Riverside Healthcare Center

Based on observation, interview, and record review the facility failed to provide clinical justification for the continued use of PRN (as needed basis) psychotropic medication (valium) for one resident (#23) out of five residents reviewed for the potential of unnecessary medication. Findings Included: Resident #23 (R23) Review of the medical record revealed R23 was admitted to the facility 01/06/2025 with diagnoses that included fracture of the lower end of right femur (upper leg), Buerger's disease (vascular disease that causes inflammation and swelling in blood vessels of the hands and feet-leading to blocked blood vessels), peripheral vascular disease (PVD), hypertension, gastro-esophageal reflux disease, depression, polyneuropathy (malfunction of nerves throughout the body), restless leg syndrome, type 2 diabetes, anxiety, asthma, right below the knee amputation, left below the knee amputation, constipation, chronic obstructive pulmonary disease (COPD), and atherosclerotic heart disease (damage or disease in the hearts major blood vessels). The most recent Minimum Data Set…

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 medication error rate less than 5% for one of four residents (Resident #37) reviewed for medication administration, resulting in an 10.34% medication error rate and potential side effects as a result of the errors. Findings include: During an observation and interview on 03/25/25 at 720 AM, RN C prepared medications to be administered to R37. RN C did not wash her hands or use hand sanitizer prior to setting up medications. RN C prepared Lantus 20 units, Loratadine10mg, Lyrica 200mg, MiraLAX 17gm, Morphine 15mg 1 tab, Pepcid 20mg, Tizanidine 2mg and Buspirone 10mg. Protein drink was declined by R37. Lexapro 5mg tab and Betamethasone cream ointment .2ml topical were not administered or applied as ordered to take in the AM. RN C also set the medication cup with the medications in them and MiraLAX mixture on the over the bed table and walked away to the sink to wash her hands, not looking back to ensure R37 took his medications and drank his MiraLAX. Record review of the medication administration 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 This citation has two deficient practice statements DPS A and DPS B. DPS A. Based on observation and interview the facility failed to ensure that accepted infection control protocols related to hand hygiene and glove use for one resident (#13) out of one resident sampled for infection control. Findings include: Resident #13 (R13) Review of the medical record reflected R13 was an initial admission to the facility on [DATE]. Diagnoses of Alzheimer's Disease with late onset, legal blindness, pressure ulcer of other part, stage 4, confined to bed, moderate protein-calorie malnutrition and muscle weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/16/2024 revealed R13 had a Brief Interview of Mental Status (BIMS) of 99 (unable to answer the questions) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R13 is dependent of all care. During an interview and observation on 03/26/25 at 9:41 AM, Registered Nurse (RN) C donned personal protective…

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 maintain a clean homelike environment for all residents exposed to insects/pests and that ate their meals in the dining room. Findings include: During an observation on 04/15/24 at 5:12 AM, certified nurse aide (CNA) D stood in the back hallway and was stomping things on the floor with the bottom of her shoe. Wow there are a lot of them. After CNA D left the hall, 25 dead ants with wings were observed on the floor and 6 alive winged ants were crawling on the floor. The winged ants were stepped on and killed so to ascertain an approximate number of alive insects in the area. During an observation on 04/15/24 at 5:20 AM, 6 winged ants were crawling on the floor near the nurses station on the back hall. Also observed on the floor was a spider. These were stepped on and killed so as not to repeat observations of the same insects that were alive. During an observation on 04/15/24 at 5:29 AM, 3 winged ants crawled on the floor near the back…

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 follow professional standards of nursing practice for medication administration for 4 residents (Resident #18, #6, #16, and #88), reviewed for the provision of nursing services, resulting in lack of blood pressure assessments prior to medication administration, medication errors, and mismanagement of controlled substances. Findings: Resident #18 (R18) Review of an admission Record revealed R18 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension and multiple sclerosis. Review of R18's Order Summary dated 3/7/24 revealed, midodrine tablet; 10 mg; Three Times A Day; Amount to Administer: 1 tab; Hold if SBP >120 (systolic blood pressure greater than 120). Review of R18's March Medication Administration Record revealed: *On 3/8/24 R18's blood pressure was 128/78 and the 1 PM dose of midodrine was administered *On 3/8/24 R18's blood pressure was 128/78 and the 7 PM dose of midodrine 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.

