Mission Point Nursing & Physical Rehabilitation Ce
For profit - Corporation
178 Beds
MISSION POINT HEALTHCARE SERVICES
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#309 of 422 in MI
Photo by Mission Point Nursing & Physical Rehabilitation Center of Warren
Photo by Mission Point Nursing & Physical Rehabilitation Center of Warren
Photo by Mission Point Nursing & Physical Rehabilitation Center of Warren
1 / 5 photos
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Mission Point Nursing & Physical Rehabilitation Center in Warren, Michigan, has received a Trust Grade of F, indicating significant concerns and a poor overall performance. Ranking #308 out of 422 facilities statewide places them in the bottom half of Michigan nursing homes, and they are #26 out of 30 in Macomb County, meaning there are only a few local options that are better. While the facility is improving, reducing issues from 35 in 2024 to 13 in 2025, it still has alarming deficiencies, including serious incidents of resident abuse and a failure to prevent a resident from eloping, which created serious safety risks. Staffing is a relative strength with a 4 out of 5 rating and a turnover rate of 38%, which is better than the state average, but their RN coverage is concerning as it is lower than 84% of similar facilities. The facility has faced $193,864 in fines, indicating compliance problems that should be carefully considered by families looking for care options.
- Trust Score
- F
- In Michigan
- #309/422
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 38% turnover. Near Michigan's 48% average. Typical for the industry.
- Penalties ✓ Good
- $193,864 in fines. Lower than most Michigan facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 22 minutes of Registered Nurse (RN) attention daily — below average for Michigan. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 67 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 27%
Review needed
35 → 13 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 35 issues
2025: 13 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (38%)
10 points below Michigan average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Michigan average (3.1)
Below average - review inspection findings carefully
Staff Turnover: 38%
Near Michigan avg (46%)
Typical for the industry
Federal Fines: $193,864
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: MISSION POINT HEALTHCARE SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 67 deficiencies on record
2 life-threatening 1 actual harm
May 2025
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure water was accessible for one resident (R115) o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure water was accessible for one resident (R115) of one resident reviewed for accommodation of needs. Findings include:
On 5/5/25 at 8:02 AM, R115 was observed in their room in bed with their water cup being out of reach on their dresser. R115 was interviewed and asked about the accessibility of their water cup and indicated they could not reach it and did not want to get up to get it because they didn't want to fall.
On 5/7/25 at 10:27 AM, an observation was made of R115 having no water cup. R115 was observed to be in their room in bed. R115 was interviewed and asked about the location of their water and indicated that someone had come into their room and taken it. R115 was asked if they felt thirsty and stated, sometimes.
On 5/7/25 at 1:30 PM, the Director of Nursing (DON) was interviewed about their expectations regarding accessibility of fresh water for residents when in their rooms and indicated fresh water should be available.
A record review of R115's electronic medical record (EMR) revealed that R115 was admitted to the facility on [DATE] with diagnoses that included Cerebral palsy (congenital disorder of movement, muscle tone, or posture) and Difficulty in walking. R115's most recent minimum data set assessment (MDS) dated [DATE] revealed that R115 had a moderately impaired cognition and required setup help-substantial assistance for all activities of daily living (ADLs) other than eating.
A review of R115's care plan revealed that R115 was at risk for falls and dehydration and had interventions on their care plan to prevent falls and monitor for signs and symptoms of dehydration.
On 5/7/25 at 10:35 AM, a facility policy regarding accommodation of needs related to provision of water for residents was requested and not received prior to survey exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to timely issue a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF/ABN - notice informing of pay charges) for one resi...
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Based on interview and record review, the facility failed to timely issue a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF/ABN - notice informing of pay charges) for one resident (R73) of three reviewed for beneficiary notification. Findings include:
An ABN list provided by the facility revealed R73 had a Medicare Part A discharge date of 2/24/25 and remained living in the facility. Review of the notices provided by the facility for R73's revealed there was no SNF/ABN notice issued to R73's resident and/or representative (RR) informing them of the potential pay charges for continued services at the facility.
On 5/7/25 at 12:30 PM, Business Office Manager A (BOM) was interviewed regarding the missing SNF/ABN notice for R73 and indicated it was an oversight (R73's RR did not recieve notice) .
On 5/7/25 at 1:02 PM, the Administrator was interviewed regarding their expectation for beneficiary notification and comfirmed they should be issued timely.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R16
A review of R16's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Major ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R16
A review of R16's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Major Depressive Disorder, Generalized Anxiety Disorder, and Spinal Stenosis. Further review revealed the resident was cognitively intact and required one person assist for bathing.
Further review of the medical record revealed an active physician order dated 3/12/25, Cymbalta (anti-depressant) Oral Capsule Delayed Release Particles 30 MG (milligrams) .Give 1 capsule by mouth one time a day.
Further review of the medical record revealed a PASARR Level I Change in Condition screening form dated for 5/3/24 in which the the following questions were documented as No. 1. The person has a current diagnosis of Mental Illness or Dementia .The person has received treatment for Mental Illness or Dementia .The person has routinely receive one or more prescribed antipsychotic or antidepressant medications within the last 14 days .
On 5/7/25 at 10:15 AM, Social Worker B was interviewed regarding R16's PASARR and acknowledged the form was completed inaccurately.
On 5/7/25 at 2:28 PM, the Director of Nursing (DON) was asked about social work services and acknowledged the need for additional social workers in the facility.
A review of the facility's Resident Assessment-Coordination with PASARR program revealed the following, 5 .a. The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID or related condition to the appropriate state designated authority for Level II PASARR evaluation and determination.
Based on interview and record review, the facility failed to ensure a Change in Condition level one screening Form DCH (Department of Community Health/3877) was submitted to the local Community Mental Health Services Program (CMHSP) for a level two OBRA (Omnibus Budget Reconciliation Act) evaluation upon a change in the resident's condition for two (R16 and R64) of two residents reviewed for Preadmission Screening/Annual Resident Review (PASARR). Findings include:
R64
A clinical record review revealed R64 was admitted to the facility on [DATE] with diagnoses of hemiparesis following a stroke, schizoaffective disorder, anxiety disorder, and major depressive disorder. A Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13/15 indicated an intact cognition.
On 5/06/25, a review of the available PASARR form revealed a 3877 form dated 4/18/24 and it was completted as a change of condition with no noted follow up. There was no evidence of R64 being referred for a level II evaluation or evaluation completed to their diagnoses of mental disorders.
On 5/06/25 at 9:44 AM, a request was made to the facility requesting documentation of R64's PASARR documentation (Level II evaluation/3878-dementia exemption).
On 05/07/25 at 9:30 AM, an interview with completed with Social Worker B regarding R64 and the incomplete [NAME] II screen. Social Worker B confirmed the level II was not done.
On 05/07/25 at 12:30 PM, an interview occurred with the Nursing Home Administrator (NHA) regarding expectations for the PASARRs and [NAME] II screens. The NHA stated the expectation is that PASARRs' and level II evaluations should be completed timely per policy.
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 interview and record review, the facility failed to initiate a Post-Traumatic Stress Disorder (PTSD) care plan for one ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate a Post-Traumatic Stress Disorder (PTSD) care plan for one resident (R87) of two reviewed for care plans. Findings include:
A review of R87's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Cerebral Infarction, Heart Failure, and Major Depressive Disorder. Further review revealed the resident was cognitively impaired and required one person assistance for bathing and dressing.
Further review of R87's medical record revealed two Omnibus Budget Reconciliation Act (OBRA) evaluations (A document that records the results of the in-person evaluation used to assess a person's need for specialized services). Both evaluations were completed in 2024 and 2025 noted the resident was diagnosed with Post-Traumatic Stress Disorder.
Further review of R87's medical record revealed a care plan which did not address R87's diagnosis.
On 5/7/25 at 10:15 AM, Social Worker B was asked about the missing care plan for R87's diagnosis and acknowledged that it should have been added.
On 5/7/25 at 2:28 PM, the Director of Nursing (DON) was asked about social work services and acknowledged the need for additional social workers in the facility.
A review of the facility's Comprehensive Care Plan policy revealed, .4. If the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes shall be incorporated into an updated summary provided to the resident and his or her representative, if applicable .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record, review the facility failed to update interventions on a psychiatric care plan for one resident (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record, review the facility failed to update interventions on a psychiatric care plan for one resident (R95) of two residents reviewed for care plans. Findings include:
On 5/5/25 at 1:57 PM, an observation was made of R95 lying in their bed, awake, yelling, screaming, and swearing.
A review of R95's electronic medical record (EMR) revealed R95 was admitted to the facility on [DATE] with diagnoses that included Mood disorder and Major Depressive disorder. R95's most recent minimum data set assessment (MDS) dated [DATE] revealed R95 had a moderately impaired cognition with no mood indicators listed on the assessment.
A review of R95's orders revealed that R95 was prescribed the following: Remeron (treament for depression) Oral Tablet 15 mg (milligrams) Give one tablet by mouth at bedtime for mood.
A review of R95's care plan revealed the following psychiatric care plan goal/intervention: Focus: I use antidepressant medication r/t (related to) Depression .Interventions/Tasks: I am followed by [Psychiatric provider agency] for psychoactive medication. Date Initiated: 6/10/22.
On 5/7/25 at 3:01 PM, Social Worker B was interviewed regarding psychiatric treatment services provided for R95 and R95's care plan and interventions were reviewed with Social Worker B. Social Worker B indicated the psychiatric service provider agency listed on R95's care plan no longer was involved with R95's treatment. Social Worker B was asked if R95's interventions listed on their psychiatrc care plan should be updated to reflect current treatment practices. Social Worker B indicated the interventions should be updated.
On 5/7/25 at 3:15 PM, the Director of Nursing (DON) was interviewed regarding their expectations for updating of interventions on care plans and confrimed interventions should be updated when needed.
A review of a facility policy titled, Care Planning Date Reviewed/Revised: .6/24 was reviewed and did not address the updating of interventions when care planning.
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
Based on interview and record review, the facility failed to obtain a gastroenterology and infectious disease consultation for one resident (R105) of one reviewed for consults. Findings include:
A rev...
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Based on interview and record review, the facility failed to obtain a gastroenterology and infectious disease consultation for one resident (R105) of one reviewed for consults. Findings include:
A review of R105's medical record revealed they were admitted into the facility on 7/17/23 with diagnoses that included Dysphagia, Peripheral Vascular Disease, and Anxiety. Further review revealed the resident was cognitively intact and independent for transfers and bed mobility.
A review of R105's medical record revealed the following progress note:
Physician Progress Note: 5/30/2024 14:55 (2:55pm) Practitioner Progress Notes. Chief complaint:
Hepatitis C and preventive screening .[R105] with PMH (previous medical history) of polysubstance abuse, Hepatitis C, Hepatitis B, COPD (chronic obstructive pulmonary disease), severe protein calorie malnutrition, hepatitis, alcoholism, diabetes, insomnia, sinusitis, and thyroid disease. Resident seen today to discuss chronic disease management, specifically [their] hepatitis C. [R105] has a history of polysubstance abuse and states [they were] told 'a long time ago' that [they have] hepatitis C but [they do] not believe [they had] ever been treated for it. We also discussed colonoscopy recommendations and GI (gastrointestinal) follow up to which [they] is agreeable.
Further review of the medical record revealed the following two active orders:
CONSULT to gastroenterology [physician] for colonoscopy/routine colorectal cancer screening. [Digestive Facility]. This order was dated 6/6/24.
CONSULT to [physician] for evaluation and management of chronic hepatitis c. History of polysubstance abuse. This order was dated 5/30/24.
On 5/6/25 at 2:40 PM, the Director of Nursing (DON) was asked about the missing consults and acknowledged they had not been followed through on.
A review of the facility's Physician Orders and Clarification Orders did not address carrying out physician orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a supra-pubic catheter (SP- catheter inserted ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a supra-pubic catheter (SP- catheter inserted via an incision through the abdomen into the bladder) urinary catheter was changed timely for one resident (R73) of one resident reviewed for catheter care. Findings include:
R73
On 05/06/25 at 9:01 AM, R73 was observed to be seated in a wheelchair. The urinary catheter tubing was observed to be coiled up on the right thigh with the connection point to the drainage bag visible. The tubing appeared faded and soiled with areas of black along the length of the visible tubing.
On 05/06/25 at 10:18 AM, the observation of the urinary catheter was reviewed with Licensed Practical Nurse (LPN) E'. LPN E reported R73 had a supra-pubic catheter and they believed R73 was out regularly to the urologist and had been out to the hospital recently.
A review of the record revealed the last urology appointment was on 02/05/24, in which the physician documented related to the urinary catheter .ECF(extended care facility) to change every 6 weeks . Notes: Patient needs SP changed every six weeks with 20 F (french) 10 cc (cubic centimeters) balloon, clean stat lock weekly, and clean around the catheter, Vaseline to be applied after showering .
Additional review of a hospital Discharge summary dated [DATE] documented R73 had a urinary tract infection, R73 has had the suprapubic catheter since 2023 and the catheter was changed during the hospital stay. A review of the nephrology (kidney) doctor's notes did not document a change of the suprapubic catheter. A nephrology consult note dated 02/27/25 documented, .Urology follow up exit site for SP catheter .
On 05/06/25 at 10:35 AM, R73 reported they were not sure when they last saw a urologist or had the urinary catheter changed. The drainage tube was observed to be clouded with sediment. At 10:39 AM further review with LPN E confirmed the last catheter change was not found.
Further review of the record revealed orders revised 03/17/25 were for a catheter (generally inserted into the bladder via the urethra) and to use an 18 French (gauge) catheter. The timing for change was not specified. An order dated revised 01/22/25 and discontinued 03/11/25 documented the catheter as a suprapubic catheter and the size to be an 18 french.
On 05/06/25 at 2:09 PM, the unit manager, LPN F for R73 reported a conversation with the urologist about when the next follow up was needed and it was not indicated at this time.
On 05/07/25 at 9:15 AM the physician for R73, Physician G reported there was no real time frame, but generally a resident with a suprapubic catheter is out to the urologist monthly to have it changed and it was not usually done by the facility.
On 05/06/25 at 5:30 PM and on 05/07/25 at 1:52 PM, the Director of Nursing (DON) was asked for documentation of the catheter changes that had been completed and reported they would look into it. The DON had reported they were not able to provide additional documentation. No further documentation of any suprapubic catheter changes for R73 was provided prior to survey exit.
A review of the record for R73 revealed R73 was admitted into the facility on [DATE] with a readmission on [DATE] and 03/14/25. Diagnoses included Heart Failure, Chronic Kidney Disease and High Blood pressure. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition and the need for partial/moderate assistance with toileting hygiene. Hospital discharge information for the readmissions was not found in the electronic medical record.
A review of the catheter information provided from the book Physiological Basis for Nursing Practice did not address the timing for change of the suprapubic catheter.
A review of the facility policy titled, Physician Orders and Clarification Orders dated 12/01/21, revealed, .The clarification order is needed to initiate treatment according (to) the plan of care .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete monthly medication regimen reviews (MRRs) and follow up ph...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete monthly medication regimen reviews (MRRs) and follow up physician notification of pharmacy recommendations for four residents (R62, R68, R73 and R105) of five reviewed for unnecessary medications. Findings include:
R105
A review of R105's medical record revealed they were admitted into the facility on 7/17/23 with diagnoses that included Dysphagia, Peripheral Vascular Disease, and Anxiety. Further review revealed the resident was cognitively intact and independent for transfers and bed mobility.
Further review of R105's medical record revealed a missing medication regimen review for July 2024. In addition, the dates of: 11/20/24, 12/27/25, and 3/15/25 noted the following, [x] See report for any noted irregularities.
On 5/6/25 at 1:40 PM and 2:14 PM, and again on 5/7/25 at 8:30 AM, R105's July MRR and irregularities reports were requested from the facility however, they were not received by the end of this survey.
R62
A review of the record for R62 revealed R62 was admitted into the facility on [DATE] with a readmission on [DATE]. Diagnoses included Schizoaffective Disorder, Biploar Disorder and Insomnia. A review of the pharmacy medication regimen reviews revealed the review for July 2024 had not been completed.
R68
A review of the record for R68 revealed R68 was admitted into the facility on [DATE]. Diagnoses included Dysphagia (Difficulty Swallowing) and Alzheimer's. The Minimum Data Set (MDS) assessment dated [DATE] documented impaired cognition, substantial/maximal assistance was needed for eating. A review of the pharmacy medication regimen reviews revealed the review for July 2024 had not been completed.
R73
A review of the record for R73 revealed R73 was admitted into the facility on [DATE] with a readmission on [DATE] and 03/14/25. Diagnoses included Heart Failure, Kidney Disease and High Blood pressure. A review of the pharmacy medication regimen reviews revealed the review for July 2024 had not been completed.
On 5/7/25 at 2:28 PM, the Director of Nursing (DON) was asked about the missing MRRs and confirmed they never received the July MRRs. Regarding the irregularity reports, they explained they were unsure of what occurred as they had been provided to the unit managers upon receipt.
A policy and procedure for pharmacy services related to pharmacy reviews was requested via email on 05/07/2025 at 12:46 PM, but not received prior to survey exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one delayed release medication and two extende...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one delayed release medication and two extended release medications were not crushed prior to administration and a cranberry tablet dosage was correctly administered out of 33 medications observed, resulting in a medication error rate of 12.12%. Findings include:
On 05/07/25 at 9:29 AM, a medication pass observation for R68 was conducted with Licensed Practical Nurse (LPN)C. The following medications were prepared, crushed and placed into applesauce: Aspirin 81 mg (milligrams) tablet one time a day, Megestrol 400 mg/10ml, liquid, 10 ml (milliliters) two times a day; Zunveyl (Benzgalantamine Gluconate) Oral Tablet Delayed Release 10 mg two times a day; Loratadine 10 mg one time a day; Cranberry 400 mg tablet one time a day, (450 mg tablet given); Losartan 100 mg tablet in the morning; Metoprolol succinate 100 mg ER (extended release) tablet; Amlodipine 5 mg tablet in the morning; and Klor-con potassium ER 20 MCG (micrograms) tablet one time a day. The Zunveyl was for Alzheimer's and the Metoprolol was for blood pressure control. The observation was noted to the Director of Nursing (DON) at this time and the DON acknowledged the error concern.
On 05/07/25 at 1:54 PM, Nurse Practitioner D reported the delayed release and extended release medications should not be crushed. The Nurse Practitioner further noted they had not been made aware these medications were being crushed.
A review of the record for R68 revealed R68 was admitted into the facility on [DATE]. Diagnoses included Dysphagia (Difficulty Swallowing) and Alzheimer's. The Minimum Data Set (MDS) assessment dated [DATE] documented impaired cognition, substantial/maximal assistance was needed for eating and a mechanically altered diet (ground/minced) for food was required.
A review of the facility policy titled, Medication Crushing Guidelines dated June 2019, revealed, .The solid dosage forms of many medications should not be crushed for a variety of reasons . Timed release tablets are designed to release over a sustained period, usually 8-24 hours. These formulations are designed to reduce stomach irritation in some cases and to achieve prolonged medication action in other cases. In either case these tablets should not be crushed .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to ...
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Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include:
On 05/05/25 between 7:15 AM-7:45 AM, during an initial tour of the kitchen, the following items were observed:
In the walk-in cooler, there was a large piece of cardboard on the floor underneath the rack holding the milk crates. The surface of the cardboard was covered with a spotty, black mold-like substance. In addition, there was an opened 1 gallon container of Italian dressing with a use-by date of 4/28.
According to the 2017 FDA Food Code section 4-101.19 Nonfood-Contact Surfaces, NonFOOD-CONTACT SURFACES of EQUIPMENT that are exposed to splash, spillage, or other FOOD soiling or that require frequent cleaning shall be constructed of a CORROSION-RESISTANT, nonabsorbent, and SMOOTH material.
According to the 2017 FDA Food Code section 6-101.11 Surface Characteristics, (A) Except as specified in (B) of this section, materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: .(3) Nonabsorbent for areas subject to moisture such as food preparation areas, walk-in refrigerators, warewashing areas, toilet rooms, mobile food establishment servicing areas, and areas subject to flushing or spray cleaning methods.
The ice scoop holder located in the dining room was observed with a black, slimy gel accumulated on the bottom inside surface. The tip of the ice scoop was resting in the slimy gel.
According to the Food & Drug administration (FDA) 2017 Model Food Code, Section 3-304.12 In-Use Utensils, Between-Use Storage, During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: .(E) In a clean, protected location if the utensils, such as ice scoops, are used only with a food that is not potentially hazardous (time/temperature control for safety food) .
On 05/05/25 at 7:50 AM, when queried about the moldy cardboard in the walk-in cooler, Food Service Manager (FSM) H stated it would be removed right away. When shown the soiled ice scoop holder, FSM H stated it would be cleaned right away.
On 05/05/25 at 7:30 AM, there were individual covered bowls of oatmeal (approximately 45 bowls) on a tray next to the steam table . The oatmeal was not being held hot. On 05/05/25 at 8:00 AM, there were 6 bowls of oatmeal left on the tray, to be served to the last few residents for breakfast. The internal temperature of the oatmeal was measured to be 125 degrees Fahrenheit. When queried, FSM H provided no explanation as to why the oatmeal was not being held at 135 degrees Fahrenheit or above.
According to the 2017 FDA Food Code section 3-501.16 Potentially Hazardous Food (Time/Temperature Control for Safety Food), Hot and Cold Holding, 1. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C) of this section, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be maintained: 1. (1) At 57ºC (135ºF) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54ºC (130ºF) or above; P.
Apr 2025
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation has two deficient practice statements.
Deficient practice number one.
This citation pertains to Intake MI00059836....
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation has two deficient practice statements.
Deficient practice number one.
This citation pertains to Intake MI00059836.
Based on observation, interview, and record review, the facility failed to protect one resident from physical abuse from staff (R800) out of three reviewed for abuse, this deficient practice resulted in an Immediate Jeopardy (IJ) and the likelihood for serious physical and /or psychosocial harm, injury, impairment, or death. Findings include:
R800
A review of Facility Reported Incident (FRI) noted the following, On April 3, 2025, Abuse coordinator made aware of an abuse allegation by DON [Director of Nursing] .around 10AM. [DON] stated, while rounding the A-wing unit, [R800] stated [they] was slapped by [their] midnight nurse. [R800] BIM [Brief Interview for Mental Status] score of 15, who also locomotes freely within the facility with a wheelchair. Around ten am, [R800] reported to the DON that a midnight nurse slapped [their] arm during care. The employee was immediately suspended, pending investigation .
On 4/16/2025 at 10:12 AM, an interview was completed with R800 regarding the incident with Licensed Practical Nurse (LPN) E on 4/3/2025. R800 reported they were having a bowel movement and LPN E took their wheelchair so they could not go to the bathroom. R800 reported LPN E was very mean to them and would not let them use the bathroom. R800 reported LPN E told them to shut the f*** up and was calling them names. R800 reported LPN E then slapped them in the arm twice. R800 reported another person (Certified Nurse Assistant (CNA) C, was in the room with them and tried to tell LPN E to stop, but they did not listen. R800 reported the other person in the room left, and they were in there with LPN E until their assigned nurse came back, and subsequently went to the hospital. R800 indicated nothing like that ever happened to them in the facility before and they felt embarrassed about the whole situation. R800 reported they do not feel safe in the facility at this time.
A review of the medical record revealed R800 was admitted into the facility on [DATE] with the following medical diagnoses, Dysphagia and Weakness. A review of the Minimum Data Set (MDS) assessment revealed Brief Interview for Mental status (BIMS) score of 15/15 indicating an intact cognition. R800 also required staff assistance with bed mobility and transfers.
On 4/16/2025 at 3:06 PM, a phone interview was conducted with LPN D. LPN D reported R800 was having diarrhea, throwing up, and sweating profusely. LPN D reported LPN E came to sit with R800 along with CNA C, while they prepared the paperwork to send them out to the hospital. LPN D reported while they were at the nurses' desk when CNA C walked by and said they were not going to be involved with what LPN E had going on. LPN D reported CNA C did not report anything else to them and they were focused on getting everything together for R800's transfer to the hospital. LPN D reported after they were done getting R800's transfer together, they went back in the room with LPN E and R800. LPN D indicated the whole event started approximately around 2:00 AM until 3:00 AM when R800 left the facility. LPN D reported that after R800 left the facility, LPN E went back to their set and continued working their assigned residents until the end of their shift.
