Inspection Reports for Notting Hill of West Bloomfield
6535 Drake Rd, West Bloomfield Township, MI 48322, United States, MI, 48322
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
21.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
313% worse than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 25, 2025
Visit Reason
The inspection was conducted based on complaints alleging rough handling causing injury to a resident and failure to provide appropriate care for a cholecystostomy biliary drain.
Complaint Details
The complaint alleged that a staff member intentionally caused a skin tear to resident R701 during a transfer and that the facility failed to provide proper care for resident R704's biliary drain, resulting in delayed surgical intervention. The investigation found inadequate investigation of the injury and falsification of nursing documentation related to the biliary drain care.
Findings
The facility failed to thoroughly investigate an injury of unknown origin for one resident, resulting in potential undetected abuse, and failed to provide care for a biliary drain consistent with physician orders, leading to delayed surgical intervention and falsified nursing documentation.
Deficiencies (2)
Failed to thoroughly investigate an injury of unknown origin for one resident, resulting in potential undetected incidences of abuse.
Failed to provide care for a cholecystostomy biliary drain consistent with professional standards and physician orders, resulting in delayed surgical intervention and falsified documentation.
Report Facts
Date of survey completed: Nov 25, 2025
Drainage volume documented: 60
Dates with zero output not identified: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse I | Nurse | Entered progress note about skin tear and reported incident despite instruction not to |
| Nurse H | Day shift Nurse | Documented falsified drainage amount and quit after being confronted |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding both incidents and acknowledged falsification of documentation |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 6, 2025
Visit Reason
The inspection was conducted based on complaint intake 1245809 regarding catheter care and intake 2563408 regarding food labeling and storage practices in the facility.
Complaint Details
This citation pertains to intake 1245809 related to catheter care resulting in a penile full thickness urethral tear for resident R702, and intake 2563408 related to food labeling and dating deficiencies in the kitchen.
Findings
The facility failed to prevent excessive tension and tugging of an indwelling urinary catheter for one resident, resulting in a full thickness urethral tear requiring surgical evaluation. Additionally, the facility failed to ensure food in the kitchen was properly labeled and dated when opened or prepared, potentially affecting all residents.
Deficiencies (2)
Failed to provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Failed to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including proper labeling and dating of opened or prepared food.
Report Facts
Wound measurement length: 4.3
Wound measurement width: 1.91
Wound area: 8.347
BIMS score: 15
Food labeling discard timeframe: 3
Food labeling discard timeframe for sour cream: 14
Food labeling discard timeframe for commercially prepared dressings: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing A | Director of Nursing | Acknowledged the catheter-related injury and concern during interview |
| Interim Director of Nursing A | Interim Director of Nursing | Acknowledged the catheter-related injury and concern during interview |
| Licensed Practical Nurse D | Wound Care Licensed Practical Nurse | Confirmed notification of catheter-related wound and trauma |
| Doctor C | Wound Care Provider Doctor | Assessed catheter-related wound and ordered urology consultation |
| Dietary Aide F | Dietary Aide | Observed unlabeled and undated food items in kitchen refrigerators |
| Dietary Manager G | Dietary Manager | Reported facility food labeling procedures and policies during telephone interview |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: May 14, 2025
Visit Reason
The inspection was conducted in response to complaints alleging failure to provide regularly scheduled bathing, inadequate supervision leading to accidents, failure to administer pain medications per physician orders, and failure to honor resident food preferences.
Complaint Details
The complaint investigations included allegations that resident R802 was not provided regular scheduled bathing and good tasting food according to preferences, residents R804, R806, and R807 were inadequately supervised leading to accidents and injuries, and resident R803 did not receive pain medications as ordered resulting in uncontrolled pain and hospital transfer.
Findings
The facility failed to ensure regularly scheduled bathing was offered to resident R802, failed to provide adequate supervision to prevent accidents resulting in injuries to residents R804, R806, and R807, failed to administer pain medications timely for resident R803 leading to uncontrolled pain and hospital transfer, and failed to honor food preferences and maintain proper food temperatures for resident R802.
Deficiencies (4)
Failed to ensure regularly scheduled/routine bathing was offered for resident R802.
Failed to provide adequate supervision and implement effective interventions to prevent falls and accidents for residents R804, R806, and R807, resulting in fractures and unsafe behaviors.
