Maples Benzie County Medical Care

Inspectors wroteBased on observation, interview, and record review the facility failed to store, discard, and label medication in two of two medication rooms and one of two medication carts reviewed for medication storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dignified dining experience based on the reasonable personal concept for two Residents (#47 and #33) of eighteen residents reviewed for resident rights.

Inspectors wroteBased on interview and record review, the facility failed to provide written notifications of the reason for hospital transfers to residents/responsible parties and document information communicated to the receiving hospital for three Residents (R3, R13, and R49) of four residents reviewed for hospitalizations.

Inspectors wroteBased on interview and record review, the facility failed to monitor and document clinical assessment of changes of condition for two Residents (#3 & #15) of 18 residents reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety, resulting in the potential to spread food borne illness among all residents that consume food from the kitchen.

Inspectors wroteThis citation pertains to Facility Reported Incident (FRI) 2611699. Based on observation, interview, and record review, the facility failed to identify and mitigate environmental hazards, ensure the appropriate use of assistive devices, and implement care planned interventions resulting in falls for three Residents (#24, #25, #26) of three residents reviewed for accident hazards and supervision. This deficient practice resulted in actual harm when Resident #24 sustained multiple lower leg fractures requiring surgical intervention.

Inspectors wroteThis deficient practice pertains to Facility Reported Incident (FRI) 2573015. Based on observation, interview, and record review, the facility failed to follow the care plan to prevent falls for one Resident (#3) of three residents reviewed for accident hazards and supervision.

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. This deficient practice has the potential to result in food borne illness among any and all 77 residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement revised care plan interventions for falls sustained by one Resident (#67) of three residents reviewed for falls. This deficient practice resulted in the potential for potential for additional falls and potential for subsequent injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary storage of respiratory equipment for two Residents (#19 and #20) of two residents reviewed for respiratory services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adaptive dining equipment for one Resident (#27) of one resident reviewed for nutrition. This deficient practice resulted in increased difficulty with independent eating.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection control practice during dressing changes for one Resident (#46) of three residents reviewed for wound care. Findings Include: Resident #46 (R46) On 12/2/24 at 12:42 PM, during an interview, Registered Nurse (RN) R stated R46 stage II pressure injury which was in-house acquired. RN R stated she believed it to be from R46 having periods of prolonged sitting. On 12/3/24 at 2:30 PM wound care was observed performed by Licensed Practical Nurse (LPN) S for the pressure injury located on the coccyx of R46. During this observation LPN S failed to perform any hand hygiene after taking off her gloves following removal of the old dressing. LPN S applied new gloves on her hands and failed to perform any hand hygiene before cleansing and applying the new dressing. [...]

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 adequate and proper hand washing fixtures in two of four satellite kitchens. 2. Failing to ensure proper cooling procedures were followed for cooked food, cooled and stored in the walk in freezer. 3. Failing to maintain hot food at the proper temperature during holding on the steam table. 4. Failing to provide back flow protection on a hose connection in the kitchen. 5. Failing to provide proper back flow protection on two waste lines serving food preparation sinks in the kitchen. These deficient practices have the potential to result in food borne illness among any and all 78 residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly with the required committee members. This deficient practice resulted in the potential for ineffective coordination of medical care and delayed resolution of facility issues, placing all 75 residents in the facility at risk for quality care concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor resident's rights and provide a dignified dining experience for four Residents (R45, R6, R68, and R22) of four residents reviewed for dignity while dining. This deficient practice resulted in the disrespectful treatment of residents and the potential for avoidable weight loss, decreased socialization, and feelings of frustration and helplessness. On 1/30/24 at 12:59 p.m., Resident #45 (R45) was observed to be sleeping at one of the dining room tables during the noon meal on the 200-unit. R45's head was tilted fully-forward with his chin on his chest and a long string of saliva flowing from R45's mouth. An untouched plate of food was in front of R45. Registered Nurse K (RN K) was eating yogurt while sitting directly across the table from R45. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to investigate injuries of unknown source for one Resident (R68) of one resident reviewed for abuse. This deficient practice resulted in the potential for unidentified abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure weights were obtained accurately, monitored weekly, and nutritional assessments were completed monthly for one Resident (#31) of two Residents reviewed for weight loss. This deficient practice resulted in the potential for further significant weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure the licensed pharmacist reported recommendations and medication regimen irregularities to the attending physician, Medical Director, and the Director of Nursing for Two Residents (R68 and R8) of five residents reviewed for medication regimen reviews and recommendations by the licensed pharmacist. This deficient practice resulted in the potential for clinically significant adverse medication consequences affecting all 75 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand hygiene was performed in accordance with accepted standards of practice and facility policy during the provision of wound care and medication administration for two Residents (R8 and R376) of three residents reviewed for infection prevention and control. This deficient practice resulted in the potential for the development and transmission of communicable diseases and infections.