The Springs At Rochester Hills Rehab And Nursing C
The Springs at Rochester Hills Rehab and Nursing C in Rochester Hills, MI — inspection on August 28, 2024.
Found 31 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
because they were a hospice respite patient.
shortness of breath, pain and disturbance of salivary secretion. A further review of the record
On [DATE] at 11:02 AM, a conversation with the hospice nurse was held and she was asked what the code status was for R315.
The hospice nurse replied, [R315] is a do not resuscitate (DNR). R315 asked for the question to be repeated and R315 was asked did they want to be resuscitated, R315 replied Oh, NO.
On [DATE] at 3:00 PM, the Director of Nursing (DON) was interviewed and asked how the facility communicated with the hospice company for R315, the DON explained that they have been communicating verbally and that there is no actual book or log (used to communicate with hospice) at this moment.
The DON was then questioned about R315's code status and if the facility was aware that resident wished to be a DNR.
The DON replied that the resident was a full code on hospice according to the hospice company representative.
The DON was informed that the Hospice Nurse and Resident both confirmed that R315 was to be a DNR.
The DON stated she would have to investigate.
On [DATE] at 3:13 PM an interview was held with R315 and was asked were they sure they wanted to be a DNR. R315, replied, Yes I'm sure, I believe I signed some papers to reflect my wishes, but you can bring me whatever paper it is that needs to be signed because I do not want to have CPR done.
On [DATE] at 9:25 AM a review of the record revealed that R315 was still a full code.
On [DATE] at 9:32 AM a conversation was held with the Administrator and the [NAME] Clinical Nurse they were asked if they were made aware of R315 code status and that the resident would like to be considered a DNR.
They explained that they spoke with the hospice representative when they came to the facility and told then that R315 was a full code.
They were then asked if someone wanted to change their code status could they do so and who would be the team member to initiate those conversations with residents.
The administrator replied, yes a code status could be changed at any time and the social worker would be the team member to see where person stood, however any nurse could have done so as well.
She also stated that R315's hospice communication book was now available.
A review of the hospice communication binder was obtained and within the communication book there was a signed DNR paper for R315 dated [DATE].
There was no additional information provided by exit of survey.
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
minimal harm (ABN) for three (R317, R318 and R54) of three residents reviewed and failed to provide Notice of Medicare Non-coverage (NONMC) for two (R317 and R318) of three residents reviewed.
Findings
A SNF (Skilled Nursing Facility) Beneficiary Notification Review form was completed by the State Agency representative and provided to the facility for residents R317, R318, and R57 to be filled out by facility staff and returned for notification review.
On 8/28/24 at 10:00 AM, the administrator indicated that they were unable to find any of the ABN's and NONMC's for the residents that were requested.
There was no additional information provided by the exit of the survey.
be made to the Administrator ' s Designee.
All allegations of abuse will be reported to the appropriate
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
The facility failed to conduct an investigation for R25's injury of unknown origin.
No further explanation or documentation was provided by the end of the survey.
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
Review of a level I Screening dated 2/16/24, documented a Hospital Exemption Discharge .
Mental Illness .
The person has routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days .
Review of a Level II Screening dated 2/16/24, documented in part Hospital Exempted Discharge . is being admitted after a hospital stay . requires nursing facility services for the condition for which he/she received hospital care . is likely to require less than 30 days of nursing services .
R54 remained in the facility more than the 30-day exemption criteria and the facility did not submit a level II screening to be completed.
On 8/27/24 the Administrator was asked to have the facility's Social Worker (SW) present for an interview. At approximately 10:30 AM, the Administrator stated they were currently assisting in the role as the SW until the new SW began employment.
The Administrator was asked about R54's initial hospital exemption screening and why after the 30 days of being at the facility had they not submitted another Level I or II for R54.
The Administrator explained they were recently hired at the facility, since the new ownership change thirty days prior, but would look into it and follow back up. At 11:36 AM, the Administrator stated R54 should have had another screening completed.
The Administrator stated they identified guardianship issues and concerns initially since the start of their employment which was their focus, however, will also add PASARR screenings to their list.
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
Review of a care plan titled I am at risk for impaired communication related to cognitive impairment, As evidenced by: difficulty making self-understood, As evidenced by: difficulty understanding others, As evidenced by: language barrier; English is not resident's primary language created on 8/30/23.
The complete list of documented interventions were .
Allow ample time for the resident to comprehend what is being communicated and allow time for response .
Anticipate and meet the resident's needs .
Encourage conversations in calm, quiet locations with minimal background noise .
Maintain eye contact, approach resident from the front .
Observe for physical/non-verbal indicators of discomfort or distress and follow-up as needed .
Pay attention to resident's body language and facial expressions .
Provide translator as needed to communicate with the resident.
Translator is (Family or activities aide) . SLP (speech language pathologist) screen/ eval (evaluation) / treat as needed .