Failed to ensure pain medications were refilled timely, pulled from back-up supply, and administered per physician orders for resident R803, resulting in uncontrolled pain and emergency room transfer.
Failed to ensure resident food preferences were honored and food was served at safe and appetizing temperatures for resident R802.
Report Facts
Bathing offers: 4
Medication doses delayed: 2
Food temperature degrees: 121
Food temperature degrees: 112
Food temperature degrees: 115
Food temperature degrees: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Acknowledged deficient practices related to bathing, supervision, and medication administration; interviewed regarding incidents and investigations. |
| CNA A | Certified Nursing Assistant | Reported challenges providing 1:1 supervision to residents R804 and R807 and described incident with bleach wipes. |
| CNA B | Certified Nursing Assistant | Assigned sitter for resident R804 and R807, described supervision challenges. |
| CNA G | Certified Nursing Assistant | Involved in resident R806 fall incident. |
| Nurse H | Nurse | Entered progress note regarding resident R803's uncontrolled pain and hospital transfer. |
| Nurse Practitioner I | Nurse Practitioner | Entered progress note regarding resident R803's hospitalization and medication delays. |
| Nurse Practitioner J | Nurse Practitioner | Entered progress note regarding resident R803's pain control and hospital transfer. |
| Kitchen Manager K | Kitchen Manager | Interviewed about food preferences and food temperature procedures. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 12, 2025
Visit Reason
The inspection was conducted due to allegations of physical abuse and neglect involving two residents (R901 and R902) at the facility.
Complaint Details
The complaint investigation was substantiated based on video evidence and staff interviews. CNA A was terminated for abuse and a warrant for arrest was issued. Nurse D was suspended pending further reporting to the State Agency.
Findings
The facility failed to protect residents from physical abuse and neglect by staff, substantiated by video evidence showing CNA A slapping resident R901 and Nurse D improperly handling resident R902's wheelchair, resulting in physical harm and neglectful care.
Deficiencies (1)
Failure to protect residents from physical abuse and neglect, including CNA A slapping resident R901 and Nurse D mishandling resident R902's wheelchair causing physical harm.
Report Facts
Residents reviewed for abuse/neglect: 5
Residents affected: 2
Date of incident: Jan 18, 2025
Date of separation: Jan 21, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant A | CNA | Named in physical abuse finding for slapping resident R901. |
| Nurse B | Nurse | Involved in altercation with resident R901 and observed in video. |
| Nurse D | Nurse | Observed mishandling resident R902's wheelchair and suspended. |
| Maintenance Director E | Maintenance Director | Reported and reviewed video evidence of abuse incident. |
| Detective I | Detective | Reported police investigation and warrant for CNA A's arrest. |
| Nurse Practitioner H | Nurse Practitioner | Observed Nurse D's behavior and stayed with resident R902. |
| Administrator | Facility Administrator and Abuse Coordinator | Reported substantiation of abuse and termination of CNA A. |
| HR Manager | Human Resource Manager | Directed Nurse D to punch out and go home after observed neglect. |
Inspection Report
Routine
Census: 99
Deficiencies: 13
Date: Jan 16, 2025
Visit Reason
Routine inspection of Notting Hill of West Bloomfield nursing home to assess compliance with regulatory standards including sanitation, care planning, medication administration, staffing, infection control, and resident safety.
Findings
The facility was found deficient in maintaining a sanitary environment, developing comprehensive care plans, ensuring professional nursing services, medication administration and documentation, resident supervision, nutritional assessments, medication storage, infection control practices, and vaccination administration. Multiple residents were affected by these deficiencies, with observations and interviews confirming lapses in care and safety.
Deficiencies (13)
Failed to provide a sanitary homelike environment in common areas and resident rooms, including soiled floors, dirty shower rooms, and unkempt storage areas.
Failed to develop a comprehensive nutritional care plan for a resident with specific nutritional needs.
Failed to ensure nursing services met professional standards for medication administration and documentation for one resident self-administering medication.
Failed to ensure communication devices and services were in place for a resident with impaired communication, resulting in potential unmet care needs.
Failed to provide timely toileting and brief care for residents, resulting in residents being left wet for extended periods.
Failed to notify a physician of a resident's change in condition related to skin issues.
Failed to complete comprehensive nutritional assessment and ongoing evaluation per physician order for a resident.
