Riverview Health and Rehab Center North

Based on observation, interview, and record review, the facility failed to: 1. Maintain food service equipment in a clean and sanitary manner; 2. Ensure walls in areas where food was prepared were clean; 3. Store the ice scoop in a clean and sanitary manner; 4. Ensure food items past the use-by-date were not stored with active food stock; 5. Properly date-label food; and, 6. Maintain cleanable surfaces (knife storage area and floor underneath the can opener). These deficient practices have the potential to affect all residents who eat food served from the kitchen. Findings include: On 2/22/24 at 8:50 AM the kitchen was observed and the following was noted: Brown colored, scale-like material on the silver plating inside of the ice machine. Dried and crusted, grayish/brown sediment/debris on grease trap. Shiny, black debris observed in various areas around the kitchen walls near the sinks and stove area. The shiny, black debris was approximately -1/2 to 1 and 1/2 inch thick. The ice machine scoop was stored in a bin with brownish-gray colored film at the bottom of the bin. The scoop…

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 interview and record review the facility failed to ensure that the Medical Director (MD) attended the Quality Assurance and Performance Improvement (QAPI-program aimed on improving processes involved in health care delivery and resident quality of life) meetings quarterly, resulting in the potential for impaired resolution of identified issues or decreased quality of care with the potential to affect all 141 residents that reside in the facility. Findings include: During an interview and record review on 2/21/2024 at 12:32 PM, the QAPI program was reviewed with the Nursing Home Administrator (NHA). The NHA said that QAPI team members met monthly and included managers and interdisciplinary team members. When queried if the medical director attends the required quarterly QAPI meeting the NHA stated The medical director did not participate in April, May, or June of 2023. The NHA agreed the medical director is required to attend quarterly meetings. Record review of the provided QAPI attendance records dated April 2023 through June 2023 sign in sheets revealed the signature…

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 initiate and/or accurately complete residents' advance directives in a timely manner for five residents (R41, R43, R46, R67, and R105) of thirteen reviewed for resident's rights, resulting in the potential for resident wishes to not be honored. Findings include: R43 Record review of the Electronic medical record (EMR) revealed resident had no documentation of an advance directive (legal document that provides directions for medical care when resident is unable to communicate wishes) being initiated since admission into facility. Record review of electronic medical records revealed R43 was admitted into facility on 1/11/24 with a pertinent diagnosis of chronic respiratory failure. According to the Minimum Data Set (MDS) dated [DATE], R43 had intact cognition with a Brief Interview of Mental Status (BIMS) of 15/15. R105 Review of the EMR revealed resident had no documentation of an advance directive being initiated since admission into facility. Record…

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, interview, and record review the facility failed to develop comprehensive individualized care plans for four residents (R43, R104, R120, and R20) out thirty-eight residents reviewed for care plan interventions, resulting in the potential of unmet care needs. Findings include: R43 Record review of electronic medical records (EMR) revealed R43 was admitted into facility on 1/11/24 with a pertinent diagnosis of chronic respiratory failure. According to the Minimum Data Set (MDS) dated [DATE], R43 had intact cognition with a Brief Interview of Mental Status (BIMS) of 15/15. During observation on 02/11/24 at 02:16 PM, R43 had an oxygen concentrator and had oxygen being administered. A nebulizer machine was at the bedside. Record review of R43's Physician Orders revealed the following orders: 1. ipratropium-albuterol solution (respiratory medicine) for nebulization; 0.5 mg-3 mg (milligrams) (2.5 mg base)/3 mL; amount to Administer1 3 ml (milliliters) 1 inhalation. Every six hours prn (as needed)…

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 interview and record review, the facility failed to ensure that five out of five (FF, MM, NN, OO, and PP ) certified nurse aides (CNA) whose in-service files were reviewed, had the required annual competency evaluation in skills and techniques necessary to care for residents, resulting in the potential for staff incompetency and/or harm to resident's well-being. Findings include: On 2/13/24 at 9:31 a.m. the following five certified nurse aide annual competency evaluations were reviewed: -CNA FF was hired on 10/25/19. The CENA Competency Evaluation was had a completion date of 8/10/22. -CNA MM was hired on 12/29/10. The CENA Competency Evaluation was had a completion date of 12/19/22. -CNA NN was hired on 6/23/17. The CENA Competency Evaluation was had a completion date of 12/20/22. -CNA OO was hired on 7/22/96. The CENA Competency Evaluation was had a completion date of (no date). -CNA PP was hired on 11/21/14. The CENA Competency Evaluation was had a completion date of 8/20/22. The facility did not have competencies for the year of 2023 for any the certified nurse aides…

