Van Buren Healthcare And Rehabilitation Center

Number of residents sampled: Number of residents cited: Based on record review, interview and facility policy review, the facility failed to develop and implement a person-centered comprehensive care plan that included dementia care needs for one (Resident #37) of one resident reviewed. The findings include: Review of Resident #37's admission Record revealed the facility admitted Resident #37 on 08/05/2023 with diagnoses that included dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance with an onset date of 09/02/2025. Review of Resident #37's Physician Orders revealed Resident #37 was admitted to [the facility] long-term care (LTC) with an order date of 11/03/2025. Review of Resident #37's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 03/08/2026, revealed Resident #37 had a Brief Interview for Mental Status score of 10, which indicated Resident #37 had moderate cognitive impairment. The MDS also revealed active diagnoses in the last seven days that included non-Alzheimer's dementia. Review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the care plan was followed related to fall interventions for 1 (Resident #32) of 1 sampled resident with a history of falls. The findings are: On 09/20/2024 at 2:45 PM, the Surveyor observed one fall mat in place on the right side of Resident #32's bedside. The Surveyor observed adhesive strips on the left side of Resident #32's bedside. On 09/22/2024 at 09:00 AM, review of the Care Plan, with an initiated date of 06/19/24, noted Resident #32 was a moderate risk for falls, with falls recorded on 7/21/2024, 7/27/2024, and 9/11/2024 without injury. Interventions include a fall mat placed on both sides of the bed. On 09/22/2024 at 09:30 AM, review of the Medical Diagnosis sheet reported Resident #32 had diagnoses of unspecified lack of coordination, severe protein calorie malnutrition, reduce mobility, muscle wasting, and abnormalities of gait and mobility. On 09/22/2024 at 11:51 AM, the Surveyor observed one fall mat in place on the right side of Resident #32's bedside. No fall mat was observed on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide alternative communication methods for 1 (Resident #15) of 1 sampled resident who required alternative formats for communication. The findings are: On 09/16/2024 at 2:00 PM, during initial rounds and interviews with the residents, Resident #15 indicated they wanted to speak with the Surveyor. Upon entering the Resident #15's room, the Surveyor became aware that Resident #15 struggled to communicate verbally. No communication board or note tablet was visible in the resident's room. Resident #15 became agitated as the Surveyor struggled to understand what Resident #15 was trying to communicate. When asked if there was a way Resident #15 could communicate with the Surveyor easily, Resident #15 looked around room then indicated no. On 09/16/2024 at 10:00 AM, review of Resident #15's Medical Diagnosis sheet reported a history of traumatic brain injury, and dementia. On 09/16/2024 at 10:30 AM, review of Resident #15's Care Plan, with an initiated date of 12/15/21, noted Resident #15 had a communication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record review, and facility policy review, it was determined the facility failed to ensure 1 (Resident #4) of 7 residents reviewed for accidents and hazards received adequate supervision to prevent the potential for accidents. Specifically, the facility failed to ensure Resident #4 was supervised to prevent the access and potential for ingestion of hand sanitizer, on the overbed table next to a cup of water in Resident #4's room. Findings included: A review of the admission Record, indicated the facility admitted Resident #4 with diagnoses that included senile degeneration of the brain, benign neoplasm of prostate, unspecified dementia, and metabolic encephalopathy. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/14/2024 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 1 which indicated the resident had severe cognitive impairment. Resident #4's functional abilities indicated resident required set up and clean up assistance with eating and oral hygiene. Resident #4 utilized a manual wheelchair for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure food items stored in the refrigerator/freezer were covered, sealed and dated; expired food items were promptly removed/discarded by the expiration or use by dates to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 97 residents who received meals from the kitchen (total census: 98), as documented on a list provided by the Dietary Supervisor on 07/11/23 at 2:22 AM. The findings are: 1. On 07/10/23 10:33 AM, the following observations were made in the walk-in refrigerator: a. A container of leftover apple cobbler dated 6/30/2023. b. An opened box of sausage not covered or sealed. 