Failed to provide enough nursing staff to meet resident needs, resulting in complaints of delayed care, lack of supervision, and potential for unmet care needs.
Failed to ensure appropriate indication for use, non-pharmacological interventions, and documentation prior to administration of PRN psychotropic medication.
Failed to ensure drugs and biologicals were labeled and stored in locked compartments, with observations of unlocked medication and treatment carts and medications found on the floor.
Failed to maintain sanitary conditions in the kitchen, including undated food items, improper utensil storage, and accumulation of grease and food debris.
Failed to ensure effective infection control practices during medication pass and implementation of Enhanced Barrier Precautions for a resident with a urinary catheter.
Failed to ensure administration of pneumococcal and influenza vaccines for a resident despite consent.
Report Facts
Census: 99
Medication doses: 15
Staffing counts: 16
Staffing counts: 24
Staffing counts: 4
Staffing counts: 6
Staffing counts: 7
Staffing counts: 10
Food items: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HD D | Housekeeping Director | Acknowledged housekeeping deficiencies and responsibility for unkempt areas |
| RD 'I' | Registered Dietician | Confirmed incomplete nutritional assessments and care plans for resident R297 |
| LPN M | Licensed Practical Nurse | Acknowledged leaving medication at bedside without confirming application for resident R55 |
| NHA | Nursing Home Administrator | Apologized for medication administration issues involving LPN M |
| CNA V | Certified Nurse Aide | Reported frequent finding of resident R55 soaked in urine and admitted not wearing name badge |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including staffing, supervision, medication, and care planning |
| Nurse 'A' | Infection Control Nurse | Observed unlocked medication carts and confirmed lack of assignment |
| Nurse 'N' | Nurse | Assigned nurse for medication cart found unlocked |
| DM Q | Dietary Manager | Observed unsanitary kitchen conditions and undated food items |
| Nurse FF | Nurse | Observed medication pass without hand hygiene |
| Nurse F | Nurse | Observed medication pass without hand hygiene |
| Nurse E | Nurse | Observed medication pass without hand hygiene |
| Nurse P | Nurse | Observed placing Enhanced Barrier Precautions signage late |
| ICP A | Infection Control Preventionist | Acknowledged vaccine administration failure and lack of follow-up |
Inspection Report
Routine
Census: 99
Deficiencies: 15
Date: Jan 16, 2025
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements including resident rights, environment, care planning, medication administration, staffing, infection control, and other areas.
Findings
The facility was found deficient in multiple areas including failure to provide adequate privacy for resident council meetings, unsanitary conditions in common areas and kitchen, incomplete nutritional assessments and care plans, medication administration and documentation issues, insufficient nursing staffing, inadequate supervision of residents with wandering behaviors, incomplete fall investigations, delayed radiology services, improper medication storage, failure to implement infection control practices, and failure to ensure administration of vaccines.
Deficiencies (15)
Failed to provide adequate privacy for Resident Council group meetings and addressing grievances for four of 14 residents reviewed.
Failed to provide a sanitary homelike environment in residential common areas including shower room and dining areas.
Failed to develop a comprehensive nutritional care plan for one resident with specific nutritional needs.
Failed to ensure nursing services met professional standards for medication administration and documentation for one resident.
Failed to ensure communication devices and services were in place for one resident with impaired communication.
Failed to provide timely toileting and brief care for three residents resulting in residents being left wet for extended periods.
Failed to ensure timely physician notification and complete investigations for multiple falls for one resident.
Failed to provide restorative therapy services for one resident with range of motion deficits.
Failed to ensure sufficient nursing staff was provided consistently, resulting in complaints of delayed care and lack of supervision.
Failed to ensure drugs and biologicals were labeled and stored properly; medication and treatment carts were found unlocked.
Failed to complete comprehensive nutritional assessment and ongoing evaluation per physician order for one resident.
Failed to ensure appropriate indication, non-pharmacologic interventions, and documentation for PRN psychotropic medication for one resident.
Failed to obtain and coordinate timely radiology services for one resident after a fall.
Failed to ensure effective infection control practices including hand hygiene during medication pass and implementation of Enhanced Barrier Precautions for one resident with urinary catheter.
Failed to ensure administration of pneumococcal and influenza vaccines for one resident after consent.
