Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Riverview Health And Rehab Center North during CMS and state inspections, most recent first.
Surveyors found multiple food service deficiencies, including improperly dated or expired ready-to-eat foods in the walk-in cooler and resident-use refrigerators, unlabeled food items, and a container of pasta and meat sauce left on a counter without a date or label. They also observed an outdoor grease receptacle filled with water and grease, a worn wooden countertop, a cracked floor tile with missing grout near the 3-compartment sink, and an employee on the serving line touching their glasses and forehead with gloved hands without changing gloves or washing hands.
Failure to follow the water management plan and infection control practices was identified after multiple low-use or nonfunctional water fixtures were observed, the water management program was found to lack an annual review and consistent oversight, an LPN returned a blood glucose meter to the med cart without disinfecting it after use, and staff provided care to a resident on EBP without the required PPE. The resident involved in the EBP concern had PEG tube, wound, diabetes, dementia, and other chronic conditions, and the care plan required gown and gloves for high-contact care.
Poor cleanliness, storage, and maintenance in common and bathing areas: The facility had uncapped utility lines, missing floor and wall materials, rusted and deteriorated surfaces, water damage, and dirty toilets and shower areas. Staff also observed supplies and equipment piled in shower and tub rooms, opened personal items left on rails and counters, and mop sinks with chemical pre-dispensing systems left running, creating poor sanitary conditions throughout the facility.
A resident’s room contained a fly trap ribbon full of dead flies and gnats hanging near the bed, and the resident said it had been there for about a year and did not look good. Housekeeping saw the trap during room cleaning, the UM acknowledged it, and maintenance said the building’s fly traps had been put up but were forgotten and could not recall when they were installed or how they were monitored. The resident had intact cognition, was wheelchair bound, and had ESRD and age-related physical debility.
Failure to assist with discharge planning for a resident who wanted to return to the community. The resident, who had diagnoses including PVD, A-fib, HTN, DM2, and MDD, had a BIMS score of 15/15 and said the facility was not helping with discharge plans or providing information about community living. The record showed active discharge planning on the MDS, but no referral to the local contact agency was made, and social work notes stated the resident lacked sufficient support for community transition without documenting who made that determination.
Undated Tube Feeding Formula Bags: Two residents receiving enteral nutrition were observed with tube feeding formula bags hanging and pumps running, but neither bag had a date showing when the feeding was started. Both residents had severely impaired cognition and gastrostomy status, and an LPN confirmed the missing dates. The DON stated the floor nurse is responsible for dating, timing, and initialing the enteral nutrition bag, and the facility policy requires the resident's name, room, date, start time, and rate.
Failure to Report Allegation of Physical Abuse: The facility failed to report an allegation that a resident was physically assaulted by a male staff member and injured. The allegation was reportedly shared with the NP, UM, DON, and SSD, but no FRI was found and the State Agency was not notified in the required timeframe. The resident had severe cognitive impairment, required limited one-person assist with ADLs, and had diagnoses including vascular dementia, schizoaffective disorder, and left arm pain/cellulitis.
The facility did not repair or document corrective action for a coolant leak behind the generator's radiator, as identified in a preventative maintenance report. Staff interviews confirmed that the deficiency was not addressed, and records did not show that the generator was repaired or that corrective action was taken, in violation of NFPA standards.
The facility failed to properly date-label food in storage, with some items stored past their use-by dates. Additionally, commercial ice machines and kitchen surfaces were not cleaned in a timely manner, posing a potential risk for food-borne illness to residents.
A resident with moderate cognitive impairment expressed a desire to get out of bed and socialize, but the facility failed to document and honor these preferences, leading to frustration and boredom. The resident's activity care plan was outdated and did not reflect their current wishes, and there was no documentation of one-to-one interactions. The Nursing Home Administrator acknowledged the need for individualized activities and proper documentation, but the facility's policy on one-to-one activities was not provided.
A resident expressed dissatisfaction with cold meals, and upon testing, scrambled eggs and pancakes were found below the required temperature. The resident, with legal blindness and other conditions, was on a specific diet. The Dietary Manager acknowledged the issue, and the NHA confirmed the need for proper temperature ranges.