Further review of CNA C witness statement dated 4/11/2025 noted the following, On the morning of 4/3/2025 .R800 threw himself to the floor. We placed him back on the toilet. That's when LPN E started yelling and told R800 if you have to s*** then take a s***. [LPN E] was speaking loudly, very loud. R800 yelled saying [they] were sick, after that [LPN E] took [their] right hand and slapped [R800] on [their] left arm two times. I told [LPN E] to stop and [LPN E] yelled at me, got in my face, and was very aggressive. I ran out the room and told [LPN D] that [LPN E] was 'tripping' .I called the Administrator immediately and I texted the DON at 7:00 AM when I got off work.
On 4/16/2025 at 12:35PM, an interview was conducted with the DON. The DON reported that they were informed about the incident around 7:30AM-8:00AM on April 3rd, when they came in the facility. The DON reported when they came in the facility R800 was also coming back in from their hospital visit.
At 12:55, an interview was conducted with the Nursing Home Administrator (NHA). The NHA reported they were informed about the incident around 10:00 AM from the DON when they were completing room rounds. The NHA reported they informed Human Resources, and they called and suspended LPN E. The NHA reported they called the police, reported the incident to the State Agency (SA) and began their full investigation. The NHA reported that LPN E did continue to work their entire shift following the incident and was suspended the following morning.
Further review of incident submitted to State Agency on 4/3/2025 at 11:49 AM, the abuse was substantiated.
The Immediate Jeopardy (IJ) started on 4/3/2025 and was identified on 4/16/2025.
The Nursing Home Administrator (NHA) was notified of the IJ on 4/16/2025 at 3:35 PM and was asked to submit a plan to remove the immediacy.
The IJ was removed on 4/17/2025, based on the facility's implementation of the removal plan as verified onsite.
Although the immediacy was removed on 4/17/2025, the facility's deficient practice was not corrected and remained isolated with actual harm.
Removal Plan:
1.
Identification of Residents Affected or Likely to be Affected:
o
On 4/16/25 the DON and designee(s) interviewed/assessed residents with BIMS scores of 8 and above for potential abuse. Residents with BIMs below 8 were assessed by a license nurse for an acute change in condition. Concerns were/were not identified.
o
On 4/16/25 Social Services completed a supportive visit with R800.
2.
Actions to Prevent Occurrence/Recurrence:
The facility took the following actions to prevent an adverse outcome from reoccurring.
o
LPN E was suspended pending investigation on 4/3/25 and has not returned to the facility.
o
On 4/4/25, the Abuse, Neglect and Exploitation policy was reviewed by the Administrator and deemed appropriate.
o
Beginning on 4/16/25, the Administrator/designee re-educated all staff on the Abuse, Neglect and Exploitation policy, highlighting the requirement to notify the Abuse Coordinator (Administrator) immediately with all abuse allegations. No staff member will be permitted to work until re-education is received.
o
The facility Medical Director was notified of this event on 4/16/25.
o
Facility IDT Team held an ADHOC QAPI meeting on 4/16/25.
o
From the abuse policy all staff were educated all on:
VI. Protection of Resident
o
The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:
o
A. Responding immediately to protect the alleged victim and integrity of the investigation;
o
B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed;
o
C. Increased supervision of the alleged victim and residents;
o
D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator;
o
E. Protection from retaliation;
o
F. Providing emotional support and counseling
o
CENA that left the room, was provided 1:1 education regarding not to leave resident alone with abuser and the LPN assigned to the resident was provided 1:1 education to immediately report allegations of abuse and remove abuser as well and the educations received will be added to both their employee files.
o
Facility IDT Team conducted an audit on all residents for their Safety/ Abuse on 4/16/25. Any negative findings will be Immediately corrected.
o
All findings will be taken to QAPI on 5/8/25 to follow up/ track for any systematic changes that may be needed.
Deficient practice number two.
This citation pertains to Intake MI00152184.
Based on observation, interview and record review, the facility failed to protect one resident (R801) from physical abuse by another resident (R802) out of three reviewed for abuse. Findings include:
A review of Facility Reported Incident (FRI) noted the following, .Around 10 AM, [Receptionist A] communicated that while both residents were in the lobby, [R802] walked up to [R801] and slapped [them] in the face .
A review of the medical record revealed R801 was admitted into the facility on 7/14/2023 with the following medical diagnoses, Cerebral Infarction and Anxiety Disorder. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 12/15, indicating an impaired cognition. R801 also required assistance with bed mobility and transfers.
A review of the medical record revealed R802 was readmitted into the facility on [DATE] with the following medical diagnoses, Schizoaffective Disorder and Bipolar Disorder. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 10/15 indicating an impaired cognition. R802 also required staff assistance with bed mobility and transfers.
On 4/16/2025 at 11:14 AM, an interview was conducted with R801. R801 did not recall the incident and stated they did not have a problem with anyone in the facility.
On 4/16/2025 at 11:52 AM, an interview was conducted with Receptionist A. Receptionist A reported the incident occurred at approximately 9:05 AM and R802 was already in the lobby. Receptionist A reported R801 was sitting on one couch and R802 was sitting opposite of them on another couch. Receptionist A reported R802 got off the couch, walked towards R801 and slapped them in the face. Receptionist A reported they went over to R802 and informed them they could not put their hands on anybody to which R802 stated they will do it again. Receptionist A reported R802 then walked away and they (the receptionist) went and told the Nursing Home Administrator (NHA) what they witnessed.
On 4/16/2025 at 12:04 PM, an interview was conducted with the Social Service Director (SSD) B. SSD B stated Receptionist A came in morning meeting and told the NHA about the incident. The SSD reported they asked R802 did they slap R801?, and the resident confirmed they did and will do it again.
At 1:04 PM, an interview was conducted with the NHA. The NHA reported R802 was sent to in patient psychiatric and has not returned since the incident.
A review of a facility policy titled, Abuse, Neglect, and Exploitation Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.
Apr 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00151378.
Based on interview and record review, the facility failed to honor the rights, noti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00151378.
Based on interview and record review, the facility failed to honor the rights, notify, or obtain consent from a Durable Power of Attorney (DPOA) regarding a resident discharge for one resident (R504) of three sampled residents reviewed, resulting in the released to an unauthorized family member. Findings include:
R504
R504's Electronic Medical Record EMR was reviewed on 4/8/25 at 11:30 AM. R504 was admitted to the facility on [DATE] with the diagnosis of Cervical Disc Disorder, Type 2 Diabetes Mellitus, and Carcinoma of the Prostate, in addition to other diagnoses. R504's Brief Interview for Mental Status (BIMS) Score dated 1/15/25, assessed by the facility, was 6/15. A BIMS score of 6 indicates severe cognitive impairment. R504 Minimum Data Set (MDS) assessment dated [DATE] revealed they are frequently incontinent with both bowel and bladder elimination patterns and requires substantial/maximal assistance with Activities of Daily Living (ADLs).
A review of R504's electronic record revealed on 3/4/25, the facility discharged R504 with another family member not listed in the contact list of R504's Face Sheet to another state (Indiana). No home care, Rehab Therapy, Pharmacy, or Physician were arranged for follow-up care after R504 was discharged .
According to Adult Protective Services staff member A, on 4//8/25 at 9:15 AM, during an interview by phone, the facility did not honor the resident's Durable Power of Attorney and Designated Patient's Advocate despite legal documents submitted to show evidence that R504's stepson was the legally appointed Durable Power of Attorney. As a result, R504 was released and discharged to an estranged family (birth son), who did not notify nor obtain permission from the DPOA.
An interview with the Social Services Director (SSD) B was conducted on 4/8/25 at 12:15 PM. R504 was admitted in January 2025, and was their own responsible party. However, the stepson was making decisions for them. SSD B revealed she called the stepson on March 4, 2025, to update him on the plan. Because the stepson did not call back, the facility released R504 to the estranged family member (son) who showed up and presented his birth certificate as proof that he was R504's son.
R504's family came to visit and decided to bring R504 home with them in Indiana; SSD B added that the facility called R504's estranged ex-wife, who was the mother of the estranged son, and confirmed that he was the birth son of R504. The SSD B indicated it was the DON and her who decided to release R504 to the birth son. SSD B confirmed not arranging home care, no physician order, no pharmacy, no DME (Durable Medical Equipment), or hospice arrangement when R504 was discharged . When asked why, SSD B explained that they took the resident to Indiana, where the son and his family live. SS'B was questioned why the signed Patient Advocacy form or the DPOA documents were not honored and replied R504 was their own responsible party and did not have a change in cognition.
The Social Services Notes were reviewed. A late entry: written by SSD B dated 2/14/25 was noted. It revealed that: SW (Social Worker) informed APS (name mentioned) that the staff had tried to inform DPOA (name mentioned) of resident's medical health decline and that it would be in the resident's (R504) best interest to remain in LTC (Long Term Care) placement .
R504's Designation of Advocate Form was reviewed on 4/8/25 at 1:35 PM. It specified the name and address of residence of the appointed Patient Advocate with the instructions:
My Patient Advocate may only act if I am unable to participate in making decisions regarding my medical treatment. My Patient Advocate shall have the authority to make
all decisions and to take all actions regarding my care, custody, and medical treatment . This document is to be treated as a Durable Power of Attorney for Health Care and shall survive my disability or incapacity . If I am unable to participate in making decisions for my care and there is no Patient Advocate able to act for me, I request that the instructions I have given in this document be followed and that this document be treated as conclusive evidence of my wishes . I am providing these instructions of my free will. I have not been required to give them in order to receive or have care withheld or withdrawn . Signed by R504 on October 17, 2024, with two witnesses and acknowledged by the designated by the appointed Patient Advocate on 10/18/2024.
An interview with the Director of Nursing (DON) was conducted on 4/8/25 at 2:59 PM. The DON revealed that on 3/8/25, R504's family (birth son and granddaughters) came to visit R504. They have been estranged for over 5 years. The son came in and presented a Birth Certificate, and the estranged son's mom (R504's ex-wife) confirmed the family in possession of the birth certificate was their son together over the phone. When the DON was asked how she verified the ex-wife's identity, she said she did not. When the DON was asked if R504's son or ex-wife was on R504's contact list, She stated, No.
The Administrator was interviewed on 4/8/25 at 3:16 PM. He stated that R504 had not changed from their baseline since admission, so there was no indication to change anything. The Power of Attorney papers were for Financial POA, not medical decisions.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00151133.
Based on interview and record review, the facility failed to protect and prevent ab...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00151133.
Based on interview and record review, the facility failed to protect and prevent abuse from occurring for one resident (R504) who was inappropriately touched by another resident (R505) of three residents reviewed for abuse. Findings include:
A review of the facility investigation revealed that on 3/3/25 at 3:30 PM. The Activities Director reported witnessing R505 inappropriately touching R504 to the Social Service Director. The incident occurred in the dining room with no staff present. The Activities Director happened to step out of her office door and saw R505 touching R504's breast. The Activities Director called out R505's name. She said that the behavior was unacceptable and immediately separated both residents (R504 and R505). The Social Services Director reported the incident to the Abuse Coordinator.
R504
Record review revealed F504 was admitted to the facility on [DATE] with diagnosis of cervical disc disorder with myelopathy, carcinoma of the prostate, repeated falls, and adult failure to thrive. R504's Brief Interview for Mental Status (BIMS) Score dated 1/15/2025 assessment was 6/15. A score of 6 indicates severe cognitive impairment. A care plan for mood difficulties and adjustment concerns related to psychotropic medication use was created on 1/10/25. R504 had been identified with Activities of Daily Living (ADL) Care deficit and initiated a plan of care, which included a Bowel and Bladder incontinence on 1/7/25.
R505
Record review revealed R505 was admitted to the facility on [DATE] with a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left non-dominant side, unsteadiness on feet, reduced mobility, and dysphagia in addition to other diagnoses. R505's ADL Self Care Performance requiring extensive assistance was created on 6/27/24 with Bowel and Bladder Incontinence Care.
An interview with the Activities Director was conducted on 4/8/25 at 12:15 PM. The Activities Director confirmed witnessing R505 touching another resident's chest in the dining room. The Activities Director described, There were 3 to 4 residents in the dining room, but no staff was there to supervise them. I just stepped out of my office when I saw the incident.
Social Services Director SSD B was interviewed on 4/8/25 and confirmed R504 was right next to R505 when R505 inappropriately touched R504.
Certified Nurse Aide CNA J was interviewed on 4/8/25 at 3:30 PM. CNA J was assigned to R505 and revealed that R505 was heard exhibiting sexual behaviors before the incident occurred. R505
was at the B-wing. CNA J stated, I did not see it for myself but heard staff talk about it. R505 looks at you in an inappropriate way and was warned by other staff to be careful when providing care for R505.
The Director of Nursing (DON) on 4/8/25 at 4:20 PM stated no staff reported any inappropriate or sexual behavior observed for R505. We separated both and updated their care plan. There are many activities staff, and they should not have been left unsupervised.
The facility's Policy for Abuse and Neglect was reviewed on 4/8/25 at noon.
________________________________________
Nov 2024
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00147420.
Based on observation, interview, and record review the facility failed to maintain ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00147420.
Based on observation, interview, and record review the facility failed to maintain clean and repaired flooring, handrails and furniture items throughout the facility potentially affecting all 126 residents residing there. Findings include:
On 11/14/24 at 10:36 AM, observations of the environment were initiated and revealed:
The A wing 100 hall shower room had some dried build up of debris on the strainer for the drains in the left hand shower stalls. The toilet bowel had an amount of used tissue which filled the bowl. The six to eight foot long baseboard heater register was observed to have rust scattered across the surfaces, a portion of the cover hung down on one end and multiple tines of the register were dented or mashed. room [ROOM NUMBER] had an unoccupied bed which tilted down at one corner, the mattress did not fit the width of the bed, the bed sheet was soiled with a few tan/brown spots and the sheet rock at the wall side of the bed had a softball size dent with a hole in it; room [ROOM NUMBER] had a line of vertical marring of the sheet rock behind the head of the first bed, the wall opposite the first bed had a continuous black line of marring about an inch wide which went from one wall into the next resident area.
Further observations of the environment noted the resident closets/armoires in all the resident rooms had some variation of scratches and marring which had taken the varnish like finish off in places to reveal the lighter wood beneath; Continued observation of the three facility resident wings revealed consistent items: The flooring in the resident rooms was dull, with a gray hue over a more yellowed/tan colored tile. lt was not determined if the tile had originally been white as the tile in the hall. Residents in some of the rooms were asked, but did not recall if the flooring had appeared different. The tiles at the entry to the resident rooms had a greater discoloration of a more black or gray. The entry door thresholds had a build up of black soil along the room side of the threshold which extended out an eighth to a quarter inch in places. The black soil extended into the corners of the doorways and behind the doors. Chipped paint on the lower portion was noted in a majority of the door jambs. The B and C wing resident rooms had a greater amount of soil build up along the entry thresholds than the A wing. (Rooms, 211, 212, 215, 216, 217, 218, 219, 309 and 311 in particular). Similar soiling was noted along the front edge of the closets. The hand rail throughout the resident hallways appeared scratched and worn with a uniformly distressed appearance. The handrail was missing the darker layer of finish to reveal a lighter natural wood color.
Along the main transition hallway which connected the wings of the resident areas: The paint on the door to the kitchen had worn off in the area above the door knob. The tile at the base of the door was cracked at the door jamb. Across the hallway from the kitchen crumbling sheet rock was observed above the sill at the right side of the right hand window. A broken out section of tile (about 12 inches by five inches) was observed at the right side of the door to the courtyard; A second softball size area of missing tile was observed at the doorway to the courtyard; At the 300 nursing station the window area had screws holding down the formica and the screws were not fully set to the level of the counter. The wall cladding and cove base at the left side of the C wing staff restroom door, was peeled away at the floor level up about six inches; In 307-1 the night stand had a drawer which leaned in toward the back as if off the runners; room [ROOM NUMBER] had metal chicken wire over the baseboard heater register, the top drawer of the night stand was missing the face and the floor was dull and soiled with a gray appearance over the yellowed/tan tile as compared to the whiter tile in in the hall. A crack ran through eight tiles in the hall area entry to the 200 shower room; The hallway tile at the left side of the employee break room door and the right side of room [ROOM NUMBER] had irregular areas of missing tile. Cracks were observed in the tile at the entry to room [ROOM NUMBER]. A rectangle of wall paper above the hand rail was torn away at left side of the door to room [ROOM NUMBER]. A tile outside room [ROOM NUMBER] had a piece missing to reveal the darker area beneath; Rust was observed at the base of the entry door jamb for room [ROOM NUMBER]; The exit door at the end of the 200 hall had a visible rust crack along the base of the door; The exit door to the left of the 200 nurse station had rusted out areas centered at the bottom. The area was around eight inches by one inch high, with visible depth; Rust was also at the sides of the door jamb; Two tiles in front of the same exit door had broken out areas; room [ROOM NUMBER] had parallel black marks 15 tiles into the room; The star/chevron area at entry from the front sitting areas to the 100 hall had three ore more tiles that appeared crackle; The counter pass through for the A wing/100 hall nurse station was pinned with sheet rock screws; The wallpaper was peeling away at the left side of room [ROOM NUMBER], above the hand rail; Five cracked tiles were observed in the hallway outside rooms [ROOM NUMBERS]; room [ROOM NUMBER] had chicken wire mesh over the baseboard heater register; The 100 hall exit door had a approximate quarter inch high build up of sand colored dirt at each side of the door jamb at the floor level.
On 11/14/24 at 12:45 PM, with the Administrator and the Director of Nursing (DON) and at 3:55 PM, with the Administrator and Maintenance Director environment observations were reviewed. A water leak in the basement was confirmed. The DON and Administrator verbalized concerns related to the condition of the building since the administrator arrived at the facility almost a year ago. The Maintenance Director confirmed they had been the lone staff member for maintenance for the better part of a year and most of their days are spent trying to keep up on items like unclogging toilets. It was reported that maintenance concerns submitted from staff had been verbal or on paper until recently. It was reported a layoff off of housekeeping, floor care and maintenance staff had occurred the year before and the facility was not fully staffed in these departments until September of 2024. A written plan or quality assurance project to address the facility environment was reported not to have been completed but a process had been initiated to address the condition of the environment. It was reported that housekeeping had recently resumed deep cleans due to improved staffing numbers.
A review of the facility policy, Safe and Homelike Environment with date implemented of 1/11/2021 revealed, Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. A homelike environment is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A determination of homelike should include the resident ' s opinion of the living environment. Orderly: is defined as an uncluttered physical environment that is neat and well-kept. Sanitary: includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living . Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment .
Sept 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00146878 and MI00146890.
Based on interview, and record review, the facility failed to ensure...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00146878 and MI00146890.
Based on interview, and record review, the facility failed to ensure physican was timely provided notification off an abnormal blood sugar (glucose) for one resident (R901) of three reviewed for a change in condition. Findings include:
A physician order documented, sliding scale insulin order for humalog revised 01/28/24 revealed 401 to 450 give 12 units, greater than 450 call doctor for further coverage orders .
The blood glucose results documented for 09/09/24 revealed:
- a blood glucose of 450 documented at 9:56 AM,
- a blood glucose of 550 documented at 11:57 AM and,
- a blood glucose of 550 documented at 3:53 PM.
All documented by Licensed Practical Nurse (LPN) A. Further review of the record revealed no notification to the physician for the abnormal 450 blood glucose levels at 9:56 AM and 11:57 AM.
A progress note dated 9/9/24, by Licensed Practical Nurse (LPN) A at 16:01 (4:01 PM after third high blood glucose reading): Alert Note Text: Resident was observed lethargic with a unreadable blood sugar. Vital signs were also obtained and (oxygne saturation) spo2 read 66 (out of 100 percent). Physician was notified and gave an order for Resident to be sent to hospital 911. Resident was transported via ambulance to (hospital name) .Emergency contact #1 was notified and understood report given by writer. R901 was discharged to the hospital on [DATE].
R901 was admitted into the facility on [DATE]. Diagnoses included Stroke with Paralysis of one side and Diabetes.
The care plan included Insulin Dependent Diabetes .I will be free of any (signs/symptoms) of hyper (high)/hypo (low) glycemia (blood sugar level) .follow hyper/hypglycemia protocol .
The Minimum Data Set (MDS) assessment date 08/21/24 indicated moderately impaired cognition and dependence for care of at least one person for all activities of daily living except eating.
On 09/17/24 at 3:00 PM, Physician B reported the medical practice has a provider in the facility every day but they personally had not been aware of the 450 glucose number earlier in the day. The physician reported they were notified of the 550 and unresponsivness and that is when the resident was sent out. The physican further noted the blood sugar at the hospital emergency room was over 1200 and questioned how the glucose elevated so fast. The physician commented they may need to ask for a print out of all the glucose number for other diabetic residents.
On 09/17/24 at 4:13 PM, the Director of Nursing (DON) reported nurses are to use their judgement to notify the provider when the glucose number is at the top end of the scale and document.
On 09/17/24 at 4:47 PM, LPN A was asked about the glucose numbers for R901 and reported the 450 glucose reading was taken around 8:15 AM to 8:30 AM and coverage was given and the provider was not contacted at this time. When LPN A went back to do the lunchtime glucose check (around 11:30) she reported the meter read high and R901's hear rate was elevated.
A review of the undated facility Change of Condition Physician Notification documented, (greater than) 430 (milligrams/deciliter) mg/dl or machine regiters high, in diabetic patient using sliding scale insulin . as the number to notify the physician.
A review of the facility plicy titled, Diabetic Management: Hyper/Hypoglycemic Events revised 01/2024 revealed, .Hyperglycemic Event: Notify physician if blood sugar reading is over 400mg/dl or the threshold established by the physician. Signs and symptoms of hyperglycemia (any, all, or none may be present) include:
a. Blurred Vision b. Dehydration c. Increased Thirst d. New or increasing confusion e. Lethargy f. Polydipsia or polyphagia g. Weight loss h. Worsening incontinence.
A review of the facility policy titled, Change in Condition revised 07/2024 revealed, Policy: It is the policy of this facility to inform residents/legal representative, attending physician or designee of a
change in the resident ' s condition. Policy Explanation and Compliance Guidelines: 1. The organization utilizes an interactive platform in the electronic health record to recognize and manage a potential change in condition. 2. The facility will inform the resident, consult with the resident ' s provider, and notify, consistent with his or her authority, the resident representative(s) when there is . A significant change in the resident ' s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); c. A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or d. A decision to transfer.
Aug 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation petains to Intakes MI00145830 and MI00146169.
Based on observation, interview, and record review, the facility fai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation petains to Intakes MI00145830 and MI00146169.
Based on observation, interview, and record review, the facility failed to implement a plan of
care for two residents (R700 and 701) of out of two residents reviewed for quality or care care plans.
Findings include:
R700
On 08/13/24 at 10:00 AM, R700 was observed sitting up in electric chair listening to music on their head phones.
R700 discussed concerns about care of their (indwelling tube inserted into the bladder to drain urine) catheter.
A review of R700's medical record revealed they were admitted into the facility on 7/01/24 with
diagnoses of Paraplegia; Opioid Independence; Major depressive disorder; and Anxiety disorder.
A review of R700's Minimum Data Set (MDS) assessment dated [DATE] revealed, R700's Brief
Interview for Mental Status assessment score was a 15 indicating intact cognition.
Further review of R700's medical record revealed no care plan with goals or interventions for the care of the catheter.
R701
On 08/13/24 at 11:30, R701 was observed sitting on the side of the bed watching television. R701 discussed recurring teeth pain.
A review of 701's medical record revealed they were admitted into the facility on 7/14/2023 with diagnoses of Encephalopathy; Atherosclerotic heart disease, Hemaplegia and Schizophrenia. A review of R701's Minimum Data Set (MDS) assessment dated [DATE] revealed, R701's Brief Interview for Mental Status assessment score was a
14 indicating intact cognition.
Further review of R701's medical record revealed no oral/dental care plan with goals and interventions for care or pain.
On 08/13/24 at 01:55 PM, an interview was held with the Director of Nursing (DON) regarding care plans. When asked about 700's and 701's catheter and dental care plans, DON replied, each resident should have care plans to address their care.
A review of a facility policy titled, Care Planning revealed The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care.
Jul 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
This citation pertains to Intake MI00145065.
Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable, homelike environment for one (R803) of five resid...
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This citation pertains to Intake MI00145065.
Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable, homelike environment for one (R803) of five residents reviewed for homelike environment. Findings include:
On 7/3/24 at 10:15 AM, R803 was observed lying in bed and was asked about their stay at the facility and stated, Yesterday was the first time I got a shower at this new room. I have not had the bed linen changed since getting to this room. R803's was observed with a gown on that material had been worn that cause the gown to be see through. R803 pillowcase was observed stained with a yellow ring around it. R803 reported the facility had a lack of linen.
During this same time, observation of R803's bathroom revealed, the toilet was observed with water that dripped to the floor. The floor was observed with black and gray substance that appeared to be mold along the crease of the wall. The bathroom vent was observed with a thick layer of a buildup of dust and debris.
On 7/03/24 at 9:15 AM and 10:00 AM, the two linen closets were observed without towels, wash cloths, fitted sheets, and gowns.
On 7/03/24 at 10:20 AM, the Laundry aide (LA B) was asked about the washing machines at the facility. LA B explained the facility only had one washer of two that worked and two out of three dryers that worked. LA B was asked about the linen and stated, I have no towels, or fitted sheets. We put them out and we don't get them back. During the interview the clean storage in the laundry room was observed with approximately eight gowns, 14 flat sheets, four fitted sheets, and 16 mattress pads/under pads. LA B was asked if this was all the linen and stated, I have a couple of towels in the dryer and a couple in the washer. Not many at all.
On 7/03/24 at 10:30 AM, the Maintenance/Housekeeping/Laundry Director was asked about the linen and stated he was going to pull some out and place them on the units. The Director was asked the reason he was refilling the units and he stated, The staff was asking for it.
At this time,the Director was asked about R803's bathroom and explained that he wasn't aware of the problem.
On 7/03/24 at 1:00 PM, the Director of Nursing (DON) was asked about the staff and the lack of linens at the facility. The DON explained that there has been a lot of cuts to the housekeeping, laundry, and maintenance departments.
On 7/03/24 at 1:27 PM, the Nursing Home Administrator (NHA) was asked about the washing machine. The NHA stated they have purchased a larger washer but is not able to fit into the building. The NHA also stated they are providing ongoing education regarding the linen storage.
A review of the facility's policy titled, Handling Clean Linen, dated 1/11/2021, Purpose: To ensure that clean linen is handled properly to the units and in the laundry . The policy did not address how often to restock the closets or ensure that the facility had enough linen available for the residents.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
This citation pertains to Intake MI00145065.
Based on observation and interview the facility failed to provide a safe and functional environment for the facilities census of 133 residents. Findings in...
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This citation pertains to Intake MI00145065.
Based on observation and interview the facility failed to provide a safe and functional environment for the facilities census of 133 residents. Findings include:
On 7/03/24 at 10:20 AM, the floor tile in the basement were observed to be broken and missing in multiple areas of the basement.
On 7/03/24 at 10:30 AM, the Maintenance/Housekeeping/Laundry Director was asked about the basement floor and stated, They are asbestos, corporate knows and we are to not touch it.
On 7/03/24 at 11:36 AM, during another observation in the basement the Maintenance/Housekeeping/Laundry Director was asked about the asbestos tile and now stated, I'm not sure if it's asbestos. The Director was asked about the statement prior that it was asbestos and he said that because of how the tile looked and the size of them. The Director was asked if the tile problem was reported to corporate. The Director reported, They don't know, I will tell them today.
On 7/03/24 at 1:27 PM, the Nursing Home Administrator (NHA) was asked about the basement floor tile being asbestos. The NHA explained that he was not aware of the floor tile being asbestos.
On 7/03/24 at 12:03 PM, a request was made to the NHA for the environment policy that addressed floor tiles. The facility did not provide a policy by the end of this survey.
Mar 2024
23 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
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 catheter bag privacy for one (R103) of six re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain catheter bag privacy for one (R103) of six residents reviewed for privacy. Findings include:
Review of the facility record for R103 revealed an admission date of 12/11/21 with diagnoses that included Dementia, Pulmonary Edema/Hypertension, and Kidney Failure. The Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 9/15 indicating moderate cognitive impairment.
On 03/26/24 at 9:05 AM and 10:08 AM, R103's room door was open and their catheter bag was observed hanging on the side of the bed facing the doorway clearly visible from the hallway. The catheter bag was clear and was not in a privacy bag and staw colored urine was visible in the bag.
On 03/26/24 at 10:39 AM, R103's catheter bag remained clearly visible from the hallway, uncovered and containing urine. An interview was attempted as R103 appeared alert and was making eye contact however they were unresponsive to verbal cues and therefore could not express their feelings concerning the exposure of the catheter bag.
On 03/28/24 at 1:58 PM, Certified Nursing Assistant (CNA) D was interviewed regarding residents who require catheter privacy and reported that they are instructed to put a privacy cover on catheter bags if the bag is not the type that is made with privacy coloring and to put the bag on the side of the bed that is not facing the doorway in order to prevent visibility from the hallway.
On 03/28/24 at 2:12 PM, the facility Director of Nursing (DON) reported the expectation is that a catheter bag should be covered by a privacy bag and should not be visible or exposed to the hallway or viewable by non-clinical individuals.
Review of the facility policy Promoting/Maintaining Resident Dignity dated 12/20 revealed the Policy statement It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. The Compliance Guidelines portion of the policy included the entry 12. Maintain resident privacy.
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 F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00143520.
Based on observation, interview, and record review, the facility failed to ensure t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00143520.
Based on observation, interview, and record review, the facility failed to ensure that the call light was within reach for one resident (R287) out of two reviewed for call lights. Findings Include:
On 3/26/2024 at 9:29 AM, R287 was observed laying in their bed. R287 stated that they were doing okay. R287 call light was noted to be behind them on their nightstand. R287 was asked to try and reach their call light. R287 stated that they were unable to reach their call light. R287 was asked if this happens often and R287 stated that it does.
On 3/26/2024 at 10:03 AM, 10:58 AM, and 1:58 AM, R287's call light was observed on the nightstand and still out of reach.
On 3/27/2024 at 8:47 AM and 9:14 AM, R287's call light was observed on the nightstand and still out of reach.
A review of the medical record revealed that R287 admitted into the facility on [DATE] with the following diagnoses, Metabolic Encephalopathy and Muscle Wasting and Atrophy. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R287 also required assistance with bed mobility and transfers.
On 3/28/2024 at 12:17 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that their expectation is that the call light is always within reach.
A review of a facility policy titled, Call Lights System noted the following, 1. Staff will have knowledge of the resident call system, including how the system works and ensuring resident access to call light.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00143093.
Based on interview and record, the facility failed to report an employee to residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00143093.
Based on interview and record, the facility failed to report an employee to resident incident of alleged abuse for one resident (R8) of seven residents reviewed for abuse. Findings include:
On 3/26/24 at 1:08 PM, during an initial tour of the facility R8 was interviewed about their satisfaction with the care and services that they were receiving at the facility. R8 indicated that Licensed Practical Nurse (LPN) T had twisted her arm. R8 was asked when this had occurred and R8 stated, One or two months ago. R8 was asked if they reported it to anyone at the facility saying, Yes I reported it to (previous Nursing Home Administrator (NHA). R8 stated, Thank you for looking into this.
R8's electronic medical record (EMR) was reviewed and revealed that R8 was originally admitted to the facility on [DATE] with diagnoses that included Multiple sclerosis (Autoimmune disease), Bipolar disorder, and Schizoaffective disorder. R8's most recent minimum data set assessment (MDS) dated [DATE] revealed that R8 had an intact cognition.
An incident/accident (I/A) report dated 1/11/2024 18:58 (6:58 PM), involving R8 and LPN T revealed the following, Allegation from (R8) that a staff member noted that (R8) was in a peer's room and grabbed their arm .No injuries observed.
On 3/27/24 at 12:45 PM, the Director of Nursing (DON) was interviewed regarding the incident involving R8 and LPN T on 1/11/24, and asked if the incident had been reported to the State Agency (SA). The DON indicated that they remembered completing an I/A related to the incident and nothing further than that.
On 3/27/24 at 12:54 PM, the NHA was interviewed regarding the incident involving R8 and LPN T and asked if the incident had been reported to the SA. The NHA indicated that they had only been the NHA for the past two weeks and had no knowledge of the incident involving R8 and LPN T.
A facility policy titled Abuse, Neglect, and Exploitation Date Reviewed/Revised: 6/23 was reviewed and stated the following: VII. Reporting and Response: 1. The facility will implement the following: 2. Reporting of all alleged violations to the .state agency .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to investigate and protect a resident after an allegation of abuse for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to investigate and protect a resident after an allegation of abuse for one resident (R8) of seven residents reviewed for abuse. Findings include:
On 3/26/24 at 1:08 PM, during a tour of the facility R8 was interviewed about their satisfaction with the care and services that they were receiving at the facility. R8 indicated that Licensed Practical Nurse (LPN) T had twisted her arm. R8 was asked when this had occurred and R8 stated, One or two months ago. R8 was asked if they reported it to anyone at the facility saying, Yes I reported it to (previous Nursing Home Administrator -NHA). R8 stated, Thank you for looking into this.
R8's electronic medical record (EMR) was reviewed and revealed that R8 was originally admitted to the facility on [DATE] with diagnoses that included Multiple sclerosis (Autoimmune disease), Bipolar disorder, and Schizoaffective disorder. R8's most recent minimum data set assessment (MDS) dated [DATE] revealed that R8 had an intact cognition.
An incident/accident (I/A) report dated 1/11/2024 18:58 (6:58 PM), involving R8 and LPN T revealed the following, Allegation from (R8) that a staff member noted that (R8) was in a peer's room and grabbed their arm .No injuries observed.
On 3/27/24 at 12:45 PM, the Director of Nursing (DON) was interviewed regarding the incident involving R8 and LPN T on 1/11/24, and asked if the incident had been reported to the State Agency (SA). The DON indicated that they remembered completing an I/A related to the incident and nothing further than that.
On 3/27/24 at 12:54 PM, the NHA was interviewed regarding the incident involving R8 and LPN T and asked if the incident had been reported to the SA. The NHA indicated that they had only been the NHA for the past two weeks and had no knowledge of the incident involving R8 and LPN T.
On 3/28/24 at 2:48 PM, LPN T was interviewed regarding the incident which occurred between themselves and R8 on 1/11/24. LPN T stated, (R8) was in another resident's room and it was reported to me by Certified Nursing Assistant (CNA) U. I went down to where R8 was and observed them going through another resident's personal belongings. I explained to (R8) that they couldn't go through another resident's belongings and that they needed to leave the resident's room. (R8) refused to leave the room and then took a (personal item) out of the room and came out into the hall, yelling and screaming. (R8) went up to the NHA's office and reported that I had twisted their arm. I never twisted (R8's) arm. The police were contacted and arrived, talked to (R8) and left. LPN T was asked if they were sent home following the incident and/or suspended during an investigation of the incident and stated, No, I was assigned to work on another unit of the facility. I don't work on (R8's) unit anymore.
A facility policy titled Abuse, Neglect, and Exploitation Date Reviewed/Revised: 6/23 was reviewed and stated the following: V. Investigation A. An immediate investigation is warranted when suspicion of abuse .or reports of abuse occur. B. Investigations may include but are not limited to: 1. Identifying staff responsible for the investigation. i. The facility Administrator is the Abuse Coordinator of the facility. b. Providing complete and thorough documentation of the investigation.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
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 an update for a preadmission screening (PAS) 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 ensure an update for a preadmission screening (PAS) and resident review (ARR) /Hospital Exempted Discharge for a Level II evaluation was completed for three residents (R12, R65 and R121) of four residents reviewed for PASARR, resulting in the potential for unmet mental health services. Findings include:
R12
On 3/26/24 at 9:50 AM, R12 was observed sitting in room watching television. R12 appeared very anxious about not going back home and staying at facility.
On 3/27/24 at 1:00 PM, R12 was observed going to dining room and speaking with other residents.
A review of R12's medical record revealed the last 3877 was completed on12/20/22 and last level II 2/23/23.
A review of the medical record revealed that R12 admitted into the facility on 5/02/19 with the following diagnoses of Major Depressive disorder, Psychosis, Schizophrenia and Adjustment Disorder. A review of the most recent Minimum Data Set assessment dated [DATE] was completed with a Brief Interview for Mental Status (BIMS) score of 12 indicating mildly impaired cognition.
R65
On 3/26/24 at 1:15 PM, R65 was observed walking to his room with assistance from staff. R65 is nonverbal and has a history of wandering.
An observation made on 3/26/24 at 4:00 PM of R65 lying in bed asleep, television was playing loudly.
On 3/27/24 at 9:00 AM R65 was observed being redirected to room after breakfast by staff.
A review of R65's medical record revealed no current 3877 and 3878 from admission.
A review of the medical record revealed that R65 admitted into the facility on 7/14/23 with the following diagnoses of Severe Dementia. A review of the most recent Minimum Data Set assessment dated [DATE] was completed with a Brief Interview for Mental Status (BIMS) score of 99 indicating severely impaired cognition.
R121
On 3/26/24 at 9:20 AM Resident 121 (R121) was observed sitting in room watching television. R121 was awaiting assistance to be changed.
On 3/27/24 at 2:45 PM R121 was observed sitting in chair outside of room looking at staff and residents as they passed by. R121 would speak to familiar staff and residents.
A review of the medical record revealed that R121 admitted into the facility on 7/14/23 with the following diagnoses of Dementia, Psychosis, and Major Depressive Disorder. A review of the most recent Minimum Data Set assessment dated [DATE] was completed with a Brief Interview for Mental Status (BIMS) score of 9 indicating an impaired cognition.
A review of R121's medical record revealed that R121 did not have a proper 3878 completed.
On 03/28/24 at 3:32 PM, an interview with the Social Worker (SW) occurred. The SW was asked about the missing 3877s and 3878s. After not being able to located them, she stated, I do not do the 3877's or 3878's due to licensure. However it is my expectation that the 3877s' and 78's are completed timely and accurately by the MDS nurse.
A review of the facility policy Resident Assessment Coordination with PASARR Program revealed this facility coordiantes assessments with the preadmission screening and resident review (PASARR) program under medicaid to ensure that individuals with a mental disorder, intellectual disability , or a related condition recieves care and services in the mostintegrated stting appropriate to their needs.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for one (R103) of f...
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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 a comprehensive care plan for one (R103) of four residents reviewed for care plans. Findings include:
R103
Review of the facility record for R103 revealed an admission date of 12/11/21 with diagnoses that included Dementia, Pulmonary Edema/Hypertension, and Kidney Failure. The Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 9/15 indicating moderate cognitive impairment.
On 03/28/24 at 3:20 PM, during review of R103's facility record pertaining to their catheter care, it was noted that no care plan was identified that addressed R103's catheter as well as no physician order pertaining to the catheter or related care.
On 03/28/24 at 3:41 PM, the facility Director of Nursing (DON) reviewed R103's electronic medical record and acknowledged that there was no care plan or physician order pertaining to R103's catheter. The DON reported the expectation is that any resident with a catheter should have a care plan addressing catheter care and that a physician order should have been entered by the admitting nurse when R103 most recently returned from the hospital with the catheter.
Review of the facility policy Care Planning dated 6/23 revealed the Policy statement The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. The Policy Explanation and Compliance Guidelines portion includes the entries 1. The baseline care plan will: b. Include the minimum healthcare information necessary to properly care for a resident . and 2. The admitting nurse shall gather information from the admission physical assessment, hospital transfer information, physician orders, . Once gathered, initial goals shall be established . [care plan] Interventions shall be established that address the resident's current needs .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00143520.
Based on observation, interview, and record review, the facility failed to update t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00143520.
Based on observation, interview, and record review, the facility failed to update the fall care plan following a fall for one resident (R15) of two residents reviewed for care plans. Findings include:
On 3/26/2024 at 9:29 AM, R287 was observed laying in bed. R287 stated that they had a fall not too long ago and had gone to the hospital. R287 stated that they did not remember how they fell, they just remember being dizzy.
A review of the medical record revealed that R287 admitted into the facility on [DATE] with the following diagnoses, Metabolic Encephalopathy and Muscle Wasting and Atrophy. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R287 also required assistance with bed mobility and transfers.
A review of the Incident and Accident (I/A) report dated for 3/16/2024 noted the following, Nursing Description: Pt. (Patient) found on floor beside bed. C/O (complained of) hitting head and notable bruise noted on right arm. Resident Description: I fell and hit my head and I'm dizzy.
A review of the progress notes revealed the following, Date: 3/16/2024 at 20:15 (8:15 PM) .Resident was found laying on the floor beside her bed. Resident stated that [R287 hit their head and feels dizzy no c/o pain noted .bruise noted to right upper inner arm, no other injuries noted. Pt. alert with hallucinations noted. (Physician) and DON (Director of Nursing) notified. Order given to send pt. to hospital.
A review of the care plan revealed that the last updated intervention was dated 11/29/2022.
R15
On 3/26/2024 at 9:27 AM, R15 was observed laying in bed. Their bed was not noted to be in the lowest position. R15 was in bed screaming that they were hungry.
A review of the medical record revealed that R15 admitted into the facility on 7/1/2023 with the following diagnoses, Senile degeneration of Brain and History of falling. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score 0, indicating an impaired cognition. R15 also required assistance with bed mobility and transfers.
A review of an Incident and Accident (I/A) report dated 3/26/2024 noted the following, Nursing Description: Writer summoned to residents room via call for help, upon entering, writer observed resident on floor Resident Description: When asked what happened, resident stated I fell cause I was trying to get the covers off. Its too hot.
A review of a progress note dated 3/26/2024 noted the following, [At] approx (Approximately) 1:40 AM, writer summoned to residents' room via call for help. Upon entering, writer observed resident on floor lying face upward between bed and bedside table. When asked what happened, resident stated, I fell because I was trying to get the covers off. It's too hot in here .
A review of the care plan revealed that the last updated intervention was dated 2/26/2024.
On 3/28/2024 at 12:20PM, an interview was conducted with the Director of Nursing (DON). The DON stated that there should be immediate interventions on the I/A and the care plan updated.
No further information was provided prior to the end of survey.
A review of a facility policy titled, Fall Reduction Policy noted the following, .f. Implement (or revise) new fall prevention intervention (s).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice Statement #2.
Based on interview and record review, the facility failed to complete blood sugar and blood pre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice Statement #2.
Based on interview and record review, the facility failed to complete blood sugar and blood pressure monitoring as well as, notify the physician of change in condition for one resident (R13) of two residents reviewed for care needs. Findings include:
A review of R13's medical record revealed they were admitted into the facility on 7/14/2023 with the following relevant diagnoses: Diabetes Mellitus, Atrial Fibrillation (rapid heart rate), Heart Failure, Hyperglycemia (high blood sugar). Further review of the medical record revealed that the resident had an intact cognition.
On 3/27/2024 at 2:53 PM, an interview was conducted with R13 that indicated their blood sugar was taken, 3/25/2024. R13 revealed it was over 200 (The normal range for blood sugar is 60 to 100) and insulin was administered, another blood sugar was not taken following the administration of insulin. R13 further revealed that their blood sugar is not taken regularly. R13 expressed frustration and stated, The staff do not care.
A review of the electronic medical record (EMR) revealed a single blood sugar reading on 3/25/2024 at 1:59 PM of 594 in the vitals section of the EMR. R13 was treated with Lantus (long-acting insulin) at 10:00 AM on 3/26/2024.
A review of the EMR revealed that there were two orders for blood sugar testing. One order was written on 3/3/2024 stated, acc check BID (twice daily) and another on 3/25/2024 stated, acc check ac (before meals and hs-at bedtime).
Further review of the EMR revealed physician progress notes for 8/21/23, 9/7/23, and 9/22/23 that indicated R13 has a history of hypoglycemia (low blood sugar) and to monitor accu checks (blood sugar testing). Further review of the physician progress notes dated 1/8/2024, 1/11/2024, indicated to continue accu checks. The EMR further revealed that an order for blood sugar testing was not written for any of those dates.
On 3/27/2024 at 2:30 PM, Nurse E was interviewed and queried why the blood sugars were not completed for R13. Nurse E revealed that the blood sugar tab did not pop-up on her screen indicating that there was an order to be followed. Further review with Nurse E revealed that the two orders for blood sugar testing did not have a start date.
On 3/28/2024 at 4:00 PM, an interview was conducted with the Director of Nursing (DON) regarding the expectation for monitoring a diabetic resident. The DON indicated that their expectation is that when a resident is diabetic, regular blood sugar monitoring should occur.
Review of the EMR revealed that R13 had nine abnormal blood pressures between 2/23/2024 and 3/27/2024 with systolic (upper number) ranges from 162 to 182 and diastolic (lower number) from 79 to 111. A review of the medical record did not reveal any documentation of notification to the physician regarding the elevated blood pressures.
On 2/27/2024 at 3:00 PM, Physician S approached writer and stated, The resident frequently refuses medication, blood pressure monitoring and blood sugar testing. Physician S indicated that the R13's most recent A1C (Hemoglobin A1C, blood sugar averages over a 3 month period), was 14.1 (normal range is under 6.0). There was no documentation to verify the 14.1 value in the EMR. The most recent A1C in the EMR was dated August, 2023.
A review of the EMR failed to reveal refusal of blood pressure monitoring prior to medication administration for January 2024, or February 2024, or March 2024. The EMR indicated blank spaces where the medication was not administered for the 10:00 PM dose on 3/12, 3/14, 3/19, and 3/27/24 without notation of refusals. There was no other documentation of medication refusal for January, February or March 2024.
On 3/28/2024 at 4:00 PM, an interview was conducted with the Director of Nursing (DON). When queried regarding their expectation regarding contacting the physician about reporting of abnormal blood pressures, the DON indicated that abnormal blood pressures should be reported to the physician and documented at the time of the occurrence.
The blood sugar policy was requested on 3/27/2024 at 2:25 PM. The policy was not received by survey exit.
A review of the Change in Condition policy stated, A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications.) .B. The facility will inform the resident, consult with the resident's provider, and notify consistent with his or her authority, the resident respresentative(s) when there is .
This citation pertains to Intake MI00143520.
This citation has two deficient practice statements.
Deficient Practice Statement #1.
Based on interview and record review, the facility failed to implement pre-surgery orders for one resident (R287) out of one reviewed for care and services, resulting in the R287 missing their surgery. Findings include:
A review of Intake Called inot the State Agency noted the following, .(R287) is scheduled to have surgery on Tuesday 3/26/2024 and the (surgery) facility has been trying to contact (nursing home) to provide instructions on when to stop medications and confirm transportation and has not been able to make contact.
A review of the medical record revealed that R287 admitted into the facility on [DATE] with the following diagnoses, Metabolic Encephalopathy and Muscle Wasting and Atrophy. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R287 also required assistance with bed mobility and transfers.
Further review of the medical records revealed a set of surgery instructions dated 3/21/2024 that stated R287 had to be NPO (nothing by mouth) after 10 PM on 3/25/2024.
On 3/28/2024 at 8:49 AM, an interview was conducted with Unit Clerk (UC) L. UC L stated that R287 was supposed to be NPO, and they were not, so they had to cancel the surgery. UC L stated that it is not currently rescheduled, and they were waiting for the doctor's office to give a new date for R287's surgery.
A request for a policy addressing outside surgeries was requested on 3/28/2024 at 9:26 AM and not received prior to the end of survey.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0729
(Tag F0729)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to document Nurse Aide Registry Verification for three Certified Nursing Assistants (CNA's J, I, F) of three CNAs reviewed for verification of...
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Based on interview and record review, the facility failed to document Nurse Aide Registry Verification for three Certified Nursing Assistants (CNA's J, I, F) of three CNAs reviewed for verification of ability to provide resident assistance. Findings include:
On 3/28/2024 at 1:40 PM, the survey team was provided with the personnel files of three certified nursing assistants CNAs J, I, and F. Review of the files failed to reveal Nurse Aide Registry Verifications for all three CNAs.
On 3/28/2024 at 5:00 PM, an interview with the Director of Nursing (DON) revealed that no other records were available at the time of the interview. When queried regarding the expectation for file documentation, the DON indicated that the file should be complete including the Nurse Aide Registry Verification. No further records were provided by the facility at the time of exit.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to label and date when opened eye medication for two residents (R71 and R98) in two of four medication carts. Findings include:
On 3/27/2024 at ...
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Based on observation and interview, the facility failed to label and date when opened eye medication for two residents (R71 and R98) in two of four medication carts. Findings include:
On 3/27/2024 at 1:30 PM, the medication cart located on the 200 Hall revealed two eye medications that were opened and not dated for R98. Two additional eye medications were opened and not labeled for another unknown resident.
