Frazee Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jun 16, 2023

  Based on observation, interview and document review, the facility failed to ensure 3 of 6 residents (R1, R2, R3) were appropriately re-assessed to safely smoke independently at the facility and failed to ensure implementation of smoking interventions. This resulted in an Immediate Jeopardy when R1 sustained fourth degree burns to the left side of face, left side of neck, left shoulder, left arm, left chest, left abdomen, and left upper leg when she was left outside to smoke with out a smoking apron on, dropped a spark from her cigarette on her left side which set fire to her clothing. The immediate jeopardy began on 6/10/23, at approximately 7:55 p.m. when R1 was found by staff outside the facility, under a covered patio, on fire resulting in hospitalization and fourth degree burns. […]

• Immediate jeopardy, isolatedF578Mar 2, 2023

  Based on observation, interview, and document review, the facility failed to ensure resident advance directives were accurately documented in the clinical record to reflect the residents' current wishes which affected 1 of 17 residents (R20) reviewed for advanced directives. This deficient practice resulted in an immediate jeopardy (IJ) for R20 who would have received cardiopulmonary resuscitation (CPR), contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE], when R20's electronic health record (EHR) main screen and orders identified R20 was to have CPR however, R20's updated POLST signed on [DATE], identified R20's wishes of do not resuscitate (DNR). […]

• Immediate jeopardy, isolatedF689Nov 4, 2021

  Based on interview and document review, the facility failed to implement appropriate foot wear and use of a gait belt during transfers for 1 of 1 residents (R1) reviewed for falls. These findings resulted in an immediate jeopardy (IJ) situation for R1 when R1 fell during a transfer while wearing regular socks and staff were not using a gait belt. R1 required surgical repair of the [CONDITION(S)]. All residents have the potential for serious injury, impairment or death with improper use of transfer devices and improper footwear. […]

• Actual harm, isolatedF692Sep 24, 2021

  Based on observation, interview and document review, the facility failed to complete comprehensive, accurate and ongoing nutritional assessments for 4 of 5 residents (R20, R24, R31, R30) who had experienced significant weight loss. R20 sustained actual harm when the facility failed to identify, assess and implement interventions in a timely manner to prevent continued weight loss while receiving all nutrition via tube feeding. R20 R20's quarterly Minimum Data Set (MDS) dated [DATE], identified R20 had severe cognitive impairment and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R20's MDS indicated she required extensive assistance with dressing, personal hygiene and bed mobility and had a feeding tube with 51% or more of total calories received through the tube feeding. […]

• No harm, potential for more than minimal, widespreadF851Feb 13, 2024

  Based on interview and document review, the facility failed to submit complete and accurate data for staffing information based on payroll during Quarter 4 (July 1st-September 30th, 2023) to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. This deficient practice had the potential to affect all 33 residents residing in the facility. Finding include: Reviews of the Payroll-Based Journal Report (PBJ) [NAME] report 1705D Quarter 4 from 7/1/23-9/20/23, identified excessively low weekend staffing. Review of the staffing timecards identified staff, their position, and total hours worked. During the review of time cards from 7/1/23-9/20/23, revealed a shortage on 7/23/23, from 3:20 p.m. […]