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 interview and record review the facility failed to ensure certified nurse aides (CNAs) fulfilled the requirement to complete 12 hours of in-service education annually for five of five certified nurse aides (FF, MM, NN, OO, and PP) resulting in the potential for care performance concerns. Findings include: On 2/13/24 at 10:31 a.m. the following five certified nurse aide annual 12-hour nurse aide training/ in-services were reviewed: -CNA FF was hired on 10/25/19. There were no 12-hour training/ in-services provided by the facility. -CNA MM was hired on 12/29/10. There were no 12-hour training/ in-services provided by the facility. -CNA NN was hired on 6/23/17. There were no 12-hour training/ in-services provided by the facility. -CNA OO was hired on 7/22/96. There were no 12-hour training/ in-services provided by the facility. -CNA PP was hired on 11/21/14. There were no 12-hour training/ in-services provided by the facility. There was no evidence provided by the facility that annual 12-hour trainings/ in-services were completed for the certified nurse aides reviewed. On…

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 This citation has three deficient practice statements. DPS#1 Based on observation, interview, and record review the facility failed to follow infection control practices for five residents (R40, R43, R47, R97, and R104) out of five residents reviewed for respiratory care, resulting in improper storage of nebulizer tubing and the potential for cross-contamination. Findings include: R43 Record review of electronic medical records revealed R43 was admitted into facility on 1/11/24 with a pertinent diagnosis of chronic respiratory failure. According to the Minimum Data Set (MDS) dated [DATE], R43 had intact cognition with a Brief Interview of Mental Status (BIMS) of 15/15. During observation on 02/11/24 at 02:16 PM, th Nebulizer and tubing was sitting on nightstand. The tubing and mouthpiece was not stored in a dated plastic bag with resident's name. When asked, resident R43 reported that they use the same tubing all the time. During an observation of R43's room on 2/12/24 at 10:30 AM, Nebulizer and tubing was…

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 and interview the facility failed to ensure hand sinks were in good repair to be easily cleaned and sanitized in four rooms (1039,1040,1041, and 1044) out of fifteen rooms located on Trans East Nursing Station, resulting in the potential for harmful growth of microorganisms and injury. Findings include: During an observation of room [ROOM NUMBER] on 2/11/24 at 10:40 AM, A hand sink in a resident's room was found to have buckled Formica on front of sink area revealing sharp edges and porous water damaged wood exposed. During an observation of room [ROOM NUMBER] on 2/11/24 at 10:45 AM, A hand sink in a resident's room was found to have buckled formica on front of sink area revealing sharp edges and porous water damaged wood exposed. During an observation of room [ROOM NUMBER] on 2/11/24 at 11:00 AM, A hand sink in a resident's room was found to have buckled formica on front of sink area revealing sharp edges and porous water damaged wood exposed. During an observation of room [ROOM NUMBER] on…

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, interview, and record review, the facility failed to provide dignified dining for one resident (R17) of one resident reviewed for eating assistance while in room, resulting in the potential for feelings of being ignored. Findings include: On 2/11/24 at 1:24 p.m., R17 was observed lying in bed resting with the television on. CENA FF brought the lunch meal tray into the room and proceeded to set up to assist with R117 with eating. CENA FF was then observed standing next to R17's bedside with left hand on the left hip with eating utensil and food in the right hand, and turned slightly to put food in the R17's mouth while CENA FF continued watching the television. On 2/11/24 at 1:27 p.m., CENA FF was asked was it appropriate to stand over the resident while assisting with eating. CENA FF stated, No. I didn't have a chair, so I guess yeah. On 2/13/24 at 10:42 a.m. record review revealed R17 was initially admitted into the facility on 3/6/18 and readmitted from the hospital on 2/6/24 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 observation, interview, and record review, the facility failed to ensure a call light was within reach of one (R92) of one resident reviewed for accommodation of needs, resulting in the potential for unmet care needs. Findings include: On 2/11/24 at 12:50 PM, R92 was observed calling out for help. R92 was observed lying in bed, and stated, I need to be scooted up, I'm uncomfortable. The call light cord was observed clipped to the head of the mattress and the call light button was observed on the floor next to bed. When asked, Can you use your call light to call for help? R92 attempted to reach for call light but was unable to find the call light. Record review of R92's face sheet revealed admitted to facility on 3/22/2021 diagnoses included congestive heart failure, cardiomyopathy, bilateral knee osteoarthritis. Review of the Minimum Data Set (MDS) dated [DATE] for R92 revealed a Brief interview for Mental Status BIMS of 7/15 severely impaired cognition and dependent assistance for mobility. Record…

