 p.m., Nurse, LPN E stated The acuity of care makes it difficult to do with one aide (CNA). He (the Administrator) should staff by acuity not numbers.
Resident Council Meeting:
During an anonymous Resident Council Meeting held on 6/16/22 at 9:57 a.m., 2 confidential resident's revealed they have had to wait for 45 minutes for their lunch meal at times and they did not feel the facility staffed enough people to serve meals in the main dining room. Both confidential resident's said they frequently get cold food.
Review of the facility Resident Rights policy dated 5/95, stated that the facility believes that the residents rights are the responsibility of the entire staff under the close supervision of the Administrator.
Review of the facility Feeding The Resident policy dated 3/26/19, stated that the facility ensures that residents receive nutritious well-balanced meals for their well-being. Resident's who are dependent on staff for feeding will be guaranteed appropriate temperature, nutritious food in a timely manner.
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 1) Failed to maintain food preparation and kitchen equipment in a sanitary and good working condition, and 2) Failed to properly dated o...
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Based on observation, interview and record review, the facility 1) Failed to maintain food preparation and kitchen equipment in a sanitary and good working condition, and 2) Failed to properly dated opened and partly used food items, resulting in an increased potential for food borne illness, with the likelihood to affect 37 of a census of 38 resident's who consume oral nutrition from the facility kitchen.
Findings include:
Review of the U.S. Public Health Service 2009 Food Code, as adopted by the Michigan Food Law, effective October 1, 2012, directs that equipment cleaning frequency is to be throughout the day at frequency necessary to prevent recontamination of equipment and utensils. Foods shall be clearly marked to indicate the date or day by which the food shall be consumed, and foods are to be discarded after this date.
During the initial tour of the facility kitchen done on 8/15/22 at 8:43 a.m. to 12:20 p.m., accompanied by staff member A (Dietary Manager), the following observations were made:
-At 8:43 a.m., the staff hand wash sink was observed to be very slow to drain.
-At 8:45 a.m., the large metal can opener was observed to have dried food on the blade area and chipped silver paint on the blade, which comes in contact with food when in use.
-At 8:46 a.m., the counter top white blender which was clean and ready for use, was observed to have dried food particles on the attachment area directly above the large mixing bowel.
-At 8:47 a.m., the resident microwave was observed to have dried food particles inside on the back, sides and top.
-At 8:50 a.m., in the Bakers Refrigerator was observed an open and partly used container of whipped topping; it was dated opened on 7/12/22 and use-by date of 8/14/22. This whipped topping was past it's use-by date; this is a potential dangerous food.
During an interview done on 8/15/22 at 8:50 a.m., Dietary Manager A stated, staff should have thrown it out if past the use by date.
During an interview done on 8/17/22 at 12:15 p.m., Dietary Manager A stated We put a open date and use-by date on foods. I check the refrigerators daily, and the [NAME] checks them on the weekends.
-At 8:52 a.m., a clean and ready for use gray, heavy plastic food plate cover was observed to have 2 large cracks on the top of it. This top was being used to cover residents food plates.
During an interview done on 8/15/22 at 8:52 a.m., the Dietary Manager A stated, they needed to be thrown away if cracked.
-At 8:55 a.m., the large floor mixer which was clean and ready for use was noted to have dried on food near the attachment area, which is directly over the mixing bowel area.
During an Interview done on 8/15/22 at 1:35 p.m., Dietary Manager A stated, I don't have a check-off for cleaning duties; we use job descriptions.
Review of the facility [NAME] Job Description (un-dated), revealed the [NAME] was to wipe out microwave.
Review of the facility Baker, Night [NAME] and Dietary Supervisor Job Descriptions (all un-dated), revealed no documentation of who is responsible to clean the blenders, bakers refrigerator and the can opener.
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.
- • 35% turnover. Below Michigan's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 2 harm violation(s), Payment denial on record. Review inspection reports carefully.
- • 28 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
Bottom line: Mixed indicators with Trust Score of 70/100. Visit in person and ask pointed questions.
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About This Facility
What is Iosco County Medical Care Facility's CMS Rating?
CMS assigns Iosco County Medical Care Facility an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Michigan, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Iosco County Medical Care Facility Staffed?
CMS rates Iosco County Medical Care Facility's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 35%, compared to the Michigan average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Iosco County Medical Care Facility?
State health inspectors documented 28 deficiencies at Iosco County Medical Care Facility during 2022 to 2024. These included: 2 that caused actual resident harm and 26 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Iosco County Medical Care Facility?
Iosco County Medical Care Facility is owned by a government entity. Government-operated facilities are typically run by state, county, or municipal agencies. The facility operates independently rather than as part of a larger chain. With 78 certified beds and approximately 52 residents (about 67% occupancy), it is a smaller facility located in Tawas City, Michigan.
How Does Iosco County Medical Care Facility Compare to Other Michigan Nursing Homes?
Compared to the 100 nursing homes in Michigan, Iosco County Medical Care Facility's overall rating (5 stars) is above the state average of 3.2, staff turnover (35%) is significantly lower than the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Iosco County Medical Care Facility?
Based on this facility's data, families visiting should ask: "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?"
Is Iosco County Medical Care Facility Safe?
Based on CMS inspection data, Iosco County Medical Care Facility 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 5-star overall rating and ranks #1 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 Iosco County Medical Care Facility Stick Around?
Iosco County Medical Care Facility has a staff turnover rate of 35%, which is about average for Michigan nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Iosco County Medical Care Facility Ever Fined?
Iosco County Medical Care Facility 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 Iosco County Medical Care Facility on Any Federal Watch List?
Iosco County Medical Care Facility 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.