Report Facts
Resident census: 99
Falls: 10
PRN Alprazolam doses: 15
Staffing counts: 4
Staffing counts: 6
Staffing counts: 7
Staffing counts: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| C-4 | Resident Council President | Named in findings related to resident council meeting attendance and privacy concerns |
| C-7 | Resident Council President | Named in findings related to resident council meeting attendance and grievances |
| AD R | Activity Director | Named in findings related to resident council meetings and grievance follow-up |
| NHA | Nursing Home Administrator | Named in findings related to grievance process and resident council meeting minutes |
| LPN M | Licensed Practical Nurse | Named in medication administration deficiency for resident R55 |
| CNA V | Certified Nurse Aide | Named in toileting and brief care deficiency for resident R55 |
| RD 'I' | Registered Dietician | Named in nutritional assessment and care planning deficiency for resident R297 |
| DON | Director of Nursing | Named in multiple findings including staffing, fall investigations, nutritional care, and medication administration |
| Nurse 'A' | Infection Control Nurse | Named in infection control deficiency related to medication and treatment cart security |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 18, 2024
Visit Reason
An unannounced onsite investigation was conducted on 11/18/24 in response to a complaint alleging the facility failed to assess a change in condition for resident R801, specifically regarding a diabetic ulcer that worsened and resulted in amputation.
Complaint Details
The complaint alleged that resident R801 was not assessed for a change in condition related to a diabetic ulcer. The investigation confirmed the allegation with findings of delayed and inadequate wound care leading to amputation.
Findings
The facility failed to accurately assess, timely treat, and identify the worsening of a diabetic ulcer on resident R801's left great toe, leading to hospital transfer and amputation. There were delays in treatment orders, inconsistent wound assessments, and missing skin assessments between 6/22/24 and 9/5/24. Interviews with staff revealed issues with wound care coordination and documentation.
Deficiencies (2)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, resulting in actual harm to resident R801.
Failure to maintain a sanitary and comfortable environment in the hallway near the main dining room due to a strong, putrid odor.
Report Facts
Wound measurements: 4
Wound measurements: 5.6
Occlusion percentage: 99
Dates of hospital stay: Hospital stay from 8/27/24 through 9/5/24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 'A' | Wound Care Coordinator | Interviewed regarding wound assessments, treatment delays, and documentation for resident R801's diabetic ulcer |
| PA 'B' | Physician Assistant (contracted wound provider) | Responsible for diagnosing wounds and treatment plans; interviewed about wound resolution and treatment delays for R801 |
| Director of Nursing (DON) | Director of Nursing | Interviewed about wound care coordination issues and documentation discrepancies related to R801's wound |
| Registered Dietician 'E' | Registered Dietician | Interviewed about odor in hallway near dining room |
| Staff 'D' | Infection Control Nurse/Staff Development Nurse | Acknowledged pungent odor in hallway near dining room |
| Housekeeping Supervisor 'F' | Housekeeping Supervisor | Reported odor due to dish machine issue |
| Dietary Manager 'G' | Dietary Manager | Reported waiting for dish machine repairs |
| Administrator | Administrator | Interviewed about odor in hallway; reported no odor detected |
| Maintenance Assistant 'H' | Maintenance Assistant | Reported awareness of odor near dining room hallway and unknown source |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 26, 2024
Visit Reason
The inspection was conducted following a complaint filed on 2024-08-06 alleging that RN B failed to administer medications to resident R701 on 2024-07-31 as documented, and concerns about medication administration to other residents.
Complaint Details
Complaint filed on 2024-08-06 alleging RN B did not administer medications to R701 on 2024-07-31 despite documentation indicating otherwise. Investigation confirmed neglect for three residents (R701, R704, R705).
Findings
The facility failed to protect residents from neglect related to medication administration by RN B, who documented giving medications that were not administered, as confirmed by surveillance footage and interviews. Three residents (R701, R704, and R705) were affected by missed or untimely medication administration.
Deficiencies (1)
Failure to administer medications timely or at all to residents R701, R704, and R705 as documented by RN B.
Report Facts
Medication administration time: 8.38
Medication administration time: 7.2
Medication administration time: 8.49
Medication administration time: 9
Medication doses missed: 2
RN B time card punches: 14.72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in medication administration neglect findings; documented medications not given; left early on 2024-07-31 |
| LPN E | Licensed Practical Nurse | On-Call Nurse on 2024-07-31; contacted but did not return call |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding RN B's early departure and medication administration documentation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 5, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging that Nurse A was working at the facility with a suspended nursing license.