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 showers as desired for one resident (R103) of two residents reviewed for choices, resulting in resident dissatisfaction. Findings include: On 02/11/24 at 3:43 PM during interview R103 explained they had desire to have a shower. R103 said the last shower had been October of 2023. On 02/12/24 at 11:55 AM record review revealed a physician order dated 2/10/22 designating shower days as Wednesday and Saturday on day shift. On 02/13/24 at 10:32 AM record review of Bath/Shower sheets revealed: 1/2/24 Bed bath 1/9/24 Bed Bath 1/16/24 No documentation of type of bath. 1/19/24 Refused X 3 (Did not specify if resident refused bath or shower.) 1/23/24 Refused X 3 (Did not specify if resident refused bath or shower.) 1/26/24 Bed bath 1/30/24 Refused X 3 (Did not specify if resident refused bath or shower.) According to record review, R103 had a pertinent diagnosis of bilateral primary osteoarthritis of hip. R103 had a BIMS (Brief Interview for Mental Status) score of 15 indicating intact cognition. According to…

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, interview, and record review the facility failed to provide a clean and comfortable environment for two residents (R40 and R79) out of two residents reviewed for safe, clean, homelike environment resulting in resident dissatisfaction and discomfort with living conditions. Findings include: R40 On 2/11/2024 at 2:38 PM, R40 was interviewed about their satisfaction with the care and services that they were receiving at the facility. R40 stated, There is a ceiling tile missing over my toilet it got wet and fell off and the other ceiling tile is stained probably from the toilet above me leaking. R40 expressed dissatisfaction with the appearance of the bathroom and reported that he has told staff numerous times about the bathroom condition. In an observation and interview on 2/13/2024 at 8:45 AM with Maintenance Supervisor (MS) C R40's bathroom ceiling tile was replaced. A new active yellow stain on replaced ceiling tile was observed. When queried about the active yellow stain MS C stated 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 interview and record review the facility failed to file a report with the state of Michigan within a 24-hour period concerning an allegation of staff to resident abuse for one resident (R115) of 10 residents reviewed for abuse. Findings include: Record review of the Facility Reported Incident (FRI) dated 7/09/23 at 04:50 AM, documented LPN (licensed practical nurse) I grabbed the gown of (R115) swinging the chair (wheelchair) around hitting the water fountain. According to the FRI, this action (wheelchair coming in to contact with the water founntain) dislodged the water fountain from the wall. On 2/21/24 at 12:09 PM, the nursing home administrator (NHA) was queried regarding the incident involving R115. The NHA said the incident should have been reported immediately. Review of the facility's undated policy titled Abuse and Neglect Prohibition Policy revealed documentation concerning reporting and stated in part, The facility will report all allegations and substantiated occurrences of mistreatment, abuse, neglect, misappropriation of property or injuries of unknown source…

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 ensure a Pre-admission Screening and Annual Resident Review (PASARR-determines whether or not an individual who has a diagnosis of Mental Illness or Intellectual/Developmental Disability [ID/DD] meets the criteria for a nursing home and their needs are met) Level I (3877) was completed for three sampled resident's (R93, R97, and R89) from a total sample of 38 resulting in the potential for unmet mental health care needs. Findings include: R93 Record review of R93's face sheet revealed admitted to facility on 1/19/2021 diagnoses included hemiplegia and hemiparesis following cerebral infarction, anxiety disorder, bipolar disorder, major depressive disorder. Review of the Minimum Data Set (MDS) dated [DATE] for R93 revealed a Brief interview for Mental Status BIMS of 13/15 indicating intact cognition. A review of R93's electronic medical record (EMR) did not reveal any current PAS/ARR forms (DCH-3877) or Level ll evaluation. There was no Mental…