On 3/27/2024 at 1:40 PM, the second medication cart, located on the 200 Hall revealed two eye medications for R71 without an open date and three eye medications that expired on the following dates, 1/4/2024, 1/25/2024, and 2/4/2024.
On 3/28/24 at 2:00 PM an interview with the Director of Nursing (DON) revealed that expired medications should not be in the medication cart and that all medications for multi-use should have an open date and labeled with resident identification.
On 3/27/24 at 10:40 AM, the facility policy for the labeling and storage of medication was requested from the facility however, it was not received by the end of survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Deficiency Practice Statement #2.
Based on observation, interview, and record review, the facility failed to maintain infection control practices of multi-use equipment between resident use for three ...
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Deficiency Practice Statement #2.
Based on observation, interview, and record review, the facility failed to maintain infection control practices of multi-use equipment between resident use for three residents (R90, R78 and R17) of three residents observed for infection control practices. Findings include:
On 3/27/2024 at 9:32 AM, Nurse F was observed using the blood pressure cuff on R90 and R78 without cleaning equipment between and after use. When Nurse F was queried regarding cleaning devices between residents and they indicated that equipment should be cleaned between residents. A search by Nurse F of the medication cart for the germicidal wipes revealed that no germicidal wipes were in the cart.
On 3/27/2024 at 10:42 AM, Nurse E was observed to using a blood pressure cuff on R17. After leaving the room, Nurse E failed to clean the device. When Nurse E was queried about cleaning the device, they stated that they use an alcohol wipe to clean the screen between residents. When queried about cleaning the cuff portion, Nurse E was unable to answer.
On 3/28/2024 at 4:00 PM, the Director of Nursing (DON), when queried regarding how and when cleaning of multi-resident equipment is to occur, the DON indicated that multi-use equipment for resident use should be cleaned between residents.
The policy for cleaning multi-use equipment was requested on 3/27/2024 at 11:00 AM and again at 4:00 PM. The policy titled Cleaning and Disinfecting Portable IT Equipment was provided after each request. At the time of exit on 3/28/2024 the correct policy had not been provided.
This citation has two deficient practice statements.
Deficient Practice Statement #1.
Based on observation, interview, and record review, the facility failed to date and label a tube feeding bottle for one resident (R130) out of one reviewed for tube feeding. Findings Include:
On 3/26/2024 at 9:15 AM, R130 was observed in the bed. It was noted that they had their tube feeding connected and running. The tube feeding bottle and water were noted to not have a label or date.
On 3/26/2024 at 9:19 AM, Licensed Practical Nurse (LPN) E was shown the tube feeding bottle and water. LPN E was queried as to when the bottle was hung. LPN E stated that they were unable to know for sure, but it goes up on the evening shift at 6:00 PM and comes down at 1260CC. LPN E was observed dating the bottle and the water.
On 3/28/2024 at 12:00 PM, an interview was conducted with the Director of Nursing (DON). The DON was interviewed regarding the tube feeding not being labeled and dated. The DON stated that the bottle should be labeled and that when it was not, a new bottle should have been put up.
Further review of a facility policy titled, Care and Treatment of Feeding Tubes noted the following, .a. Date bottle/bag of enteral formula.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
This citation pertains to Intake MI00143093.
Based on observation, interview, and record review the facility failed to ensure that towels and wash clothes were available for seven confidential group r...
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This citation pertains to Intake MI00143093.
Based on observation, interview, and record review the facility failed to ensure that towels and wash clothes were available for seven confidential group residents of seven residents reviewed for homelike environment, resulting in resident dissatisfaction. Findings include:
On 3/27/24 at 10:00 AM, a confidential group meeting was held with seven confidential group residents and the group was asked about their overall level of satisfaction with the care and services at the facility. All seven group members expressed dissatisfaction with the amount of towels and wash clothes they were provided. The group indicated that the facility runs out of towels and wash clothes on the units approximately, Two times a week.
On 3/28/24 at 1:28 PM, An observation of the 100 unit linen closet revealed no towels or wash clothes observed in the closet.
On 3/28/24 at 1:30 PM, An observation of the 200 unit linen closet revealed no towels or wash clothes observed in the closet.
On 3/28/24 at 1:32 PM, an interview was conducted with 200 unit Certified Nursing Assistant (CNA) A regarding the available of towels and wash clothes on the unit. CNA A stated, There are not enough.
On 3/28/24 at 1:35 PM, An observation of the 300 unit linen closet revealed no towels or wash clothes observed in the closet.
On 3/28/24 at 1:37 PM, an interview was conducted with 300 unit Licensed Practical Nurse (LPN) B regarding the available of towels and wash clothes on the unit. LPN B stated, Towels and wash clothes are thrown away by staff after use instead of being rinsed off and/or washed.
On 3/28/24 at 1:40 PM, Environmental Services Director (ESD) C was interviewed regarding the lack of towels and wash clothes on the units. ESD C showed the surveyor the location of towels and wash clothes located in the main laundry room. ESD C stated, Staff are welcome to come to the laundry room and get towels and wash clothes as needed.
On 3/28/24 at 2:00 PM, the Administrator (NHA) was interviewed regarding their expectations for towels and wash clothes being available for residents. The NHA stated, To have enough linen for each resident on each shift in a timely manner.
On 3/28/24 at 2:30 PM, a facility policy titled, Handling Clean Linens Date Reviewed/Revised: 1/24 was reviewed and stated the following, Definitions: Linen includes .towels, washcloths .5a. Clean linen shall be delivered to resident care units .c. A separate room, closet, or other designated space will be used to store clean linen.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes MI00142583 and MI00142441.
Based on interview and record review, the facility failed to protec...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes MI00142583 and MI00142441.
Based on interview and record review, the facility failed to protect resident funds for seven residents (R8, R15, R34, R75, R84, R92, and R108) of seven residents reviewed for misappropriation of funds. Findings include:
In a complaint, as well as, a facility reported incident (FRI) reported to the State Agency indicated; An audit of the facility's trust fund accounts revealed missing funds.
R84
On 03/27/24 at 8:55 AM, R84 was interviewed in their room regarding the alleged misappropriation of funds that was noted in their complaint to the State agency. R84 stated Usually I get my social security check to sign around the second or third day of the month and when it got to be about the 10th of the month (January 2024) and I hadn't seen it. I asked the Business Office Manager (BOM) M (who was covering at the time for BOM N) about my check. (BOM M) came back to me and said they had called Social Security and they were waiting to hear back. I didn't hear anything so I called (former facility administrator) staff R and left them a message but I didn't hear back from them. I called Social Security. The Social Security office told me to call the fraud hotline so I did that. After that I called the State (State Agency) because staff R never came to speak to me so I did not know if they (the facility staff) had reported it to the State Agency. I thought they weren't doing anything.
R84 reported that they did refuse to speak with (local law enforcement) stating I don't trust them. R84 reported that a day or two after speaking with BOM M, staff R came to their room and offered to reimburse them for the missing check with cash. R84 reported that they refused the cash as they had been told by Social Security staff and BOM M that a replacement check was being issued. R84 reported that staff R had stated to them that they could accept the cash and then if a replacement check arrived it could be returned, but indicated that they didn't trust that this was the proper process.
Review of the facility record for R84 revealed an admission date of 05/13/20 with diagnoses that included Atherosclerotic Heart Disease, Rheumatoid Arthritis and Chronic Obstructive Pulmonary Disease. The Brief Interview for Mental Status (BIMS) assessment dated [DATE] was scored 15/15 indicating intact cognition.
Review of the facility investigation completed by Regional BOM (RBOM) O documented the following summary:
- Audits of all facility residents funds revealed missing funds from the 12/23/23 and 1/24/24 checks for one resident (R84) and from the 1/24/24 checks from six additional residents (R8, R15, R34, R75, R92, and R108).
- Audit pertaining to R84's account indicated $638.00 was missing while the combined amount confirmed missing amount of money for all seven residents was $6,067.00.
- Former BOM N ultimately confessed to the misappropriation of the resident funds and, following an initial suspension, was terminated.
On 03/27/24 at 4:37 PM, RBOM O was interviewed via phone call. RBOM O verified that former BOM N had been terminated after admitting that they had been misappropriating resident funds and the matter had been referred to the Attorney General's office.
On 03/28/24 at 2:40 PM, former BOM N was interviewed via phone call and reported that the misappropriation of funds did take place by their own actions.
On 03/28/24 at 4:27 PM, the Nursing Home Administrator (NHA) reported that the expectation regarding management of resident checks/funds is that they never be misappropriated away from the appropriate recipient or destination.
R34
On 3/26/24 at 9:45 AM, R34 was interviewed about any concerns/issues involving their money/funds at the facility. R34 was unable to respond to any questions.
A review of R34's electronic medical record (EMR) revealed that R34 was originally admitted to the facility on [DATE] with diagnoses that included Schizoaffective disorder, Bipolar type and Type 2 diabetes. R34's most recent minimum data set assessment (MDS) dated [DATE] revealed that R34 had a severely impaired cognition.
R75
On 3/26/24 at 9:58 AM, R75 was interviewed about any concerns/issues involving their money/funds at the facility. R75 was unable to respond to any questions.
A review of R75's electronic medical record (EMR) revealed that R75 was originally admitted to the facility on [DATE] with diagnoses that included Muscle weakness and Chronic obstructive pulmonary disease (COPD) (Lung disease). R75's most recent MDS dated [DATE] revealed that R75 had a severely impaired cognition.
R92
On 3/26/24 at 10:27 AM, R92 was interviewed about any concerns/issues involving their money/funds at the facility. R92 was unable to respond to any questions.
A review of R92's electronic medical record (EMR) revealed that R92 was originally admitted to the facility on [DATE] with diagnoses that included Dementia and Psychotic disorder. R75's most recent MDS dated [DATE] revealed that R92 had a severely impaired cognition.
R108
On 3/26/24 at 10:45 AM, R108 was interviewed about any concerns/issues involving their money/funds at the facility. R108 indicated that they had No concerns regarding their money.
A review of R108's electronic medical record (EMR) revealed that R108 was originally admitted to the facility on [DATE] with diagnoses that included Cerebral Ischemia (Impaired blood flow to the brain) and Alcohol use, with intoxication. R75's most recent MDS dated [DATE] revealed that R108 had an Intact cognition.
R15
On 3/26/24 at 11:45 AM, R15 was interviewed about any concerns/issues involving their money/funds related to the facility. R15 was unable to answer any questions.
A review of R15's EMR revealed that R15 was originally admitted to the facility on [DATE] with diagnoses that included Bipolar disorder and Adult failure to thrive. R15's most recent MDS dated [DATE] revealed that R15 had a Severely impaired cognition.
R8
On 3/26/24 at 1:08 PM, R8 was interviewed about any concerns/issues involving their money/funds related to the facility. R8 stated, I've never had any problems with my money.
A review of R8's EMR revealed that R8 was originally admitted to the facility on [DATE] with diagnoses that included Multiple sclerosis (Autoimmune disease), Bipolar disorder, and Schizoaffective disorder. R8's most recent minimum data set assessment (MDS) dated [DATE] revealed that R8 had an intact cognition.
Review of the facility policy Resident Trust Funds dated 1/21 revealed the Policy statement entry The facility will establish and maintain a system that assures a separate and complete accounting of resident's personal funds entrusted to the facility. The Policy Explanation and Guidelines portion includes the entry 2. A resident trust fund is a method of accounting for the resident's personal finances entrusted to the facility that meets State and Federal standards.
Review of the facility policy Abuse, Neglect and Exploitation dated 6/23 revealed the Policy statement It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The Definitions portion of the policy includes the entry Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent, use of a resident's belongings or money without the resident's consent.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0807
(Tag F0807)
Could have caused harm · This affected multiple residents
R84
On 03/26/24 at 10:52 AM, R84's water was observed to be undated. When asked about the water R84 reported that it is often difficult to get ice water because there is only one functioning ice machi...
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R84
On 03/26/24 at 10:52 AM, R84's water was observed to be undated. When asked about the water R84 reported that it is often difficult to get ice water because there is only one functioning ice machine in the facility.
On 03/27/24 at 9:14 AM, R84 reported that they didn't receive ice water for the previous afternoon until 1:00 AM and that no ice water had been provided since that time. The water cup that was observed on the bedside table was room temperature and undated.
On 03/27/24 at 10:24 AM, Licensed Practical Nurse (LPN) X reported that the ice machine in the dining room was the only working ice machine. LPN X verified that the broken ice machine near the entrance to the 300 hallway is the only other ice machine in the building and that it has been broken for approximately six months. LPN X and LPN E reported that this situation resulted in situations when ice is not available and LPN E reported that ice machine takes about 15 minutes to refill once it is empty.
On 03/27/24 at 10:38 AM, Certified Nurse Assistant (CNA) Y was observed attempting to fill multiple cups with ice/water at the dining room ice machine. CNA Y reported that the ice machine does run out and there are times when they are not able to get the ice they need to complete a thorough resident water pass.
ON 03/27/24 at 10:46 AM, facility Dietary Manager Z (DM) reported that there is not an ice machine inside the kitchen and that there are times when the kitchen requires ice and they use the machine in the dining room that everyone else uses. DM Z reported that there are times that they cannot get enough ice and that the ice machine takes about 20-30 minutes to refill.
On 03/27/24 at 11:00 AM, CNA A reported that the ice machine does run out and that the staff are often not able to complete a thorough water (with ice) pass and that they were not able to do so that morning.
On 03/27/24 at 12:42 PM, the Environmental Services Director (ESD) C reported that the primary ice machine has been broken for approximately six months. ESD C reported that a quote was obtained to repair the machine and was submitted to corporate management and they had not received a response yet.
On 03/28/24 at 11:01 AM, R89 reported there are consistently times when the staff tell them there is no ice especially during the day and afternoon shift when things are busier and they get room temperature water.
On 03/28/24 at 11:05 AM, the facility Administrator (NHA) was interviewed regarding the report that a quote for a new ice machine had been submitted to the corporation. The NHA reported that the corporation and the facility have not yet been able to agree upon which ice machine to order due to cost concerns and therefore they continue to negotiate regarding the final choice of a model to order. The NHA was asked if there is a plan in place to temporarily improve the ice supply for the residents and they stated there was not. The NHA reported that the expectation is that ice/ice water should be available whenever residents need it.
Review of the facility policy Hydration dated 01/21 revealed the Policy statement The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health.
Based on observation, interview, and record review, the facility failed to pass and date water for five residents (R7, R11, R16, R84, and R287) of five residents reviewed for hydration. Findings Include:
R7
On 3/26/2024 at 2:09 PM, R7 was observed in bed. No water was observed at the bedside.
R11
On 3/26/2024 at 11:40 AM, R11 was observed sitting in their room. R11 had no ice or ice water. R11 stated that they never get ice for their pop they have in the room. R11 stated that there is only one ice machine for the whole building and its runs out of ice often. R11 stated that this has been going on for about six months.
R16
On 3/26/2024 at 2:02 PM, R16 was observed in the bed. R16 stated that they wanted some ice water. R16 activated their light and told their certified nursing assistant (CNA) that they wanted some water. CNA Q stated that they were waiting for a meeting to conclude in the dining room where the ice machine was and then they could get them some ice water. CNA Q stated that there was only one working ice machine and that if often runs out of ice.
R287
On 3/26/2024 at 1:59 PM, R287 was observed laying in bed. R287 stated that the water that they had was not new and they could not remember when they had it. R287 was observed with a water cup on their bedside table that was not dated.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
This citation pertains to Intake MI00142424.
Based on interview and record review, the facility failed to maintain complete and accurate medical record for six residents (R237, R54, R90, R107, R108, a...
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This citation pertains to Intake MI00142424.
Based on interview and record review, the facility failed to maintain complete and accurate medical record for six residents (R237, R54, R90, R107, R108, and R37) of seven records reviewed for complete medical records. Findings include:
R237
Review of the March 2024 Medication Administrated Record (MAR) revealed, Nurse H on December 23, 2023, day shift, documented giving R237, 13 medications while the resident was on a Leave of Absence (LOA) from the facility. Review of the medical record progress notes for R237 dated 12/23/2023 at 2:36 AM revealed, Resident on LOA with daughter until 12/24/2023. A subsequent note dated 12/24/2023 at 8:07 PM revealed Received resident back into facility.
On 3/26/2024 at 11:00 AM and again at 3:00 PM it was noted that the shower room was filled with equipment near front and door to the room. Upon reviewing the medical record, showers were not documented for seven (R237, R54, R90, R107, R108, R69, and R37) of seven residents for at least 14 days.
On 3/28/2024 at 12:00 AM, the shower sheets were requested. Seven paper shower sheets dated 3/27/2024 documented showers were given to R54 and R90 that morning. A review of the facility record no shower documentation from 3/12/2024 to 3/26/2024.
R54
On 3/28/2024 at 12:45 PM an interview was attempted with R54, they were out of their room on several attempts.
Review of the record for R54 revealed, that the MDS (Minimum Data Set) assessment by Social Work determined the resident had a BIMS (Brief Interview for Mental Status) of 13 (moderately impaired cognition).
R108
Review of the record for R108 revealed no shower documentation from 3/12/2024 to 3/26/2024.
On 3/28/2024 at 1:34 PM an interview with R108 revealed that they had received a shower on 3/26/2024. Review of the facility record for R108 revealed, that the MDS assessment by Social Work determined the resident had a BIMS of 15 (intact cognition).
R107
On 3/28/2024 at 1:38 PM, the shower sheet for R107 revealed that resident receives a shower QD (daily). In an interview with R107 they said they do not get a bed bath or shower and that they are not asked. A review of the record for R107 revealed no shower documentation for 14 days. A review of the facility record for R107 revealed, that the MDS assessment by Social Work determined the resident had a BIMS of 14 (cognitively intact).
R37
On 3/28/2024 at 1:40 PM an interview with R37 revealed that they only receive bed bath and would prefer a shower. A review of the record for R37 revealed no shower documentation from 3/12/2024 to 3/26/2024. A review of the facility record for R37 revealed, that the MDS assessment by Social Work determined the resident had a BIMS of 14 (cognitvely intact).
On 3/28/2024 at 2:00 PM, an interview with the Director of Nursing (DON) was not aware that medication had been documented as given.
When the DON was queried about shower documentation, she indicated that it was to be documented in the twice weekly Skin Sweep Assessment by the nurse who would be given the shower sheets by each Certified Nursing Assistant (CNA) after the task was completed.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
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 document the education regarding benefits and offering of immunizat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document the education regarding benefits and offering of immunizations (influenza vaccine) for four residents (R287, R91, R84 and R5) of five sampled residents reviewed for immunizations. Findings Include:
R287
Review of the medical record revealed that R287 admitted into the facility on [DATE].
During the Infection Control task, the consent or declination related to the influenza vaccine was requested.
The facility staff provided a declination dated for 9/22/2022.
No further information was provided related to the current influenza season.
R91
Review of the medical record revealed that 91 admitted into the facility on [DATE].
During the Infection Control task, the consent or declination related to the influenza vaccine was requested.
Provided was a consent dated 9/21/2022.
No further information was provided related to the current influenza season.
R84
Review of the medical record revealed that R84 admitted into the facility on 5/13/2020.
During the Infection Control task, the consent or declination related to the influenza vaccine was requested.
Provided was a declination dated for 9/22/2022.
No further information was provided related to the current influenza season.
R5
Review of the medical record revealed that R5 admitted into the facility on 8/24/2022.
During the Infection Control task, the consent or declination related to the influenza vaccine was requested.
Provided was a declination dated for 9/15/2022.
No further information was provided related to the current influenza season.
On 3/28/2024 at 3:58 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that they were looking for the book with the recent consents and declinations. The DON stated that they were only able to find the old ones at this point. The DON stated that the were continuing to look for them.
No further information was provided by the end of survey.
A review of a facility policy titled, Infection Prevention and Control Program noted the following, a. Residents will be offered the influenza vaccine each year between October 1 and March 31, unless contraindicated or received the vaccine elsewhere during that time .e. Documentation will reflect the education provided and details regarding whether or not the resident received the immunizations.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
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 offer or document the COVID-19 vaccination to three residents (R287...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer or document the COVID-19 vaccination to three residents (R287, R91, and R84) out of five reviewed for immunizations and one employee (Licensed Practical Nurse-LPN E) of five employees reviewed for COVID vaccines. Findings include:
R287
Review of the medical record revealed that R287 admitted into the facility on [DATE].
During the Infection Control task, the consent or declination related to the COVID-19 vaccine was requested.
Provided was a form with the following question, .3. Do you want to receive the COVID-19 Vaccine or Booster (Available per CDC (Center for Disease Control) Guidelines)? Yes or No The area was blank with no response recorded.
No further information was provided related to the Covid-19 vaccine.
R91
Review of the medical record revealed that 91 admitted into the facility on [DATE].
During the Infection Control task, the consent or declination related to the COVID-19 vaccine was requested.
Provided was a form with the following question, .3. Do you want to receive the COVID-19 Vaccine or Booster (Available per CDC (Center for Disease Control) Guidelines)? Yes or No The area was blank with no response recorded.
No further information was provided related to the Covid-19 vaccine.
R84
Review of the medical record revealed that R84 admitted into the facility on 5/13/2020.
During the Infection Control task, the consent or declination related to the COVID-19 vaccine was requested.
Provided was a form with the following question, .3. Do you want to receive the COVID-19 Vaccine or Booster (Available per CDC (Center for Disease Control) Guidelines)? Yes or No The area was blank with no response recorded.
No further information was provided related to the Covid-19 vaccine.
On 3/28/2024, during the Infection Control Task, a request was made for LPN E Covid-19 vaccination card, consent, or declination.
On 3/28/2024 at 3:58 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that they were looking for the book with the recent consents and declinations. The DON stated that they were only able to find the old ones at this point. The DON stated that the were continuing to look for them.
No further information was provided related to the Covid-19 vaccination prior to the end of survey.
A review of a facility policy titled, Infection Prevention and Control Program noted the following , Documentation will reflect that education was provided and details regarding whether or not the resident or staff received the vaccine.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to develop and maintain a QAPI ( Quality Assurance and Process Improvement) program, resulting in the lack of the facility's ability to identi...
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Based on interview and record review, the facility failed to develop and maintain a QAPI ( Quality Assurance and Process Improvement) program, resulting in the lack of the facility's ability to identify areas needing improvement and enacting a process for correction of those issues, potentially affecting all 136 residents' quality of life.
Findings include:
During an interview on 03/28/24 at 12:07 PM with the Nursing Home Administrator (NHA), a request was made to review the facility's QAPI Program Plan for the past 6 months. The NHA stated, I have not been able to locate QAPI notes nor information since the last QAPI meeting on 9/25/23. I have only been administrator for two weeks at this facility.
Review of the policy titled QAPI Data Colllection Systems revise date 3/24 revealed: It is the policy of this facility to systematically collect data as part of the Quality Assurance Performance Improvement (QAPI) program to ensure the care and services it delivers meet acceptable standards of quality in accordance with recognized standards of practice.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to implement an effective Quality Assurance and Performance Program that identified, developed, and implemented appropriate plans of action to...
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Based on interview and record review, the facility failed to implement an effective Quality Assurance and Performance Program that identified, developed, and implemented appropriate plans of action to correct quality deficiencies, which has the potential to affect all 136 residents in the facility.
On 3/28/24 at 12:07 PM a meeting was held with the Nursing Home Administrator. When asked about identified plans, concerns or brought to QAPI. The NHA revealed that he was a recent hire two weeks ago and the last QAPI meeting was 9/25/23. When asked about his expectation for QAPI, NHA stated, My expectation are that a full QAPI meeting should be held at least quarterly and monthly monitoring of care concerns and system deficiencies.
Review of the policy titled QAPI Data Colllection Systems revise date 3/24 revealed: It is the policy of this facility to systematically collect data as part of the Quality Assurance Performance Improvement (QAPI) program to ensure the care and services it delivers meet acceptable standards of quality in accordance with recognized standards of practice.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly with the required committee members. ...
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Based on interview and record review, the facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly with the required committee members. This deficient practice resulted in the potential for ineffective coordination of facility issues and concerns affecting all 136 residents i the facility.
On 3/28/24 at 12:07 PM a meeting was held with the Nursing Home Administrator. When asked about the the meeting minutes and sign in sheets for the QAPI meeting. The NHA stated,The last QAPI meeting was 9/25/23. I have not been able to find any sign sheets or minutes since then. When asked about the expectation for the QAPI committe, NHA stated, My expectation are that a full QAPI meeting should be held at least quarterly and monthly monitoring of care concerns and system deficiencies.
