Thornapple Manor

Inspectors wroteBased on interview and record review the facility failed to obtain informed consent for psychotropic medications (prescription drugs that alter chemical levels in the brain to affect a person's mood, thoughts, behavior or perception) for 2 residents (Resident #80, Resident #88) out of 5 residents reviewed for psychotropic medications resulting in lack of documentation of communication/education to the resident/resident representatives for initiation and/or dose changes of psychotropic medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement enhanced barrier precautions (EBP) related to the presence of a pressure wound for 1 (Resident #5) of 3 residents reviewed for pressure wounds resulting in the potential for the spread of infection, cross contamination, and disease transmission.

Inspectors wroteThis citation pertains to intake #2737521. Based on interviews and record review, the facility failed to effectively implement abuse policies and procedures that ensure staff report all alleged violations of abuse immediately to the Nursing Home Administrator (NHA) or designee for 1 resident (Resident #101) of 1 resident reviewed for an allegation of staff to resident abuse, resulting in delayed investigation of an allegation of potential abuse/mistreatment with the potential to impact safety.

Inspectors wroteThis citation pertains to Intake # 2605454. Based on interview, and record review, the facility failed to implement care plan interventions to ensure safety and thoroughly document/investigate a fall in 1 of 4 residents (Resident #102) reviewed for safety and fall prevention, resulting in a fall with a right fibula fracture for Resident #102, and the potential for additional falls/injuries.

Inspectors wroteThis citation pertains to Intake # 2606671. Based on interview, and record review, the facility failed to protect the resident's right to be free from misappropriation of property in 1 of 4 residents (Resident #103) reviewed for misappropriation of property, resulting in the resident's money being taken by a staff member without the resident's consent.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care plan interventions to prevent falls in 1 of 28 residents (Resident #114) reviewed for comprehensive care plans, resulting in the potential for falls and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate and adequate oxygen management and tubing care for 3 of 3 residents (R19, R53, and R117) reviewed for respiratory and oxygen care, resulting in the potential of a vulnerable population being at risk for infection and harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1.) implementation of Enhanced Barrier Precautions (EBP) per standards of practices for 1 of 6 residents (R53) all reviewed for infection control, and 2.) adequate handling of soiled linen, resulting in the potential for cross-contamination, harborage of bacteria, and increased infections in a vulnerable population.

Inspectors wroteThis citation pertains to intake MI00147758. Based on interview and record review, the facility failed to recognize and report an injury of unknown origin for 1 (Resident #101) of 3 residents, reviewed for reporting, resulting in the lack of reporting and the potential for a delay in the investigation.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Clean food and non-food contact surfaces to sight and touch; 2. Ensure general repair of kitchen areas; 3. Ensure proper working order of dish machines; and 4. Use sanitizer in a manner that minimizes the risk of contamination. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 142 residents who consume food from the kitchen. Findings Include: 1. During a tour of the facility, at 10:15 AM on 1/31/24, an interview with Director of Dining Services (DDS) R found that the slicer gets used a couple times a week for slicing up meats. Observation of the slicer found some dried accumulation of meat shavings on the top and bottom backside of the blade. [...]

Inspectors wroteBased on observation and interview the facility failed to properly secure medications in a treatment cart (1 of 5 medication carts) resulting in the potential for compromise of medications and/or misappropriation of medications, and accidental ingestion.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food at a palatable temperature for 4 of 28 sampled residents (Resident #21, #84, #13, and #51) reviewed for food palatability, resulting in dissatisfaction with meals and the potential for decreased food consumption and nutritional decline.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1.) promptly implement isolation precautions for a symptomatic resident, 2. ) implement wearing of Personal Protective Equipement (PPE) in a room where a resident had a contagious disease in 2 of 26 sampled residents (Resident #34 and #98), and 3.) properly sanitize shared equipment, reviewed for infection control, resulting in a potential for the transmission/transfer of pathogenic organisms and cross contamination between residents and staff.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate supervision for 1 resident (Resident #38) of 7 residents reviewed for accidents/hazards resulting in the potential for residents to sustain a fall injury which have the potential to negatively affect the residents highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to position a urinary catheter collection bag to facilite drainage for 1 resident (Resident #22) of 4 residents reviewed for urinary catheter care, resulting in the increased risk of urinary tract infections and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure that a written agreement/policy between the facility and the dialysis provider (Name Omitted) was established and maintained for 1 resident (Resident #108) of 1 reviewed for dialysis services resulting in the potential for disruption in the continuity of care and /or the interruption of dialysis treatments.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify post-traumatic stress disorder (PTSD) triggers and develop individualized care plan interventions to mitigate triggers for 2 (Resident #33 and #90) of 3 residents reviewed for trauma informed care, resulting in the potential of re-traumatization due to staff not being informed and knowledgeable of the resident's past trauma.

Inspectors wroteThis citation pertains to MI00141167. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a fall with major injury, and ensure that assistive devices (a gait belt) were used according to the care plan during a transfer for 1 (Resident #103) of 3 residents reviewed for falls, resulting in major injury when Resident #103 sustained a fall with a head laceration, multiple rib fractures, right scapular fracture, and an ADL (activities of daily living) decline.

Inspectors wroteThis citation pertains to intake #MI0014167 and MI00140487. Based on interview and record review, the facility failed to immediately report incidents of abuse (resident to resident) and neglect in 3 (Resident #101, #102, and #103) of 3 residents, when Resident #102 struck Resident #101 multiple times with a closed hand causing bruises, and Resident #103 sustained a fall with multiple fractures after staff failed to provide adequate supervision and assistive devices (gait belt) according to the care plan, resulting in the potential for continued abuse and neglect.

Inspectors wroteThis citation pertains to Intake # MI00133911. Based on interview, and record review, the facility failed to immediately report an elopement incident (a situation involving possible neglect involving a system failure) to the State Survey Agency in 1 of 3 residents (Resident #101) reviewed for elopement/supervision, resulting in the potential for a delayed/incomplete investigation.

Inspectors wroteThis citation pertains to Intake # MI00133911. Based on interview, and record review, the facility failed to provide adequate supervision and respond timely to an alarming exit door to prevent an elopement in 1 of 3 residents (Resident #101) reviewed for elopement/supervision, resulting in Resident #101 exiting the facility without staff supervision/awareness, exposure to the elements, and the potential for injury.