Use simple and direct communication (i.e., yes/no questions) to promote understanding, use gestures or pictures if necessary .
On 8/27/24 at 9:42 AM, the Administrator was interviewed and asked what resources the facility had for staff to communicate with residents whose first language was not English or was unable to understand English.
The Administrator stated they had an interpreter hotline that will accommodate various languages.
The Administrator was then asked why the intervention of the hotline number and protocol was not implemented in R3's care plan and why CNA K had no knowledge of the interpreter hotline and the Administrator stated they would start education with staff today. A policy was requested at this time.
A policy was not provided by the end of the surveyor, however the Administrator did return at 11:35 AM and stated the facility also had a flip guide in Arabic and will update R3's care plans and educate the staff.
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
Based on interview and record review the facility failed to facilitate a safe and coordinated discharge
A complaint was submitted to the State Agency with the allegations of an improper discharge of a trach and peg tube resident into the community with no home health care or adequate nutrition for the resident's needs.
On 8/28/24 at 1:12 PM the Director of Nursing (DON) was interviewed and asked who was in charge of the discharge planning process and what home health agency was used for R312.
The DON explained that in most cases the discharging of residents usually goes through the interdisciplinary team (IDT) and is discussed what a resident will need, the community tools and any additional medical providers may need to conduct a safe discharge.
However, at that time, the facility did not have a social worker to help facilitate outside agencies effectively.
Upon further discussion, it was expressed to the DON that there was no discharge progress note nor a Home Health Care agency ordered in the medical record for R312.
The DON replied, I can get the number of the agency used.
On 8/28/24 at 1:39 PM an interview was held with the Home Health Care(HHC)agency provided by the DON.
The HHC representative was asked if R312 was on their case load, the HHC replied, No, [R312] was not on the case load due to difficulty with insurance coverage, and we communicated that with the facility that we were unable to accept them at this time.
There was no additional information provided by the exit of survey.
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
located inside of the room. R316 was at dialysis and the curtain was opened in room.
pneumonia, hypertension and end stage renal disease.
On 8/27/24 at 8:32 AM, R316 was observed lying in the bed reading some papers. An interview was conducted. R316 was asked about their current stay at the facility, R316 replied, It is a pretty decent facility, but the wait times are a bit excessive in my opinion. R316 was asked could they recall why they were put in contact isolation. R316 stated, No, whatever I had was at the hospital and it was in my coccyx wound.
On 8/27/24 at 9:10 AM, the facility's Infection control preventionist (ICP) was interviewed and asked the reason R316 was placed in contact isolation, what changed in R316 diagnosis from 8/26/24 to 8/27/24 since taken off contact precautions and, lastly, why a contact isolation cart was placed inside of room instead of outside of the room.
The ICP explained R316 was placed on isolation because of the diagnosis from the hospital, however when the hospital paperwork was reviewed, it was found that R316 had completed their round of antibiotics and no longer needed isolation so precautions were discontinued.
The ICP further stated, The reason I was able to place the isolation cart in the room as opposed to the outside of the room was because there is a curtain in the room, and we use that for a barrier.
A review of the medical record revealed that R316's hospital paperwork did not mention being in contact isolation, there was an antibiotic ordered with an incorrect indication for use as well as a total of three medications transcribed improperly from the hospital discharge to the current medication list.
On 8/27/24 at 12:08 PM, an interview was conducted with the Unit Manager(UM), Director of Nursing(DON), and the ICP.
They were asked when there is a new admission, what was the protocol for the facility when placing orders, and what paper from the hospital did they use to get medication orders from.
The DON replied, We are supposed to call the medical doctor(MD), read the orders from the hospital paper work and the MD decides whether they want to continue with treatment or not. We are supposed to use the hospital discharge paper work or the after visit summary to transcribe orders.
A review of the hospital paper work was made with the DON, UM and ICP.
They were asked how did they get the orders for R316 for their Entresto and Dicyclomine when the hospital after visit summary stated to discontinue and start amiodarone which there were no current active orders for amiodarone in the medication administration record(MAR) for R316.
The DON replied, We would have to call the MD to verify (the medication discrepancies).
The DON explained that medication clarification should be done upon admission and the orders should reflect the hospital discharge paperwork.
No addition information was presented by the exit of the survey.
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
The surveyor then questioned the resident up close to their left ear and the resident was able to proceed with the interview. R7 explained they tried getting hearing aides at the facility but no one would direct them on who to talk to or where to go.
A review of the medical record revealed R7 was admitted to the facility in 2016, with diagnoses that included major depressive disorder and Parkinson's disease. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition.
Review of the medical record revealed no consultations of an audiology assessment and/or examination.
Multiple physician notes documented hard of hearing.