A resident with a history of hip fracture and dementia was found with a swollen and painful left hip, later confirmed as a fracture. Despite the facility's policy requiring immediate reporting of injuries of unknown origin, the incident was not reported to the abuse coordinator or State Agency. Interviews with staff, including the DON and NHA, confirmed the oversight.
A resident with a history of hip fracture and dementia experienced multiple falls in the facility. Despite being identified as at risk for falls, the care plan was not updated in a timely manner to reflect these incidents. Interviews with staff confirmed the care plan was not revised according to the facility's fall management guidelines.
A resident with Parkinson's and major depressive disorder was moved to a new room without notifying the resident or their family, contrary to facility policy. The move was reportedly due to wandering behavior, but there was no documentation or care plan addressing this. The family, in the process of becoming the legal guardian, was not informed, violating the resident's rights.
A resident with multiple diagnoses, including Parkinson's disease and Paranoid Schizophrenia, was not provided with a behavior care plan despite exhibiting wandering behaviors. The resident was moved to a different floor without clear communication or documentation of the behaviors. Staff interviews revealed a lack of awareness and documentation, and the facility's policy on care planning was not followed.
A resident with multiple health conditions and a low BIMS score required two-person assistance for bed mobility, as outlined in their care plan. However, a CNA provided care alone without reviewing the POC, resulting in the resident falling and sustaining a fractured pelvis and head hematoma. The facility's policy did not specify procedures for checking the POC, and staff were not utilizing it as intended, leading to the resident's death in the hospital.
The facility failed to readmit a resident after hospitalization, citing the resident as a danger to himself and others without proper documentation or informing the Guardian. Interviews revealed a lack of documented assessment justifying the refusal of readmission.
Food Storage, Sanitation, and Glove Use Deficiencies
Penalty
Summary
The facility failed to maintain best practices in the food service area, with surveyors finding multiple food storage and sanitation issues during observation, interview, and record review. On 05/05/2026, the Dietary Manager stated that food items should have receive, discard, and open dates. In the walk-in cooler, surveyors observed an opened package of sliced turkey with a facility-marked receive date of 4/30 and discard date of 6/1, and the Dietary Manager stated that it was not right and should have an open date. Surveyors also observed sliced cheese with a discard date of 05/03/2026 in the walk-in cooler, and a tossed salad in the first floor west hall nourishment room refrigerator with a facility-marked date of 4/30-5/2; the Dietary Manager removed the salad to be discarded. Additional observations found food items in resident-use and other refrigerators that were not properly dated or were expired. The Dietary Manager stated that porters look through refrigerators and remove out-of-date items, but also stated that the facility does not check the first floor activities refrigerator and was not sure if residents use it. In that refrigerator, surveyors observed a small carton of 2% milk with a manufacturer expiration date of 5/2/26 and a takeout bag with no date or label. In the first floor transitional rehabilitation east nourishment room, surveyors observed a container of pasta and meat sauce on the counter with no date or label. The Activities Director stated that the refrigerator in the activities room is used to store resident food and is usually cleaned out at the end of the day. Surveyors also observed other food service and kitchen sanitation concerns. The outdoor grease receptacle was observed filled with water and grease, with the lid on the ground next to the bin and grease-containing water puddled on the cement nearby; the Dietary Manager stated the rainstorm had blown off the cover and that the company had recently been switched. The wooden countertop beneath the coffee maker was worn and no longer smooth and easily cleanable, and a cracked and loose floor tile with missing grout was observed near the three-compartment sink. In addition, an employee on the serving line was observed repeatedly touching their glasses and forehead with the back of a gloved hand and continuing to work without changing gloves or washing hands.
