Clark Retirement Community

Inspectors wroteThis citation pertains to intake: 1293524 Based on record review and interview, the facility failed to ensure a safe transfer and implement facility policy to prevent falls in 1 of 4 residents (Resident #2) reviewed for fall prevention, resulting in a fall during a lift transfer resulting in a right fractured humorous for Resident #2, which had impacted the resident's functional status and quality of life with the potential for further injury and falls due to unsafe transfers.

Inspectors wroteBased on interview and record review, the facility failed to provide a Registered Nurse (RN) for 8 consecutive hours per day, 7 days per week, resulting in the potential for unmet care needs, resident change of condition to not be properly assessed and negative clinical outcomes. This deficient practice has the potential to impact all 29 residents currently residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain best practices in accordance with professional standards of food service safety. The deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a qualified Infection Preventionist worked at least part-time at the facility, was provided sufficient time to perform the Infection Preventionist role, and to properly assess, implement, and manage the Infection Prevention and Control Program.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in residents' satisfaction of living.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote a dignified dining experience for 3 (Resident #21, Resident #4 and Resident #14) of 4 residents reviewed for dignity, resulting in a potential for a reduced quality of life, feelings of frustration, helplessness and a decreased sense of self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents maintained their right to self-determination for 1 resident (Resident #32), of 1 reviewed for choices, resulting in feelings of anxiety when staff did not wear a surgical mask while caring for the resident, despite her preference for them to do so.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and Centers for Disease Prevention and Control (CDC) guidance to administer pneumococcal vaccinations to residents who consented for immunization, screen and assess residents for eligibility of receiving pneumococcal vaccinations, and offer pneumococcal vaccinations to residents who were eligible to receive it, for 1 of 5 (R19) residents reviewed for pneumococcal vaccinations, resulting in the potential for contracting the virus.

Inspectors wroteThis citation pertains to intake #MI00146821. Based on observation, interview, and record review, the facility failed to effectively develop and implement comprehensive, person centered care plans for 2 residents (Resident #106 and #107), of 8 residents reviewed, resulting in unmet care needs and the potential for negative physical, mental and psychosocial outcomes.

Inspectors wroteThis citation pertains to intake #MI00146821 Based on observation, interview, and record review, the facility failed to ensure timely, effective incontinence care was provided for 1 resident (Resident #106) of 3 residents reviewed for bowel and bladder incontinence, resulting in an increased risk for UTI (urinary tract infection) and the potential for skin breakdown.

Inspectors wroteBased 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 35 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively implement Transmission-Based Precautions (TBP) for COVID-19 positive residents and Enhanced Barrier Precautions (EBP) per facility policy and Centers for Disease Control and Prevention (CDC) guidance, in 4 of 7 residents (Resident #3, #20, #17, and #11) reviewed for infection control, with the potential to affect all 36 residents who reside at the facility, resulting in the potential for disease exposure, cross-contamination, and the development and spread of infection to a vulnerable population.

Inspectors wroteBased on interview and record review, the facility failed to provide annual required abuse prevention education for all staff members who provide care, services, and supports to the residents. This has the potential to affect all 36 residents residing in the facility at the time of the survey.

Inspectors wroteBased on interview, and record review, the facility failed to implement an effective training program for all staff in regard to infection prevention and control and Enhanced Barrier Precautions, resulting in the potential for the spread of disease and infection to a vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that promoted and enhanced resident dignity for 1 resident (Resident #13) of 2 reviewed for dignity, resulting in the potential of feelings of frustration, anxiety, embarrassment and loss of self-worth, impacting their quality of life and promoting a negative psychosocial outcome for the residents.

Inspectors wroteBased on interviews and record review, the facility failed to report an allegation of neglect in 1 of 1 (Resident #34) of 16 residents reviewed for reporting, resulting in the potential for continued violations involving neglect and/or abuse going unreported.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of abuse/neglect for 1 of 1 resident (Resident #34) reviewed for abuse, resulting in an allegation of abuse not being identified and thoroughly investigated allowing for the potential for mistreatment and/or abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement resident comprehensive care plans for 1 resident (Resident #28) of 2 residents reviewed for care planning resulting in a lack of service for residents to maintain their highest practicable physical, mental, and psychosocial well-being

Inspectors wroteBased on observation, interview, and record review, the facility failed to update/revise a comprehensive care plan after a change in resident condition in 1 of 14 residents (Resident #30) reviewed for comprehensive care plans, resulting in an inaccurate reflection of the resident's status, and the potential for unmet medical, physical, mental, and psychosocial needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' mechanical diet order recommeded by the speech language pathologist was added in a timely manner and the recommended diet was followed for meals; 2. resident was evaluated by therapy and interventions implemented to address positioning were in place in 1 of 1 resident resulting in the potential for aspiration, decreased range of motion and worsening of contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services, consistent with professional standards of practice to prevent, treat, and promote healing of pressure uclers in 1 of 3 residents (Resident #31) reviewed pressure ulcers, resulting in the lack of repositioning and implementation of care planned interventions, delayed healing of pressure ulcers for the resident, and the potential for infection and the development of new ulcers.

Inspectors wroteBased on interview and record review, the facility failed to attempt a required Gradual Dose Reduction (GDR) of an antidepressant medication, in the absence of a documented contraindication, for 1 (Resident #6) of 5 residents reviewed for unnecessary medications, resulting in the potential that the resident received the medication at an unnecessary dose or for an unnecessary length of time.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who was eligible for a recommended vaccine was offered that vaccine in a timely manner for 1 resident (Resident #29) of 5 residents reviewed for immunizations, resulting in a delay in the resident to be given the opportunity to receive or decline the pneumococcal vaccination.

Inspectors wroteThis citation pertains to Intake #MI00143296. Based on interview and record review, the facility failed to implement fall interventions (utilize a bedside impact/fall mat) for 1 resident (Resident #100) of 4 residents reviewed for accidents and hazards, resulting in Resident #100 falling out of bed sustaining a soft tissue laceration over the midline frontal scalp, non-displaced facial fractures, and mild displaced angular fracture of the left humeral shoulder and the potential for further accidents and hazards to occur for residents at risk for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1) ensure hand hygiene during meals and incontinence care for 1 (Resident #33) of 1 resident reviewed for activities of daily living, 2) ensure sanitization of shared equipment, and 3) ensure sanitary handling of dirty linens, resulting in the increased potential for the development and transmission of communicable diseases and infection in a vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and ensure the right to safe self-administration of medication in 1 of 6 residents (Resident #20) reviewed for medication administration, resulting in the potential for unsafe self-administration of medication, medication errors, and medications not being stored in a secure manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions for safe transfers for 1 (Resident #33) of 1 resident reviewed for falls, resulting in the potential for falls and injury and residents to not meet their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to maintain complete and accurate medical records for 1 (Resident #27) of 12 residents reviewed for complete and accurate medical records, resulting in incomplete documentation of advance directives (personal choices of medical treatment options).