2. On 07/10/23 at 10:34 AM, the following observation was made in the in the walk-in freezer: a. An opened box of egg omelets not covered. 3. On 07/10/23 at 11:22 AM, there…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure privacy and confidentiality of personal and medical information was maintained during medication administration by not locking the computer screens when not in use for 2 (Residents #29 and #59) of 2 sampled residents. The findings are: 1. On 07/12/23 at 8:33 AM, on the East Hall the medication cart was left unattended with the laptop screen opened and unlocked with Resident #29's name, information, and photo visible. 2. On 07/12/23 at 8:33 AM, the Surveyor asked Licensed Practical Nurse (LPN) #3 to look at the computer on the medication cart and tell this Surveyor what was wrong. LPN #3 stated, I left it open. The Surveyor asked if she should lock the laptop computer when she left her medication cart unattended. LPN #3 stated, Yes. The Surveyor asked what could happen if she didn't lock her laptop screen and left it unattended for others to see. LPN #3 stated, A violation of HIPPA [Health Insurance Portability and Accountability Act]. 3. On 07/13/23 at 3:49 PM, on the North Hall the medication cart was unattended with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately record the resident assessment for 4 (Resident #6, #48, #86, #89) of 4 sampled residents. The findings are: 1. Resident #6 had a diagnosis of Bipolar Disorder. a. Resident #6's electronic medical records contained a Preadmission Screening and Resident Review (PASARR) Level II dated 12/23/20. b. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 03/24/23 documented the resident was not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. 2. Resident #48 had a diagnosis of Schizoaffective Disorder. a. A letter from [State Designated Professional Associates] dated 01/30/20 regarding Resident #48's documented Resident #48 does not require specialized services and recommended the following rehabilitative services: Mental health Evaluation/Diagnosis; Pharmacological Management by Physician; Periodic Review of Master treatment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered plan of care for 2 (Residents #27 and #86) of 13 (Residents #6, #27, #29, #48, #55, #59, #63, #71, #84, #86, #89, #91 and #96) sampled residents whose Care Plans were reviewed. The findings are: 1. Resident #27 was admitted on [DATE] with a diagnosis of Bipolar Disorder. a. The Care Plan with an initiated date of 10/06/21 did not address interventions and care related to Bipolar Disorder. b. A Physicians Orders dated 05/08/23 indicated the resident was to receive Depakote Sprinkles (Divalproex Sodium) 125 milligrams one time a day related to Bipolar Disorder, Current Episode Depressed, Mild. c. Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/15/23 documented the resident had a diagnosis of Bipolar Disorder. d. On 7/12/23 at 3:17 PM, the Surveyor asked the MDS if all serious mental health diagnoses should be represented on a resident's Care Plan. The MDS Coordinator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure Activities of Daily Living (ADL) care was provided to promote cleanliness and good personal hygiene for 1 (Resident # 71) of 10 (Residents #15, #20, #30, #63, #65, #68, #71, #86, #89 and #91) sampled residents who required staff assistance with shaving on the South Hall (Secure Unit). This failed practice had the potential to affect 24 residents who required assistance on the South Secured Unit with ADL care as documented on a list provided by the Director of Nursing (DON) on 07/14/23 at 9:06 AM. The findings are: 1. Resident #71 had diagnoses of Unspecified Dementia, unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety and Unspecified Lack of Coordination. a. On 07/10/23 at 11:37 AM, Resident #71 was sitting in the Dayroom. She had ½ inch long facial hair on her chin. b. On 07/11/23 at 8:37 AM, Resident #71 was in the Dayroom for breakfast. She had facial hair on her chin approximately 1/2 inch long. c. On 07/12/23 at 8:51 AM, Resident #71 was lying…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure an indwelling catheter bag was covered to maintain privacy for 1 (Resident #63) of 6 (Residents #12, #22, #29, #51, #63 and #78) sampled residents who had an indwelling catheter. The findings are: 1. Resident #63 had diagnoses of Alzheimer's Disease with Early Onset, Neuromuscular Dysfunction of