Review of the policy titled QAPI Data Colllection Systems with the revision date of 3/24 revealed: It is the policy of this facility to systematically collect data as part of the Quality Assurance Performance Improvement (QAPI) program to ensure the care and services it delivers meet acceptable standards of quality in accordance with recognized standards of practice.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
Based on interview and Record review, the facility failed to implement and operationalize an Antibiotic Stewardship Program and failed to ensure accurate monitoring and documentation of antibiotic use...
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Based on interview and Record review, the facility failed to implement and operationalize an Antibiotic Stewardship Program and failed to ensure accurate monitoring and documentation of antibiotic use resulting in the potential for inappropriate antibiotic utilization and worsening or non-improving infections for all 134 facility residents. Findings Include:
On 3/28/2024 at 12:00PM, the Infection Control task was completed with the Director of Nursing (DON). The DON stated that they were acting as the Infection Control (IC) nurse at the time. The DON was asked to provide the antibiotic monitoring and line listing starting from January, February and March 2024. The DON stated that they had not been monitoring antibiotic use for the 2024 year. The DON was asked how the facility is ensuring that antibiotics are being prescribed correctly and there are no adverse effects. The DON stated that it is being managed by the physicians at this time, but the antibiotic stewardship program was not being utilized at the time.
A review of a facility policy titled, Infection Prevention and Control Program noted the following, .b. Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP-individual who is responsible for assessing, developing, implementing, monitoring, and managing the ...
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Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP-individual who is responsible for assessing, developing, implementing, monitoring, and managing the Infection Prevention and Control Program) completed specialized training in infection prevention and control. Findings Include:
On 3/28/2024 at 12:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that they were also acting as the IP in the facility. The DON stated they had been in the role for a couple months due to some company changes. The DON stated they had started the Centers for Disease Control and Prevention (CDC) course for infection control, however had not completed it yet. The DON stated they did not have a corporate IP and they had no other training related to IP.
A review of a facility policy titled, Infection Prevention and Control Program noted the following, .a. All staff shall receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job function.
MINOR
(C)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Deficiency F0727
(Tag F0727)
Minor procedural issue · This affected most or all residents
Based on interview and record review, the facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week affecting all 137 residents in the fac...
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Based on interview and record review, the facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week affecting all 137 residents in the facility. Findings include:
On 3/28/24 at 10:21 AM, a request for daily nursing staff postings for the past 6 months were requested from the facility in an effort to verify RN coverage however, they were not provided by survey exit.
The Director of Nursing (DON) was interviewed regarding the lack of postings, and stated, I have had four schedulers in six months, I cannot find them.
Jan 2024
4 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
This citation pertains to Intakes: MI00139923, MI00139924, MI00138212.
Based on observation, interview, and record review, the facility failed to ensure the safety and prevent an elopement for one res...
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This citation pertains to Intakes: MI00139923, MI00139924, MI00138212.
Based on observation, interview, and record review, the facility failed to ensure the safety and prevent an elopement for one resident (R905) who has a legal guardian, and is incapable of making safe decisions. R905 eloped from the facility which is located on a busy four lane intersection on 7/25/2023 between 12:00pm and12:30pm without the facility staff being aware of the resident's whereabouts for approximately one hour.
R905 was allowed to exit the facility by a visitor between 12:00-12:30pm on 7/25/23. R905 exited through the front door which requires a code to enter/exit. R905 walked toward their home of origin, which is approximately 2 miles away, and admitted ly got into the car of an unknown male who drove them the remainder of the way. R905 attempted to enter their old home, and the local police department was contacted by the owner. The local police notified the facility to inform them that they had the resident in their custody at approximately 1:28pm. R905 was returned to the facility at approximately 1:45pm. This resulted in an Immediate Jeopardy (IJ) to the safety and health to the residents in the facility and the likelihood for serious harm, injury, or death.
Immediate Jeopardy:
The Immediate Jeopardy (IJ) started on 7/25/23 and the immediacy was removed 7/26/23 per review of the facility's responding interventions as verified on 1/19/24.
The IJ was identified on 1/18/24 during an abbreviated survey. The facility was notified of the IJ on 1/18/24 at 2:52pm and was asked for a removal plan.
The IJ was removed on 7/26/23, based on the facility's implementation of the removal plan as verified onsite on 1/19/24. Findings Include:
A review of R905's medical record revealed that they were admitted into the facility on 2/22/22 with diagnoses that included Bi-Polar Disorder, Unspecified Psychosis, Adjustment Disorder with Anxiety, Vascular Dementia, and Hypertension. Further review revealed that the resident was cognitively intact, and was independent for activities of daily living. Further review of R905's medical record revealed an elopement risk assessment dated 6/8/23 indicating that the resident was at risk for elopement.
Further review of R905's medical record revealed the following progress notes:
6/28/2023 13:23 (1:23pm) Social Service Progress Note
Note Text: Resident continues to come to SS (social services) office to state [they are] leaving the building, resident has a wander guard related to [them] being a elopement risk. [R905] is re-directed from the door. Unit manager aware that resident has been sitting in the front lobby, [R905] is monitored related to [them] verbalizing [they want] to leave the building. Resident has a Guardian in place.
7/20/2023 14:50 (2:50pm) Nursing Progress Note
Note Text: writer noted that wander guard was not in place at this writing, patient would not give location of wanderguard or how it was removed, unit manager notified, no replacement not available at this this time per unit manager.
7/25/2023 18:54 (6:54pm) Nursing Progress Note
Note Text: Resident had left the building looking to go to [their] house. Responsible party notified, Physician notified, Administrator notified, DON (Director of Nursing) notified. Immediate intervention implemented: resident has 1:1 Staff supervision.
7/25/2023 18:44 (6:54p)
Nursing Progress Note
Note Text: Event occurred on 07/25/2023 2:00 PM. Resident was outside of the building and had a fall after trying to go to [their] house . Physician and responsible party notified.
On 1/17/24 at 1:40 PM, R905 was observed in their room sitting on their bed, and was asked about the day they left the building, and were returned by the police. R905 explained that they were in the lobby, and exited out the front door as a visitor was entering the building. R905 explained that they began walking to their home and ultimately fell which was witnessed by an unknown male who offered to drive them to their home. R905 explained that they did not know the driver but willingly got into the car so that they could drive them to their residence.
R905 explained that upon arriving at their home, there was someone inside the home that was there illegally and would not allow them to enter. R905 explained that as a result of not being allowed inside the home, they walked across the street to speak with the neighbors. R905 explained that the police arrived, and transported them back to the facility. R905 explained that they should not be residing the facility and needs an attorney to get the woman living in their home out. R905 was asked if they had spoken to their guardian about concerns with the facility and wanting to discharge, and they stated, I don't have a guardian.
A review of the local police department's police reports dated, and time stamped for 7/25/23 at 12:58pm revealed the following, Spoke to caller [identifying information] who resides at [R905's previous address]. [caller] stated the [R905] attempted to gain
entry into [their] house. Located the subject across the street and [R905] was identified as listed [R905]. [R905] used to reside there as listed on [their] driver's license. [R905] also had a [nursing facility] card on [their] person. Dispatch confirmed that [R905] was a walk away from there. We transported [R905] back and turned [them] over to [facility staff] .
A review of the facility's investigation revealed that the R905 was last seen by facility staff, Nurse G between 12:00pm-12:30pm on 7/25/23, and that the facility received a call from the local police at 1:28pm informing them that R905 was in their custody. R905 returned to the facility at 1:45pm with a scraped knee and forearm due to the fall they sustained while walking.
On 1/18/24 at 10:43 AM, Social Worker F was asked about R905's elopement risk and current behaviors. Social Worker F explained that R905 had a guardian in place prior to their admission into the facility, and that the guardian has spoken to the resident and explained that their home has been sold, and they cannot return there. Social Worker 'F explained that R905 has mental health concerns, and had made comments about leaving which is why they were considered a resident that staff needed to watch. Social Worker F was asked about R905 removing their Wander Guard, and explained that R905 had removed their Wander Guard at least 3 times that she is aware of.
A review of R905's medical record revealed the following Elopement Care Plan:
Focus: I am at risk for elopement r/t (related to) the fact that I refuse to wear a Wander Alert and my efforts to exit the facility independently. I frequently say that I am leaving the building
and I am going to call the police. I am high functioning, ambulate independently and
have the potential to present as a visitor. I do not take medications that have been
prescribed to me. I have the potential to remove my wanderguard device. I am
required to be re-directed away from the front door for safety. Date Initiated: 06/08/2022. Revision on: 08/03/2023 .
Interventions:
-Document any behaviors I exhibit in POC. Date Initiated: 02/22/2022.
-Educate resident/family/friends on LOA (leave of absence) procedure Date Initiated: 08/07/2022.
-Elopement risk assessment on admission, then quarterly and PRN (as needed). Date Initiated: 02/22/2022 do not have a wanderguard device on my ankle. Please notify the NHA (nursing home administrator) if I require a replacement band. Right now, I have increased supervision to keep me safe from elopement. Date Initiated: 08/02/2023.
-I need direct supervision while outside the facility. Date Initiated: 08/07/2022.
-Increase supervision from staff to assist in keeping me safe from the potential harm that could result as a result of my wandering. Date Initiated: 07/25/2023.
-Notify the DON or designee if I remove my wanderguard device. Date Initiated: 07/25/2023
-Place information in the elopement book per policy. Date Initiated: 08/07/2022 .
On 1/18/24 at 11:10 AM, an interview was conducted with the NHA regarding R905 eloping from the facility, and she explained that R905 exited out of the front door, which is equipped with a Wander Guard alarm, and requires a code to exit out of the facility. The NHA explained that the Ombudsman held a resident council meeting and informed the residents that they can leave whenever they want to, and R905 felt as though this applied to them. The NHA was asked about the increased supervision and monitoring of R905 who was a known elopement risk and had previously removed their Wander Guard. The NHA explained that the resident was a part of the facility's elopement program, which means that staff is aware that they are an elopement risk, observations are made if a resident is approaching doors, and that they are placed in the elopement book.
On 1/18/24 at 1:43 PM, the DON was asked about R905 eloping from the facility, and she explained that she was new in her role at that time, and could not speak to what monitoring and supervision was in place for the resident, but that they have implemented interventions for R905 who has not eloped from the facility since July 2023. The DON was asked about the progress note on 7/20/23 indicating that R905 had taken off their Wander Guard, and that there were none available to replace it. The DON explained that that is not true, and that it was a poorly written progress note, and that another Wander Guard had been provided to the resident after that date, which they had taken off and threw it in the trash.
A review of the facility's Elopements and Wandering Residents policy was reviewed and revealed the following, Policy: This facility ensures that residents who exhibit wandering behavior and/or are risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing unique factors contributing to wandering or elopement risk .5. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing intervention to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary .
Facility Removal Plan:
The facility provided the following information to demonstrate that the immediacy of the cited deficiencies has been removed;
.The following plan has been implemented for compliance:
Maintenance has checked doors and alarms 2x per day.
Elopement drills will be conducted monthly
Access codes will be changed at least once a month or as needed.
An elopement assessment will be completed for all new admissions. If deemed at risk information will be added to the elopement binder.
Wander alert will be checked daily. Administrator will ensure wander alerts are available. If resident is non-compliant DON or designee will be notified and appropriate individualizes interventions will be initiated to ensure safety.
The IDT will review residents at risk for elopement weekly.
Signs were posted on exit doors asking visitors not to assist residents out of the building and to be mindful of residents who may try to exit with them.
Areas identified requiring quality improvement.
An AD-HOC QAPI was held 7/26/2023. The organization's elopement policy and procedures were reviewed and deemed appropriate by the committee.
Actions to prevent occurrence/recurrence
The DON or designee will check the clinical dashboard daily for any new/re-admisssions identified at risk for elopement. Interventions will be initiated.
Maintenance Director or designee will check doors and alarm weekly and report any concerns to the Administrator.
Maintenance Director will change access codes and conduct elopement drills monthly
Social Services will review the Elopement binders weekly for 4 weeks to ensure accuracy.
Administrator will ensure extra wander alerts will be available for residents deemed at risk and needing the alert.
New hires will be in-serviced on the Elopement policies and procedures.
Negative findings from the audits will be addressed immediately. Results will be brought to QAPI for review and recommendations. Administrator will be responsible for sustained compliance.
Date of compliance: 7/26/23
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
This citation pertains to Intake: MI00142002.
Based on interview and record review the facility failed to update a care plan following a fall for one resident (R909) of one resident reviewed for care ...
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This citation pertains to Intake: MI00142002.
Based on interview and record review the facility failed to update a care plan following a fall for one resident (R909) of one resident reviewed for care plan interventions. Findings include:
A review of R909's medical record revealed that they were admitted into the facility on 7/14/23 with diagnoses that include Dementia, Heart Disease, Depression, and Anxiety. R909 was discharged from the facility on 1/5/24. Further review revealed that the resident was severely cognitively intact, and required one person assistance for Activities of Daily Living.
Further review of R909's medical record revealed the following fall care plan,
I am at an increased risk for falls r/t (related to) blindness to Left Eye/dementia. Date Initiated: 07/15/2023. Interventions:
-Assist and stay with me while I am in the bathroom
Date Initiated: 07/15/2023
-Be sure my call light is within reach and encourage me to use it for assistance as
needed. I need prompt response to all requests for assistance.
Date Initiated: 07/15/2023
-Ensure that I am wearing non-skid footwear.
Date Initiated: 11/01/2023
-Fall risk: Blindness to Left Eye/dementia.
Date Initiated: 07/15/2023
-Offer calming music (gospel) during periods of increase risk
Date Initiated: 10/29/2023
-Place me in a common area such as nursing station when increased supervision is
needed. Date Initiated: 10/30/2023
Provide soft, calming music
Date Initiated: 11/27/2023
PT evaluated and treated as indicated.
Date Initiated: 11/01/2023
-Reduce my risk for falling by cleaning up spills or clutter from my floor, accessible
working call light, bed set at height deemed appropriate by PT/OT/Nurse (as
applicable), my personal items within reach.
Date Initiated: 07/15/2023
A review of R909's Incident and Accident reports reveal that the resident had falls on the following dates, and interventions as implemented:
On 8/26/23 R909 fell onto their left elbow. No new intervention noted.
On 9/21/23 R909 was found sitting upright on the floor. No new intervention noted.
On 10/20/23 R909 was attempting to ambulate on their own. No new intervention noted.
On 10/29/23 R909 jumped out of wheelchair.
On 11/1/23 R909 was found on floor sitting upright.
On 11/26/23 R909 was located halfway on the floor, holding onto overhead table and bed.
On 12/2/23 R909 Slipped out of their wheelchair onto floor. No new intervention noted.
On 12/3/23 R909 was located lying on the floor mat in their room. No new intervention noted.
On 1/18/24 at 1:43 PM, the Director of Nursing (DON) was asked for her expectations for care plan revisions and interventions following a fall of a resident. The DON explained that the care plan should be revised whether it is the fall goal itself, or the intervention.
A review of the facility's Fall Reduction policy revealed the following, Policy Explanation and Compliance Guidelines: .4. Each resident's risk factor, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. a. The plan of care will be revised as needed. 5. When a resident experiences a fall, the facility will: .IDT (interdisciplinary team) review of the resident's care plan and update as indicated. F. Document assessments and actions .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
This citation pertains to Intake: MI00142002.
Based on interview, and record review, the facility failed to complete skin observations weekly for one sampled residents (R909) of one reviewed for skin ...
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This citation pertains to Intake: MI00142002.
Based on interview, and record review, the facility failed to complete skin observations weekly for one sampled residents (R909) of one reviewed for skin management. Findings include:
A review of R909's medical record revealed that they were admitted into the facility on 7/14/23 with diagnoses that include Dementia, Heart Disease, Depression, and Anxiety. R909 was discharged from the facility on 1/5/24. Further review revealed that the resident was severely cognitively impaired, and required one person assistance for Activities of Daily Living.
Further review of R909's medical record revealed the following care plan:
Focus: I am at risk for impaired skin integrity r/t (related to) poor safety awareness, risk for moisture d/t (due to) incontinence, dementia, violent behavior. Date Initiated: 08/29/2023 .Interventions: Inspect skin daily with care - Report any concerns to nurse. Date Initiated: 08/29/2023 .Licensed Nurse skin assessment per protocol. Date Initiated: 08/29/2023 .
Further review of R909's Weekly Skin Sweeps revealed that the resident had skin sweeps on the following dates:
-7/19/23
-7/26/23
-8/2/23
-8/9/23
-8/25/23
-9/1/23
-9/8/23
-9/20/23
-9/27/23
-10/4/23
-10/13/23
On 1/18/24 at 1:43 PM, the Director of Nursing (DON) was asked if residents' weekly skin assessments were documented somewhere other than the resident's electronic medical record, as R909 hadn't had any documented after 10/13/23, and was not discharged from the facility until 1/5/24. The DON explained that all weekly skin sweeps should be located in the electronic medical record, and that they should be completed weekly.
A review of the facility's Skin and Pressure Injury Risk Assessment and Prevention policy revealed the following, .1. A skin assessment will be conducted by a licensed or registered nurse upon admission/readmission and weekly thereafter .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
This citation pertains to Intake: MI00142002.
Based on interview and record review, the facility failed to include a 14-day stop date on an as needed (PRN) anti-anxiety medication for one resident (R9...
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This citation pertains to Intake: MI00142002.
Based on interview and record review, the facility failed to include a 14-day stop date on an as needed (PRN) anti-anxiety medication for one resident (R909) of one reviewed for unnecessary medications. Findings include:
A review of Intake MI00142002 called into the State Agency revealed the following, I begin complaining on Thanksgiving Day that [R909] was being over medicated because [R909] came and slept for 12 hours straight and [R909] was in such a deep sleep we could not wake [them], [R909] did not eat dinner or engage .
A review of R909's medical record revealed that they were admitted into the facility on 7/14/23 with diagnoses that include Dementia, Heart Disease, Depression, and Anxiety. R909 was discharged from the facility on 1/5/24. Further review revealed that the resident was severely cognitively impaired, and required one person assistance for Activities of Daily Living.
Further review of the medical record revealed the following physician orders:
Lorazepam Oral Tablet 0.5 MG (milligrams, Lorazepam). Give 1 tablet by mouth every 8 hours as needed for anxiety. Order date: 12/4/23, no stop date initiated.
Lorazepam Injection Solution 2MG/ML (Lorazepam). Inject 2 mg intramuscularly every 24 hours as needed for agitation. Order date: 11/16/23, no stop date initiated.
A review of R909's December Medication Administration Record (MAR) revealed that the resident received the Lorazepam Oral Tablet 0.5 MG on the following dates: 12/7/23, 12/9/23, 12/10/23, 12/18/23, 12/20/23 (two times), 12/22/23, 12/23/23, and 12/28/23.
Further review revealed that R909 received the Lorazepam Injection Solution 2MG/ML on 12/18/23 and 12/24/23.
On 1/18/24 at 1:43 PM, the Director of Nursing (DON) was interviewed regarding R909's PRN anti-anxiety medication not having a stop date. The DON acknowledged that there should have been a stop date for the medication.
A review of the facility's Antipsychotic Reduction Program policy revelaed the following, All PRN psychoactive medication orders require a 14-day end date. The provider must review for effectiveness and determine the need to continue at that time. A new order must be written, if indicated .
Jan 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice Statement #1
This citation pertains to Intake M100141178.
Based on interview and record review, the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice Statement #1
This citation pertains to Intake M100141178.
Based on interview and record review, the facility failed to prevent the verbal abuse by a staff member of one (R903) of six residents reviewed for abuse. Findings include:
Review of the facility record for R903 revealed an admission date of 12/08/21 with diagnoses that included Chronic Obstructive Pulmonary Disease, Emphysema and Depression. The Minimum Data Set (MDS) assessment dated [DATE] indicated R903 required supervision to moderate assistance for activities of daily living (ADLs). The Brief Interview for Mental Status (BIMS) assessment score of 15/15 indicated intact cognition.
On 01/09/24 at 11:55 AM during an interview, R903 reported that they did recall an incident involving a Certified Nurse Assistant (CNA) named [CNA D]. R903 reported that they have difficulty getting their medication at times and they were having a verbal altercation with CNA D about their medication during which CNA D called them a bitch. R903 admitted that they had called CNA D a bitch prior to CNA D using that word. R903 was asked how they felt about being spoken to in that manner and stated Its not right .I know I said the same thing but I was mad. I still don't think they should talk back that way. R903 reported that there were no witnesses to the incident that they could recall.
Additional review of the facility record revealed a statement signed by CNA D indicating that they responded It takes one to know one after R903 called them a bitch. Additional facility investigation documents were noted to include CNA D's admission of responding It takes one to know one to R903 and denying that they had used the word bitch.
On 01/10/24 at 10:15 AM, the facility Administrator (NHA) reported that CNA D had admitted to stating to R903 It takes one to know one when R903 called them a bitch. The NHA reported that when a resident addresses staff in an unpleasant or derogatory manner the facility expectation is that staff will not take the bait and will respond only in a professional manner.
On 01/10/24 at 10:31 AM, a call was placed to CNA D and a voice message was left requesting a return call. No response was received.
On 01/10/24 at 3:13 PM, the facility Director of Nursing (DON) reported that the expectation when a resident speaks in a derogatory manner to staff is that staff respond professionally and maintain resident dignity and rights.
Review of the facility policy Abuse, Neglect and Exploitation dated 03/28/22 includes the Policy Statement It is the policy to follow facility protocol to provide protections for the health, welfare and rights of each resident by developing and implementing policies and procedures that prohibit and prevent abuse and included the Definition that Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.
Deficient Practice Statement #2
This citation pertains to Intakes M100141259 and M100141393.
Based on observation, interview and record review, the facility failed to prevent the inappropriate touching of one (R905) vulnerable resident by another resident, of six residents reviewed for abuse. Findings include:
Review of the facility record for R905 revealed an admission date of 03/24/20 with diagnoses that included Alzheimer's Disease, Major Depressive Disorder and Anxiety Disorder. The MDS assessment dated [DATE] indicated R905 required supervision to moderate assistance with activites of daily living (ADLs). The BIMS assessment dated [DATE] and scored 03/15 indicated severe cognitive impairment.
Review of the facility record for R907 revealed an admission date of 07/14/23 with diagnoses including Dementia, Schizoaffective Disorder and Post-Traumatic Stress Disorder. The MDS assessment dated [DATE] indicated R907 required primarily supervision for ADL's other than showering. The 10/19/23 BIMS assessment score of 13/15 indicated intact cognition.
Review of the facility-reported incident report indicated that on 11/21/23 Nurse Practitioner (NP) F reported having witnessed R907 grab R905's buttocks and then their breast.
On 01/09/24 at 2:55 PM, R905 was interviewed in their room. They were not able to recall any incident such as described in the incident report.
On 01/09/24 at 3:10 PM, R907 was interviewed in their room and reported that they recalled being accused of touching R905. R907 reported that they had touched R905's elbow to turn them so they were facing each other so they could see what R905's t-shirt said and when they did so some woman, I don't know who she was, came up and accused me. That [R905] is about [AGE] years old and a white woman at that, what would I want with her.
On 01/10/24 at 11:30 AM, NP F was interviewed via phone and reported that they did recall the incident between R905 and R907. NP F reported that they were charting in the hallway in the B wing area and R905 was walking along the wall using the handrail when R907 came up from behind R905 in their wheelchair and grabbed R905's buttock. NP F reported that R905 turned around with a confused look on their face then R907 reached up and grabbed R905's breast. NP F reported that a group of staff, who they could not identify, were at the nurse's station and verbally responded when R907 grabbed R905's breast but NP F reported they were closest to the residents and therefore they approached and intervened to separate the residents. NP F reported that when they intervened R907 did not deny what occurred and was apologetic.
On 01/10/24 at 3:16 PM, the DON reported that the facility expectation is that residents would not be touched in an inappropriate or unwanted manner and that the facility would take all reasonable measures to prevent such an incident.
Review of the facility policy Abuse, Neglect and Exploitation dated 03/28/22 includes the Definition: Sexual Abuse is non-consensual sexual contact of any type with a resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake M100141170.
Based on observation, interview and record review, the facility failed to respond t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake M100141170.
