PRINTED: 04/13/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 235475 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 04/03/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 21630 HESSEL BEACONSHIRE NURSING CENTRE (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED DETROIT, MI 48219 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 000 INITIAL COMMENTS PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 000 Beaconshire Nursing Center was investigated for a Focused Infection Control Survey on 4/2/20. Census: 78 F 880 Infection Prevention & Control SS=J CFR(s): 483.80(a)(1)(2)(4)(e)(f) F 880 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (X6) DATE TITLE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZHL11 Facility ID: 834670 If continuation sheet Page 1 of 9 PRINTED: 04/13/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 235475 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 04/03/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 21630 HESSEL BEACONSHIRE NURSING CENTRE (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED DETROIT, MI 48219 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 1 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to properly maintain infection control practices during a COVID-19 Infection Control Survey resulting in the risk of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZHL11 Facility ID: 834670 If continuation sheet Page 2 of 9 PRINTED: 04/13/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 235475 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 04/03/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 21630 HESSEL BEACONSHIRE NURSING CENTRE (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED DETROIT, MI 48219 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 2 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 serious harm to three sampled resident (R#1, 2 and 3) out of a total sample of three reviewed for infection control practices. The surveyor identified the Immediate Jeopardy (IJ) on 4/2/20 at 12:25 PM and determined that the IJ began on 4/2/20 as a result of R#1 being in respiratory isolation (droplet precaution) for presumptive Corona Virus (COVID-19) symptoms which included cough, temp 100.4, lethargy, diarrhea, nausea and vomiting and staff using inadequate Personal Protective Equipment (PPE), subsequently observed entering in and out of two resident rooms. The Director of Nursing (DON) was notified of the Immediate Jeopardy (IJ) on 4/2/20 at 3:40 PM. A plan to remove the immediacy was requested. The IJ was removed on 4/2/20 at 4:57 PM. Although the IJ was removed, the facility's deficient practice was not corrected and remained isolated with risk of serious harm. Findings include: Resident #1 Record review revealed that R#1 was admitted into the facility on 1/1/19 with diagnoses that included schizophrenia, high blood sugars and anxiety disorder. The Quarterly Minimum Data Set Assessment (MDS) dated 12/24/19 noted the resident's cognition was moderately impaired. Nurses progress notes documented the following: -3/31/2020 08:50; Resident is lethargic and not eating. Resident had cough. Skin is hot and dry to touch. Temp 100.4. (name of physician) notified and orders received to transfer resident to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZHL11 Facility ID: 834670 If continuation sheet Page 3 of 9 PRINTED: 04/13/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 235475 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 04/03/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 21630 HESSEL BEACONSHIRE NURSING CENTRE (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED DETROIT, MI 48219 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 3 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 hospital. Orders noted and resident ready for transport to the hospital. -3/31/2020 11:47; Unable to transfer resident to the hospital because hospital's are not accepting new patients... -3/31/2020 15:01; Resident having episodes of nausea and vomiting. Also having diarrhea. Ambulance called for resident transport to the hospital. Resident continues to be lethargic and is not eating or taking fluids. Temp 99.7... -3/31/2020 23:25; Resident moved to (private room) from previous room (shared room). Resident is more lethargic. Responds to verbal stimuli. Presents with dry, non productive cough. Lungs clear to auscultation and diminished throughout...Will continue to monitor. -4/1/2020 06:59; Resident received alert and responsive ,contact precautions in progress... -4/1/2020 11:49; Resident is alert and verbal with confusion, on antibiotic in progress... A care plan dated 3/31/20 documented: "I am at risk for exposure to the COVID-19 virus, due to my clinical state. COVID-19 precautions" with an approach of "place on droplet contact and airborne precautions resident is to remain in isolation until no s/s (signs or symptoms) of COVID-19 are observed". At 11:45 a.m., Unit Manager "B" reported Resident #1 was the only resident in the building with respiratory symptoms. At 12:25 pm, observation was made of Certified FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZHL11 Facility ID: 834670 If continuation sheet Page 4 of 9 PRINTED: 04/13/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 235475 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 04/03/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 21630 HESSEL BEACONSHIRE NURSING CENTRE (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED DETROIT, MI 48219 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 4 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 Nurse Assistant (CENA "F") in R#1's room feeding the resident her lunch. Observation was made of PPE equipment in a bin out side of the resident's room. There was no posting on the door indicating to visitors, staff or other residents what type of isolation precautions R#1 was in. While observing from the doorway, CENA was noted to be eating her own food while feeding R#1. The CENA had no gloves or gown on (creating the potential for uniform contamination-the presence of an impurity or undesirable element that spoils or corrupts). The CENA had her face mask pulled down under her chin (not covering her mouth so that she could consume her own food). Upon entering the room observation was made of a divided plate of pureed textured food which CENA "F" was feeding to the resident. Also noted sitting on the meal tray (not on a plate) was a regular textured half eaten piece of chicken, a half eaten roll and a completely eaten piece of corn on the cob. No paper products were observed in use. When the CENA was asked if she was eating she stated, "No. I mean "Yes, me and (name of resident) are having lunchy, lunch. We are having a lunch date. I have lunch with her because she is in isolation and in here by herself". The CENA was asked where she got the food she was eating to which she responded, "from the kitchen". At this time Staff Nurse "E" was asked to come to the room. Nurse "E" said that R#1 was in "Contact isolation precautions" (used for infections that spread by touching. Healthcare workers should wear gown and gloves while in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZHL11 Facility ID: 834670 If continuation sheet Page 5 of 9 PRINTED: 04/13/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 235475 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 04/03/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 