Failure to Follow Water Management and Infection Control Practices
Penalty
Summary
The facility failed to implement its infection prevention and control program, including its water management plan and required infection control practices. During observation, multiple water-related fixtures were found in disrepair or showing signs of low use, including inoperable water fountains on the second floor outside the dining room and in the first floor physical therapy room, a toilet with low water level and debris in the first floor west transitional rehabilitation tub room, a toilet with a film-like substance on the water surface and a nonfunctional hand sink in the first floor west transitional rehabilitation shower room, a hopper bowl with no water in the second floor soiled utility room, and a hopper with a nonfunctional flush apparatus in the third floor soiled utility room. The Maintenance Supervisor stated the annual review had not been completed, that chlorine was tested quarterly with a pool test kit, that the boiler domestic water was set to 119 degrees F, and that unoccupied rooms were flushed only for sinks and not toilets. Record review showed the facility’s water management binder included policies approved on 1/21/26 and a document describing key Legionella control activities, including identifying areas where Legionella could grow and spread, establishing control measures, and preventing water stagnation. The binder also referenced CDC guidance stating that low-flow piping runs and dead legs should be flushed at least weekly and infrequently used fixtures such as eyewash stations and emergency showers should be flushed regularly. Interviews with the NHA, DON, and Dietary Manager showed inconsistent understanding of the water management team and its responsibilities, and the Dietary Manager stated they did not perform tasks related to Legionella. The Maintenance Supervisor also stated some drinking fountains had been broken and turned off for awhile, and eyewash stations were flushed only every couple of months. The facility also failed to follow infection control practices for resident care. During morning medication administration, an LPN used an Accu-Chek meter to check a resident’s blood sugar and returned the meter to the med cart without sanitizing it after use. The LPN later stated the meter should have been wiped off and sanitized after use, and the DON agreed that the meter should be disinfected after each use by all nurses. In a separate observation, two staff members were providing care to a resident with enhanced barrier precautions in place, but the door signage did not identify which resident required the precautions and neither staff member was wearing the required PPE. The resident had diagnoses including Parkinson’s disease, hypertension, chronic kidney disease, gastrostomy, type II diabetes, and dementia, and the record showed orders for enhanced barrier precautions related to a PEG tube and wound. The resident’s care plan directed staff to wear gown and gloves during high-contact care activities and to use hand hygiene before and after resident contact, including before applying and after removing PPE.
Poor cleanliness, storage, and maintenance in common and bathing areas
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the premises and failed to properly store clean and sanitary supplies. During observation, a section of wall covering had been cut out in the third floor common area outside the dining room, leaving two protruding utility lines uncapped with a paper towel pressed inside one of them. Additional environmental concerns were observed throughout the building, including a missing four-by-two foot area of floor tiles under the clean linen rack in the first floor east transitional rehabilitation room, various nursing equipment and bags of linen piled along the half wall across from the third floor shower rooms, and brown and black buildup on ceiling tiles in the first floor library consistent with water damage. Multiple shower, tub, and toilet rooms were observed with poor sanitation and deterioration. These included a toilet bowl with low water level, debris, and brown stained streaks in the first floor west transitional rehabilitation tub room; a toilet with a film-like substance on the water in the first floor west transitional rehabilitation shower room; brown stained streaks in the second floor toilet room; aprons, padding, disposable gloves, and washcloths left in a therapy tub in the second floor toilet room while the shower was running; and opened personal shower supplies lined along a handrail in the second-floor shower room. Other observations included a missing cover from a wall-mounted soap container with items stored inside it, rust and chipping on the adjacent door frame, deterioration of lower corner walls near shower areas, exposed framing, missing siding with sharp edges near a door, and cracked ceramic wall tile creating a rough and uneven surface. The report also documented water and maintenance issues in several areas. A maintenance supervisor stated the shower water in one room does not turn off and had been in that condition for about a month. Observations showed puddles of yellow-tinted water across the floor from the tub area to the shower, a broken and missing baseboard wall corner, missing wooden floor tile with exposed and cracked cement, and brown staining on a ceiling tile with raised paint on a wall surface in another shower room. In custodial closets on multiple floors, mop sinks with chemical pre-dispensing systems were observed with the faucets left on, creating undue pressure on the faucets' internal atmospheric vacuum breakers. An environmental services director stated that some residents use the shower room, that it is cleaned daily, and that CNAs are responsible for cleaning equipment in the room, while a unit manager stated opened shower items should remain in resident rooms after opening.