Based on observation and interview, the facility failed to secure smoking materials per protocol. Findings: During an observation on 04/15/24 at 5:21 AM the following was noted: (a) the door to the shower room behind the nurses desk was open, (b) the shower room had 2 separate closets, one on the right contained linens and supplies and the one on the left had a open door and contained a plastic box, (c) the lid on the plastic box lifted off and the box contained 7 packs of cigarettes and 2 lighters, and (d) the lid to the box had a small padlock attached to it. During an interview on 04/17/24 at 11:47 AM the Administrator stated that resident smoking materials were kept in a plastic box and double locked. Cigarettes and lighters were stored in a closet in the shower room and the closet door was kept locked. There was also a pad lock on the lid of the plastic box that stored the smoking materials.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation is related to intake # MI00140670 Based on observation, interview, and record review, the facility failed to accommodate the needs of four residents (Resident #10, Resident #20, Resident #19 and Resident #18) out of 6 residents reviewed, resulting in (a) call lights placed out of reach of the residents and (b) a resident not receiving timely incontinence care. Findings: Resident #10 (R10) Review of a Face Sheet revealed R10 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses of a stroke causing left sided weakness and paralysis, history of falls, high blood pressure, and vascular dementia. R10 received hospice services, had severe cognitive impairment, and was dependent on staff for all activities of daily living. During an observation on 12/19/23 at 1:20 PM, R10 sat up in a broda chair, facing the doorway, and the call light sat at the head of the bed out of sight and out of reach of the resident. During an observation on 12/19/23 at 2:10 PM, R10 laid in bed,…

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 #'s: MI00140117, MI00140120, MI00140122, MI00140239, MI00140670, MI00140239, MI00140348, and MI00137588 This citation has 2 Deficient Practice Statements. Deficient Practice Statement A: Based on interviews and record review, the facility failed to protect the resident ' s(s ' ) right to be free from mental abuse, verbal abuse and physical abuse by a resident when the facility failed to implement interventions to prevent escalating behaviors for one resident (R1) of four residents reviewed for abuse, resulting in R8 verbally abusing R1, R1 getting in a physical altercation with R13 and R11, and emotional distress. Findings include: Review of an admission Record revealed R1 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: schizoaffective disorder bipolar type (a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania.) Review of a Minimum…

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 follow professional standards when utilizing a central line catheter (CVC) for the delivery of antibiotics to one resident (Resident #17) out of one resident reviewed for central line catheter (CVC) access, resulting in the potential for bloodstream infections, air embolism (an air bubble that travels to the heart or lungs like a blood clot) and occlusions (blockage). Findings: A central line (or central venous catheter-CVC) is like an intravenous (IV) line. But it is much longer than a regular IV and goes all the way to a vein near the heart or just inside the heart. Resident #17 (R17) Review of a Face Sheet revealed R17 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses of anoxic (no oxygen) brain injury and bed confinement status. R17 had severe cognitive impairment, utilized a tracheostomy and feeding tube, and was completely dependent on staff for all activities of daily living. R17 had a surgically implanted…

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 #'s: MI00140670, MI00141505, MI00140348, and MI00140239 Based on observation, interview, and record review, the facility failed to (a) provide adequate supervision to prevent a resident to resident altercation, (b) provide a nursing assessment to a resident after an unwitnessed fall that resulted in an injury, (c) accurately and thoroughly complete documentation (Event Reports) for a resident with multiple falls, (d) provide adequate staffing to supervise residents, and (e) safely secure smoking materials, for 4 of 6 residents reviewed for accidents and supervision (Resident #10, Resident #14, Resident #19, and Resident #1) resulting in an injury to R10, an unassessed head injury after a fall for R19, and R1 attempting to start a fire inside the facility. Findings: Resident #10 (R10) Review of a Face Sheet revealed R10 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses of a stroke causing left sided weakness and paralysis, history of falls,…

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.

