McLaren Lapeer Region

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 residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and change bandages for two residents Resident #9 and Resident #32) out of two residents reviewed for bandages, resulting in old or undated bandages going unchanged and assessed.

Inspectors wroteBased on interview and record review the facility failed to ensure that the Quality Assessment and Process Improvement (QAPI) meetings were held quarterly, resulting in the lack of identification of concerns in the facility or corrective action being provided and no monitoring of issues, potentially affecting all residents living in the facility. Findings Include: FACILITY QAPI and QAA On 9/09/2024 at 3:54 PM, the Director of Nursing/DON was interviewed about the facility Quality Assurance Process Improvement/ QAPI program. When asked how often the QAPI committee met, the DON said the committee was supposed to meet quarterly and showed 2 meeting sign in sheets for a QAPI meeting in May 2024 and June 2024. She said she started at the facility in June 2024 and when she looked for the QAPI committee meeting minutes and sign in sheets, there were none. [...]

Inspectors wroteThis Citation pertains to Intake Number MI00141690. Based on observation, interview and record review, the facility failed to perform assessments and perform ongoing monitoring of all bed rails to identify potential areas of entrapment for all facility residents including the following residents: #'65, #70, #115, #116, and #120, resulting in the potential for zones of entrapment to remain unidentified, posing a risk to all 15 residents. Findings Include: Resident #65: A record review of the medical record, indicated Resident #65 was admitted to the facility on [DATE] with diagnoses: history of falls with left knee fracture, arthritis, neck pain, hypertension, atrial fibrillation and macular degeneration. On 9/03/2024 at 11:33 AM, Resident #65 was observed sitting in her wheelchair in the day room waiting for lunch. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that needs were being accommodated for three residents [Resident # 70 (R70), Resident #116 (R116), and Resident #120 (R120)], including comfortable room temperatures for Resident #70 and Resident #120, a request for a room change for Resident #116 and a request for a wider bed for Resident #120 of a total sample of 15 residents, resulting in discomfort and being unable to get enough rest and sleep for Resident #116, feeling unsafe to move and afraid of falling out of a narrow bed for Resident #120 and feeling too cold in the room for Resident #70 and Resident #120.

Inspectors wroteThis Citation pertains to Intake Numbers MI00141690 and MI00145384, Based on observation, interview, and record review, the facility failed to ensure a safe environment with adequate supervision and implement interventions to prevent a fall for two residents (Resident #14 and Resident #119) and failed to do a complete investigation for both residents resulting in Resident #14 sustaining multiple rib fractures after a fall and a potential for pain and a decline in medical condition and the likelihood of fall with injury to recur due to incomplete investigations for both Resident #14 and Resident #119.

Inspectors wroteBased on observation, interview and record review the facility failed to appropriately store supplies in one Clean Utility/ Medication Storage Room of one room reviewed and ensure that one Medication/Treatment Cart of two carts reviewed was properly secured and that confidential resident information was secured, resulting in the potential for use of contaminated and outdated supplies and access to residents' medications and confidential information. Findings Include: FACILITY Medication Storage and Labeling A review of the facility medication carts with Nurse J, on 9/4/2024 at 2:00 PM, identified a medication cart unattended in the hallway outside of the day room with several medication drawers open; the medication cart was unlocked. In addition, resident information was on the computer screen: visible to anyone nearby. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Infection Prevention and Control standards of practice were followed for 1). Hand Hygiene and Personal Protective Equipment/PPE use for one resident (Resident #120), 2.) a Water Management program specific to the facility, and 3.) Pneumonia and COVID Vaccination consent was not obtained and administered for one resident (Resident #71), resulting in the potential for the spread of infection, which could cause serious illness. Findings Include: FACILITY Infection Control: On 9/05/2024 at 9:38 AM, during an interview with the Infection Preventionist/IP A she was asked about the facilities Water Management Program. The IP A said the maintenance department in the hospital handled the Legionella water testing for the facility and it was last performed in the summer. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement baseline care plans to guide the care provided to 8 residents (Resident #7, Resident #58, Resident #59, Resident #60, Resident #62, Resident #108, Resident #110, and Resident #112) of 12 residents reviewed for care plans, resulting in the failure to provide instructions to the staff for effective and person -centered care to promote well-being and manage care needs. Findings Include: Resident #7: Death: A record review of the Face sheet and progress notes indicated Resident #7 was admitted to the facility on [DATE] and died on 6/28/2023 with diagnoses: Myopathy, diabetes, heart failure, thrombocytopenia, candidal esophagitis, gastritis, dysphagia, hypertension, arthritis, and weakness. The Minimum Data Set assessment was not completed, as the resident was only in the facility for a few days. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that food products were properly labeled with an Opened on and Use by dates and dispose of expired food items, resulting in the potential for bacterial harborage and food borne illness. This deficient practice had the potential to affect all residents that consume food prepared in the kitchen for a census of 11 Residents.

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of adequate notice of Medicare Part A benefits of non-coverage for 1 resident (Resident # 63) of 3 Residents that were reviewed for notice of non-coverage of Medicare Part A benefits, resulting in the resident's inability to exercise the right to file an appeal in a timely manner.