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, interview, and record review the facility failed to provide adequate Activities of Daily Living (ADL) care for one resident (R101) out of nine residents reviewed for hygiene, resulting in a dependent residents nail care not being performed. Findings include: R101 Record review of R101's electronic medical record revealed admission into the facility on 6/7/23 with a pertinent diagnosis of hemiplegia and hemiparesis (paralysis on one side of body). According to the Minimum Data Set (MDS) dated [DATE], R101 had slight impaired cognition and required substantial to maximal assistance with ADL care. During an interview on 2/11/24 at 2:03 PM, R101 reported that foot and nail care had not been provided. Observation of bilateral hands revealed all fingernails protruded past fingertips and had dark brown debris underneath. R101 further reported, It would be nice if they could be cut. During observations on 2/12/24 at 11:30 AM, 2/13/24 at 10:20 AM, and on 2/14/24 at 10:29 AM, R101's bilateral hands…

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, interview, and record review the facility failed to provide vision services for one of one resident (R120) reviewed for vision concerns, resulting in inadequate accommodations of vision needs and potential for further deterioration of vision. Findings include: On 2/11/24 at 1:49 p.m. R120 was observed resting in bed with a pair of red glasses on. R120 was alert and oriented to name only. R120 was nonverbal however responded by looking and smiling when name was called. Due to the R120's verbal communication and cognitive impairment, the resident was unable to participate in the interview. On 2/11/24 at 3:12 pm during the resident representative interview, the family member expressed concern with the resident's vision. The family member said R120 was never seen by an eye doctor since admission (one year ago). The family member also said the resident has had the same pair of glasses for the last 15 years and stated, Never had good vision anyway but still deserves to see the eye doctor. On…

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, interview, and record review the facility failed to provide adequate foot care for one resident (R101) out of nine residents reviewed for Activities of Daily Living (ADLS), resulting in R101 having overgrown toenails with debris. Findings Include: During an interview on 2/11/24 at 2:03 PM, R101 reported that foot and nail care had not been provided. An observation of bilateral feet revealed resident's toenails were greenish in color and had had debris underneath. Nails were thick and had grown passed the end of toes and had started curving outwards. R101 further reported, It would be nice if they could be cut. Record review of R101's electronic medical record revealed admission into the facility on 6/7/23 with a pertinent diagnosis of hemiplegia and hemiparesis (paralysis on one side of body). According to the Minimum Data Set (MDS) dated [DATE], R101 had slight impaired cognition and required substantial to maximal assistance with ADL care. During observations on 2/12/24 at 11:30 AM,…

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, interview and record review, the facility failed to follow therapy recommendations to initiate restorative services to maintain range of motion (ROM) and mobility for one resident (R98) of six residents reviewed for ROM, out of a total of 28 sampled residents resulting in the potential for a decline in range of motion, and mobility and worsening of contractures. Findings include: R98 On 2/11/2024 at 10:28 AM, R98 was queried about life in the facility, R98 said, I'm only getting speech therapy I was supposed to have someone work on my hand and legs. I finished physical and occupational therapy but haven't had anyone else come in and work with me. R98 was observed with both lower extremities flexed in a side lying position with left hand flexed into a fist. Record review of R98's face sheet revealed admission into facility on 11/18/2022 with most recent readmission on [DATE]. R98's diagnoses included hemiplegia and hemiparesis following cerebral infarction, pressure ulcer sacral region.…

