Lahser Hills Care Centre

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent pressure ulcer formation, document accurate skin assessments and implement interventions for one (R80) of three residents reviewed for pressure ulcers resulting in R80 acquiring a Stage 4 (full-thickness skin and tissue loss).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure weights were taken appropriately and verified as accurate per professional standards of nutritional practice for one Resident (R21) of two residents reviewed for nutritional status, with multiple facility residents affected who were weighed.

Inspectors wroteBased on interview and record review, the facility failed to consistently maintain a system that consistently met criteria for antibiotic use, this had the ability to affect any resident prescribed an antibiotic of the 107 residents that resided in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a working clock for one (R67) of one resident reviewed for choices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe homelike environment for two Residents (R15 and R99) of two residents reviewed for equipment safety, when their toilet durable medical equipment was found in disrepair.

Inspectors wroteBased on interview and record review the facility failed to notify the local state mental health authority of Preadmission Screening and Resident Review (PASARR) changes for one (R60) of two residents reviewed for PASARR.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure that wound care was completed according to physician's orders for two residents (R13 and R6) of three reviewed for impaired skin conditions (non pressure related).

Inspectors wroteBased on interview and record review, the facility failed to ensure freedom from unnecessary antibiotic therapy for three (R40, R85, and R86) of three residents reviewed for unnecessary antibiotic (ABT) use, resulting in the potential for the development of antimicrobial resistance.

Inspectors wroteThis citation pertains to Intake(s): MI00151185 Based on observation, interview and record review, the facility failed to ensure an oxygen dependent resident was provided continuous physician ordered respiratory care for one (R601) of two residents reviewed for respiratory care, resulting in R601's SPO2 (blood oxygen saturation level) to have dropped to an abnormal range level and the resident being transferred to the hospital for a higher level of care.

Inspectors wroteThis citation pertains to Intake #MI00151195 Based on observation, interview and record review the facility failed to timely evaluate the competency of a resident and obtain legal guardianship for a resident with impaired cognition for one (R601) of three residents reviewed for Hospice Services.

Inspectors wroteThis citation pertains to Intake MI00148859 Based on observation, interview and record review, the facility failed to prevent pressure ulcer formation, document accurate skin assessments, implement interventions and complete pressure ulcer wound care per physician orders for two (R903 and R904) of three residents reviewed for pressure ulcers resulting in R903 acquiring one Stage 4 (full-thickness skin and tissue loss) which became infected and required antibiotics and acquired a Deep Tissue Pressure Injury (DTPI - persistent non-blanchable deep red, maroon or purple discoloration) and R904 who aquired an unstageable wound to their coccyx.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate infection control practices related to enhanced barrier precautions (EBP) for two residents (R903 and R904) of three residents reviewed for wounds, resulting in the potential for the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. 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 medications were administered, documented, and stored according to professional standards of practice for four (R215, R11, R95, and R265) residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and secure storage of medication from three of three medication carts reviewed to assure medications are inaccessible to unauthorized staff and residents. Findings Include: On 4/30/24 at 8:35 AM, a medication administration observation was conducted with Registered Nurse (RN) E. Medications were prepared from the medication cart identified as Second Floor Short Hall. After medications were prepared for a resident, RN E proceeded into the resident's room leaving the medication cart unlocked, unattended, and out of sight. Review of the facilities policy, Medication Administration General Guidelines Section 7.1, 01/21 stated: . The medication cart is kept closed and locked when out of sight of the medication nurse . [...]

Inspectors wroteThis citation pertains to Intake MI00143763 Based on observation, interview and record review, the facility failed to treat a resident with dignity and respect for one (R19) of two residents reviewed for dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure a level I Preadmission Screening (PAS)/Annual Resident Review (ARR) Mental Illness/Intellectual Disability/Related Conditions Identification was completed accurately and sent to local community mental health for a level II OBRA (Omnibus Budget Reconciliation Act of 1993) evaluation for one (R49) of one resident reviewed for PASARR's resulting in the potential for the resident to be excluded from receiving necessary care and services appropriate to meet their mental health and intellectual disability needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure continuous oxygen was provided per physician orders for one (R19) of one resident reviewed for oxygen therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all controlled substances were accounted for and accurately documented for one (215) resident reviewed.