Fly Trap Left Hanging in Resident Room
Penalty
Summary
The facility failed to provide a clean and homelike environment for one resident, R20, when a fly trap ribbon full of dead flies and gnats was observed hanging from the ceiling near the foot of the resident’s bed and in front of the bed. The resident, who had intact cognition, was wheelchair bound, and had diagnoses including end stage renal disease and age-related physical debility, stated that the fly trap had been up for about a year, that someone from the facility had put it there, and that it did not look good and should be taken down. The resident also stated there had not been a problem with flies and that he could not reach it to remove it himself. Housekeeping staff observed the fly trap while cleaning the room but did not address it. The Unit Manager acknowledged the fly trap full of dead bugs and stated maintenance had put it up and monitored it. The Maintenance Supervisor said the maintenance department had put up fly traps in the building but must have forgotten to take them down, and was unable to recall when they were installed or provide information about monitoring them. The Nursing Home Administrator stated the expectation was that the facility not use fly traps at all, and if they were used, they were to be monitored and disposed of properly. The facility policy on maintaining a clean environment stated that items that collect dust or secretions may harbor microorganisms and that some items need to be cleaned on a regular schedule.
Failure to Assist with Discharge Planning for a Resident Seeking Community Living
Penalty
Summary
The facility failed to assist with discharge planning for a resident who wanted to return to community living. The resident was observed in bed in their room and stated they had been in the facility for two years and wanted to live with family or on their own. The resident said they did not have a guardian, that the facility was not assisting with discharge plans, and that they had not been given information about returning to the community. The resident’s record showed diagnoses including peripheral vascular disease, atrial fibrillation, hypertension, type II diabetes, and major depressive disorder, and the MDS indicated a BIMS score of 15/15 with no cognitive impairment. The record also showed active discharge planning on the MDS, but no referral was made to a local contact agency. The care plan included a focus dated 9/24/2024 stating the resident had been placed for LTC needs with no plan for discharge. Social work notes dated 11/22/2025 and 2/24/2026 stated the resident continued to inquire about community living but did not have sufficient support for community transition/living, with no further evidence in the record showing how that determination was made or by whom. A psychiatry note dated 5/5/2026 documented a goal to encourage the resident to maintain motivation in seeking alternate housing with ongoing support from family. During interview, the social worker confirmed awareness of the resident’s wish to return to community living but stated no referral was made because the resident was on Medicaid and did not have financial support.
Undated Tube Feeding Formula Bags
Penalty
Summary
The facility failed to ensure tube feeding nourishment was dated for two residents receiving enteral nutrition. On 5/5/2026, R13 was observed in bed with an enteral nutrition bag hanging on a tube feeding pole and the pump running at 50 cc per hour, but there was no date on the formula bag to show when it had been hung and started. R13 had diagnoses including hemiplegia and hemiparesis, gastrostomy status, hypertension, cardiomyopathy, chronic obstructive pulmonary disorder, and heart failure, and the MDS showed severely impaired cognition. Also on 5/5/2026, R129 was observed in bed with an enteral nutrition bag hanging on a tube feeding pole and the pump running at 55 cc per hour, but there was no date on the formula bag to indicate when it had been hung and started. R129 had diagnoses including Parkinson's disease, hypertension, chronic kidney disease, gastrostomy, type II diabetes, and dementia, and the MDS showed severely impaired cognition. An LPN confirmed that no date was on either formula bag and stated there should be a date on the bags. The DON stated that the floor nurse is responsible for putting a date, time, and initials on the enteral nutrition formula bag, and the facility policy titled Enteral Feeding Ready-to-Hang states to fill in the resident's name, room, date, start time, and rate.