This citation pertains to intake #: MI00140348 Based on interview and record review, the facility failed to 1.) ensure Certified Nursing Assistants (CNAs) yearly performance review was conducted, and 2.) failed to develop and implement appropriate and effective in-service training programs based on the yearly performance evaluation for 5 of 6 CNAs reviewed for competencies/education, resulting in the potential for CNA's to not be able to safely provide necessary care and services to residents, a lack of training, and the potential for unmet care needs for residents residing at the facility. Findings: Review of the Facility Assessment last reviewed/updated 2/10/23 revealed, .The facility will complete a performance review and competency evaluation of nursing staff annually and provide regular in-service education based on the outcome of these reviews, or as determined to meet the educational needs of the facility. During an interview on 12/20/23 at 12:12 PM, Human Resources Director (HRD) S reported that CNAs were to have yearly performance evaluations completed by the Director of…

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 #: MI00140348 Based on interview and record review, the facility failed to 1.) permit a resident to return to the facility following hospitalization, 2.) provide documentation that the facility had fully evaluated the resident, and did not base the discharge on the resident's status at the time of transfer, and 3.) notify the residents guardian in writing of their appeal rights for 1 resident (Resident #1) reviewed for facility initiated transfers, resulting in Resident #1 being denied return to the facility, the inability of Resident #1's guardian to appeal the involuntary discharge, and the potential for R1 to have feelings of sustained confusion, anger, and frustration. The reasonable person would be distressed at the prospect of not returning to their home after a hospitalization. Findings: Resident #1 (R1) Review of an admission Record revealed R1 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included:…

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 portable oxygen equipment was properly installed and readily accessible for 1 resident (Resident #16) out of a total sample of 20 residents reviewed, resulting in the potential for complications from hypoxia and hypoxemia and anxiety due to delayed oxygen administration. Findings: Review of a facility policy Oxygen Safety (undated) specified the following pertinent information: 5. Handling Oxygen Cylinders- . b. Protect cylinders from contamination with dust and dirt. Cylinder-valve protection caps, where provided, shall be kept in place, except when cylinders are in use or connected for use. 6. Oxygen in Use- a. Licensed staff using oxygen equipment will be trained in its operation, safety precautions, and manufacturer's instructions for using the equipment. Training will occur upon hire and periodically for review of safety guidelines and usage requirements . Resident #16 (R16) Review of a facility Resident Face Sheet reflected…

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, and operationalize an antibiotic stewardship program and failed to ensure accurate monitoring and documentation of antibiotic use, resulting in the potential for inappropriate antibiotic utilization and worsening or non-improving infections for all 28 Residents residing within the facility as well as the potential for antibiotic resistance. Findings include: Review of a policy titled Antibiotic Stewardship Program implemented 11/1/22 revealed: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. 4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: . b. Monitoring antibiotic use: . 11. Documentation related to the program is maintained by 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow physician orders and provide treatments for contractures for 1 (Resident #1), resulting in the potential for pain and worsening contractures. Findings include: Review of a Face Sheet revealed R1 was originally admitted to the facility on [DATE] and has pertinent diagnoses of anoxic brain damage, contractures, and pressure ulcers. Review of the Minimum Data Set (MDS) dated [DATE] for R1 revealed a Brief Interview for Mental Status (BIMS) assessment was not completed. She is totally dependent on 2 staff for cares and has limited range of motion (LROM) on bilateral upper and lower extremities. She is incontinent of bowel and bladder and has no pressure ulcers but is at risk. Review of a Physician order for R1 dated 3/25/22 revealed: Encourage (patient) to wear B elbow, B hand splints and hip abd (abductor) at all times for improved positioning and decreased contracture. Nursing to check for redness and skin integrity during AM/PM…

