Four Chaplains Nursing Care Center

In the surveyor’s words

From the most serious findings on record at Four Chaplains Nursing Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF803Jan 25, 2024

  This citation pertains to Intakes: MI00142187, MI00142251, MI00142309. Based on observation, interview, and record review, the facility failed to ensure one resident (R901) received and consumed pureed foods as prescribed, resulting in airway obstruction/choking. On [DATE] at approximately 8:30am, R901 consumed a peanut butter sandwich resulting in the resident's airway becoming obstructed, requiring the use of the Heimlich Maneuver, CPR (Cardiopulmonary Resuscitation), and the use of forceps to remove copious amounts of the peanut butter sandwich from the resident's airway that led to hospitalization where the resident was placed on life-sustaining treatment, and died eight days later. […]

• Immediate jeopardy, isolatedF760Aug 18, 2022

  This citation pertains to intake #MI 688, MI 9378, and MI 691 This citation has 2 Deficient Practice Statements DPS 1 Based on interview, and record review, the facility failed to (1) ensure controlled medications (benzodiazepines) were administered with a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . (2) failed to follow the FDA dispensing regulations for [MEDICATION(S)] for 1 resident (R20) resulting in the lack of laboratory monitoring, the withholding of [MEDICATION(S)] from the pharmacy, and the abrupt stopping of [MEDICATION(S)]. This deficient practice resulted in an immediate jeopardy when, beginning on 8/4/22, facility staff failed to provide proper administration of controlled substances and promptly notify the physician of medication errors. […]

• Actual harm, isolatedF689May 3, 2023

  This citation pertains to complaint intake MI00132492. Based on interview and record review the facility failed to ensure two persons were utilized for bed mobility per the care plan for one resident (R902) of three reviewed for falls, resulting in a fall to the floor from the bed and injury. Findings include: A review of the identified intake revealed, .(R902) had fallen during care. (R902) stated that (R902) was on (their) way to the hospital because (R902) was in severe pain . (R902) stated that the direct care worker had violated the facility's standard of care; thus causing (them) to fall from bed and fracturing (their) hip. (R902) was a bariatric, bedridden patient and it was documented that (R902) required a 2+ person assist for care. […]

• Actual harm, isolatedF684Aug 18, 2022

  Based on observation, interview, and record review, the facility failed to provide quality care for 3 residents (Resident #28, Resident #64, and Resident #184) out of 4 residents reviewed for quality of care, resulting in (a) the potential for dehydration, (b) an unassessed infection that developed into [CONDITION(S)] and required hospitalization , and (c) an unreported acute change in condition that required emergency medical treatment. Findings: Resident #28 (R28) Review of an Admission Record revealed R28 was a [AGE] year old female, most recently admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812Dec 5, 2024

  Based on observation, interview, and record review, the facility failed to store food to prevent cross contamination, and failed to maintain adequate sanitizer concentration in the sanitizer bucket. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 12/3/24 at approximately 9:20 AM, in the reach-in cooler, there was pan of cooked noodles stored directly underneath a box of raw pork. Dietary Staff H confirmed the cooked noodles should not have been stored under the raw meat. […]