Boulevard Temple Care Center, LLC

Inspectors wroteThis citation pertains to intake 3003803 and 3006486. Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from verbal and physical abuse by staff.

Inspectors wroteThis citation pertains to intake 2706021. Based on interview and record review, the facility failed to obtain legal consent and failed to provide education for the Covid-19 vaccination for one resident (R101) out of three residents reviewed for immunizations.

Inspectors wroteThis citation pertains to 2677888. Based on interview and record review, the facility failed to report an incident of injury of unknown source to the State Agency in a timely manner for one resident (R105), out of six residents reviewed for abuse, resulting in the potential for unresolved resident concerns.

Inspectors wroteThis citation pertains to Intakes 2628767 and 2674347. Based on interview and record review, the facility failed to timely submit documentation of completed investigations to the State Agency for alleged resident-to-resident sexual abuse for two residents (R101 and R102) and alleged resident-to-resident physical abuse for two residents (R102 and R103) out of six residents reviewed for abuse, resulting in the potential delay for opportunities to implement corrective measures and interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered properly and per physician's orders for one resident (R108) of three residents reviewed for medication administration, resulting in the potential for less than therapeutic effect of the prescribed medication when medications were not taken or administered properly.

Inspectors wroteThis citation pertains to intake 2635308. Based on observation, interview, and record review, the facility failed to properly secure a television for one resident (R101) out of four residents reviewed for accidents resulting in R101 receiving a head injury.

Inspectors wroteThis citation pertains to intake MI00153561. Based on observation, interview and record review the facility failed to ensure adequate supervision for one resident (R902) out of one resident with severe cognitive impairment, resulting in three residents (R901, R903, and R904) verbalizing lack of privacy and security.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Properly date-label food in the freezer; 2. Ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food, macaroni and cheese; 3. Recognize unpasteurized shell eggs were used for the preparation of over easy eggs; 4. Ensure kitchen staff properly used hair restraints; and 5. Ensure pans were allowed to air dry before stacking. These deficient practices had the potential to affect all residents who consumed food from the kitchen, resulting in the increased potential for food borne illness.

Inspectors wroteBased on interview and record review the facility failed to employ a qualified social worker on a full-time basis to meet the psychosocial, mental, and behavioral health care needs of residents in a facility with more than 120 beds. This deficient practice had the potential to affect all residents that reside within the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide follow-up to the (Department of Community Health/ form 3877/78) during annual review and to ensure the form was submitted to the local Community Mental Health Services Program (CMHSP) for a level two OBRA (Omnibus Budget Reconciliation Act) evaluations annually for six (R28, R48, R77, R96, R97 and R99) of six residents reviewed for Preadmission Screening/Annual Resident Review (PASARR).

Inspectors wroteBased on observation, interview and record review the facility failed to revise the care plan for one (R97) of one resident reviewed for updated care plans when a resident diagnoses was corrected and changed.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide one to one meal assistance for one resident (R24) out of five residents reviewed for nutrition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that medications were not left at resident bedside for two (R93 and R108) of thirty-three residents reviewed regarding medications found at bedside.

Inspectors wroteThis citation pertains to intakes MI00146539 and MI00146638. Based on interview and record review, the facility failed to ensure staff to resident verbal abuse did not occur for one resident (R102) and physical abuse did not occur for two residents (R103 and R106) out of four residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to submit an incident of resident-to-resident abuse and the 5-day investigation to the State Agency involving two residents (R102 and R106).

Inspectors wroteThis citation pertains to intake MI00145800. Based on interview and record review, the facility failed to ensure proper care was provided as indicated on the resident care guide for one resident (R101) dependent on staff for performance of activities of daily living (ADL).

Inspectors wroteThis citation pertains to intake MI00146939. Based on interview and record review, the facility failed to ensure the proper medications were provided to a resident (R104) discharged from the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to store delivered food stock properly, resulting in a potential for contamination and deterioration of food products.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a homelike environment for one resident (R74) of eight residents reviewed for comfortable, homelike environments.

Inspectors wroteBased on observation, interview, and record review the facility failed to: maintain cooking equipment and the physical environment in the kitchen in a safe and sanitary manner, repair five rooms and the dining area on the 5th floor, clean the inner spaces of handrails on the fourth and fifth floor and ensure the elevator doors had a smooth, cleanable surface. This deficient practice had the potential to affect all 104 residents that resided within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently implement interventions (a properly functioning specialty mattress) for one (R57) of seven residents reviewed for pressure ulcer care when R57's specialty mattress resulting in the potential for continued impaired skin integrity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one (R2) of five residents reviewed for limited range of motion received appropriate services and equipment to maintain or improve mobility.

Inspectors wroteBased on interview and record review, the facility failed to facilitate a psychiatric evaluation as prescribed for one (R11) of five sampled residents reviewed for unnecessary medications, resulting in the potential for psychosocial disorders to go unaddressed and to exacerbate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Infection Control protocols were followed during care for two residents (R58 and R91) of five reviewed for Infection Control when appropriate protective personal equipment (PPEs) was not applied during direct care. R58 was positive for Covid-19 and R91 was prescribed to have Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on interview and record review the facility failed to perform life saving measures to a resident that was documented as a full code (When a person has no heartbeat and not breathing, CPR/cardiopulmonary resuscitation should be administered). This deficient practice resulted in an Immediate Jeopardy on [DATE] when nursing staff failed to perform CPR on R19 or call emergency services (911) when found with no heartbeat and was not breathing. This deficient practice placed all 95 residents at risk for the likelihood of serious injury, harm, and/or death from code status not being followed by staff.