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 Registered Nurse (RN) coverage for at least eight hours a day resulting in no RN coverage for a Skilled Care facility and the potential for resident tasks and care to be completed by staff operating out of their scope of practice. Findings: On 3/28/23 an unannounced Annual Recertification Survey was initiated at the facility. On entry to the facility the survey team was informed that the facility had a new Director of Nursing (DON) who was currently on vacation. Review of the staff schedule provided by the facility reflected that no RNs were scheduled at the facility the week of 3/26/23 through 4/1/23. At the time of survey entry, one Licensed Practical Nurse (LPN) was observed to be on duty. On 3/31/23 at 9:18 AM an interview was conducted with the Nursing Home Administrator (NHA) in his office. The NHA reported that the facility has not had comprehensive RN coverage since the previous DON had quit about six weeks prior. The NHA acknowledged that were a lot of gaps in RN coverage. The NHA reported 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 Based on observation, interview, and record review, the facility failed to ensure that controlled drugs and resident medications were properly secured and failed to ensure excessive medications were returned to the pharmacy, resulting in the potential for diversion and misuse of medications, and the potential for inadvertent self-administration of unsecured medication by cognitively impaired residents. Findings: The CMS Form 672 Resident Census and Condition of Residents signed by the facility 3/28/23 was reviewed. The Form 672 reflected a total census of 28 residents with 9 residents diagnosed with some form of dementia and 9 residents with documented psychiatric diagnoses. On 3/28/23 at 10:44 AM one of two doors to the East Hall medication room was discovered to be unlocked. Resident medications were observed to be on a shelving unit in the room and the medication refrigerator was observed to have a clasp attached to the side but no lock in place to secure the contents of the refrigerator. Inside 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation has 2 DPS. DPS A This citation pertains to intake MI000129898 Based on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions according to Centers for Disease Control and Prevention (CDC) guidelines and facility policy for 1 resident (Resident #25), resulting in the potential for complications from cross contamination of Multidrug-Resistant Organisms (MDROs). Findings: Review of a facility policy Enhanced Barrier Precautions implemented 11/1/2022 reflected It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). The policy indicated All staff receive training on enhanced…

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 operationalize policies and procedures to ensure influenza vaccinations were offered with accessible documentation of acceptance or declination in the medical record during the 2022-2023 influenza season for 3 (Resident #1, Resident #3, and Resident #10) of 5 residents reviewed, resulting in the residents not being offered or receiving their vaccinations. Findings include: Review of policy titled Influenza Vaccination implemented on 11/1/22 revealed: It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza. Review of a policy titled Pneumococcal Vaccine (Series) with no date revealed: It is our policy to offer our residents, staff and volunteer workers immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations. Review of an influenza 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI000129509, MI000129898, MI000130296 Based on observation, interview, and record review, the facility failed to maintain the physical facilities, maintain a clean environment, and provide a backflow protection device, resulting in a non-homelike facility and potential contamination of the domestic water supply, affecting all residents in the facility. Findings include: On 3/28/23 at 10:12 AM, the bathroom of room [ROOM NUMBER] was observed to have a black trash bag on the floor between the toilet and the wall. On 3/28/23 at 10:37 AM, the wall around the hand sink, located in the bathroom of room [ROOM NUMBER], was observed to have peeling paint, exposing the rough cinder block. The floor of the bathroom was observed to have a gritty texture when stepped on. Additionally, the walls were observed to be soiled with an unidentified dried splatter. At this time, a bag of clean linens was observed in room [ROOM NUMBER] on the floor across from Bed 1, and a television was observed 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 ensure required Minimum Data Set (MDS) assessments accurately reflect the resident's status for 1 resident (Resident #25), resulting in the potential for unmet physical and psychosocial care needs. Findings: Resident #25 (R25) Review of a Face Sheet reflected R25 admitted to the facility with diagnoses that included anoxic brain damage, pneumonia, urinary tract infection, anemia, osteomyelitis of vertebra, sacral and sacrococcygeal region, stage 4, pressure ulcer of right hip, stage 4, pressure ulcer of left hip, stage 4, functional quadriplegia, tracheostomy status, gastrostomy status. During an observation on 3/28/2023 at 10:01 AM, R25 was observed in bed. A tracheostomy was in place. During a follow-up observation on 3/28/2023 at 11:19 AM, Licensed Practical Nurse (LPN) P was observed providing tracheostomy care that included suctioning. Review of Section O - Special Treatments and Programs from an OBRA admission Minimum Data Set…