On 8/27/24 at 9:45 AM, the Administrator (who was also assisting with the Social Worker - SW duties) was interviewed and asked about any completed audiology examinations for R7.
The Administrator stated they would check into it and follow back up. At 11:52 AM, the Administrator stated they were unable to find documentation of an audiology appointment for R7 in their medical record.
The Administrator stated they called the audiology group utilized by the facility and they stated R7 was seen in the past and would send over the consultation.
Review of an audiology consult dated 2/7/24, documented in part .
Complains of tinnitus (ringing in ears).
Family/staff notices recent decreased responsiveness .
Moderate to Severe Sensorineural Hearing Loss - Both Ears .
Was needs removal - Right (ear) .
Medical Consult due to: To obtain medical clearance for aid(s); Wax Removal - Right Ear .
Patient in need of wax removal; Medical Consult to obtain medical clearance for Hearing Aid .
Review of the medical record revealed no follow up was completed per the audiologist recommendations.
Review of the care plans revealed no identification of the audiologist recommendations or concerns.
On 8/28/24 at 8:54 AM, the Director of Nursing (DON) was interviewed and R7's audiology consult was reviewed.
The DON was asked about the lack of follow-up regarding the audiologist recommendations and the DON explained they were recently hired at the facility and acknowledged the concerns.
The DON stated R7 has been added to the audiology list and should be seen today (8/28/24).
No further explanation or documentation was provided before the end of the survey.
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
the notification .Re-evaluate existing treatment regimen in connection with the resident's clinical
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
incident with R11 pouring coffee on R37 and grabbing her.
Nurse E indicated they walked into the
informed them of what had happened.
Nurse E was queried if any staff had been in the dining room to
they indicated that no staff was in the dining room at that time.
Nurse E indicated that R11 needed staff supervision.
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
interventions implemented to prevent further weight loss. RD C stated they had started coming to the
C stated they could not answer for the previous Dietician, however implemented interventions once
No further explanation or documentation was provided by the end of the survey.
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
Review of R315's physician order documented in part . 02 (oxygen) @ (at) 4 liters per minute via nasal canula . every shift for shortness of breath .
The medical record revealed R315 was admitted with the diagnosis of shortness of breath.
Further review of the medical record revealed no documentation on why R315's oxygen administration was increased to 5L.
On 8/27/24 at 2:49 PM, the Director of Nursing (DON) was interviewed and informed of the observation with LPN A and R315.
The DON stated the nurses should verify the oxygen levels ordered by the physician and verify the levels being administered before signing it off in the electronic record.
Review of a facility policy titled Oxygen Administration dated 8/1/24, documented in part . It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained .
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
revealed R58 had a Stage 4 pressure ulcer to the left ischial tuberosity, present since 7/3/24.
There
A review of all progress notes for R58 revealed R58 was seen by a physician on 6/20/24 for a
documentation in the electronic medical record that indicated R58 was evaluated by a medical practitioner after 6/26/24, including after the development of a pressure ulcer that continued to worsen from a Stage 2 to a Stage 3/Unstageable and then a Stage 4 with acute osteomyelitis on the day R58 arrived at the hospital.
The next time R58 was evaluated by a medical provider was on 8/13/24 when he was seen by the facility's newly contracted wound physician.
On 8/28/24 at 8:54 AM, an interview was conducted with the Director of Nursing (DON).
When queried about whether residents with pressure ulcers received evaluations by a medical provider, the DON reported the facility had an issue with some of the physicians seeing residents in a timely manner.
When queried about whether the facility contracted with a wound provider, the DON reported the facility hired a wound physician on 8/1/24 and he started seeing residents on 8/13/24.
On 8/28/24 at 9:20 AM, an interview was conducted with LPN 'L'.
When queried about how it was ensured that residents with pressure ulcers were overseen by a medical provider, LPN 'L' reported she added residents to physician's logs when they developed pressure ulcers, but was not sure if they evaluated residents' wounds in the absence of a wound provider. LPN 'L' reported prior to 8/13/24, there was not a wound provider who came to the facility for some time. LPN 'L' reported all wounds were discussed during interdisciplinary team (IDT) meetings.
On 8/28/24 at 11:25 AM, an interview was conducted with the DON.
The DON confirmed there were no documented evaluations by a medical provider to address R58's pressure ulcer from the time it developed on 7/4/24 until 8/13/24 when the new contracted wound physician started seeing residents in the facility.
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
documented evaluations by a medical provider for R58 after 6/26/24.
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
way that maximizes each resident's well being.
observation, interview, and record review, the facility failed to ensure one (Certified Nursing
care for residents' appropriately, resulting in CNA 'H' providing care to R58 in an unsafe manner and not according to assessed needs.
Findings include: On 8/26/24 at 10:34 AM, R58 was observed positioned on his back in bed with a tracheostomy tube (a tube inserted into the windpipe to provide breathing assistance) and a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube inserted into the stomach to directly provide nutrition).