Inspectors wroteBased on interview and record review, the facility failed to administer blood pressure medications according to physician ordered parameters for one (R59) of five residents reviewed for unnecessary medications, resulting in the resident receiving a medication used to treat low blood pressure when it was not needed.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident received psychotropic medication as ordered for one (R265) out of five residents reviewed for unnecessary medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent when total of two medication errors were observed for one resident (R54) out of four residents observed during medication administration for a total of 32 opportunities resulting in an error rate total of 6.25%. On 4/30/24 at 8:46 AM, a medication administration observation was conducted with Licensed Practical Nurse (LPN) I for R54. A prepackaged medication identified as Clopidogrel (Plavix, a medication that prevents the blood from clotting) 75 milligram (mg) was removed from the packaging, and placed into the medication cup. Further observation revealed LPN I removed a bottle from the medication cart and was identified as Aspirin Enteric Coated (EC) 81 mg, removed 1 tablet, and placed into the medication cup. [...]

Inspectors wroteThis citation refers to Intake #MI00137826 Based on interview and record review, the facility failed to ensure a safe and proper transfer from the bed to Geri chair for one resident (R808) of two residents reviewed for falls/accidents, resulting in seven stitches over the left eye, two lumps (hematomas) on the forehead, bruising to the left side of their neck, bruising on the left side of their chest, pain, and a three-day hospital stay.

Inspectors wroteThis citation pertains to intake(s): MI00137911, MI00138369, & MI00138641. Based on observation, interview, and record review the facility failed to timely initiate treatment and consistently and accurately implement the wound practitioner treatment as recommended for two (R's 805 & 807) of four residents reviewed for pressure ulcers.

Inspectors wroteThis citation pertains to Intake number(s): MI00138261. Based on observation, interview, and record review, the facility failed to follow infection control practices related to safe and sanitary disposal of biohazardous material located on five of five medication carts and sanitary use of an ice cooler (when R816 was observed reaching in an ice bin and removing ice with their bare hands).

Inspectors wroteThis citation pertains to Intake Number(s): MI00138563. Based on observation, interview, and record review, the facility failed to ensure one (R805) of two residents reviewed for activities of daily living, received showers according to their plan of care.

Inspectors wroteThis citation pertains to intake #MI00129778 This citation contains three Deficient Practice Statements (DPS). DPS #1 Based on interview and record review the facility failed to consistently monitor a resident in respiratory distress, notify the physician of ineffective interventions and failed to transfer the resident to a higher level of care for appropriate treatment for one (R312) of three residents reviewed for infection prevention and control, resulting in staff to not have completed and documented consistent respiratory assessments and monitoring once staff identified R312 with a low oxygen saturation rate of 72%, staff failed to inform the physician of the supplemental oxygen to not have been effective, and failed to transfer the resident to a higher level of care for further treatment causing Immediate Jeopardy (IJ), when R312 expired two hours and twenty five minutes after [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment in which residents were provided privacy and treated in a dignified manner for three residents (R416, R23, and R55) of three residents reviewed for privacy/dignity.

Inspectors wroteThis citation pertains to Intake Number MI00133944. Based on observation, interview, and record review, the facility failed to provide showers regularly for one (R20) of six residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and follow up on pressure reducing interventions order by the physician and indicated treatment plan for one (R86) of one resident reviewed for pressure ulcers, resulting in the potential for development of new pressure ulcers, worsening of existing vascular ulcers, and delayed wound healing.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure splints/braces were applied per Physician's order for one resident (R4) of two residents reviewed for positioning/mobility.

Inspectors wroteThis citation pertains to Intake Number MI00132707 and MI00129778. Based on observation, interview, and record review, the facility failed to provide incontinence care to two (R104 and R48) of two residents reviewed for bowel and bladder, resulting in resident distress and discomfort when they had to wait an extended period of time in a urine soaked brief.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one (R99) was free of any significant medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store a controlled substance and ensure it was not expired for one of two medication rooms reviewed.

Inspectors wroteBased on interview and record review the facility failed to ensure a Physician ordered laboratory (lab) draw was completed timely for one resident (R40) of one residents reviewed for laboratory diagnostics.