Complaint Details
A complaint was filed with the State Agency alleging Nurse A was working with a suspended license. The complaint was substantiated by review of the State Licensing Verification website and interviews.
Findings
The facility failed to ensure that Nurse A had an active license to practice as a Licensed Practical Nurse (LPN). Nurse A's license had been suspended since February 3, 2024, but Nurse A continued to work at the facility, posing potential risk to multiple residents. Facility leadership was unaware of the suspension until the investigation.
Deficiencies (1)
Failure to ensure that one Nurse (Nurse A) had an active license to practice as a Licensed Practical Nurse (LPN).
Report Facts
Date of license suspension: Feb 3, 2024
Date of inspection: Jun 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Licensed Practical Nurse | Named in deficiency for working with a suspended license. |
| HR Staff B | Human Resource Staff | Interviewed regarding facility protocol for license verification. |
| Representative C | State Licensing Board Representative | Confirmed Nurse A's license suspension. |
| Administrator | Interviewed and confirmed unawareness of Nurse A's license suspension. | |
| Director of Nursing | Director of Nursing (DON) | Interviewed and confirmed unawareness of Nurse A's license suspension. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jan 31, 2024
Visit Reason
The inspection was conducted in response to complaints submitted to the State Agency regarding the facility's failure to prevent the development and worsening of pressure ulcers for residents R502 and R504.
Complaint Details
Complaints submitted to the State Agency documented concerns about the facility's failure to prevent the development and worsening of pressure ulcers for residents R502 and R504.
Findings
The facility failed to accurately complete Braden assessments, implement preventive interventions for pressure wounds, timely implement wound treatments, and properly collaborate with the Dietician, resulting in severe pressure ulcers for two residents. One resident developed multiple wounds including a Stage 4 sacrum pressure ulcer and a Stage 3 right ear pressure ulcer, and another developed a Stage 4 coccyx pressure ulcer that contributed to hospitalization, severe sepsis, and death.
Deficiencies (4)
Failure to accurately complete Braden assessments and implement preventive/effective interventions for pressure wounds.
Failure to implement wound treatments timely or at all.
Failure to accurately implement Dietician orders to aid in wound healing.
Failure to consistently identify worsening of wounds for residents reviewed.
Report Facts
Braden score: 15
Braden score: 16
Wound measurement: 5.8
Wound measurement: 3
Wound measurement: 1.5
Wound measurement: 1
Wound measurement: 11
Wound measurement: 10
Wound measurement: 1
Wound measurement: 4
Wound measurement: 5
Wound measurement: 1
Undermining measurement: 3.5
Leukocytosis: 33.9
Oxygen volume: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RD A | Registered Dietician | Interviewed regarding notification and implementation of Active Liquid Protein order for resident R502. |
| Director of Nursing | DON | Interviewed regarding inaccurate Braden scores, delayed wound treatments, and collaboration with Dietician for resident R502 and R504. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Dec 14, 2023
Visit Reason
The inspection was conducted based on complaints and allegations regarding resident care, including dignity during dining, neglect in toileting assistance, pressure ulcer care, fall prevention, and accident hazards.
Complaint Details
The complaint investigation included allegations of neglect, abuse, and failure to provide adequate care and safety measures for residents, including delayed assistance after toileting, improper fall prevention, and inadequate wound care. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to provide dignified dining experience, neglect in timely toileting assistance, inadequate pressure ulcer care, ineffective fall prevention interventions, failure to follow bed mobility care plans, and malfunctioning wheelchair safety devices. Several residents experienced harm or potential harm due to these deficiencies.
Deficiencies (6)
Failed to provide a dining experience with dignity that promoted independence with eating for one resident (R90), including serving meals in Styrofoam containers contrary to care plan.
Failed to ensure a resident (R107) was free from neglect by not providing timely assistance from the commode chair after toileting, resulting in frustration and emotional distress.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for residents R42 and R104, including delayed treatment orders and failure to use specialty beds.
Failed to determine root cause of falls and implement effective interventions for residents R26 and R90, resulting in serious injuries including femur fracture and emotional distress.
Failed to follow plan of care for bed mobility for resident R55, resulting in nondisplaced fracture of proximal humerus and other injuries.