Based on observation, interview and record review, the facility failed to respond to door alarms in a manner timely to prevent the elopement for one (R902) out of three residents reviewed for elopement. Findings include:
Review of the facility record for R902 revealed an admission date of 05/20/15 with diagnoses that included Cerebral Infarction with Right Hemiplegia and Expressive Aphasia, Schizophrenia and Bipolar Disorder. The Minimum Data Set (MDS) assessment dated [DATE] indicated that R902 was not functionally ambulatory and required supervision for self-propelling their wheelchair up to 50 feet with two turns. The Brief Interview for Mental Status (BIMS) assessment dated [DATE] was scored 14/15 indicating intact cognition.
On 01/09/24 at 12:55 PM, Licensed Practical Nurse (LPN) A, who was identified as the first staff to respond to the main entrance door alarm after R902 exited the building, was interviewed via phone call. LPN A reported that they recalled the evening that R902 exited the building and went to the gas station next door. LPN A stated that they recalled it being very early in the morning, very roughly around 4 AM and they were using the bathroom nearest to the main entrance when they heard the door alarm going off. LPN A reported that they required time to finish in the bathroom and therefore did not exit the bathroom immediately, but as quickly as possible. LPN A did not say why other staff members did not respond to alarming door. LPN A reported going to front entrance area and looking outside where they could view clearly to the left and right and did not see anyone. LPN A reported that they went to the unit to notify staff and initiate a head count when Certified Nurse Assistant (CNA) B approached them and said the gas station next door had just called and said R902 was in the store. LPN A stated that CNA B then went to the gas station to assist the resident back to the facility.
On 01/09/24 at 2:40 PM, R902 was interviewed in their room. R902 was pleasant and cooperative and used head nods, single word responses and a communication sheet, demonstrating the ability to communicate in a clear and functional manner. R902 reported that they did recall the night they went to the gas station next door. R902 reported that they decided to go to the gas station and propelled their wheelchair out the front entrance, through the parking lot to the sidewalk that leads past the wall dividing the facility parking lot and the gas station parking lot. When asked if they were approached by staff as they exited they indicated No. When asked if the alarm sounded when they exited the facility door they indicated Yes. When asked to estimate how long they were gone R902 indicated about 15 minutes.
On 01/09/24 at 4:18 PM, CNA B was interviewed via phone call and reported that they did recall the incident of R902 leaving the facility and going to the gas station. CNA B stated that a gas station employee who they were familiar with facetimed them to report and show live video of R902 in the store attempting to purchase items without money and the employee expressed that they wanted to let them know because they were going to call the police if the staff did not know/retrieve the resident. CNA B stated that they identified R902 and went to the gas station immediately and assisted R902 back to the facility without incident.
On 01/10/24 at 8:40 AM, LPN C, who authored the Progress Notes in R902's record addressing the elopement, was interviewed via phone call and reported that they did recall the incident of R902 leaving the facility and going to the gas station next door. LPN C reported that they came out of a resident's room and could hear the door alarm and LPN A was coming down the hall and asked for the door code to silence the alarm. LPN C reported that LPN A stated that CNA B had been called by the gas station and had gone there to assist R902 back to the facility. LPN C reported that they left for the gas station to assist and when they exited to the parking lot CNA B and R902 were on their way back to the facility.
On 01/10/24 at 9:43 AM, The front entrance alarm was tested with the facility Administrator (NHA) who reported the Maintenance Director was on vacation. The main entrance door required a code to disable the alarm and without the code required 15 seconds of pressure with the initial alarm sounding immediately, then the door opened after 15 seconds which triggered an additional alarm. The NHA demonstrated that alarm indicators near the nurse's stations display the location of the alarm. The alarm could be heard at the end of the hallways furthest from the entrance.
On 01/10/24 at 10:10 AM, the NHA reported that they were not able to specify an expectation for a time frame of staff response to a door alarm or whether or not, in this specific instance, staff's response time met expectation.
On 01/10/24 at 3:03 PM, the facility Director of Nursing (DON) reported that the expectation regarding response to door alarms is that, in this case, the resident should not have been able to leave the premises (property) to the other side of the gas station wall without being observed by staff.
Review of the facility policy Elopements and Wandering Residents dated 04/23 includes the following entries under Policy Explanation and Compliance Guidelines:
2. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so.
4. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner.
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 F0790
(Tag F0790)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake M100141302.
Based on interview and record review, the facility failed to provide routine dental...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake M100141302.
Based on interview and record review, the facility failed to provide routine dental services for one (R909) of three residents reviewed. Findings include:
Review of the facility record for R909 revealed an admission date of 05/20/15 with current primary diagnoses that included Rhabdomyolysis, Dementia, Schizophrenia and Metabolic Encephalopathy. The Minimum Data Set (MDS) assessment dated [DATE] indicated R909 required set up to moderate assistance with activities of daily living (ADLs). The Brief Interview of Mental Status (BIMS) assessment score of 10/15 indicated moderate cognitive impairment.
On 01/09/24 at 10:55 AM, the complainant was interviewed via phone call and reiterated that R909 had recently received assessment for their dental needs due to the complainant's persistent requests but that R909 had not received any routine dental exam or service in approximately four years prior to the recent assessment. They reported that R909 complained of painful and broken teeth.
Review of R909's facility history of consultative services dating back to 09/18/19 revealed no record or indication of dental service until initiated 11/01/23. A request was submitted to the facility for any dental service records not located by the surveyor. The facility Administrator (NHA) provided no additional record of dental services but produced Care Conference Summaries and dietary consults that they felt indicated the resident had no dental concerns or dental service requests and therefore dental services were not pursued.
Further review of the three provided Care Conference Summaries revealed the section including special requests. This section on the form dated 09/22/21 included the statement No concerns with hearing/dental. The form dated 03/09/22 included the entry has teeth that are decayed in this section. The form dated 08/31/22 included the entry teeth decayed in this section. Review of the recently initiated dental service order dated 12/03/23 indicated poor oral hygiene and decayed, loose teeth.
On 01/10/24 at 3:28 PM, the facility Director of Nursing (DON) reported that their expectation for routine dental exams would be similar to community standards like annually or at least bi-annually.
Review of the facility policy Dental Services dated 06/23 includes the Policy statement It is the policy of this facility, in accordance with resident needs, to assist residents in obtaining routine and emergency (to the extent covered under the State dental plan) dental care. The Definitions portion of the policy includes the entry Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, .
Sept 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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00134945.
Based on observation, interview, and record review, the facility failed to protect...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00134945.
Based on observation, interview, and record review, the facility failed to protect a resident from inappropriate sexual advances for one sampled resident (R901) of three reviewed for abuse, resulting in R901 experiencing inappropriate sexual touching and advances, and the potential for decreased psychosocial well-being. Findings include:
A review of Intake MI00134945 revealed the following, Incident Summary: Residents were sitting in dining room. Employee noted that [R902] placed hand in [R901's] pants. Employee intervened and removed [R901] from the dining room .
On 9/19/23 at 2:45 PM, R901 was observed lying in bed. Attempts to interview them were to no avail as they refused to speak to surveyor.
A review of R901's medical record was reviewed, and revealed that R901 was admitted into the facility on [DATE] with diagnoses that included Dementia, Dysphagia, and Muscle Weakness. Further review revealed a quarterly Minimum Data Set (MDS) assessment dated for 12/13/22 revealing that the resident at the time of the incident had a Brief Interview for Mental Status score of 9/15 indicating a moderately impaired cognition, and required extensive assistance for Activities of Daily Living (ADL's).
On 9/20/23 at 1:08 PM, an interview was completed with Certified Nursing Assistant (CNA) A regarding the incident between R901 and R902. CNA A explained that she was walking past the dining room, and observed R902 with their hand on the top portion of R901's brief, appearing to place their hand inside of R901's brief. CNA A explained that R902 appeared startled upon approach and was ultimately removed R901 from the dining room.
A review of the local police department's police report dated 2/15/23 revealed the following, .Officers spoke with [R902] while in the administrative office in the presence of [Nursing Home Administrator]. I asked [R902] if something happened between [them] and [R901] in the lobby on today's date. [R902] stated he stuck him (his) left hand down [R901's] pants and he did not know why he did it .
On 9/20/23 at 1:55 PM, R902 was observed sitting in the dining room playing on his computer tablet, and was asked about the incident between them and R901, however, due to R902's slurred speech, surveyor was unable to understand what they were attempting to articulate.
A review of R902's medical record revealed that they were admitted into the facility on 5/8/19 with diagnoses that included Cerebral Palsy, Diabetes, Developmental Disorder of Motor Function, and Muscle Weakness. A review of R902's quarterly Minimum Data Set assessment dated [DATE] revealed that at the time of the incident, R902 had a Brief Interview for Mental Status score of 15/15 indicating an intact cognition, and required supervision with Activities of Daily Living.
Further review of R902's medical record revealed the following progress note by R902's mental health provider: 2/20/2023 20:36 (8:36pm) Psychiatric Service Progress Note . Complaint: resident to resident. HPI (history of present illness) .Pt (patient) observed sitting in his wheelchair in his room, pt recognized this writer and welcomed the visit. Per staff, pt was observed trying to put his hands down another resident's pants- when approached by staff pt reported both that he was 'checking to see if she was wet' and 'tucking in her shirt.' When asked about this pt responded, 'I know' and shook his head back and forth .PT reassured this writer that he would not engage in any inappropriate touching .
A review of the facility's investigation regarding the incident revealed the following: Findings: After a thorough investigation of the incident the facility did substantiate that the incident did occur and [R901] is unable to consent due to cognition and legal status. It should also be noted due to [R902's] developmental delay he does not seem to fully understand the implication of the incident and denies intention to hurt [R901] .
On 9/20/23 at 2:18 PM, the Director of Nursing (DON) was asked about the incident between R901 and R902, and explained that she was not working at the facility at the time of the incident, but did indicate that her goal as the new DON is to provide a safe environment for all residents.
A review of the facility's Abuse, Neglect and Exploitation policy revealed the following,
TTS will follow facility implementation policies and procedures to prevent and prohibit abuse. Neglect, misappropriation of resident property and exploitation that achieves: A. Establishing a safe environment .
Dec 2022
18 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice Statement #2
Based on observation, interview and record review, the facility failed to reassess and monitor a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice Statement #2
Based on observation, interview and record review, the facility failed to reassess and monitor after a noted health concern for one sampled resident (R117), of two residents reviewed for change in condition, resulting in unmet care needs and hospitalization. Findings include:
On 12/15/22 at 9:34 AM, R117 was observed sitting in the hallway. They were pleasant upon approach and denied any concerns regarding the facility.
A review of R117's medical record revealed that they were admitted into the facility on [DATE] with diagnoses of Heart Failure, Dementia, and Diabetes. Further review revealed a Minimum Data Set assessment dated [DATE] revealing a Brief Interview for Mental Status score of 11/15 indicating a moderately impaired cognition, and required supervision to extensive assistance for Activities of Daily Living.
Further review of R117's medical record revealed the following progress notes:
10/24/2022 06:29 (6:29am) Nursing Progress Note: Resident complained of pain in lower abdomen with the urge to urinate. [R117] stated 'I can not pee!'. Resident was given pain meds and a note was put in the Dr's (doctor's) book. Will pass on to dayshift . Resident currently resting in bed.
10/31/2022 08:48 (8:48am) Discharge Emergent Note. Was a physician order obtained for transfer/discharge?: Physician ordered resident to be sent to hospital.
What is the reason for resident transfer/discharge?: Resident has a Gastrointestinal Bleed . Large amount of bright red blood lost from rectum. History of Gastrointestinal Hemorrhage.
Where is the resident is being transferred? Who is providing the transportation?: Resident transferred to [local hospital]. Resident transferred via 911 Ambulance at 4:30 am .
Further review of R117's medical record revealed that R117 was admitted to the hospital on [DATE] and discharged on 11/4/22 with diagnoses of Acute LGIB (lower gastrointestinal bleeding, acute blood loss anemia, Thrombocytopenia (low platelet level), and constipation. Radiology results revealed the following, Diagnostic Results: CT (Xray images) ABD (abdominal)/Pelvis w (with)/ Contrast Impression 3 .Moderate to large amount of stool in the colon 4. Massively enlarged prostate gland measuring 10 x 8 x 11 cm (centimeters) 5. Mild circumferential wall thickening of the urinary bladder which may be due to chronic outlet obstruction .
On 12/20/22 at 12:55 PM, R117 was interviewed regarding their hospitalization and indicated that they were admitted into the hospital for feeling weak and they have always had stomach issues as a kid.
On 12/20/22 at 1:51 PM, a request for physician notes for R117 between 10/24/22 and 10/31/22 were requested from the facility. There was no documentation provided by the end of the survey.
On 12/21/22 at 1:50 PM, the Director of Nursing (DON) was asked about R117's hospitalization, and lack of assessment after complaints of pain, and inability to urinate. The DON indicated that she would look into it and get back with surveyor.
On 12/21/22 at 3:18 PM, the DON explained that there was a note written in the doctor's book however, there was no indication that it was followed up on.
This citation has three deficient practices.
Deficient Practice Statement number 1.
Based on observation, interview, and record review, the facility failed to appropriately assess and recognize skin alterations for one resident (R28) of four reviewed for quality of care, resulting in the development of untreated wounds, acute osteomyelitis, and toe amputation. Findings include:
A review of R28's medical record and Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was initially admitted into the facility on [DATE] and most recently re-admitted from the hospital on [DATE]. Further review revealed that R28's Brief Interview for Mental Status (BIMS) was 13/15, indicating an intact cognition, and that the resident's medical diagnoses include Heart Failure, Chronic Lung Disease, Muscle Weakness, Peripheral Vascular Disease, Type 2 Diabetes Mellitus, Anemia, Anxiety, Depression, Psoriasis, Hypertension, and Knee Contractures.
On 12/15/22 at 10:28 AM, R28 was observed lying in bed. R28's feet were mostly exposed except the heels, which were covered by heel cushion pads secured with Velcro. R28's right foot was observed with a lengthy incision line where their great toe used to be. R28's right foot and remaining toes appeared red with crusty skin, and there was a dark reddish-brown crusty substance (like old, dried blood) noted between R28's right toes and along the incision line. R28's former roommate, R106, was at the resident's bedside visiting R28 (R106's most recent BIMS score from 11/11/22 was noted to be a 15/15 indicating intact cognition). When queried regarding their right toe amputation, R28 stated, I was having an infection in my foot that no one knew about, and I didn't know about it until one day the nurse saw my toe and said it looked bad .Everyone came to look at it and said it didn't look good .They weren't going to send me [to the hospital] at first, but then sent me. R106 explained that this occurred when they shared a room with R28. R106 further stated, The room smelled like a rotten dead possum for a month and we told them, but they just came in and sprayed stuff. R28 explained that prior to the amputation, staff had been documenting giving them a complete bed bath. R28 further explained that although they received a bed bath, staff wasn't washing their feet. When queried further regarding past issues with their feet/toes, or if they had been seen by a podiatrist, R28 indicated that they had been seen by the foot doctor who treated a minor infection on their toe. R28 stated that the podiatrist wrapped their foot but hadn't come back since. R28 indicated that they have diabetes and neuropathy, and cannot feel anything in their feet/toes. R28 also stated that prior to going to the hospital for the toe amputation, staff hadn't been checking their feet for, around a month.
A review of R28's medical record revealed the following:
-9/12/22 Podiatrist Note: Pt c/o (complains of) elongated painful toenails .unable to trim [themselves]. Have become bothersome .Assessment: .Painful dystrophic onychomycosis (a fungal infection of the nail) with acute paronychia (infection of the tissue folds around the nails) and incurvation lateral nail border left hallux/minimal lymphagitis (sic) .Plan: .nails debrided x10 with sterile [NAME] without incident .nurse notified to perform daily dressing changes left hallux x 14 days .F/u 2 months . No podiatry note was found for the resident for November 2022.
-Shower sheets provided by the facility: 10/29/22 bed bath marked as given, both feet noted to be circled on photo but no description written of skin issue or why the feet were circled; 11/2/22 bed bath marked as given with no skin issues written other than psoriasis on resident's back.
-11/11/2022 09:17 (AM) Nursing Progress Note Note Text: Resident has a history of refusing .shower related to 11/09/2022 resident request for complete bed-bath to be given care plan reviewed and updated. [No corresponding shower/bath sheet found nor provided by facility].
-Weekly Skin Sweep .Date: 11/11/2022 10:01 (AM) [Completed by Licensed Practical Nurse (LPN) F] .tx (treatment) in progress for psoriasis - all other skin is clean, dry and intact .
-11/12/2022 08:30 (AM) Nursing Progress Note Late Entry: Note Text: Resident has a decubitus ulcer on right foot and great toe. Right foot is red and swollen. Right foot has foul odor. Right foot cleansed. Dressing applied .Physician and Director of Nursing (DON)notified. Physician ordered resident to be sent to hospital for evaluation and treatment. Resident sent to .Hospital via ambulance for evaluation and treatment. [Written by LPN E].
-11/18/2022 22:27 (10:27 PM) Nursing Progress Note Note Text: Resident received back in the facility .resident big great toe on the right foot was amputated, resident has 4 other digits on the right foot, writer counted 16 stitches on resident all together, on .toe and on the bottom of .foot area .
-R28's Infection Report dated 11/18/22 indicated that the resident was to receive oral and intravenous (IV) antibiotic treatment for 42 days due to osteomyelitis (infection into the bone) in the resident's right foot.
-11/20/2022 15:07 (3:07 PM) ., IDT (Interdisciplinary Team) met to discuss resident re-admit to facility on 11/18/2022. Resident .Alert and oriented x3 .has open area right related to recent right great toe amputated 16 stitches .single lumen picc-line (peripherally inserted central catheter) right arm for ivpb (intravenous piggyback) of ceftriaxone (IV antibiotic) 2 gm (grams) daily along with oral flagyl (antibiotic) 500 mg bid (twice a day) x 42 days. Pain managed with [opioid as needed] .
A review of R28's records from their hospitalization on 11/12/22 revealed that the resident's great right toe was amputated on 11/15/22 and they were discharged from the hospital back to the facility on [DATE].
On 12/16/22 at 2:09 PM, R28 was observed lying in bed. A PICC line was noted in the resident's right arm. When queried regarding how much longer they will be receiving antibiotic treatment, R28 stated, Supposed to be about a month total, I'm still getting them .I've been having some diarrhea . R28's right foot and remaining toes still appeared red with crusty skin, with a dark reddish-brown crusty substance (like old, dried blood) noted between R28's right toes and along the incision line.
On 12/20/22 at 9:48 AM, R28's right foot and remaining toes still appeared red with crusty skin, with a dark reddish-brown crusty substance (like old, dried blood) noted between R28's right toes and along the incision line. When queried if anyone had come to care for their feet, R28 responded that a nurse had assessed their feet but no one had offered to clean them.
On 12/21/22 at 10:11 AM, the DON was queried if LPN E or LPN F were available for interview. The DON indicated they were not in the building and provided their contact information.
On 12/21/22 at 10:20 AM, the Wound Care Nurse (WCN) wound care nurse was interviewed and queried regarding what a Weekly Skin Sweep assessment entails. The WCN responded that a skin sweep means that the resident's skin is assessed from head to toe. When queried specifically regarding the discrepancy between the skin sweep for R28 completed on 11/11/22 by LPN F and the findings on 11/12/22 by LPN E, the WCN stated she was unable to get a lot of information regarding what happened. The WCN indicated she had reviewed R28's progress notes after they had been re-admitted into the facility on [DATE], but that the resident was not being followed by wound care prior to the hospitalization because to her knowledge, the resident had no wounds. The WCN indicated no skin issues had been reported to her, and that staff knew the process for reporting and initiating treatment for new wounds or skin issues. When queried regarding the timeline for the development of osteomyelitis, the WCN stated that she did not feel this situation involving R28's right great toe could have happened over the course of one day. The WCN further explained that regardless of the resident receiving a shower or bed bath, it is the nurse's responsibility to assess all skin when a shower/bath is given, and that nurse aides are required to report new skin alterations to the resident's assigned nurse.
On 12/21/22 at 10:37 AM, R28 was observed lying in bed. The WCN assessed R28's right foot. The resident's right foot and remaining toes still appeared red with crusty skin, with a dark reddish-brown crusty substance (like old, dried blood) noted between R28's right toes and along the incision line. The WCN indicated she was unsure of what the substance was - indicated it could be blood or possibly betadine - between R28's toes and that it did not appear anyone had been tending to the resident's feet.
On 12/21/22 at 10:47 AM, the Infection Control Nurse (ICN) was interviewed and queried regarding the timeline of the development of osteomyelitis. The ICN stated, It won't develop in a day, there will be indications/symptoms first, a wound etc. When a wound is found, we would expect front line staff to be bringing it to someone's attention so it doesn't turn into osteomyelitis.
On 12/21/22 at 1:21 PM, LPN E was called for interview and left a voicemail, however no call back was received prior to survey exit.
On 12/21/22 at 1:23 PM, LPN F was called for interview and left a voicemail, however no call back was received prior to survey exit.
On 12/21/22 at 1:38 PM, the DON was interviewed and queried regarding the circumstances surrounding R28's hospitalization and right toe amputation. The DON indicated that the facility was currently working on a past non-compliance related to the issue (no PNC information was provided prior to survey exit). The DON stated, There was an odor in the room for a week. On the 12th (11/12/22), the nurse (LPN E) went into the room and noted a skin alteration on [R28's] foot. [R28] was sent to the hospital, and an X-ray showed acute osteomyelitis. They amputated the great toe and possibly one or two others. When queried regarding the discrepancy found between R28's skin assessments and the LPN E's findings, and subsequent same-day hospitalization that resulted in toe amputation, the DON explained that she discovered this was a trend and now has unit managers completing and verifying full skin sweeps of residents on their units, and that this is ongoing.
Review of the facility assessment revealed that under, Part 2: Services and Care We Offer Based on our Residents' Needs . the facility's, Management of medical conditions . included performing, Assessment, early identification of problems/deterioration, [and] management of medical and psychiatric symptoms and conditions .
Deficient practice number 3.
Based on observation interview and record review the facility failed to ensure labs for monitoring of Dilantin (for treatment of seizures) and Digoxin (for treament of high blood pressure) were completed per physician orders for one sampled resident (R13) of 31 residents whose plans of care were reviewed, resulting in the potential for decrease efficacy of the medications. Findings include:
On 12/15/22 at 10:56 AM, R13 was observed to dressed and seated on their bed. R13 was asked about care at the facility and reported that their Dilantin was not always given to them. R13 reported that the Dilantin was taken to help prevent seizures and reported they a had a couple of seizures over the last month. R13 reported they were also on Keppra for seizure control.
A review of the facility record for R13 revealed R13 was admitted into the facility on [DATE]. Diagnoses included Epilepsy, High Blood Pressure and Schizophrenia.
The care plan titled have seizure disorder dated 11/30/21 documented obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. The care plan initiated 11/30/21 indicated R13 to be at risk for elevated blood pressure.
A review of the physician orders revealed the following:
-An order dated 11/22/22 for a stat (right away) Dilantin order;
-An order dated 09/13/21 for a Dilantin and Digoxin levels;
-An order dated 02/09/21 for a Digoxin and Dilantin level next draw and then every two months;
-An order dated 12/01/19 for a Dilantin level every three months.
A review of available lab results for the Dilantin and Keppra revealed labs were completed on 04/08/21 and 11/29/22. A lab for the Dilantin was also completed on 02/09/21 and the level was low at 9.5 (range 10-20). A review of available lab results for the Digoxin revealed labs were completed on 02/09/21 and 06/08/22. Additional lab draws for the Digoxin and Dilantin were requested on 12/20/22 at 9:30 AM, but not received prior to survey exit.
A review of the December 2022 medication administration record (MAR) revealed the Digoxin and Dilantin were documented as administered. The November 2022 MAR revealed the Dilantin and Digoxin were not documented as given for at least one dose on November 7. The October 2022 MAR revealed a dose for the Dilantin on 10/13,10/15, 10/18, 10/25, 10/27, 10/29/22 and the Digoxin on 10/27, and 10/2922 were not documented as given. The September 2022 MAR revealed at lease one dose for the Digoxin on 09/04 and 09/17 and for the Dilantin on 09/04, 9/05, 9/17, 9/20/22 were not documented as given. The August 2022 MAR revealed at least one dose for the Digoxin on 08/24 and the Dilantin on 8/19, 8/24, 8/27/22 were not documented as given.
