Freeman Nursing & Rehabilitation Community

Inspectors wroteBased on observation, interview, and record review the facility failed to recognize a change in condition for one Resident (Resident #2) of one resident reviewed for hospitalization. This deficient practice resulted in rehospitalization, insertion of an indwelling catheter, and intravenous diuretic therapy.(All times are recorded in Eastern Standard Time unless otherwise indicated.)

Inspectors wroteAll times are Eastern Daylight Savings Time (EDST) unless otherwise noted. Based on observation, interview, and record review, the facility failed to perform hand hygiene during delivery of food which has the potential to result in the spread of illness and cross contamination among any or all 34 residents in the facility who receive meals.

Inspectors wroteBased on interview and record review, the facility failed to ensure advance directives were reviewed in a timely manner for one Resident (#4) and failed to ensure the documentation of advance directives upon admission for one Resident (#33) of 16 residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the provision of dignified and respectful care and treatment for four Residents (R15, R24, R131, and R17) of 13 sampled residents reviewed for resident rights. This deficient practice resulted in resident dissatisfaction, frustration, and fear of mistreatment.

Inspectors wroteThis deficiency pertains to Intake MI00143784. Based on interview and record review, the facility failed to timely report an allegation of abuse to the State Agency for one Resident (R15) of three residents reviewed for abuse. This deficient practice resulted in the potential for continuation of potential abuse for vulnerable facility residents.

Inspectors wroteThis deficiency pertains to Intake MI00143784. Based on interview and record review, the facility failed to timely and fully investigate an allegation of abuse for one Resident (R15) of three residents reviewed for abuse. This deficient practice resulted in the potential for continuation of potential abuse for vulnerable facility residents.

Inspectors wroteBased on interview and record review, the facility failed to appropriately conduct a gradual dose reduction (GDR) for an antidepressant medication for one Resident (R19) of five residents reviewed for unnecessary medications. This deficient practice resulted in the potential for adverse medication side effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident/residents durable power of attorney (DPOA) understood the purpose of binding arbitration agreements (an out of court alternate form of dispute resolution) for one Resident #19 (R19) of three residents reviewed for arbitration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure disinfection of environmental surfaces, appropriate hand hygiene and donning and doffing of gloves to prevent the spread of infection for one Resident (R15) of three residents reviewed for wound care. This deficient practice resulted in the potential for increased transmission of infectious organisms between the environment and/or contaminated hands during wound care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable mattress and functional, intact shelving for clothing storage for one Resident (R15) of 13 sample residents reviewed for comfortable and functional furniture. This deficient practice resulted in the use of an under-inflated, uncomfortable mattress and a built in four-shelf drawer unit with the third drawer missing.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to ensure a food preparation staff person washed their hands after being potentially contaminated. 2. Failing to demonstrate proper testing of the concentration of sanitizing chemicals in the three compartment sink and wiping buckets. 3. Failing to properly label and date food removed from the original packaging which was re-packaged and frozen. These deficient practices have the potential to result in food borne illness among any and all 26 residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a complete infection control program by failure to ensure social distancing of residents in COVID-19 isolation during communal dining, and failure to complete real-time tracking and surveillance of facility infections. This deficient practice resulted in the potential spread of infectious organisms within the facility, including COVID-19, and had the potential to affect all 46 residents.

Inspectors wroteR229 Review of R229's partially completed MDS assessment, dated [DATE], revealed R229 was admitted to the facility on [DATE]. R229 was noted to be a Full Code and Diabetic. Review of R229's admission Record revealed the following, in part: Type I (insulin dependent) diabetes mellitus with diabetic neuropathy, Type 1 diabetes mellitus with ketoacidosis without coma (Admission), dehydration, and anoxic (lack of oxygen) brain damage, not elsewhere classified - r/t (related to) severe hypoglycemia. Review of R229's Care Plans revealed the following, in part: Problem: Resident is at risk of complications R/T DX (diagnosis) diabetes mellitus. Interventions included: [DATE] - Administer medications as ordered. [DATE] - Monitor blood glucose as ordered. [DATE] - Monitor for signs of hyperglycemia (blood glucose elevated; increased thirst; increase urination; [...]

Inspectors wroteBased on interview and record review, the facility failed to add or revise nutritional interventions in a timely manner for one (Resident #20) of twelve residents reviewed for care plans. This deficient practice resulted in the potential for unnecessary weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services to prevent new pressure ulcers from developing for one Resident (R14) of one resident reviewed for pressure ulcer care. This deficient practice resulted in two new, facility-acquired pressure injuries to R14's coccyx.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care to prevent contamination of the urinary drainage system for one Resident (R15) of one resident reviewed for catheter care. This deficient practice resulted in the potential for cross-contamination of infectious organisms between the floor and R15's urinary drainage system.

Inspectors wroteBased on interview and record review, the facility failed to implement nutrition interventions for two (Resident #12 and Resident #20) of twelve residents reviewed for nutrition and hydration. This deficient practice resulted in significant weight loss and the potential for choking and aspiration.

Inspectors wroteBased on observation, interview and record review the facility failed to provide the appropriate treatment and services to restore oral eating skills of one Resident (R12) of one who was maintained on enteral feedings. This deficient practice resulted in resident dissatisfaction with his quality of life and resorting to stealing of food from the dietary department so he could eat food by mouth rather than via a tube.

Inspectors wroteBased on observation, interview and record review the facility failed to follow established vendor provided menus on two of two days meals were observed. This deficient practice has the potential to result in inadequate meal nutrition for any and all 26 residents.

Inspectors wroteBased on interview and record review, the facility failed to implement written Quality Assurance and Performance Improvement (QAPI) policies and procedures for adverse event monitoring after an insulin dependent Resident #27 (R27) became unresponsive, was sent to the emergency room, and expired that day. This deficient practice resulted in failure to determine root cause of significant change in condition and hospitalization to improve outcomes which could affect the entire facility population.