Failed to ensure wheelchair anti-roll back device was functional and urinal was properly placed for resident R90, increasing fall risk.
Report Facts
BIMS score: 5
BIMS score: 15
Pressure ulcer size: 4.9
Pressure ulcer size: 7.5
Pressure ulcer size: 6.5
Pressure ulcer size: 11
Pain level: 5
Incident dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member S | Dietician | Interviewed regarding resident R90's meal service in Styrofoam containers |
| Staff member T | Director of Dietary Services | Interviewed about meal service errors for resident R90 |
| Administrator A | Administrator | Interviewed regarding neglect complaint for resident R107 |
| DON B | Interim Director of Nursing | Interviewed regarding multiple deficiencies including neglect, pressure ulcer care, and fall prevention |
| CNA O | Certified Nursing Assistant | Interviewed about care and rounds for resident R42 |
| LPN K | Licensed Practical Nurse | Interviewed about care and air mattress issue for resident R42 |
| CNA G | Certified Nursing Assistant | Involved in incident causing fracture for resident R55 |
| LPN Y | Licensed Practical Nurse | Interviewed about care plan adherence and injury for resident R55 |
| Staff member K | Nurse | Interviewed about wheelchair anti-roll back device for resident R90 |
| Staff member AA | Certified Nursing Assistant | Interviewed about wheelchair anti-roll back device for resident R90 |
| Staff member U | Therapy Program Manager | Interviewed and demonstrated wheelchair anti-roll back device issue for resident R90 |
Inspection Report
Routine
Deficiencies: 14
Date: Dec 14, 2023
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility regulations, including resident care, safety, infection control, and medication management.
Findings
The facility was found deficient in multiple areas including failure to provide dignified dining experiences, neglect in timely assistance, medication errors, inadequate pressure ulcer care, fall prevention deficiencies, failure to provide timely laboratory and radiology services, and lack of a consistent infection prevention and control program.
Deficiencies (14)
Failed to provide a dignified dining experience promoting independence for Resident R90, including serving meals in inappropriate Styrofoam containers.
Failed to ensure a resident (R107) was free from neglect by not providing timely assistance from the commode chair after toileting, resulting in frustration and emotional distress.
Failed to follow nursing standards of practice for Residents R70 and R19 by not accurately transcribing physician orders and not priming insulin pens prior to administration, resulting in potential medication errors.
Failed to provide timely fingernail care for Resident R9, resulting in excessive long nails contrary to care plan.
Failed to ensure appropriate physician orders and timely implementation for monitoring and maintaining a percutaneous cholecystostomy tube for Resident R63.
Failed to determine root cause of falls and implement effective interventions for Residents R26 and R90, resulting in serious injury including a femur fracture for R26.
Failed to follow plan of care for bed mobility for Resident R55, resulting in a nondisplaced fracture of the proximal humerus and other injuries.
Failed to provide appropriate catheter care and identify signs of urinary tract infection for Resident R63, including failure to document and notify provider of abnormal urine characteristics.
Failed to ensure attending physician supervised medical care, participated in resident assessments, and was available for consultation for Residents R55 and R46.
Failed to provide timely radiology/x-ray services and follow-up for Residents R46 and R9, including failure to obtain ordered x-rays and timely communicate results.
Failed to provide timely laboratory services as ordered for Resident R100, including missed blood draws and delayed results.
Failed to establish a comprehensive infection control program that identified resident infections, tracked infection rates, and ensured staff education and departmental surveillance.
Failed to consistently have an employed Infection Preventionist to properly manage the Infection Control Program.
Failed to continuously implement an antibiotic stewardship program with consistent protocols for appropriate antibiotic use, including for Resident R9.