A pharmacy review dated 05/27/22 revealed a recommendation to the physician which indicated The resident is receiving routine doses of Digoxin every day. I would suggest a regularly scheduled Digoxin level. Serum Digoxin level now and every six months. The recommendation was signed as a telephone order per the doctor on 12/21/22.
On 12/20/22 at 12:45 PM, the missing labs for R13 were reviewed with the Director of Nursing (DON). The DON reported the labs should be completed as ordered by the physician.
A review of the Medication Monitoring policy dated June 2019 revealed, .The Consultant Pharmacist identifies irregularities through a variety of sources including the resident's medical record, pharmacy records and other applicable documents .The Consultant Pharmacist recommendations are acted on by the prescriber and/or nursing staff .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
This citation pertains to Intakes: MI00133281 and MI00133076.
Based on observation, interview, and record review the facility failed to prevent staff to resident verbal abuse for one sampled resident ...
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This citation pertains to Intakes: MI00133281 and MI00133076.
Based on observation, interview, and record review the facility failed to prevent staff to resident verbal abuse for one sampled resident (R132), of 11 residents reviewed for abuse resulting in, the potential for emotional distress. Findings include:
A review of a complaint to the State Agency revealed the following, .On 12/3/22 the writer received a report from a nurse regarding an incident involving [R132] and a CNA (certified nursing assistant). Per the report [R132] was involved in a verbal altercation with [the] CNA. During the altercation the CNA stated, 'That's why your roommate was about to beat your [expletive] .
On 12/15/22 at 11:35 AM, R132 was interviewed regarding the incident related to the verbal altercation with the CNA, CNA H. R132 explained that CNA H came into their room to provide incontinence care. R132 explained that they advised CNA H that they prefer that only women provide care to them. R132 explained that a woman CNA did come to their room however, CNA H came back into the room with them. R132 explained that they asked CNA H if they were undercover a term implying that CNA H was gay (homosexual), and a verbal altercation ensued resulting in CNA H pulling down their mask and talking a lot of junk. R132 explained that they requested the nurse (Licensed Practical Nurse, LPN I) to come into the room to address the issue, and that LPN I heard CNA H being verbally disrespectful.
A review of R132's medical record revealed that they were admitted into the facility on 4/12/22 with diagnoses that include Quadriplegia, Diabetes, and Mood Disorder. A review of the Minimum Data Set assessment dated for 10/22/22 revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition, and required extensive assistance for bed mobility, toileting, and personal hygiene.
On 12/20/22 at 10:44 AM, LPN I was interviewed via phone and asked about the verbal altercation between R132 and CNA H. She explained that R132 had requested to speak to them and upon entering the resident's room, CNA H remained in the doorway of the resident's room. LPN I explained that she was attempting to obtain information from the resident however, CNA H kept interjecting to dispute what was being said by the resident. LPN I explained that the resident referenced CNA H being an undercover boy resulting in CNA H stating, That's why I heard your roommate was about to beat your [expletive]. LPN I explained that she sent CNA H home after that statement.
On 12/20/22 at 2:19 PM, CNA H was interviewed via phone and explained that the night of the incident, they were working a double and answered the call light for R132 who indicated that they did not want a male CNA, so they went and got the woman CNA. CNA H explained that R132 was being rude and nasty toward them and the woman CNA, who removed themselves from the room as a result. CNA H explained that R132 pushed their call light again, which they responded to at which point R132 continued to be rude and nasty requesting that the nurse come to the room. CNA H explained that R132 was talking to the nurse, exaggerating and making up lies. CNA H admitted to indicating to the nurse that what R132 was saying was not true as they stood in the doorway. CNA H indicated that they had heard about a previous incident between R132 and their previous roommate, and admitted to referencing that incident stating, This is the reason your last roommate was going to kick your butt. CNA H explained that they were sent home by the nurse, suspended for two weeks, and is currently awaiting a decision regarding employment from the facility.
A review of a complaint reported to the State Agency revealed the following, On 11/9/2022 received a report from ADON (Assistant Director of Nursing) that [R132] was 'disrespected' by a CNA. Per the report, CNA K referred to resident as 'a sorry [expletive] man.'
On 12/15/22 at 11:35 AM, R132 was interviewed regarding the incident related to the verbal altercation with CNA K. R132 explained that the CNA came into the room, and that they didn't want the CNA in the room as their assigned CNA because they had been working doubles. R132 explained that in response CNA K stated, That's why your family left you in here .I can go home and get in my car .God put you in here. R132 stated that CNA K worked with them a few more days following the incident before they reported it, and stated that the CNA remained disrespectful, and that when R132 would respond back, the CNA would tell them to Shut the [expletive] up.
On 12/20/22 at 3:22 PM, CNA K was interviewed via phone about the incident between them and R132. CNA K explained that they were working midnights, and went into R132's room to empty their urinal and check on their roommate. They reported that when they turned on the overhead light, R132 got mad and called them an expletive. CNA K explained that they told the resident that they had hurt their feelings. CNA K denied that they made disparaging or derogatory remarks to R132 and that they told the resident's assigned nurse what occurred. CNA K explained that they were recently fired from the facility as a result of the allegations against them.
On 12/20/22 at 3:44 PM, LPN L was contacted via phone to no avail however, a review of LPN L's statement located in the facility investigation revealed the following, Interviewed nurse, [LPN L] who reported that [R132] reported that CNA K was disrespectful telling [them] 'the Lord put [them] in here and [their] family does not want to take care of [them].' LPN L stated that CNA K admitted to saying that the Lord put [R132] in the nursing home. LPN L reported that [they] told CNA K that that [they] couldn't say that to a resident but CNA K did not seem [to] understand the implications of the statement.
A review of R132's care plan was reviewed and revealed the following, Focus: I have potential to demonstrate behaviors verbally secondary to a diagnosis of depression. I am argumentative with staff, will not let staff provide care and at times state staff make statements to me that are
not true. Non-compliant with skin assessments. Date Initiated: 09/20/2022. Revision on: 10/19/2022. Interventions: When I become agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and
approach later. Date Initiated: 09/20/2022 .
On 12/21/22 at 1:50 PM, the Director of Nursing (DON) was asked about her expectations when working with residents who demonstrate behaviors toward them, and she explained that the expectation is for staff to walk away and return once the resident is calm and to not go back and forth with them.
A review of the facility's Abuse, Neglect and Exploitation policy revealed the following, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Verbal abuse means the use of oral, written or gestured communication or sounds that willfully include disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability, to comprehend, or disability.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
This citation pertains to intake MI00133052.
Based on interview and record review, the facility failed to report an allegation of physical abuse to the state agency for one resident (R4) out of two re...
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This citation pertains to intake MI00133052.
Based on interview and record review, the facility failed to report an allegation of physical abuse to the state agency for one resident (R4) out of two reviewed for abuse, resulting in the delayed reporting and investigation of abuse allegations. Findings Include:
A review of complaint called into the State Agency noted the following, When (R4) is out [their] room too long, a staff member will grab [them] by the arm .
A review of R4's progress notes revealed the following,
12/8/2022 at 8:26 PM, Behavior Note: Please describe behavior that was observed and was it distressing to the resident: Every time I give patient inhaler [they] want to struggle to get the inhaler, [R4] said that I hit [them]. I did not hit [R4]. [R4] did swing on me and missed.
12/10/2022 at 5:46 PM, Behavior Note: Please describe behavior that was observed and was it distressing to the resident: [R4] has been saying that I hit [them] across the left side of [their] forehead. [R4] said that they are going to get me fired. [R4's] previous roommate (sic) said that [they] saw [R4] scratch [their] forehead, and say that [they] were going to report me .The incident happened on 12/8/2022.
On 12/20/2022 at 2:56 PM, an interview was conducted with the Nursing Home Administrator (NHA) regarding the abuse allegation. The NHA stated that when they received the notification, they completed the Facility Reported Incident (FRI) on 12/14/22. The NHA was queried regarding the progress notes and if they were reviewed on the 12/8/22 and 12/10/22 when they were entered. The NHA stated that they would have to look into it.
On 12/20/2022 at 3:01 PM, a phone call was made to the nurse that was involved with R4, and received no answer and unable to leave a voicemail.
On 12/21/2022 at 1:55 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the nurse never called to report that R4 stated that they hit them. The DON stated that the nurse received abuse training, including reporting allegations, and is suspended pending investigation. The DON stated that the nurse stated that they did not call to report it because they did not hit R4.
A review of a facility policy titled, Abuse, Neglect, and Exploitation noted the following, The facility will implement the following.1.Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies .within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a Level II evaluation was completed for one resident (R40) out of two reviewed for Preadmission Screening and Resident Review (PASAR...
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Based on interview and record review, the facility failed to ensure a Level II evaluation was completed for one resident (R40) out of two reviewed for Preadmission Screening and Resident Review (PASARR Screening), resulting in the potential for unmet mental health and psychiatric care needs. Findings Include:
A review of R40's PASARR Level I screening dated 12/29/2021 was completed and revealed that Section II, numbers 1,2,3, and 4 were checked and noted the following, Yes with the diagnosis of Mental Illness checked and included a diagnosis of Mood Disorder with mixed features. R40 was also taking antipsychotics at the time.
On 12/20/2022 at 9:06 AM, a request was made to for R40's Level II Screening. A reply via email was received stating that R40 did not need a Level II Screening.
On 12/20/2022 at 12:32 PM, an interview was completed with the Social Service Tech (SST) V regarding why R40 did not need a Level II screening and if their Level I screening was ever sent to Omnibus Budget Reconciliation Act (OBRA) for an evaluation. SST V stated that they were unsure if it was ever sent to OBRA for an evaluation and that they are not responsible for completing the Preadmission Screening and Resident Review (PASARR'S), the Director of Nursing (DON) completes them at this time.
On 12/21/2022 at 1:48 PM, an interview was conducted with the Director of Nursing regarding PASARR's and R40's Level II screening. The DON stated that someone from OBRA came in and gave them an in-service on how to complete them. The DON stated that some PASARR's did not pop up (populate) on the facility's end.
A review of a facility policy titled, Resident Assessment-Coordination with PASARR Program noted the following, .a.ii. Positive Level I Screen-necessitates a PASARR Level II evaluation prior to admission.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to update a Preadmission Screening and Resident Review (PASARR screening) for on resident (R4) out of two reviewed for PASARR screenings, result...
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Based on observation and interview, the facility failed to update a Preadmission Screening and Resident Review (PASARR screening) for on resident (R4) out of two reviewed for PASARR screenings, resulting in the potential for unmet mental health and psychiatric care needs. Findings Include:
A review of R4's PASARR Level I screening dated 9/28/2022 was completed and revealed that Section II, numbers 1 and 2 on the form were checked Yes with the diagnosis of Mental Illness checked and included a diagnosis of Schizoaffective Disorder, Bipolar Type. R4 was also taking antipsychotics at the time.
The note section of the form noted the following, Note: The person screened shall be determined to require a comprehensive Level II OBRA evaluation if any of the above items are Yes Unless a physician, nurse practitioner, or physician's assistant certifies on form DCH-3878 that the person meets at least on of the exemption criteria.
Further review of the PASSAR Level I screening dated 9/28/2022 revealed a hospital exempted discharge were checked and noted the following, Yes, I certify the patient under consideration: 1. Is being admitted after an inpatient medical hospital stay, AND 2. Requires nursing facility services for the condition for which he/she received hospital care, AND 3. Is likely to require less than 30 days of nursing services.
On 12/20/2022 at 9:06 AM, a request was made to for R4's Level II Screening. A reply via email was received stating that R4 did not need a Level II Screening.
On 12/20/2022 at 12:32 PM, an interview was completed with the Social Service Technician (SST) V regarding R4's PASSAR. SST V was queried as to whether R4's Level I screening was updated after they were in the facility longer than thirty days and if a updated Level I screening was sent to OBRA for a Level II. SST V stated that the PASARR did not get updated and that they did not know why because it should have been.
A review of a facility policy titled, Resident Assessment-Coordination with PASARR Program noted the following, 5. If a resident who has not screened due to an exception above and the resident remains in the facility longer than 30 days: a. The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID, or a related condition to the appropriate state designated authority or Level II PASARR evaluation and determination.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to revise and update a care plan for one sampled resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to revise and update a care plan for one sampled resident (R132) of three residents reviewed for care plans, resulting in an inaccurate plan of care, and unmet care needs. Findings include:
On 12/15/22 11:48 AM, an interview was completed with R132 regarding their splints not being worn, as they (the splints) were observed lying on a shelf above the bed. R132 explained that no one puts the splints on for them, and that their hands are feeling tight. R132 was also asked about the verbal altercation with the CNA, CNA H. R132 explained that CNA H came into their room to provide incontinence care. R132 explained that they advised CNA H that they prefer that only women provide care to them. R132 explained that a woman CNA did come to their room however, CNA H came back into the room with them. R132 explained that they asked CNA H if they were undercover a term implying that CNA H was gay (homosexual), and a verbal altercation ensued resulting in CNA H pulling down their mask and talking a lot of junk. R132 explained that they requested the nurse (Licensed Practical Nurse, LPN I) to come into the room to address the issue, and that LPN I heard CNA H being verbally disrespectful.
A review of R132's medical record revealed that they were admitted into the facility on 4/12/22 with diagnoses that include Quadriplegia, Diabetes, and Mood Disorder. A review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition, and required extensive assistance for bed mobility, toileting, and personal hygiene.
A review of R132's care plan revealed the following, Focus: I am participating in the Restorative
Nursing Program r/t (related to) Functional Status. Date Initiated: 05/03/2022. Interventions: Attend group ex's (exercise) program 2-3/wk (week) to maintain BUE /BLE/AAROM (bilateral upper extremities/ bilateral lower extremities/ active assisted range of motion) with stretching to
all joints of BUE x 15-20 rep as tolerated prior to application of Bil (bilateral) WHOs in order to
prevent further joint deformity. BLE exercises using 2# (pound) weights all major planes/joints
2 x20. 2-3/wk for 6 wks. Date Initiated: 05/03/2022. If I am not able or willing to participate in the Restorative Nursing Program, please attempt to try another time. Date Initiated: 05/03/2022. Revision on: 05/03/2022. Restorative tasks are assigned in POC (plan of care) as recommended by therapy or the Restorative Nurse. Date Initiated: 05/03/2022 .
Further review of R132's care plan revealed the following, Focus: I am having difficulty adjusting to the nursing home environment r/t Depression. I wish to return home but I require too much care for my family to care for me at home. I continue to complain about my care and the staff that is working with me although it has been addressed by the IDT team (Interdisciplinary Team). I will have arguments with the staff and will refuse for them to do my care Date Initiated: 08/05/2022 Revision on: 09/20/2022. Interventions: .I have 2 staff when in my room at all times. Date Initiated: 09/14/2022 .Provide me with as many situations as possible which give me control over my environment & care delivery. ASK ME WHAT I PREFER! Thank me for participating. Date Initiated: 08/05/2022 .
On 12/20/22 at 11:55am, a request for R132's restorative notes were requested from the facility, and was provided with the following progress note:
6/28/2022 15:07 (3:07pm) Nursing: Restorative Weekly Note: Restorative discontinued for splinting due to refusals writer informed resident of risk of not wearing splints to prevent further contractures stated, 'I hear what you're saying I don't want the splints.' Staff will continue to monitor .
On 12/20/22 at 10:44 AM, LPN I was interviewed regarding a verbal altercation between R132 and CNA H. LPN I explained that R132 prefers only women staff caring for them, and that their preference should be documented.
On 12/20/22 at 1:00 PM, R132 was asked if they had ever requested that only women nursing staff care for them. R132 explained that this was something requested when they were initially admitted into the facility, and that they were advised that their preference would be written down.
On 12/21/22 at 1:50 PM, the Director of Nursing (DON) was asked about R132's care plan reflecting that they were receiving restorative services when their progress notes indicates that it was discontinued. The DON stated, It (care plan) should have been resolved. Regarding R132's request for women only staff caring for them, the DON indicated that she was unaware of this.
A review of the facility's Care Planning policy was reviewed and revealed the following, .4. In the event that the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes shall be incorporated into an updated summary provided to the resident and his or her representative, if applicable. 5. The comprehensive care plan is developed from the RAI (resident assessment instrument) scheduled and is reviewed and revised by the IDT (interdisciplinary team) as necessary.
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** Deficient practice number 2.
Based upon interview and record review the facility failed to provide adequate incontinence care fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient practice number 2.
Based upon interview and record review the facility failed to provide adequate incontinence care for one (R33) of 31 sampled residents resulting in the potential for extended periods of the resident remaining wet and for skin breakdown. Findings include:
Review of the facility record for R33 revealed an admission date of 11/24/16 with diagnoses including, neurogenic bladder and bowel (lack of control), and muscle weakness. Minimum Data Set (MDS) dated [DATE] indicated R33 required total assistance for toileting/incontinence care.
On 12/15/22 at 9:56 AM, R33 reported that they cannot control their bladder and that other than during first shift when the regular aide is present they are not being changed in a timely manner resulting in being soaked through their brief and bedding sometimes for extended periods. R33 reported requesting to wear double briefs to reduce the soaking through but reported being told that the staff cannot apply double briefs.
On 12/15/22 at 3:52 PM, R33 reported that second shift staff regularly provide a change/cleaning after dinner. R33 reported that difficulty with call light response occurs with some aides but it does not pertain to a particular shift.
On 12/16/22 at 8:32 AM, R33 reported that they are concerned with being able to wear double briefs too avoid being soaked, particularly in instances like a planned visit with family members today during which they will be up in the lobby. R33 reported not wanting to become soaked through their clothing while up and visiting.
On 12/16/22 at 3:51 PM, R33 was observed sitting up in the wheelchair in the hallway. R33 reported they had just finished their visit with family. R33 reported making it through the visit without soaking through their clothing as staff applied double briefs. R33 reported that staff will apply double briefs if they are in the wheelchair but not when they are in bed.
On 12/20/22 at 9:47 AM, R33 reported that if they ask for double briefs on second shift that staff tell them they cannot double brief or they will lose their job.
On 12/21/22 at 9:00 AM, the facility Director of Nursing (DON) reported that the issue of double briefing a resident is not specifically addressed in a policy/procedure. The DON reported that the facility does double brief residents on a case by case basis based upon resident request and circumstance however the facility attempts to avoid this practice as it is considered a risk factor for skin breakdown. The DON reported being aware of R33's request for double briefing while up in the chair and especially during family visits to prevent resident embarrassment if they were to become soaked through their clothing. The DON reported that the expectation for care is that the resident would be checked and changed frequently enough to avoid extended periods of being wet. The DON expressed the intention to further address the issue of R33's medical interventions for bladder management, the frequency of afternoon and evening brief changes/cleaning and the possibility of additional double briefing if no better solution were identified. The DON acknowledged that the facility changed vendors/suppliers for briefs in the recent past and had received complaints from staff regarding brief quality as R33 had also reported/complained of.
On 12/21/22 at 12:20 PM, Certified Nurse Aide (CNA) P reported that a change in the quality of briefs was noticed in the recent past and that the current briefs become soaked through more easily.
On 12/21/22 at 12:30 PM, CNA Q reported that a change in brief quality was noticed and that the more recently available briefs are thinner and less absorbent.
On 12/22/22 at 10:20 AM, the DON reported the documentation for the CNA's to record incontinence care functions as follows: The time stamp under the corresponding date is the time that the CNA documented the task, and the corresponding columns that are check marked indicate whether incontinence care was completed during that shift, and frequency.
Record review of R33's incontinence care documented for the period of 11/22/22 - 12/21/22 revealed the following:
- No incontinence care is documented in the 19 hour period between 11:28 AM 11/24 and 6:22 AM 11/25.
- No incontinence care is documented in the 12 hour period on 11/26/22 between 9:43 AM and 10:08 PM.
- No incontinence care is documented in the 12 hour period on 11/27/22 between 9:58 AM and 9:50 PM.
- On 11/29/22 the 9:30 AM time stamp is checked not applicable indicating no incontinence care documented on first shift.
- No incontinence care is documented in the 9.5 hour period on 12/4/22 between 11:39 AM and 9:11 PM.
- No incontinence care is documented in an 18 hour period on 12/6 and 12/7/22 between 9:37 AM and 5:00 AM.
- No incontinence care is documented in a 20 hour period on 12/10 and 12/11/22 between 9:43 AM and 6:10 AM.
- On 12/15/22 only one occurrence of incontinence care is documented within the 24 hour period.
- On 12/18/22 only two occurrences of incontinence care are documented within the 24 hour period.
- On 12/19/22 only one occurrence of incontinence care is documented within the 24 hour period.
- On 12/20/22 only one occurrence of incontinence care is documented within the 24 hour period.
On 12/20/22 at 3:34 PM, an ADL (activities of daily living) care policy was requested from the facility but was not received prior to survey completion on 12/21/22.
This citation has two Deficient Practice Statements.
Based on interview, and record review, the facility failed to provide showers to one resident (R134) out of two reviewed for showers, resulting in feelings of frustration and dissatisfaction with care, based on the reasonable person concept. Findings Include:
A review of the medical record revealed that R134 admitted into the facility on 4/22/2022 with the following diagnoses, Cerebral Infarction, Metabolic Encephalopathy, Muscle Weakness, and Muscle Wasting and Atrophy. A review of the Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status score of 9/15 indicating an impaired cognition. R134 also required total two-person dependence with bed mobility and transfers.
A review of shower documentation for the last thirty revealed that R134 received only bed baths on the following days, 11/25/22,12/2/22,12/9/22,12/16/22, and 12/20/22.
On 12/21/2022 at 1:39 PM, an interview was conducted with the Director of Nursing (DON) regarding when bed baths should be given. The DON stated that if a bed bath is the preference, then it should be documented, and care planned.
A review of R134's care plan did not show that bed baths were a preference for R134.
A review of the progress notes did not show any shower refusals.
No further shower documentation was provided prior to exit of survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to arrange appointments for vision care for one sampled ...
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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 arrange appointments for vision care for one sampled resident (R125) of one resident reviewed for vision concerns, resulting in inadequate accommodation of vision needs. Findings include:
On 12/15/22 at 1:49 PM, R125 was observed in their room sitting on their bed. They were asked about their stay in the facility, and explained that they wore prescription glasses prior to their admission to the facility, and had yet to be seen by an eye doctor.
A review of R125's medical record revealed that they were admitted into the facility on 2/17/22 with diagnoses that included Sarcopenia, Diabetes, and Depression. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has a Brief Interview for Mental Status score of 15/15 indicating an intact cognition, and was independent for Activities of Daily Living (ADL's).
Further review of R125's physician's orders revealed an order dated for 2/17/22 indicating the following, Optometrist, Ophthalmologist, Podiatrist and/or Dentist for evaluation and treatment PRN (as needed).
Further review of R125's medical record revealed the following progress note:
3/1/2022 10:41 (10:41am)
Social Service admission Note Late Entry . Resident has no issues with hearing and wears reader glasses which are effective Resident stated [they need] glasses, but [will] utilize reader until [they] receive [their] glasses .
On 12/20/22 at 11:55 AM, vision exams for R125 were requested from the facility however, documentation was not received by the end of the survey.
On 12/21/22 at 12:46 PM, an interview was completed with Social Worker G regarding the process in which residents receive ancillary (vision, hearing, dental, etc.) services. Social Worker G explained the process, and admitted that the social work department had a staff shortage which resulted in some residents missing their ancillary services.
On 12/21/22 at 1:50 PM, the Director of Nursing (DON) was interviewed regarding R125's missing vision services. The DON explained that they could not locate a record of the services, and is unsure why this happened.
On 12/20/22 at 9:07 AM, a policy on ancillary services was requested from the facility, and was advised that the facility did not have a policy on ancillary services.
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 implement pressure ulcer interventions per the plan o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement pressure ulcer interventions per the plan of care for two residents (R74 and R75) of four reviewed for pressure ulcers, resulting in the potential for worsening of existing pressure ulcers or the development of new wounds. Findings include:
Resident #74 (R74)
A review of R74's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was initially admitted into the facility on 8/15/22 and re-admitted on [DATE] with medical diagnoses of Diabetes, Hypertension, Neurogenic Bladder, Alzheimer's Disease, Seizure Disorder, Malnutrition, Gastrostomy Status, Psychotic Disorder, and Schizophrenia. Further review revealed that the resident is severely cognitively impaired and totally dependent on staff for all activities of daily living (ADLs).