Failure to Report Allegation of Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse from a staff member to the State Agency within the required timeframe for one resident. A complaint was submitted to the State Agency alleging that the resident was physically abused and sustained an injury, but no Facility Reported Incident was found related to the allegation. During interviews, the Nursing Home Administrator, Director of Nursing, Social Service Director, and Regional Nurse Consultant denied knowledge of any reported concerns involving the resident, while the Nurse Practitioner stated that the resident’s legal guardian reported the resident had been assaulted by a male staff member, causing a fracture to the elbow, and that the allegation was reported to the Unit Manager and Social Services immediately. The legal guardian also stated they reported the assault to the Nurse Practitioner and later to the DON and Unit Manager, and the Unit Manager stated the NHA was notified immediately and the male staff member was removed from the unit. The resident had diagnoses including schizoaffective disorder, rhabdomyolysis, pain in the left arm, cellulitis of the left upper limb, vascular dementia with severe psychotic disturbance, chronic embolism and thrombosis of an unspecified vein, and polyarthritis. The quarter MDS documented severe cognitive impairment with a BIMS score of 6 and limited one-person assistance with activities of daily living. The facility policy required allegations of abuse to be reported immediately, meaning as soon as possible but not more than 24 hours after discovery, using the state reporting form, with investigation findings reported within five working days.
Failure to Repair Generator Coolant Leak and Document Corrective Action
Penalty
Summary
The facility failed to ensure that its generator or alternative power source was maintained and tested in accordance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70 requirements. During record review on two separate occasions, it was found that the facility did not document repairs for a coolant leak behind the generator's radiator, as cited in the preventative maintenance report dated 2/13/2025. The deficiency was not addressed, and no corrective action was taken to resolve the issue noted in the generator report. Interviews with the Maintenance Director and Facility Administrator confirmed that the leak was not considered significant by facility staff, and the plan of correction only included obtaining a proposal for repair rather than actually correcting the deficiency. Written records did not show that the generator was repaired or that any action was taken to address the coolant leak, as required by the cited NFPA standards.
Plan Of Correction
This plan of correction is submitted to meet state and federal requirements. Except with respect to statements finally determined to be indisputable, submission of this plan of correction is not an admission that the deficiency exists or that it is cited accurately. ELEMENT # 1 No residents were found to be adversely affected by the cited deficiency. ELEMENT # 2 The Maintenance Director has recorded and repaired the deficiency noted on the preventative maintenance report dated 2/13/2025. The documentation and repair is available for inspection. ELEMENT #3 The citation states the facility "failed to record the generator repairs cited in the deficiencies of the preventative maintenance report dated 2/13/2025." The facility has completed the following steps to address the coolant leak: 1) On June 5, 2025, a commercial grade radiator sealant was purchased; 2) The sealant was poured into the generator radiator during the regular weekly test; 3) The generator then ran for 30 minutes continuously (temp range of 168-172 degrees); 4) A visual inspection was conducted after this test and found no leaks anywhere in the radiator; 5) On 6/9/2025, another generator test and inspection were performed and found no leaks in the generator radiator; 6) All service work and inspections were recorded in the generator maintenance binder. ELEMENT #4 The Maintenance Director will ensure all proposed and actual generator service will be documented and recorded in the generator maintenance binder. The Maintenance Director will observe and monitor the generator radiator for leaks during the weekly generator test as well as the monthly load test. Any leaks in the generator radiator will be identified, recorded, and addressed as soon as practicable with follow-up report to the Administrator. The Maintenance Director is responsible for sustained compliance. ELEMENT #5 Corrective action compliance date: 6/10/2025
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food storage and sanitation practices, as observed during a survey. In the walk-in freezer, a previously opened bag of breadsticks was found without a label, and several items in the walk-in cooler, including prepared tuna, various soups, ground turkey, and cheese, were not adequately date-marked. Additionally, some food items, such as corned beef and Swiss cheese, were stored past their use-by dates. These practices were contrary to the facility's policy, which requires all food items to be properly dated and labeled. Furthermore, the facility did not maintain cleanliness standards for its commercial ice machines and kitchen surfaces. A significant build-up of grease and dust was noted on a light cover over the stove, and drawer fronts in the cook's area were stained with dried food debris. The ice machines were overdue for cleaning, with visible dust and a mushy substance on the faceplate of one machine. The last documented cleaning of the ice machines was several months prior, indicating a lapse in regular maintenance. These deficiencies posed a potential risk for food-borne illness to all residents consuming food and ice from the facility.
