Riverside Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were administered in accordance with physician orders without errors for 2 (R5 and R32) of the 7 residents observed during the medication administration task. This resulted in a facility medication error rate of 12.2% (5 errors out of 41 opportunities). Findings include:R5 Review of a admission Record revealed R5 admitted to the facility on [DATE] with pertinent diagnoses which included dementia, anxiety disorder, schizoaffective disorder, and cognitive communication deficit. Review of a Medication Administration Record (MAR) revealed medications administered to R5 on 4/21/2026 included constulose (used to treat constipation) 20 milliliters (ml), carbamazepine (used to treat schizoaffective disorder) 7.5 ml, risperidone (used to treat schizoaffective disorder) 1 milligram (mg), and valproic acid (used to treat schizoaffective disorder) 5 ml. In an observation and interview on 4/21/2026 at 7:30 AM, Licensed Practical…

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 meet requirements for the medical director's quarterly attendance of the quality assessment and assurance committee meetings. Findings include:During an interview and record review on 4/22/2026 at 1:30 PM, the Nursing Home Administrator/Director of Nursing (NHA/DON) revealed that the medical director had not attended the required quality assurance committee meetings quarterly. NHA/DON revealed signature pages for the QAA meetings, and the last attendance recorded for the medical director was in June of 2025. Review of facility policy/procedure Quality Assurance and Performance Improvement (QAPI), revised 3/5/2025 revealed .The Quality Assessment and Assurance (QAA) Committee shall be interdisciplinary and shall consist at a minimum of.the medical director or his/her designee.Meet at least quarterly and as needed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #1322431. Based on observation, interview, and record review the facility failed to implement care planned interventions and ordered treatments for pressure ulcer prevention for 1 resident (R102) of 3 residents reviewed for pressure ulcers. Findings include:Review of a Face Sheet revealed R102 admitted to the facility on [DATE] with pertinent diagnoses which included cerebral infarction (stroke) and hemiplegia (muscle weakness or partial paralysis on one side of the body). Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R102, with a reference date of 8/5/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 6, out of a total possible score of 15, which indicated R102 was severely cognitively impaired. Further review of the same MDS assessment revealed R102 was dependent on staff for toileting hygiene, always incontinent of bowel, and at risk for developing…

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 effectively clean and maintain food service equipment affecting 38 residents. Findings Included: On 03/24/2025 at 08:32 a.m. an initial tour of food services was conduced with Dietary [NAME] I. The following items were observed: Cardboard box, containing dinex cup lids, was observed to be on the floor in the dry storage room. The base boards, on the wall that the door swung into, was observed to have black substance on it the entire length of the wall. The door jam of the dry storage room was observed to be rusted along the floor. Observation of the freezer, which staff called the vegetable freezer, revealed soiled bottom shelf that appear to be dried liquid film. Observation of 7 pots and pans contained dark colored substance on the inside of the pains. The substance appeared to be backed on food substance that could not be removed. Observation of toaster grill appeared to have backed on substances on the grates of the toaster device and what appeared to be burnt on toast crumbs. Observation of the grill,…

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 updated and accurate advanced directive information was in place for two residents (R7 and R39) of 38 residents reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility or other healthcare providers. Findings include: Resident #7 (R7) Review of the medical record reflected R7 was an initial admission to the facility on [DATE] with a readmission on [DATE]. Diagnoses of Psychosis not due to a substance or known Physiological condition, Diabetes 2, Post Traumatic Stress Disorder, Obesity, Generalized anxiety, Depression, Chronic Pain, Chronic Pulmonary Disease and muscle wasting. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/08/2025 revealed R7 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact)…

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 an accurate and timely Notice of Medicare Non-Coverage (NOMNC) was provided for three Residents (#5, #8, #35) and an accurate Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) was provided for two Residents (#8 #35) out of three residents reviewed for Beneficiary Notification. Findings Included: Resident #5 (R5) Review of the medical record revealed R5 was admitted to the facility 09/23/2019 with diagnoses that included subarachnoid hemorrhage (stroke), bipolar disorder, hypertension, anxiety, depression, peripheral venous insufficiency, lymphedema (swelling caused by lymphatic system blockage), dysphagia (difficulty swallowing), type 2 diabetes, hyperlipidemia (high fat in blood), chronic obstructive pulmonary disease (COPD), chronic pain, seizures, gout (increase in uric acid in bone joints), and gain and mobility abnormalities. The most recent Minimum Data Set (MDS), with an assessment reference date of 03/05/2025, demonstrated a Brief Interview for Mental Status (BIMS) of 12…

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 a Baseline Care Plan with necessary healthcare information for one (R37) of 14 reviewed. Findings include: Review of the medical record reflected R37 admitted to the facility on [DATE], with diagnoses that included quadriplegia (paralysis of both arms and legs) and neuromuscular dysfunction of the bladder. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/29/24, reflected R37 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had an indwelling urinary catheter. On 03/24/25 at 11:30 AM, R37 was observed seated in a wheelchair, in their room. R37 reported having a Foley catheter (indwelling urinary catheter). On 03/26/25 at 9:46 AM, R37 was observed in bed, watching TV. A urinary catheter drainage bag was observed hanging on the right side of the bed frame. R37's Baseline Care Plan, which was initiated on 12/23/24, did not reflect…

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 prevent constipation and ensure medication orders specified dosing and route instructions for one (Resident #15) of one reviewed. Findings include: Review of the medical record reflected R15 admitted to the facility on [DATE], with diagnoses that included diabetes, constipation and hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided weakness) following nontraumatic intracranial hemorrhage (brain bleed) affecting the left side. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/28/24, reflected R15 scored six out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was always incontinent of bowel and bladder. On 03/24/25 at 9:57 AM, R15 was observed in their room, watching TV. R15 reported issues with constipation since their admission to the facility, which they felt staff was doing very little about. R15's medical 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 ensure a safe environment and provide adequate supervision of smoking or screening them with form named PHCM Smoking risk to determine if they can smoke independently for two of two sampled residents (Resident #5 and Resident #2) reviewed for accidents and safety. Resident #2 (R2) During an interview and observation on 03/26/25 at 4:23 PM, R2 stated he had to turn in his lighter and cigarettes to nursing staff every time he goes inside, and he can get them back whenever he wants to go back outside. R2 also stated he can go outside anytime he wants to smoke. Did not respond to writer asking him if he had a lighter and marijuana hide outside from everyone. R2 stated he is independent with smoking, so he can come and go as he pleases. Observation of burn marks on his hoodie sweatshirt. During an interview on 03/27/25 at 10:39 AM, LNA/DON A stated the document PHCM Smoking risk, was under the assessments found under observations. Record review did not reveal that a smoking risk assessment was completed 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 interview and record review, the facility failed to ensure recommended laboratory monitoring was in place for one (R15) of five reviewed. Findings include: Review of the medical record reflected R15 admitted to the facility on [DATE], with diagnoses that included diabetes, constipation and hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided weakness) following nontraumatic intracranial hemorrhage (brain bleed) affecting the left side. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/28/24, reflected R15 scored six out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R15's medical record reflected Physician's Orders for 65 units of Basaglar insulin (used to treat diabetes) to be administered twice daily, 500 milligrams (mg) of Metformin (medication used to treat diabetes) by mouth twice daily and four units of Novolin R FlexPen 100 units per milliliter (u/mL) insulin (used to treat…

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 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.