On 12/15/22 at 10:25 AM, R74 was observed lying in bed on their back. A tube feeding pole was next to the bed and the resident was observed to have a urinary catheter. R74 appeared thin, was confused and unable to state their name or appropriately respond to interview questions. No heel protectors were present on the resident's feet nor seen in the room.
On 12/15/22 at 12:55 PM, R74 remained lying in bed on their back. A blue, triangular positioning wedge was observed slightly under R74's right side, however, it was not offloading pressure from the resident's back/behind. No heel protectors were present on the resident's feet nor seen in the room.
On 12/15/22 at 3:50 PM, R74 remained lying in bed on their back. The positioning wedge was no longer in place. No heel protectors were present on the resident's feet nor seen in the room.
On 12/16/22 at 9:00 AM, R74 was observed lying in bed on their back. No heel protectors were present on the resident's feet nor seen in the room.
On 12/16/22 at 1:25 PM, R74 remained lying in bed on their back. A blue, triangular positioning wedge was observed slightly under R74's right side, however, it was not offloading pressure from the resident's back/behind. No heel protectors were present on the resident's feet nor seen in the room and the resident's bare heels were noted to be lying on the mattress.
On 12/16/22 at 2:14 PM, R74 remained lying in bed on their back. A blue, triangular positioning wedge was observed slightly under R74's right side, however, it was not offloading pressure from the resident's back/behind. No heel protectors were present on the resident's feet nor seen in the room.
On 12/16/22 at 3:56 PM, R74 remained lying in bed on their back. A blue, triangular positioning wedge was observed slightly under R74's right side, however, it was not offloading pressure from the resident's back/behind. No heel protectors were present on the resident's feet nor seen in the room.
On 12/20/22 at 9:42 AM, R74 was observed lying in bed on their back. A blue, triangular positioning wedge was observed slightly under R74's right side, however, it was not offloading pressure from the resident's back/behind. No heel protectors were present on the resident's feet nor seen in the room.
On 12/20/22 at 10:00 AM, R74 remained lying in bed on their back. No heel protectors were present on the resident's feet nor seen in the room.
On 12/20/22 at 10:06 AM, the Wound Care Nurse (WCN) was interviewed while waiting for assistance to perform R74's wound care treatment. The WCN stated that R74 was admitted into the facility with a wound on the sacrum that is still present but has shown improvement.
On 12/20/22 at 10:09 AM, Certified Nursing Assistant (CNA) U joined to assist the WCN. When asked if the resident is supposed to wear heel protector boots, CNA U indicated that the resident does have some, but they could not be located on the resident or in the room. The WCN confirmed this and indicated that R74 has resolved skin alterations on the right heel. The WCN further indicated that she would have to see if the boots were taken down to laundry to be washed. When queried if R74 needs to be turned and repositioned, CNA U responded, Yes, every two hours, but also indicated that R74 could somewhat move themselves in bed. Upon completing wound care for R74's sacral pressure ulcer, staff placed the blue wedge back on the resident's right side, however, the wedge was not offloading pressure.
On 12/20/22 at 3:15 PM, R74 remained lying in bed on their back. A blue, triangular positioning wedge was observed slightly under R74's right side, however, it was not offloading pressure from the resident's back/behind.
A review of R74's care plan revealed:
-Focus: I have a Pressure Injury, Stage: 4; Location: sacral, (present on admission. Contributing factors DM (Diabetes Mellitus), Limited mobility, Alzheimer's Disorder, Schizoaffective Disorder, Neuromuscular Dysfunction of the bladder, Moderate protein calorie malnutrition .Date Initiated: 08/16/2022 .Revision on: 12/15/2022.
-Focus: I am at risk for impaired skin integrity r/t (related to) Hx. (history) of pressure injury and current pressure injury on admission. DM, Limited mobility, Alzheimer's Disorder, Schizoaffective Disorder, Neuromuscular Dysfunction of the bladder, Moderate protein calorie malnutrition .Date Initiated: 08/16/2022 .Revision on: 12/15/2022.
-Intervention: Assist me to turn &/or reposition routinely during CNA rounds while in bed and frequently redistribute my weight if/when I am up in my chair. Date Initiated: 08/18/2022 .Revision on: 12/15/2022.
-Intervention: Ensure appropriate protective devices are applied to affected areas. heel protectors bilat. (bilateral) feet. Wedges/pillows behind back to support while positioned on side/elevate feet off bed. LAL (low air-loss) Mattress. Date Initiated: 12/12/2022 .Revision on: 12/19/2022.
-Intervention: SKIN INTERVENTIONS-Has LAL Mattress to bed ATC (around-the-clock) please check for proper function keep plugged in, check setting, check mattress for deflation, notify Nurse if bed alarms going off. Ensure appropriate protective devices are applied to affected areas. heel protectors bilat. feet. Wedges/pillows behind back to support while positioned on side/elevate feet off bed. Date Initiated: 08/23/2022 .Revision on: 12/19/2022.
Resident #75 (R75)
A review of R75's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was initially admitted into the facility on 1/22/19 and re-admitted on [DATE] with medical diagnoses of Anemia, Hypertension, Stroke, Aphasia, Neurogenic Bladder, Respiratory Failure, and Malnutrition. Further review revealed that the resident is severely cognitively impaired and totally dependent on staff for all activities of daily living (ADLs).
On 12/15/22 at 10:22 AM, R75 was observed lying in bed with their head slightly elevated. R75 was observed to have a tracheostomy, and a tube feeding pole was noted next to the bed. R75's legs and arms appeared to be contracted and the resident was unable to respond to interview questions. No positioning/offloading devices or pillows were noted to be in use.
On 12/15/22 at 12:52 PM, R75 was observed lying in bed with their head slightly elevated and slightly turned towards the right side. No positioning/offloading devices or pillows were noted to be in use.
On 12/15/22 at 3:50 PM, R75 was observed lying in bed with their head slightly elevated and slightly turned towards the right side. No positioning/offloading devices or pillows were noted to be in use.
On 12/16/22 at 9:00 AM, R75 was observed lying in bed with their head slightly elevated and slightly turned towards the right side. No positioning/offloading devices or pillows were noted to be in use.
On 12/16/22 at 1:25 PM, R75 was observed lying in bed with their head slightly elevated and slightly turned towards the right side. No positioning/offloading devices or pillows were noted to be in use.
On 12/16/22 at 2:14 PM, R75 was observed lying in bed with their head slightly elevated and slightly turned towards the right side. No positioning/offloading devices or pillows were noted to be in use.
On 12/16/22 at 3:56 PM, R75 was observed lying in bed with their head slightly elevated and slightly turned towards the right side. No positioning/offloading devices or pillows were noted to be in use.
On 12/20/22 at 9:42 AM, R75 was observed lying in bed with their head slightly elevated and slightly turned towards the right side. No positioning/offloading devices or pillows were noted to be in use.
A review of R75's care plan revealed:
-Focus: I am at risk for pressure ulcer injury r/t (related to) risk for moisture d/t (due to) incontinence, nutritionally at risk, risk for shear & friction, PVD (peripheral vascular disease), hx (history) of pressure injuries, fragile skin, trach site, lower and upper extremity contractures, due to co-morbidities pressure ulcer injury may be considered unavoidable. Date Initiated: 07/12/2022 .Revision on: 12/19/2022.
-Focus: I have actual impairment to skin integrity r/t abrasion to right elbow, left groin abscess with hx. of stage 2 pressure ulcer to posterior neck to Mid (L) posterior neck to (R) post. and lateral neck, to which neck wounds have resolved . Will continue to assess healed neck wounds d/t trach ties always being securely in place. Date Initiated: 08/18/2022 .Revision on: 12/06/2022.
-Intervention: Wedges/pillows when repositioning to assist with off loading pressure. Date Initiated: 07/12/2022 .Revision on: 07/12/2022.
-Intervention: Reposition frequently use pillows and wedges to assist with off loading pressure. LAL Mattress. Date Initiated: 08/18/2022 .Revision on: 12/19/2022.
On 12/21/22 at 1:38 PM, the Director of Nursing (DON) was interviewed. When queried regarding pressure ulcer preventative measures for R74 and R75, the DON stated, Both [residents] have in the care plan that they should be turned and repositioned and have offloading devices.
A review of the facility's policy/procedure titled, Wound Treatment Management and Documentation, revised 07/21, revealed, To promote healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders .
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 F0699
(Tag F0699)
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 include the PTSD (post traumatic stress disorder) diagn...
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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 include the PTSD (post traumatic stress disorder) diagnosis and specific interventions in the active comprehensive care plan for one sampled resident (R133) of 31 sampled residents whose care plans were reviewed, resulting in the potential for re-traumatization. Findings include:
On 12/15/22 at 10:02 AM, R133 was observed to be dressed and seated in the main dining room. R 133 was calm and answered yes no questions. R133 was asked about their time spent at the facility and expressed no concerns.
A review of the facility record for R133 revealed R133 was admitted into the facility on [DATE]. Diagnoses included PTSD, Anxiety Disorder, Bipolar Disorder, Depression and Drug Abuse.
The active care plan dated 04/03/22 documented I use anti-depressant medication related to depression .I use anti-anxiety medication due to anxiety disorder . The I use anti-psychotic medications related to Behavior management due to Schizoaffective, PTSD, Date Initiated: 04/03/2022 was documented as resolved. The I have the potential for a nutritional/hydration problem care plan revised 12/20/22 documented, I have history of poly-substance abuse, bipolar, depression, PTSD and I am on medication to help stabilize my mood which has side effects which could affect my weight, appetite and mood . Further review of the care plan and [NAME] did not reveal documentation of potential triggers which could lead to re-traumatization.
A review of the behavior management consultant notes documented the PTSD in some but not all the visit notes and a visit conducted due to thoughts of suicide but did not indicate specific triggers.
A review of the admission Minimum Data Set (MDS) assessment revealed documentation of the PTSD diagnosis.
On 12/20/22 at 12:33 PM, Social Worker (SW) G was asked about the care of R133 and the PTSD diagnosis and reported a resident admitted with a PTSD diagnoses would be evaluated by the psychological services consultant and interventions would be put in place and the resident monitored. SW G was asked to review the consultant notes for information related to assessment of the PTSD event and potential triggers and interventions and no additional documentation was provided. SW G reported they had not had any training for staff.
On 12/20/22 at 12:36 PM, Nurse C was asked about R133 and reported they were not that familiar with R133 and had only cared for R133 once or twice but had not identified any concerns.
On 12/20/22 at 12:39 PM, (Certified Nursing Assistant) CNA B was asked about the care of R133 and reported no behavioral, concerns for R133. CNA B was not aware of R133's specific diagnoses. CNA B was asked about mental health training and trauma informed care and reported they thought the facility should do more training.
On 12/20/22 at 12:45 PM the Director of Nursing (DON) was asked about education of staff related to trauma informed care and reported that the training was newer and had been added to orientation for new hires. The DON was asked about a care plan to address R133's PTSD diagnosis and potential triggers training and indicated there should be person centered interventions for care.
A review of the facility policy titled, Trauma Informed Care revised 01/21, revealed, 4. The facility will account for resident's experiences, preferences and cultural differences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.
A review of the facility policy titled, Care Planning implemented 11/2016 revealed, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure that a physician responded to pharmacist monthly medication regimen reviews (MRR) recommendations timely for one resident (R40) out ...
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Based on interview and record review, the facility failed to ensure that a physician responded to pharmacist monthly medication regimen reviews (MRR) recommendations timely for one resident (R40) out of one reviewed for MMR's, resulting in the potential for the continuance of unnecessary medications and lack of communication of recommended medication changes. Findings Include:
A review of pharmacy progress notes for the year of 2022 revealed, see report for any noted irregularities was checked for the following months, April, June, July, August.
A request was made for the MRR irregularity reports for April, June, July, and August (2022).
The MRR irregularity report was received for the months of April and July. No other MRR irregularity reports were received by the end of survey.
On 12/20/2022 at 2:30 PM, an interview was conducted with the Director of Nursing (DON) regarding MRR's. The DON stated that they could not find the reports for June and August. No further information was provided.
A review of a policy titled, Medication Monitoring noted the following, F. Resident-Specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the resident's medical record and reported to the attending physician, the Director of Nursing, the Medical Director, and if appropriate, the Administrator. G. The Consultant Pharmacist's recommendations are acted on by the prescriber and/or the facility's nursing staff .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
On 12/20/2022 at 1:51 PM, the back C Wing medication cart was observed with Nurse W. While observing medications a bottle of Hydralazine (blood pressure medication) 25 milligrams was found in the top ...
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On 12/20/2022 at 1:51 PM, the back C Wing medication cart was observed with Nurse W. While observing medications a bottle of Hydralazine (blood pressure medication) 25 milligrams was found in the top drawer. The medication had a note that stated the following, discard after 12/17/2022.
Nurse W confirmed that the medication stated to discard after 12/17/2022 and removed the bottle from the medication cart.
A review of a facility policy titled, Medication Monitoring did not address medication storage and labeling.
Based on observation, interview and record review the facility failed to date insulin pens and inhalers when opened and discard expired medication in three of four medications carts reviewed resulting in the potential for decreased efficacy of medications and the use of expired medications. Findings include:
On 12/16/22 at 8:25 AM, the low one hundred unit medication cart had: three Novolog insulin pens, one Humalog insulin pen, and one Basalgar insulin pen, a Serevent diskus inhaler and two glucose strips containers not dated when opened.
On 12/16/22 at 12:11 PM, the middle one hundred unit medication cart had an one lantus insulin pen, not dated when opened.
A review of the package insert for the Serevent Diskus revealed it should be stored inside the unopened moisture-protective foil pouch and only removed from the pouch immediately before initial use. Discard Serevent Diskus 6 weeks after opening the foil pouch or when the counter reads 0 (after all blisters have been used), whichever comes first. The inhaler is not reusable. Do not attempt to take the inhaler apart.
A review of the prescribing information for the lantus pen revealed, Only use your pen for up to 28 days after its first use. Throw away the Lantus SoloStar pen you are using after 28 days, even if it still has insulin left in it.
A review of the prescribing information for the humalog pen revealed, Humalog prefilled pens should be stored at room temperature and must be used within 28 days or be discarded, even if they still contain Humalog.
A review of the prescribing information for the novolog pen revealed, Unopened vials should be thrown away after 28 days, if they are stored at room temperature. Throw away all opened NovoLog® vials after 28 days, even if they still have insulin left in them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
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 arrange appointments for dental care for one sampled ...
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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 arrange appointments for dental care for one sampled resident (R125) of one resident reviewed for dental concerns, resulting in inadequate accommodation of vision needs. Findings include:
On 12/15/22 at 1:49 PM, R125 was observed in their room sitting on their bed. They were asked about their stay in the facility, and explained that they hadn't seen a dentist since admission to the facility, and would like to have their teeth cleaned.
A review of R125's medical record revealed that they were admitted into the facility on 2/17/22 with diagnoses that included Sarcopenia, Diabetes, and Depression. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has a Brief Interview for Mental Status score of 15/15 indicating an intact cognition, and was independent for Activities of Daily Living (ADL's).
Further review of R125's physician's orders revealed an order sated for 2/17/22 indicating the following, Optometrist, Ophthalmologist, Podiatrist and/or Dentist for evaluation and treatment PRN (as needed).
Further review of R125's medical record did not reveal any dental records for R125.
On 12/20/22 at 11:55 AM, dental exam documentation for R125 were requested from the facility however, documentation was not received by the end of this survey.
On 12/21/22 at 12:46 PM, an interview was completed with Social Worker G regarding the process in which residents receive ancillary services. Social Worker G explained the process, and admitted that the social work department had a staff shortage which resulted in some residents missing their ancillary services.
On 12/21/22 at 1:50 PM, the Director of Nursing (DON) was interviewed regarding R125's missing dental services. The DON explained that they could not locate a record of the services, and is unsure why this happened.
On 12/20/22 at 9:07 AM, a policy on ancillary services was requested from the facility, and was advised that the facility did not have a policy on ancillary services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure that four (identified as Certified Nursing Assistant (CNA) W, X, Y, and Z out of five reviewed for required 12 hours of in-service t...
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Based on interview and record review, the facility failed to ensure that four (identified as Certified Nursing Assistant (CNA) W, X, Y, and Z out of five reviewed for required 12 hours of in-service training, resulting in the potential for unmet education needs, unmet resident care needs, and the potential for inadequate care. Findings Include:
On 12/21/2022 at 8:00 AM, a request was made for the annual 12-hour training for CNA W, X, Y, and Z.
On 12/21/2022 at 11:28 AM, an interview was conducted with the Director of Nursing (DON) regarding the annual 12-hour training. The DON stated that the website they use for the training has been down for the past two weeks, so they are unable to show that the education has been completed at this time. The DON stated that they had communication out to try and get the record of the education.
No further information was provided prior to the end of survey.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0563
(Tag F0563)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure unrestricted, 24-hour visitation for all 146 re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure unrestricted, 24-hour visitation for all 146 residents residing in the facility resulting in residents verbalizations of not being able to visit with family, anger, and sadness. Findings include:
On 12/15/2022 at 8:45 am, during the initial entry of the facility, signage was posted at the receptionist desk noting the following:
May 3, 2022
Attention Families, Guardians and Responsible Parties:
ALL visitations are during the times of 12:30 PM-6:00 PM. Each visitor must be out of the building by 6:45PM .There will only be TWO (2) visitors allowed per visitation time and children under [AGE] years of age are not allowed.
On 12/20/2022 at 10:25 AM, the resident council was held. Resident (R)130 said, We can only have visitors during 12:30 PM and 6 PM .That makes me so mad because my people work and can't come at that time . R115 said, I'm mad too because my son is six years old and is not allowed in the building .I'm so upset. R43 said, They wouldn't let my grandson in, and he had to stay in the car. R43 became tearful.
On 12/20/2022 at 11:15 AM, The receptionist at the reception desk was interviewed and queried about visiting hours and pointed to the document and reported that visiting hours were from 12:30 to 6 PM. The Nursing Home Administrator (NHA) was interviewed and queried about the document and visitation from 12:30 PM-6:00 PM. The NHA said, I don't know nothing about that .I've only been here for about three months.
A review of R130, R115, and R43 medical records had a document dated 7/4/2022, that noted the following:
(Name of nursing facility) families just a reminder about visitation/LOA (Leave of Absence). Visiting starts at 12:30 PM daily unless arrangements have been made with DON (Director of Nursing)/Administrator .
A review of the facility's policy Residents Rights dated /revised on 8/21, noted the following:
The resident has a right to receive visitors of his or her choosing at the time of his or her choosing .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0576
(Tag F0576)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure the resident right to privately and confidentially packages potentially affecting all 146 Residents who reside in the ...
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Based on observation, interview, and record review, the facility failed to ensure the resident right to privately and confidentially packages potentially affecting all 146 Residents who reside in the facility, resulting in resident mail and packages being opened by the facility prior to delivery to the resident, and a loss of personal privacy, anger, and independence. Findings include:
On 12/15/2022 at 8:45 am, during the initial entry of the facility, signage was posted at the receptionist desk noting the following:
May 3, 2022
Attention Families, Guardians and Responsible Parties:
ALL visitations are during the times of 12:30 PM-6:00 PM. Each visitor must be out of the building by 6:45 PM .All packages must be inspected prior to resident receiving any items to ensure the items are allowed in the facility .
On 12/20/2022 at 10:25 AM, the resident council was held. Resident (R)115 said, I'm mad because (Business Office Coordinator R) opened my social security check .(they) said I need to put it into their bank here, but I have my own bank account .they open our packages too .
On 12/20/2022 at 11:15 AM, The Nursing Home Administrator (NHA) was interviewed and queried about opening Residents mail/packages and the document at the receptionist desk. The NHA said, I don't know nothing about that .I've only been here for about three months. Business Office Coordinator R was interviewed and asked if they opened residents mail and they said, Oh no. The Business Office Coordinator was queried about opening Residents' mail/packages and said, During that time we had reasons for opening mail and packages .some of them were bringing in stuff that's not allow .we had reasons.
A review of the facility's policy Residents Rights dated /revised on 8/21, noted the following:
The resident has a right . to receive mail, and to receive letters, packages and other materials delivered to the facility for the resident .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure failed to ensure food items were labeled, dated, and properly store personal items, resulting in the increased potenti...
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Based on observation, interview, and record review, the facility failed to ensure failed to ensure food items were labeled, dated, and properly store personal items, resulting in the increased potential for foodborne illnesses. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include:
On 12/15/2022 at 9:07 AM, an initial tour of the kitchen was conducted. In the food preparation area, the following seasonings and condiment were opened and undated: chopped chives, poultry seasoning, and mustard. In addition, a half loaf of bread was observed opened undated.
On 12/15/2022 at 9:30 AM, At least three staff coats were observed hanging on food racks next to food in the storage room. The Director of Nutrition Services was interviewed and asked about the opened and undated seasonings and mustard they said, I will make sure they (seasonings and condiment) are dated .they do not have space in the employee lounge for their coats.
A review of the facility's policy Food Storage dated 05/25/07 and revised on 01/2021 noted the following: 7. Food items that are opened shall be put into sealable container or bag, labeled, and dated with open and use-by-date.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to provide documentation of at least quarterly meetings held by the Quality assessment and assurance (QAA) committee, affecting all residents ...
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Based on interview and record review, the facility failed to provide documentation of at least quarterly meetings held by the Quality assessment and assurance (QAA) committee, affecting all residents residing in the facility, and resulting in the potential for unidentified quality deficiencies with a lack of response and corrective action. Findings include:
On 12/21/22 at 11:00 AM, review of the Quality Assurance Performance Improvement (QAPI) task was conducted with the facility's current Nursing Home Administrator (NHA). The NHA indicated she had only been at the facility since September 2022. When asked to review the sign-in sheets for the QAA committee meetings since the last recertification survey (5/5/2021), the NHA stated, The sign-in sheets aren't together. The NHA indicated there have been QAA committee meetings since the last recertification survey, but that she was unable to establish when they were held due to lack of documentation. The facility was afforded multiple opportunities prior to exit to present proof of at least quarterly QAA committee meetings, however, nothing was received.
A review of the facility's policy/procedure titled, Quality Assurance and Performance Improvement, revised 10/22, revealed, .The QA Committee shall be interdisciplinary and shall .meet as least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary .
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 38% turnover. Below Michigan's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 2 life-threatening violation(s), 1 harm violation(s), $193,864 in fines, Payment denial on record. Review inspection reports carefully.
- • 67 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $193,864 in fines. Extremely high, among the most fined facilities in Michigan. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Mission Point Nursing & Physical Rehabilitation Ce's CMS Rating?
CMS assigns Mission Point Nursing & Physical Rehabilitation Ce an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Michigan, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Mission Point Nursing & Physical Rehabilitation Ce Staffed?
CMS rates Mission Point Nursing & Physical Rehabilitation Ce's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 38%, compared to the Michigan average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Mission Point Nursing & Physical Rehabilitation Ce?
State health inspectors documented 67 deficiencies at Mission Point Nursing & Physical Rehabilitation Ce during 2022 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 63 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Mission Point Nursing & Physical Rehabilitation Ce?
Mission Point Nursing & Physical Rehabilitation Ce is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by MISSION POINT HEALTHCARE SERVICES, a chain that manages multiple nursing homes. With 178 certified beds and approximately 120 residents (about 67% occupancy), it is a mid-sized facility located in Warren, Michigan.
How Does Mission Point Nursing & Physical Rehabilitation Ce Compare to Other Michigan Nursing Homes?
Compared to the 100 nursing homes in Michigan, Mission Point Nursing & Physical Rehabilitation Ce's overall rating (2 stars) is below the state average of 3.1, staff turnover (38%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Mission Point Nursing & Physical Rehabilitation Ce?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the substantiated abuse finding on record.
Is Mission Point Nursing & Physical Rehabilitation Ce Safe?
Based on CMS inspection data, Mission Point Nursing & Physical Rehabilitation Ce has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Michigan. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Mission Point Nursing & Physical Rehabilitation Ce Stick Around?
Mission Point Nursing & Physical Rehabilitation Ce has a staff turnover rate of 38%, 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 Mission Point Nursing & Physical Rehabilitation Ce Ever Fined?
Mission Point Nursing & Physical Rehabilitation Ce has been fined $193,864 across 4 penalty actions. This is 5.5x the Michigan average of $35,018. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Mission Point Nursing & Physical Rehabilitation Ce on Any Federal Watch List?
Mission Point Nursing & Physical Rehabilitation Ce 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.