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 operationalize policies and procedures to monitor, assess, and follow physician orders for pressure ulcer care for 1 (Resident #1), resulting in the potential for the reoccurrence of a pressure ulcer be unnoticed and treated. Findings include: Review of a Face Sheet revealed R1 was originally admitted to the facility on [DATE] and has pertinent diagnoses of anoxic brain damage, contractures, and pressure ulcers. Review of the Minimum Data Set (MDS) dated [DATE] for R1 revealed a Brief Interview for Mental Status (BIMS) assessment was not completed. She is totally dependent on 2 staff for cares and has limited range of motion (LROM) on bilateral upper and lower extremities. She is incontinent of bowel and bladder and has no pressure ulcers but is at risk. Review of the MDS dated [DATE] for R1 revealed she had a stage III pressure ulcer. Resident #1 (R1) Review of physician orders dated 9/15/22 for R1 revealed an order for weekly skin…

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 MI000129898 Based on observation, interview and record review, the facility failed to provide feeding tube care and services in accordance with professional standards of practice for 1 resident (Resident #25), resulting in the potential for avoidable complications for residents who are tube fed. Findings: Review of a facility policy Flushing a Feeding Tube implemented 11/01/2022 reflected It is the policy of this facility to ensure that staff providing care and services to the resident via a feeding tube are aware of, competent in and utilize facility protocols regarding feeding nutrition and care. Feeding tube care and services will be provided in accordance with resident needs and professional standards of practice. The policy specified 9. Prior to flushing the feeding tube, the administration of medication or providing tube feedings, the nurse verifies the proper placement by noting the length of the tubing or performing a measure of the pH of gastric secretions, if performed…

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 MI000129898 Based on observation, interview and record review, the facility failed to ensure tracheostomy care was provided according to professional standards of practice for 1 resident (Resident #25) when a nurse failed to utilize sterile technique when performing tracheostomy suctioning, resulting in the potential for serious complications from contamination of the resident's airway. Findings: Review of a facility policy Tracheostomy Care implemented 11/1/2022 reflected The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suction, is provided such care consistent with professional standards of practice, the comprehensive care plan and resident goals and preferences. The policy indicated, 5. The facility will ensure staff responsible for providing tracheostomy care (Licensed Nurse or Respiratory Therapist) including suctioning are trained and competent according to professional standards of practice. Review of a facility…

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 maintain a complete and accurate medical record for one Resident (R15), resulting in a resident record that lacked past and current pertinent health monitoring data and historical information and the potential for all facility resident records to lack vital data for health care providers who rely on an accurate health record to formulate care. Findings: Review of the Electronic Medical Record (EMR) reflects that R15 was admitted to the facility 6/23/22 with diagnoses that included seizure disorder and Anoxic Brain Injury. The EMR Progress Notes for R15 revealed an entry on 3/19/23 at 9:50 AM by Licensed Practical Nurse (LPN) B that R15 had been transferred to the hospital for stroke like symptoms. Review of the hospital documentation dated 3/20/23 reflected imaging results for R15 of an Acute Subdural hematoma in the right frontal and right anterior parafalcine. Small amount of subarachnoid hemorrhage noted in the right frontal lobe. On 3/30/23 at 10:27 AM a telephone interview was conducted with Licensed Practical Nurse…

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 the Infection Preventionist had qualified professional training to adequately assess, implement, monitor and manage the Infection Prevention Control Program, have the appropriate knowledge and skills, and consistently perform the duties of this position by being physically onsite, resulting in the potential for knowledge deficits pertaining to current infection prevention and control standards and infectious disease outbreaks potentially affecting all 28 residents who reside at the facility. Findings include: Review of a Job Description requested for the Infection Preventionist and was provided one for an Infection Control Nurse revealed they report to the Director of Nursing (DON). The infection control practitioner is responsible for disease prevention in hospitals and healthcare facilities and should be well-versed in public health. Core Responsibilities: Responsible for the prevention, investigation, monitoring and reporting of the spread of…

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.