Failure to Honor Resident's Activity Preferences
Penalty
Summary
The facility failed to document and honor a resident's activity preferences, leading to frustration and boredom for the resident. The resident, who was alert and had moderate cognitive impairment, expressed a desire to be out of bed and interact with others, but was often left in bed wearing a facility gown. The resident's activity care plan, last revised in January 2025, did not reflect their current preferences to get up and socialize, despite the resident expressing this desire to the Activity Director and nursing staff. The Unit Manager and CNA confirmed that the resident was not regularly assisted to get out of bed, and the Activity Director admitted that there was no documentation of one-to-one interactions with the resident. The Nursing Home Administrator acknowledged that resident activities should be individualized and documented in the care plan, which was not done in this case. The facility's policy on one-to-one resident activities was requested but not provided during the survey. The lack of documentation and failure to update the resident's care plan to reflect their preferences resulted in the resident experiencing boredom and frustration, as they were not able to engage in desired activities or social interactions.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to ensure meals were served at palatable temperatures for a resident, resulting in dissatisfaction with the dining experience. On March 31, 2025, the resident expressed that their breakfast was always cold. On April 2, 2025, the resident was observed in their room, and a breakfast tray was delivered to them. The food temperatures were tested, revealing scrambled eggs at 92.8°F and pancakes at 90.1°F, both below the facility's policy requirement of no less than 135°F for hot food. The oatmeal and coffee were within acceptable temperature ranges, while the milk and apple juice were slightly above the maximum allowable temperature for cold food. The resident, who has legal blindness, Parkinsonism, and Type 2 diabetes mellitus, was on a regular textured, restricted concentrated sweets, thin liquid diet. The Dietary Manager acknowledged the low temperatures and suggested an audit to determine the cause. The Nursing Home Administrator confirmed that all food should be at proper temperature ranges. During the exit conference, no additional documentation or information was provided by the facility regarding this deficiency.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident, identified as R401, to the abuse coordinator. R401, who had a history of a left femoral neck fracture and dementia, was found with a swollen and warm left hip on 11/13/24. An x-ray revealed a fracture involving the left proximal femur. Despite the severity of the injury, the incident was not reported as an injury of unknown origin to the abuse coordinator or the State Agency, as confirmed by interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA). R401 was admitted to the facility with a history of a hip fracture and had undergone a partial hip replacement. The resident required substantial assistance for activities of daily living due to severely impaired cognition. On 11/13/24, staff observed the resident's left hip was swollen and painful, and an x-ray confirmed a fracture. However, the staff, including CNAs and the DON, did not report the incident as required by the facility's policy on abuse and neglect prohibition, which mandates immediate reporting of such injuries to the Administrator and the State Agency.
Failure to Timely Update Care Plan for Resident with Falls
Penalty
Summary
The facility failed to update, revise, and review a care plan in a timely manner for a resident identified as R401. The resident, who was admitted to the facility with a diagnosis of a left hip fracture and dementia, experienced multiple falls within the facility. Despite documented falls on specific dates, the care plan was not updated to reflect these incidents. The care plan initially identified the resident as at risk for falls due to decreased mobility and poor safety awareness. However, the care plan was not revised to include the falls that occurred on 9/19/24, 10/27/24, and 10/28/24, and the updates that were made were not timely. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), confirmed that the care plan was not updated in accordance with the facility's fall management guidelines. These guidelines require that after each fall, the care plan should be updated with fall prevention interventions based on the assessment. The failure to update the care plan after each fall was acknowledged by both the LPN and the DON, indicating a lapse in the facility's adherence to its own policies for managing residents at risk for falls.
Failure to Notify Resident and Family of Room Change
Penalty
Summary
The facility failed to notify and discuss a room change with a resident, R801, and their responsible party, resulting in the resident being moved to a new room without approval. R801, who has diagnoses including Parkinson's disease and major depressive disorder, was moved from the 3rd floor to a private room on the 1st floor without prior notice. The resident expressed missing friends from the previous floor and was unaware of the reasons for the move, which was reportedly due to wandering into other residents' rooms. However, there was no documentation or care plan addressing such behavior. The facility's policy requires informing residents and their families of room changes, but this was not followed. The unit manager, LPN A, acknowledged the lack of notification to R801's family member, who was in the process of becoming the resident's legal guardian. The family member was unaware of the room change and expressed the expectation of being informed. The facility's room change policy emphasizes the resident's right to be informed and to refuse room changes under certain circumstances, which was not adhered to in this case.
