Bay Shores Senior Care and Rehab Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area, resulting in the potential to spread food borne illness to all residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an active plan for reducing the risk of l\Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens being allowed to exist and spread in the facility's plumbing system with an increased risk of respiratory infection among all residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were treated in a dignified and respectful manner by respond to call lights timely and complaints of Staff cell phone use in resident care areas for anonymous resident council residents and residents ( #1, #12, #13, #90, #46, #117, #138) resulting in a lack of timely response of care needs, extended wait times for assistance, and residents verbalizations of discourteous staff, feelings of being a burden, frustration and sadness.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate indication of a psychotropic/antidepressant drug dosage for 4 residents (#2, #9, #94, and #138), resulting in the facility's failure to fully inform the resident or responsible party by obtained signed consents with no medication dosage noted, doses per day or the route of the medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure that annual Preadmission Screening and Resident Review (PASARR) assessments were completed for 4 residents (#2, #46, #113, #116) of 8 residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to operationalize policies and procedures for safe medication storage for two residents (# 29 and #90) of two residents and one ([NAME] One) of four medication carts reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a pummel cushion (wheelchair cushion with a raised wedge in the center) was used for the treatment of documented medical symptoms for one resident (Resident #88) of one resident reviewed for restraints, resulting in a lack of a clear indication for use and ongoing assessment/reassessment for use.

Inspectors wroteBased on interview and record review, the facility failed to transmit a Minimum Data Set assessment (MDS) for one resident (Resident #108) of one resident reviewed for resident assessments.

Inspectors wroteBased on observation, interview and record review, the facility failed to store nebulizer equipment in a sanitary manner for one resident (R11) of one resident reviewed for respiratory care.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) Provide antiviral medication timely for one resident (Resident #61), 2) Ensure barrier use, and 3) Ensure reusable medical equipment was sanitized prior to clean storage, resulting in influenza symptoms going untreated, contamination of medication cart with the likelihood of continued contamination.

Inspectors wroteBased on observation, interview and record review the facility to accurately code the MDS (Minimum Data Set) for one resident (#24) and properly reflect one resident's (#61) pertinent care categories on the CMS (Centers for Medicare and Medicaid) 802 form of 22 residents reviewed for assessment accuracy, resulting in Resident #24 being miscoded as utilizing restraints on the MDS and Resident #61's infection not being designated on the CMS 802.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure timely assessment of transfer/mobility status for one resident (Resident #315) of four residents reviewed for care planning, resulting in unsupervised self-ambulation and transfer and an incomplete baseline care plan.

Inspectors wroteBased on observation, interview and record review, the facility failed to update care plan interventions for 3 residents (R23, R24, R164) of 4 residents reviewed, resulting in the likelihood for missed interventions in treatment and unmet needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide Activities of Daily Living (ADL) for one resident (R164) of 18 residents reviewed for ADL care, resulting in residents feeling frustrated, anger, embarrassment from poor hygiene, unmet needs and complaints to the state surveyor.

Inspectors wroteThis Citation pertains to Intake Number MI00150074. Based on observation, interview and record review, the facility failed to ensure timely completion of wound care for one resident (Resident #93) of one resident reviewed for dressing changes, resulting in missed wound care treatments, not following physician's orders and voiced frustration.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to prevent pressure ulcer (wounds caused by pressure) development and worsening for two residents (#4 and #217) of two residents reviewed resulting in Resident #4's Stage II (partial thickness loss of first and second layer of skin) pressure ulcer progressing to a Stage IV (full thickness tissue loss with exposed bone, tendon or muscle), and Resident #217 developing an unstageable Deep Tissue Injury (DTI- pressure ulcer with unknown depth), unnecessary pain and the potential for decline in overall health.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide feeding assistance for Resident #43 and to prevent weight loss for Resident #23, resulting in Resident #43 to be observed with no dining assist at bedside and Resident #23 experiencing a 10 pound weight loss.