21630 HESSEL BEACONSHIRE NURSING CENTRE (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED DETROIT, MI 48219 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 5 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 the patient's room). Upon entering the room Nurse "E" told CENA "F", "throw that food away. Where are your gloves? Where is your gown?" CENA "F" responded, "I didn't think we were suppose to wear gloves when we feed residents". At 12:38 pm, observed CENA "F" coming out of room belong to R#2. Continued observation revealed CENA "F" going into the room belonging to R#3. The CENA was noted entering R#3's room and adjusting the nasal cannula (tubing for the delivery of Oxygen) saying "(Name of resident) you need to wear your oxygen". Resident #2 Review of a "Admission Record" revealed, Resident #2 readmitted to the facility on 9/25/19 and with pertinent diagnosis which included Multiple Sclerosis (immune system eats away protective covering of nerves), Type 2 Diabetes, and Asthma. Review of a "Minimum Data Set" (MDS) assessment, with a reference date of 1/14/20, revealed Resident #2 had no cognitive impairment with a "Brief interview for Mental Status" (BIMS) score of 14, out of a total possible score of 15. Review of "Progress Note" on 4/2/20 at 2:30 p.m. revealed, the Physician diagnosed Resident #2 with a Urinary Tract Infection on 3/29/20. Resident #3 Review of a "Admission Record" revealed, Resident #3 readmitted to the facility on 8/1/19 and with pertinent diagnosis which included Chronic Obstructive Pulmonary disease (COPD), peripheral vascular disease and anemia. Review of a Quarterly "Minimum Data Set" (MDS) assessment, with a reference date of 12/16/19, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZHL11 Facility ID: 834670 If continuation sheet Page 6 of 9 PRINTED: 04/13/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 235475 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 04/03/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 21630 HESSEL BEACONSHIRE NURSING CENTRE (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED DETROIT, MI 48219 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 6 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 revealed Resident #3 had no cognitive impairment with a "Brief interview for Mental Status" (BIMS) score of 14, out of a total possible score of 15. At 1:00 p.m., in interview, Infection Control Nurse "C" reported Resident #1 was in "Respiratory" (droplet) isolation precautions (used for diseases that are spread through particles that are exhaled. Healthcare workers having contact with or exposure to such patient are required to wear a mask) because of respiratory symptoms. At 1:12 p.m., the Director of Nursing (DON) confirmed Resident #1 had respiratory symptoms and was in "Respiratory" isolation precautions. At 2:15 PM observation was made of a "Contact Precautions" (not "Respiratory Precautions") posting hanging on the door of the room belonging to R#1. In an interview on 4/2/20 at 2:21 p.m., the DON reported there should be a posting for "Respiratory" isolation precautions on Resident #1's door, not "Contact" isolation precautions. Review of the policy titled, "COVID-19 Outbreak Containment" dated 3/3/20 documented, "Staff will follow infection prevention and control measures to prevent and control COVID-19 transmission...a. Persons who develop acute respiratory illness symptoms, fever, cough, nausea, vomiting or diarrhea. b. Note: Elderly persons and other residents, including those who are medically fragile, may manifest atypical signs and symptoms with COVID-19 virus infection, and may not have fever...The following infection prevention and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZHL11 Facility ID: 834670 If continuation sheet Page 7 of 9 PRINTED: 04/13/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 235475 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 04/03/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 21630 HESSEL BEACONSHIRE NURSING CENTRE (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED DETROIT, MI 48219 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 7 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 control measures, recommended by the CDC (Centers for Disease Control), will be followed to prevent person-to-person transmission of COVID-19 and to control infectious outbreaks: When a resident develop acute respiratory illness symptoms, fever, cough, nausea, vomiting or diarrhea their physician will be called immediately. Respiratory isolation will be implemented until the physician has deemed the resident not infectious. Place a sign on the door that says please see staff before entering room. The resident will be serviced meals in their room while in isolation, paper products will be used and discarded after meals. Staff will don PPE prior to entering the room and discard PPE in the resident's room before leaving the room. Use alcohol rub prior to leaving. WASH HANDS WHEN YOU COME OUT OF THE ROOM...Place resident in a private room. If a private room is not available, place (cohort) suspected COVID-19 residents with other residents suspected of having COVID-19; cohort confirmed COVID-19 residents with other residents confirmed to have COVID- 19. Staff will wear a surgical mask upon entering the resident's Remove the mask when leaving the resident's room and dispose of the mask in a waste container". Abatement: Removal plan for Immediate Jeopardy 4/2/20 Action taken for resident Resident #1 remains on droplet precautions. She was assessed for changes in her condition her vital signs remain within normal limits. There is no noted decline related to this practice. Her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZHL11 Facility ID: 834670 If continuation sheet Page 8 of 9 PRINTED: 04/13/2020 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 235475 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER 04/03/2020 STREET ADDRESS, CITY, STATE, ZIP CODE 21630 HESSEL BEACONSHIRE NURSING CENTRE (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED DETROIT, MI 48219 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 880 Continued From page 8 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 880 physician was notified and her guardian company was called, her vital signs will be monitored every 2 hours to monitor for changes, x24 hours. 2 signs have been posted on the outside of her door and one sign posted inside the room to reflect the resident is on droplet precautions. There is also a notice posted to check with nurse prior to room entry. Resident #1 room was cleaned by staff. Action taken for staff The Identified CENA was immediately removed and was given a 1:1 education on droplet precautions, proper use of PPE, and Covid-19 prevention by the DON. The identified cena completed infection control transition based precautions on Health care Academy as well. The CENA was sent home. The Unit Manager was assigned to take over the CENA's duties for the remainder of her shift. On the spot education was given to staff members present regarding proper use of PPE, infection control policy regarding droplet precautions as well Covid-19 prevention outtakes and containment. The remaining staff will be educated on these policies/guidelines, prior to the start of their shifts until complete. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZHL11 Facility ID: 834670 If continuation sheet Page 9 of 9