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 This citation pertains to intake MI00141655. Based on observation, interview, and record review the facility failed to ensure that a foley catheter (urine drainage system) was properly secured to the resident's leg, for one resident (R27) out of two residents reviewed for catheter care, resulting in the potential for injury. Findings include: During an interview on 2/11/24 at 10:25 AM, R27 reported that his foley was not anchored and secured to his leg causing it to pull on his penis. During an observation on 2/11/24 at 10:25 AM, it was revealed that there was an anchor attached to tubing, but it was not adhered to R27's leg. It was further reported that it had been like that for days. During an observation on 2/12/24 at 9:00 AM, foley tubing was not anchored and secured to R27's leg. During an observation on 2/13/24 at 3:11 PM, foley tubing was not anchored and secured to R27's leg. During an interview on 2/13/24 at 3:11 PM with Licensed Practical Nurse (LPN) P, it was reported that the foley catheter should be…

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 record review and interview the facility failed to respond to a pharmacy recommendation for one resident (R3) of two residents reviewed for medication and medication regimen, resulting in a lack of follow-up for possible needed changes. Findings include: On 2/13/24 at 1:08 PM resident (R3) observed resting in bed. Review of the electronic medical record revealed R3 is a resident with a pertinent diagnosis of vascular dementia with behavior disturbance. R3 is currently in hospice care. On 2/13/24 at 2:30 PM, record review revealed a pharmacy recommendation dated 8/20/23 to consider a gradual dose reduction for R3 of Quetiapine (an antipsychotic medication). There was no documented evidence that Physician O responded agree disagree other on the form. In addition, Physician O did not sign the form. On 2/21/23 at 2:09 PM, the Director of Nursing (DON) was interviewed and said Physician O should have responded to the pharmacy recommendation dated 8/20/23 for resident R3. Review of the facility's policy titled Medication Regiment Review Policy (undated) documented, For non-urgent…

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 justify the use of three medications for one resident (R3) of two residents reviewed for medication and medication regimen, resulting in potential ineffective resident care. Findings include: On 2/13/24 at 1:08PM resident (R3) observed resting in bed. R3 is a resident with a pertinent diagnosis of vascular dementia with behavior disturbance. R3 is currently in hospice care. On 2/13/24 at 12:19PM during record review of R3's electronic medical record it was noted that Physician O had written an order on 8/10/23 for Lorazepam 2mg/ml 0.25ml every 4 hours PRN (as needed). The category for this medication listed on the order was as follows: Central Nervous System Agents | Anticonvulsants | Benzodiazepines (Anticonvulsants). The order did not indicate a resident diagnosis and did not provide an indication. (An indication for a drug refers to the use of that drug for treating a particular disease.) On 2/13/24 at 12:29PM record review of R3's electronic medical record noted that on 8/9/23 the Physician O had written…

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 maintain medical equipment in safe operating condition. Findings include: On 2/11/24 at 8:59 AM an observation of the third floor revealed the bladder scanner had a broken attachment at the portion of the cord which connects directly to the scanning device. There were multiple wrappings of clear office tape around the cord. This had separated from the device for a space approximately one half inch leaving the cords exposed. On 2/12/24 at 8:37 AM, the unit manager (UM) L was asked about the use of the bladder scanner. Unit Manager L said the bladder scanner is used for residents as needed. On 2/13/24 at approximately 2:00 PM the information the facility provided was reviewed which indicated the bladder scanner would be used for R66 on that day. On 2/13/24 at 4:31 PM during an interview, the DON and the Maintenance Supervisor C and acknowledged the bladder scanner should not be used on a resident due to its broken condition.

Based on interview and record review, the facility failed to consistently utilize the services of a Registered Nurse (RN) for eight consecutive hours per day, seven days per week, affecting all residents who resided in the facility, resulting in the potential for unmet care needs. Findings include: Record review of facility's Schedule and Staffing Sheets revealed the following: 7/03/22 (Sunday)- No RN coverage. 7/4/22(Monday)-No RN coverage. 7/17/22 (Sunday)-No RN coverage 9/5/22 (Monday)- No RN coverage. 9/11/22(Sunday)- No RN coverage. During an interview with Director of Nursing (DON), it was confirmed that an RN should be on the premises for eight consecutive hours every day. When asked the reason for this protocol, DON said, It is a regulation and RNs provide a skill level that should be available if needed. After review of facility's Schedules and Staffing Sheets during interview, DON confirmed that there were no RN coverage hours on 7/3/22, 7/4/22,7/17/22,9/5/22, and 9/11/22. Record review of policy Nursing Staffing (no date) documented the following: . 2. The nursing…