Report Facts
Resident weight gain: 47.8
Resident weight gain: 29.4
Number of residents: 91
Number of infections: 50
Infections not meeting McGeer's criteria: 42
Duration: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN J | Infection Preventionist | Interviewed regarding infection control program and antibiotic stewardship |
| DON B | Interim Director of Nursing | Interviewed regarding multiple deficiencies including infection control, medication errors, and resident care |
| Administrator A | Administrator | Interviewed regarding infection control program and physician communication |
| Staff member S | Dietician | Interviewed regarding dining experience and weight monitoring |
| Staff member K | Nurse | Interviewed regarding wheelchair anti-roll back device and resident care |
| Staff member AA | Certified Nursing Assistant | Interviewed regarding wheelchair anti-roll back device and resident care |
| Staff member U | Therapy Program Manager | Interviewed regarding wheelchair anti-roll back device |
| DON C | Former Director of Nursing | Signed consultation report and disciplinary action record |
| CNA G | Certified Nursing Assistant | Involved in resident care and fall incident |
| LPN Y | Licensed Practical Nurse | Interviewed regarding resident care and staff knowledge |
| Dr. W | Physician | Physician who agreed to pharmacist recommendation |
| Dr. N | Physician | Physician involved in resident care and communication issues |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 7, 2023
Visit Reason
The inspection was conducted in response to complaints alleging failure to follow up on resident grievances, medication availability issues, missed bathing, and inadequate wound care at the facility.
Complaint Details
The complaint investigation was triggered by allegations that the facility administration was not following up on resident concerns, residents were not receiving medications as ordered, bathing was missed, and wound care treatments were not completed timely.
Findings
The facility failed to document and resolve resident grievances, ensure medication availability and timely administration for two residents, provide regular scheduled bathing for one resident, and complete wound care treatments timely and appropriately for one resident.
Deficiencies (4)
Failed to document care concerns and follow the facility's grievance policy for one resident (R902).
Failed to ensure medications were available and administered as ordered for two residents (R902 and R903).
Failed to provide regular scheduled bathing for one resident (R902).
Failed to ensure wound care treatments were completed timely and appropriately assessed for one resident (R901).
Report Facts
Medication doses missed: 3
Missed bathing dates: 8
New wounds: 1
Untimely wound treatments: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager A | Nurse Manager | Queried about medication procurement and wound care treatment processes. |
| Director of Nursing | Director of Nursing | Queried about resident grievances and bathing schedules. |
| CNA B | Certified Nursing Assistant | Mentioned in relation to resident R902's allegation of being left wet for an entire shift. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 8, 2023
Visit Reason
The inspection was conducted following complaints and allegations of neglect and inadequate supervision at the facility, including a resident having their call light taken away by a staff member and a resident-to-resident physical altercation.
Complaint Details
The complaint investigation was substantiated. The allegation that CNA A took away resident R905's call light and was rough with the resident was confirmed based on interviews and facility investigation. The resident-to-resident altercation between R901 and R902 was substantiated based on observation, interviews, medical record review, and video surveillance.
Findings
The facility substantiated allegations that a Certified Nursing Assistant (CNA A) took away a resident's call light and was rough with the resident, resulting in the CNA's termination. Additionally, the facility failed to provide adequate supervision for two residents with impaired cognition, leading to a physical altercation where one resident entered another's room uninvited and caused injury.
Deficiencies (2)
Failure to protect residents from neglect and abuse, including a CNA taking away a resident's call light and physical mistreatment.
Failure to provide adequate supervision to prevent resident-to-resident physical altercation.
Report Facts
Residents reviewed for neglect: 5
Residents affected: 1
Residents affected: 2
BIMS score: 15
BIMS score: 9
Compliance date: Jan 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in findings for taking away resident R905's call light and physical mistreatment; terminated from facility |
| CNA B | Certified Nursing Assistant | Interviewed regarding resident R905's fear of CNA A and abuse reporting |
| CNA C | Certified Nursing Assistant | Interviewed regarding resident R905's call light being taken away and abuse reporting |
| Social Worker D | Social Worker | Interviewed resident R905 and reassured resident about safety |
| Administrator | Facility Administrator | Conducted facility investigation, substantiated allegations, and reported termination of CNA A |
| Nurse E | Nurse | Treated resident R901's injury from resident-to-resident altercation and provided supervision details |
| Social Work Director B | Social Work Director | Reviewed video surveillance related to resident-to-resident altercation |
Inspection Report
Complaint Investigation
Deficiencies: 15
Date: Oct 12, 2022
Visit Reason
The inspection was conducted based on complaints regarding failure to document resident and family grievances, failure to complete comprehensive assessments upon readmission/hospice admission, failure to accurately complete annual Minimum Data Set assessments, failure to coordinate pre-admission screening and resident review evaluations, failure to provide timely wound care and follow-up, failure to arrange audiology consultation, failure to ensure fall prevention interventions, failure to provide appropriate catheter care, failure to ensure medication reconciliation and controlled substance inventory accuracy, failure to maintain food safety standards, failure to ensure appropriate antibiotic stewardship, and failure to maintain medication error rates below 5%.