Inspectors wroteThis Citation pertains to Intake Numbers MI00149163 and MI00149254. Based on interview and record review the facility failed to ensure appropriate indication of a psychotropic drug dosage increase for one resident (Resident #47) and failed to ensure informed consent was obtained prior to administration of psychotropic medications for one resident (Resident #46) of four residents reviewed for unnecessary medications, resulting in Residents #46 and #47 bring administered antipsychotic medications without appropriate consent and risk versus benefit analysis of the medications explained to the resident/responsible party and the increased potential for serious side effects and adverse reactions . Assessment and Documentation: (c.) (ii.) Informed consent forms the resident and/or responsible party along with education regarding potential side-effects .

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper insulin administration and provide the proper medication dosage for two residents (Resident #57, Resident #164) of five residents reviewed for medication administration, resulting in unsafe injection practices, the uncertainty of an accurate insulin dose administered and improper medication reconciliation after hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe medication storage for one medication cart of four medication carts reviewed during the medication storage task, resulting in medications stored unlabeled in a clear plastic medication cup.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control practices related to the use of: (1.) Personal Protective Equipment (PPE), follow-up with employee health call-ins and (2.) proper hand hygiene, clean accu-check machine properly during medication pass and keep wound vac tubing off floor resulting in the likelihood for cross contamination and prolonged illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the dignity of 6 residents (#21, #75, #65, #79, #151, and #148) and 4 of 4 residents from the confidential resident group, by answering call lights in a dignified and timely manner, resulting in verbalizations of anger, frustration, and fear, with the likelihood for falls with injuries and hospitalization. Findings Include: Resident # 75: Review of the Face Sheet, Minimum Data Set (MDS, dated [DATE]), nurse's and physician notes dated 1/24 through 2/24, revealed, Resident #75 was 94 years-old, admitted to the facility on [DATE], had cognitive decline and required staff assistance with all Activities of Daily Living (ADL's). The residents diagnosis included, Anxiety Disorder, [NAME] Lymphoma, Mood Disorder, Embolism and Thrombosis, Dementia, Hearing Loss and age related debility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that three Certified Nurse Assistant and three licensed nurses yearly performance reviews were conducted, resulting in the lack of yearly job performance evaluation for 6 of 8 staff reviewed.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 97 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and/or develop a care plan for two (R#6, R#59) Residents, resulting in Resident #6 to have a cardiac pacemaker with no interventions for pacemaker checks/follow-up and Resident #59 to not receive showers/bathes as care planned for twice weekly with likelihood for missed care intervention.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards, to ensure 1) medications were not left at the bedside for 1 resident (Resident #88) who verbalized she chocked on a medication, 2) to document the incident on the facility occurrence report, and 3) to make a swallowing referral for further evaluation of change of condition, resulting in verbalization of fear of chocking on medications. Findings Include: Review of the Face Sheet, nursing notes dated 2/1/24 through 2/7/24, physician orders dated 1/11/23 through 1/11/24, revealed Resident #88 was 69 years-old, alert with confusion, admitted to the facility on [DATE], and required staff assistance with Activities of Daily Living/ADL's. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the provision of bathing and hygiene care for one Resident (#59) of two reviewed, resulting in the likelihood for foul body odors, lack of bathing and showers per resident preference, and verbalization of dissatisfaction. Record review of facility 'Activities of Daily Living (ADL's)' policy dated 7/1/2008, revealed the purpose was to assist residents as needed in achieving maximum functional ability with dignity and self-esteem to improve quality of life. Procedure: (1.) Staff will utilize the care plan/[NAME] to determine level of assistance and interventions required for each resident to complete Activities of Daily Living which include transfers, toileting, bed mobility, locomotion, eating, dressing and personal hygiene . Resident #59: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate supervision and monitoring to prevent injuries from falls for two residents (Resident #33, Residednt #63), resulting in falls with injuries and the likelihood for a decline in overall health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure narcotic reconciliation was completed accurately, resulting in scribbled over narcotic numbers and lack of signature with the likelihood of narcotic diversion going unnoticed.