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 interview and record review, the facility failed to ensure the Infection Preventionist completed specialized training in infection prevention and control, resulting in the potential for knowledge deficits pertaining to current infection prevention and control standards and infectious disease outbreaks in a vulnerable population. This deficient practice had the potential to affect 136 residents that reside in the facility. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Form #20054 Infection Prevention, Control and Immunizations, dated 10/26/2022, revealed that facilities are required to designate at least one qualified Infection Preventionist who completed specialized training prior to assuming the role of Infection Preventionist and that evidence of completion of this specialized training must be available. On 1/10/23 at 1:05 PM during an interview with Licensed Practical Nurse (LPN) F who is the facility's designated Infection Control Nurse said she had not completed the required specialized training for Infection Control at this time. LPN…

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 implement their COVID-19 policy and demonstrate they had screened for, educated, offered, and documented acceptance or declination for COVID-19 Immunization for five (R81, R105, R121, R145, and R149) of five residents reviewed for COVID-19 Immunization resulting in the potential for miscommunication and misunderstanding of Resident COVID-19 Immunization preferences. Findings include: A review of the facility's most recent 'Resident COVID-19 Vaccine Tracker Report' (undated) indicated that Residents R81, R105, R121, R145, and R149 were not vaccinated for COVID-19. No explanation was identified on the report. On 1/10/23 at approximately 10:30 AM during an interview with Licensed Practical Nurse (LPN) F, the facility's designated Infection Control Nurse she said the Public Health Department (PHD) had COVID-19 clinics and came into the facility to administer the COVID-19 shots. LPN F could not say when the PHD had last been to the facility or when they were…

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 ensure they consistently offered and administered influenza and pneumonia vaccines with accessible and valid documentation of acceptance or declination in the medical record for 4 (R81, R105, R145, R149) of 5 residents reviewed for vaccinations, resulting in the lack of vaccine tracking, the residents right to choose and receive vaccine treatment options, and the right to an informed consent. Findings include: On 1/10/23 at 10:00 AM the facility's influenza and pneumonia vaccination records were reviewed with Licensed Practical Nurse (LPN) F, the facility's designated Infection Control Nurse. LPN F said the completed consent/declination forms for the influenza and pneumonia vaccines should be in the 'preventative health' section of the resident's Electronic Medical Record (EMR). LPN F explained the facility's vaccination documentation process, There is a binder for the vaccine consent forms. When the resident accepts the vaccine (consents), the signed…

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, interview, and record review the facility failed to accurately transcribe a physician's medication order and correctly document the medication administration on the Medication Administration Record (MAR) for one of one resident (R1) reviewed for standards of practice resulting in R1 not receiving a lidocaine pain patch (topical anesthetic) in accordance to the physician's orders. Findings include: On 1/9/23 at approximately 11:00 AM R1 was observed laying in her bed on her left side, complaining of pain in her lower back area. R1 said, I get a pain patch on my back once a day, and I haven't gotten it yet. I told the nurse I wanted my pain patch. She said I already got it and I know I didn't. R1 was laying on her left side with the patch visible on the right side of her lower back. The patch had an administration time of 1/8/23 at 6 AM clearly written on it. A review of R1's Electronic Medical Record (EMR) revealed that R1 admitted to the facility on [DATE] with multiple diagnoses that…

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 This citation pertains to intake MI0027872. Based on observation, interview and record review, the facility failed to ensure fresh water was passed in a timely manner for one resident (R105) out of two residents reviewed for hydration, resulting in the potential for feelings of thirst and dehydration. Findings include: In an observation on 1/9/23 at 12:53 p.m., two foam water cups sat on Resident #105's (R105) bedside table. One cup had no date and the other was dated 1/7/23. Review of a Face Sheet revealed, R105 admitted to the facility on [DATE] with pertinent diagnosis which included Parkinson's disease and Adult Failure to thrive. Review of a Minimum Data Set (MDS) assessment, with a reference date of 10/16/22 revealed R105 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15 out of 15. R105 required extensive assist of one staff with eating. In an observation on 1/10/23 at 12:13 p.m., two foam water cups with a date of 1/9 sat on R105's bedside table. Review of a Daily…

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.