Complaint Details
The complaint investigation was triggered by multiple concerns including failure to document grievances, medication errors, delayed wound care, failure to arrange audiology services, fall incidents, catheter care deficiencies, medication reconciliation issues, food safety violations, and antibiotic stewardship program deficiencies.
Findings
The facility was found deficient in multiple areas including grievance documentation, resident assessments, wound care, audiology services, fall prevention, catheter care, medication reconciliation, food safety, antibiotic stewardship, and medication administration accuracy. Several residents were affected by these deficiencies, with some issues posing potential harm such as medication errors and untreated wounds.
Deficiencies (15)
Failure to document resident and family grievances per facility policy affecting multiple residents including R43.
Failure to complete a comprehensive Minimum Data Set (MDS) assessment upon readmission/hospice admission for resident R17.
Failure to accurately complete a comprehensive annual Minimum Data Set assessment for resident R18.
Failure to complete annual OBRA Level II Evaluation for residents R18 and R46.
Failure to promptly identify changes in skin and implement timely interventions for resident R74 with non-pressure injury wounds.
Failure to timely follow-up and assess uncontrolled pain and delayed hospital transfer for resident R21.
Failure to timely arrange and ensure audiology consultation for resident R43.
Failure to ensure wound care was performed per physician orders for resident R82, resulting in treatment applied to the wrong body area.
Failure to ensure care planned fall interventions were implemented and maintained for resident R35.
Failure to ensure appropriate indwelling catheter care for residents R2 and R13.
Failure to ensure appropriate nurse shift hand-off and reconciliation of controlled substances for one medication cart.
Failure to timely review, acknowledge, and act upon pharmacist recommendations for unnecessary medications for residents R28, R46, R6, and R66.
Failure to discard expired food items, maintain refrigerator gaskets, eliminate standing water, ensure staff handwashing, and maintain insect control in the kitchen.
Failure to operationalize an antibiotic stewardship program ensuring appropriate clinical indication for antibiotic use.
Medication error rate of 19.23% observed during medication administration for resident R43.
Report Facts
Medication error rate: 19.23
Controlled substances count discrepancies: Multiple discrepancies in controlled substance inventory sheets with illegible entries and missing nurse signatures
Expired food items: 6
Antibiotic line listings not meeting criteria: 19
Antibiotic line listings not meeting criteria: 18
Antibiotic line listings not meeting criteria: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager D | Unit Manager | Interviewed regarding grievance documentation and medication concerns for resident R43 |
| Ombudsman S | Facility Ombudsman | Interviewed regarding unresolved family concerns for resident R43 |
| Director Of Social Work E | Director of Social Work | Interviewed regarding grievances and PASARR evaluations for residents R43 and R18 |
| Nurse 'A' | MDS Coordinator | Interviewed regarding MDS assessments for residents R17, R18 |
| Nurse 'Q' | Nurse | Assigned nurse for resident R74 during wound care observation |
| Unit Manager 'C' | Unit Manager | Observed wound care and interviewed regarding wound care and fall prevention |
| Licensed Practical Nurse P | Licensed Practical Nurse | Interviewed regarding pain management and hospital transfer for resident R21 |
| Administrator | Facility Administrator | Interviewed regarding medication administration errors for resident R43 |
| Nurse M | Nurse | Documented falls and interviewed regarding fall prevention for resident R35 |
| Physical Therapy Manager T | Physical Therapy Manager | Interviewed regarding therapy and ambulation status for resident R35 |
| Director of Nursing (DON) | Director of Nursing | Interviewed multiple times regarding various deficiencies including medication reconciliation, wound care, fall prevention, catheter care, and antibiotic stewardship |
| Infection Control Nurse D | Infection Control Nurse | Interviewed regarding antibiotic stewardship program |
| Nurse Practitioner G | Nurse Practitioner | Interviewed regarding wound care treatment for resident R82 |
| Licensed Practical Nurse H | Licensed Practical Nurse | Wound care nurse interviewed regarding wound care for resident R82 |
| Dietary Staff V | Dietary Staff | Observed handling soiled and clean dishware without handwashing |
| Audiology Scheduler AS R | Audiology Scheduler | Interviewed regarding audiology appointment scheduling process |
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