Bladder, Unspecified and Chronic Kidney Disease, Unspecified. a. A Physicians Order dated 01/01/23 indicated the resident had a 16 Fr (french) foley catheter due to Neurogenic Bladder. b. A Care Plan with an initiated date of 01/12/23 indicated to position the catheter bag and tubing below the level of the bladder and away from entrance room door. The Care Plan did not address a privacy bag. c. On 07/10/23 at 3:13 PM, Resident #63 was sitting in his wheelchair in the Dayroom. His catheter bag was hung under the wheelchair approximately half full of a clear yellow liquid. No cover was on the bag. d. On 07/11/23 at 8:50 AM, Resident #63 was sitting in his wheelchair eating breakfast. The catheter bag was hanging…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 71 residents who received regular diets, 18 residents who received mechanical soft diets, and 6 residents who received pureed diets from the kitchen according to a list provided by the Dietary Supervisor on 07/11/23. The findings are: 1. The facility lunch menu provided by the Dietary Supervisor on 07/10/23 at 1:37 PM documented that each resident who received a regular diet was to receive 3 ounces of honey glazed turkey. All residents were to receive baked sweet potatoes and residents on a pureed diet were to receive one 2 inch by 3 inch square of pureed marble cake with frosting. 2. The following observations were made during preparation of the noon meal: a. On 07/10/23 at 11:44 AM, Dietary Employee (DE) #1 was wearing gloves on her hands while she transferred slices of marble cake into individual plates with a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a comfortable, homelike, social dining experience was provided for residents who resided on the facility's Secure Unit. This failed practice had the potential to affect 31 residents as documented on the Census for the Secure Unit South Hall provided by the Registered Nurse (RN) Consultant on 07/10/23 at 1:39 PM. The findings are: 1. On 07/10/23 at 1:20 PM, the Dining Room area of the Secure Unit contained two tables on one side with two chairs near a piano and a recliner, and 3 tables pushed together and a table in the corner on the other side with 4 chairs. 2. On 07/10/23 from 12:45 PM to 1:35 PM, Resident #55 was going back and forth from her room to the Secure Unit Dining Room. At 1:59 PM, the Surveyor asked Resident #55 if she preferred to eat in her room. Resident #55 stated, Yes, it's too crowded out there. There is not enough room. The Surveyor asked would you eat in the Dining Room if there was more room. Resident #55 stated, Yes, probably. 3. On 07/12/23 at 12:40 PM, there were no empty chairs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure food preparation, service areas, and resident areas were free from visible signs of rodents and pests. This failed practice had the potential to affect 98 residents who received a meal tray from the kitchen as documented on a list provided by the Dietary Supervisor on 07/11/23 at 2:22 PM. The findings are: 1. On 07/10/23 at 12:16 PM, the following observations were made around the food preparation area: a. There was a fly crawling on the back of a saucepan hanging on the bar above the food preparation counter. b. A fly was on a pole. c. A fly was on a whisk. d. A fly was a sifter, one was crawling on a knife, and one was flying around the food area. The flies were shown to the Dietary Supervisor. e. A fly was on the wall by the hand washing sink. f. 4 flies were on a food cart close to the hand washing sink. g. A fly was on the wall by the dish window, and one was on the floor close to the food cart. The flies were shown to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure meals were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 2 of 2 meals observed. The failed practice had the potential to affect 8 residents who received meal trays in their room on the 100 Hall; 31 residents who received meal trays in their room on the South Hall (Secure Unit); 16 residents who received meal trays in their room on the [NAME] Hall; 17 residents who received meal trays in their room on the North Hall and 26 residents who received meal trays in their room on the East Hall, as documented on a list provided by the Dietary Supervisor on 07/11/23 at 6:30 PM. The findings are: 1. On 07/11/23 at 5:07 PM, an unheated cart containing 6 meal trays for the assist residents for supper was delivered to the East Hall by Certified Nursing Assistant (CNA) #1. At 5:34 PM, Immediately after the last resident received their tray in their room, the temperatures of the food items on a test tray from the cart were checked and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.