Failure to Implement Behavior Care Plan for Resident
Penalty
Summary
The facility failed to develop or implement a person-centered behavior care plan for a resident, identified as R801, who exhibited behaviors of wandering and had potential psychosocial needs that went unmet. The resident, who had diagnoses including Parkinson's disease, Paranoid Schizophrenia, and major depressive disorder, was observed in a private room and expressed confusion about being moved from the third floor to the first floor. The resident's Electronic Health Record (EHR) and Minimum Data Set (MDS) quarterly assessment did not document any behaviors or care plans for wandering, despite a Behavioral Care progress note indicating inappropriate behaviors and theft. Interviews with staff, including an LPN, a social worker, and the Director of Nursing (DON), revealed a lack of awareness and documentation regarding the resident's behaviors and the absence of a care plan. The LPN and social worker acknowledged the need for a care plan, and the DON confirmed that a care plan should have been developed. The facility's policy requires comprehensive care plans to include measurable objectives and time frames, but this was not adhered to in the case of R801.
Failure to Review Care Plan Leads to Resident's Fall and Injury
Penalty
Summary
The facility failed to review the Plan of Care (POC) and ensure adequate assistance when providing care for a resident, resulting in a serious accident. The incident involved a resident who required total assistance with activities of daily living due to multiple health conditions, including dementia, congestive heart failure, and a history of cardiovascular accident with right-sided hemiparesis. The resident's care plan specified the need for two-person assistance with bed mobility. However, on the day of the incident, a Certified Nurse Assistant (CNA) provided care alone, without reviewing the POC, which led to the resident falling and sustaining a fractured pelvis and a hematoma to the head. The investigation revealed that the staff, including the CNA involved, did not check the POC before providing care, despite having access to it on the units. The Director of Nursing (DON) acknowledged that staff were instructed during orientation to always check the POC, but it was not being utilized as intended. The facility's policy on bed mobility did not specify the procedures for checking the POC, contributing to the oversight. The resident was admitted with significant health issues and had a low Brief Interview for Mental Status (BIMS) score, indicating a high level of dependency and need for assistance, which was not adequately provided, leading to the resident's subsequent death in the hospital.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident (R609) to the facility upon discharge from a hospital. R609 was initially admitted to the facility and had a recent readmission. On 3/11/24, R609 was discharged to a hospital via a mental health petition for aggressive behavior. The complainant's intake statement indicated that the Admissions Director informed them that R609 could not return to the facility because he was considered a danger to himself and others. The Guardian was not informed, and the facility did not follow the proper procedure, resulting in R609 being abandoned at the hospital. Interviews with the Admissions Coordinator, Interim Director of Nursing (IDON), and the previous Admission Coordinator/Business Office Coordinator (BOC) revealed that there was no documentation of a resident assessment regarding the refusal of readmission. The Nursing Home Administrator (NHA) agreed that there should be a documented assessment in the Electronic Medical Record (EMR) explaining why the facility could not care for the resident and justifying the refusal of readmission. R609's EMR showed diagnoses including schizophrenia, epilepsy, and cerebral infarction, with moderately impaired cognition and independence in activities of daily living (ADLs). The Minimum Data Set (MDS) assessment indicated that the resident and legal guardian participated in discharge planning, with no active plans to return to the community and an anticipation of returning to long-term care.
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Illustrative
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Detroit
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Rivers Health & Rehabilitation Center Of Gross | 1.3 mi | ★★★★★ | 1 | 0 |
| The Orchards At Harper Woods | 1.7 mi | ★★★★★ | 11 | 0 |
| Optalis Health And Rehabilitation Of Grosse Pointe | 2.8 mi | ★★★★★ | 0 | 0 |
| Omni Continuing Care | 3.5 mi | ★★★★★ | 8 | 0 |
| Regency At St. Clair Shores | 3.5 mi | ★★★★★ | 2 | 0 |
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