Inspectors wroteThis Citation Pertains to Intake Number MI00137064. Based on interview and record review, the facility failed to ensure an allegation of abuse was reported timely to the State Agency for one resident (Resident #4) of one resident reviewed for Abuse, resulting in the facility reporting an allegation of abuse 5 days after it occurred and the nurse reported the allegation to her supervisor. Findings Include: Resident #4: Abuse: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #4 was admitted to the facility on [DATE] and discharged [DATE] with diagnoses: Anoxic brain damage, history of a pulmonary embolism, dysphagia, anemia, thrombocytopenia, schizoaffective disorder, severe intellectual disabilities, conduct disorder, and weakness. [...]

Inspectors wroteThis Citation Pertains to Intake Number MI00137064. Based on interview and record review, the facility failed to investigate an allegation of abuse upon notification of the incident for one resident (Resident #4) of one resident reviewed for abuse, resulting in the potential for ongoing resident abuse. Findings Include: Resident #4: Abuse: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #4 was admitted to the facility on [DATE] and discharged [DATE] with diagnoses: Anoxic brain damage, history of a pulmonary embolism, dysphagia, anemia, thrombocytopenia, schizoaffective disorder, severe intellectual disabilities, conduct disorder, and weakness. The MDS assessment dated [DATE] revealed the resident had cognitive decline and was not able to participate in the Brief Interview for Mental Status assessment. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive resident-centered care plans for three residents (Resident #108, Resident #110, and Resident #112) of 12 residents reviewed for care planning, resulting in the potential for unmet care needs and decline in overall health and wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) incorporate the standards of care into the fall policy and operationalize the fall policy for Resident #110, who had a fall and hit their head and 2) maintain an environment free of safety hazards for Resident #112, of six residents reviewed for safety and falls, resulting in the failure of communication of a fall for Resident #110 with the potential for continued safety concerns and injury, and the potential of neurological changes to go unidentified and untreated, and Resident #112 obtaining a skin tear on their arm and the potential for further injury with sharp edges of tiles in the bathroom and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that nebulizer equipment was maintained in a clean and sanitary manner for one resident (Resident #108) of one resident reviewed for respiratory care and oxygen needs, resulting in the potential for respiratory infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one resident ( Resident #60) of one resident reviewed for physician services, had physician's orders for care and treatment upon admission, resulting in the lack of necessary medications, including medication to treat the resident's pain. Findings Include: Resident #60: Pain Management: On 7/11/23 at 11:49 AM, Resident #60 was observed lying in bed in her room with a visitor sitting in a chair beside her. She said she was admitted to the facility from the hospital the day prior 7/10/2023 about 5:00 PM. The resident said she came to the hospital after falling and obtaining a right hip fracture. She said she was having pain, but the nurse told her the physician had not provided orders and the resident could not have any medications including pain medication. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff competence and education for abuse for two of five staff members, resulting in the staff lacking necessary qualifications to provide safe resident care. Findings Include: FACILITY Sufficient and Competent Nurse Staffing: On 7/13/23 at 3:43 PM, staff education was reviewed with Staff Educator A and the Director of Nursing/DON. The facility is connected to a hospital and staff from the hospital float to the facility from the hospital to work as needed. The staff from the hospital did not all receive Long Term Care required education. A review of the yearly training and competencies revealed some of the competencies did not have a year on them: Staff D and F. Staff H's Yearly competency was dated 10/1/2019; it was her new hire competency. There was no more recent competency received. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) Properly store/secure medications for Resident #109 and a cart that stored skin/wound treatments and prescribed skin applications and 2) Label intravenous (IV) fluids and IV tubing for Resident #112, of two medication carts, one medication room and one treatment cart reviewed for proper storage and expired medications and one resident with IV infusion, resulting in the potential for drug diversion, ingestion of medicated substances, and phlebitis/infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide Resident #112, who had signs/symptoms of hypoglycemia and diagnoses of diabetes, with a bedtime (HS) snack and offer HS snacks to a Confidential Group of residents, of three residents reviewed for food services, resulting in the potential for uncontrolled blood glucose levels, signs and symptoms of hypoglycemia, feelings of frustration and hunger.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the required composition of the Quality Assurance Process Improvement (QAPI) committee members were in attendance for 2 of 4 quarterly meetings, resulting in the potential for impaired resolution of services, unidentified issues or decreased quality of care with the potential to effect all 11 residents in the facility. Findings Include: FACILITY QAPI and QAA: On 7/13/23 at 3:55 PM, during a review of the Quality Assessment Process Improvement/QAPI meetings with the Director of Nursing/DON she said she was new to the facility and had been there since May 1, 2023. She said the committee met quarterly and the next meeting would be the 3rd week in July. During the review, it was noted that the March 2023 and September 2022 meetings lacked the required attendees. Only 5 staff attended the March 28, 2022 meeting. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that 1 of 3 nurse aides, reviewed for mandatory 12 hours of yearly training,, had the required training, resulting in the potential for the nurse aides to not be able to safely provide the necessary care and services for the residents of the facility. Findings Include: FACILITY Sufficient and Competent Nurse Staffing: During a review of education documents for CNA's working in the facility, it was identified that 1 Certified Nursing Assistant D did not have the mandatory 12 hours of yearly CNA training for Long Term Care. On 7/13/23 at 3:43 PM, staff education was reviewed with Staff Educator A and the Director of Nursing/DON. The facility is connected to a hospital and staff from the hospital float to the facility to work as needed. [...]