Four Chaplains Nursing Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate diagnoses in comprehensive assessments for one (R14) of 18 sampled residents reviewed for accurate Minimum Data Set (MDS) assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely repositioning for two residents, (R11, R78) of three reviewed for services to prevent pressure ulcer development.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate below 5% in three (R79, R14, R23) of six residents reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food to prevent cross contamination, and failed to maintain adequate sanitizer concentration in the sanitizer bucket. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was served at the preferred temperature for eight residents (R81, R45, and six confidential group residents) of eleven reviewed for food palatability.

Inspectors wroteBased on interview and record review the facility failed to correctly document the discharge disposition of one (R85) of three residents for discharge.

Inspectors wroteBased on interview and record review, the facility failed to notify the local state mental health agency of Pre-admission Screening and Resident Review (PASARR) Level I changes for one resident (R77) of one resident reviewed for PASARR completions.

Inspectors wroteThis citation pertains to Intake MI00148040. Based on interview and record review , the facility failed to timely initiate a care plan addressing a pressure ulcer for one (R388) of one resident reviewed for care planning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an orthotic foot device (designed for the prevention of pressure ulcers at the heel) was implemented per physicians order for one resident (R77) of three residents reviewed for pressure injuries. Findings Include: On 12/03/24 at 2:17 PM, R77 was observed lying in their bed without an orthotic foot device. On 12/04/24 at 10:00 AM, R77 was observed in bed lying on their back without an orthotic foot device on thier feet. On 12/04/24 at 12:10 PM, a nurse was observed completing care with R77. The was noted to be in bed without any orthotic device on their feet. A review of R77's medical record revealed a physician order dated 5/6/24 documenting, orthotic device on while in bed for each shift. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely podiatry care was provided for one resident (R1) and two confidential group residents of eight residents reviewed for foot care.

Inspectors wroteThis Citation pertains to Intakes MI00146232 and MI00146569. Based on observation, interview, and record review, the facility failed to ensure care was provided timely for five residents (AR1, AR2, AR3, R901, R902, and R907) of eight whose care was reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to change a dressing for one resident (R706) out of one reviewed for wounds.

Inspectors wroteThis citation pertains to Intakes: MI00142187, MI00142251, MI00142309. Based on observation, interview, and record review, the facility failed to ensure one resident (R901) received and consumed pureed foods as prescribed, resulting in airway obstruction/choking. On 1/17/24 at approximately 8:30am, R901 consumed a peanut butter sandwich resulting in the resident's airway becoming obstructed, requiring the use of the Heimlich Maneuver, CPR (Cardiopulmonary Resuscitation), and the use of forceps to remove copious amounts of the peanut butter sandwich from the resident's airway that led to hospitalization where the resident was placed on life-sustaining treatment, and died eight days later. Immediate Jeopardy: The Immediate Jeopardy (IJ) started on 1/17/24 and the immediacy was removed 1/25/24 per review of the facility's responding interventions as verified on 1/25/24. [...]

Inspectors wroteThis citation pertains to Intake MI00141213. Based on observation, interview, and record review, the facility failed to protect one resident's (R702) right to be free from physical abuse by another resident (R700) from a total sample of three resident's reviewed for abuse, resulting in a skin injury to the forehead and treatment. Findings Include: A review of Intake called into the State Agency noted the following, On 11/11/23 the resident (R702) asked the nurse to turn up the TV, which [they] did. The nurse and the roommate (R700) ended up getting into an altercation over it. The roommate (R700) was overheard asking someone how long it takes to kill someone. The resident (R702) feels very scared and threatened. (R702) has asked staff to move the resident (R700), but nothing was done. [...]

Inspectors wroteThis citation pertains to Intake MI00139764. Based on observation, interview and record review the facility failed to ensure interventions were implemented and/or included in the care plan for six residents (R10, R19, R27, R34, R42 and R63) from a total sample of 28 whose care needs were reviewed, resulting in and the potential for skin breakdown and/or unmet care needs.

Inspectors wroteThis citation pertains to Intake MI00138108. Based on observation, interview, and record review, the facility failed to ensure colostomy (an opening in the large intestine to the abdomen) care was received on a consistent basis for one Resident (R282) of one reviewed for ostomy services, resulting in the potential for infections and skin alterations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label/date and flush/disconnect an enteral feeding (tube feeding) for one resident (R54) of two reviewed for PEG (percutaneous endoscopic gastrostomy) care, resulting in the potential for administration error, altered nutrition, and/or PEG tube occlusion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a pain management intervention as ordered by the physician for one (R66) of six residents reviewed, resulting in sustained resident discomfort and dissatisfaction with care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the date opened and or resident name was indicated on the actual medication or glucometer strip container in three of four medication carts.

Inspectors wroteThis citation has two deficient practices. Deficient practice one. Based on observation interview and record review the facility failed to ensure hand hygiene was completed when appropriate during resident care for two of five staff observed during care administration, resulting in the potential for the spread of infection.