When spoken to, R58 did not make eye contact and did not verbally respond to questions.
A review of R58's clinical record revealed R58 was admitted into the facility on 6/10/24, and readmitted on [DATE] with diagnoses that included: diffuse traumatic brain injury with loss of consciousness, acute respiratory failure with hypoxia, type 2 diabetes, and seizures. A review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed R58 had severely impaired cognition, was dependent on staff for all activities of daily living, transfers, and bed mobility (all assistance provided by staff).
On 8/27/24 at 10:32 AM, Certified Nursing Assistant (CNA) 'H' was observed entering R58's room with supplies, including linens, a gown, and a brief. An observation was made of CNA 'H' alone in R58's room preparing R58 for a brief change. No other staff members entered R58's room.
When CNA 'H' exited R58's room with a bag of dirty linens and brief, an interview was conducted. CNA 'H' was asked what tasks he performed while in R58's room. CNA 'H' reported he changed R58's brief, cleaned him up, and repositioned him.
When queried about what level of assistance R58 needed and if a second staff member was required, CNA 'H' stated, I did it alone because I can.
That's what I always do.
When queried about how the CNAs know what level of assistance a resident needed for care, CNA 'H' reported he did not have access to the care plans or any instructions so he decides what to do.
CNA 'H' reported they could also ask the nurse, but he did not ask the nurse regarding R58 because he had been taking care of that resident forever.
A review of R58's care plans revealed R58 required two person assistance for bed mobility.
On 8/28/24 at 2:21 PM, CNA 'H's personnel file was requested along with any competency evaluations and/or performance evaluations.
A review of CNA 'H's personnel file revealed a date of hire of 9/7/23.
There was no competency evaluation and/or skills checklist to verify CNA 'H' was evaluated prior to working with residents.
On 8/28/24 at approximately 3:30 PM, an interview was conducted with the Administrator, who began working in the facility reported the facility identified a concern with competency evaluations and performance reviews and that they were not completed.
The Administrator reported they were still working on it and have provided some education for nursing staff.
Education sign in sheets were provided, but did not include following the care plan/[NAME] or CNA 'H'.
The Administrator reported moving forward all CNAs would have to demonstrate appropriate skills before being assigned to the floor.
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
need-to-know basis.
Promotes and Protects Resident Rights by assisting Residents to make informed
current professional standards; and supporting independent expression, choice and decision-making
Responsibilities: Supervises employees in the department and others for whom they are administratively or professionally responsible (if applicable) by following policies and applicable laws.
Uses independent judgment and discretion on behalf of the organization in the performance of these duties
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
On 8/27/24 at 2:49 PM, the DON was interviewed, informed of the observation of LPN A and the
corporation (the facility had recently been taken over by a new corporation) that they don't specific non controlled medications from controlled medications and count the cards as full or halves.
The DON stated the new corporation had a better system in place which would be implemented.
No further explanation or documentation was provided by the end of the survey. Resident #59 (R59) On 8/27/24 at 11:06 AM, LPN 'A' was observed at the medication cart located on the North East Unit.
LPN 'A' was observed going through the double locked box that contained controlled substance medications and comparing the number of pills with what was written on the controlled substance count sheet. LPN 'A' was observed writing on the count sheet without removing a tablet from the supply.
At that time, LPN 'A' was interviewed and the controlled substance count sheet was observed. It was for R59 (klonopin - an antianxiety medication). LPN 'A' dated the entry 8/27/24 at 9:00 AM (two hours earlier) and documented that he removed one pill from the supply with a total count of 13 pills.
When queried about why he documented that a pill was removed when it was not, LPN 'A' reported he gave the medication earlier in the morning but did not document it on the count sheet.
When queried about the appropriate process for accounting for controlled substances, LPN 'A' reported he should have documented the removal of the pill at the time it was removed and administered.
On 8/27/24 at approximately 3:00 PM, the DON was interviewed.
The DON reported that any controlled substance that was removed from the supply should be documented on the associated count sheet for that medication at the time it was removed.
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
Based on observation, interview and record review the facility failed to follow the facility's policy on
observed.
Findings include: On 8/27/24 at 8:20 AM, an observation of the medication back up storage room refrigerator was conducted. A refrigerator temperature check list was observed with the date of 8/20/24 to have been the last date staff had checked the temperature of the refrigerator.
Two applesauce containers were found in the refrigerator next to medications and insulins that were also stored in the refrigerator.
The Director of Nursing (DON) was asked to confirm the findings and stated the nightshift nurses are responsible for checking the refrigerator temperature.
The DON stated they would start education with their staff.
The DON also stated there should be no food stored in the refrigerator with the residents medications and if so, should be separated.
Review of a facility policy titled Medication Access and Storage review date of 8/1/24, documented in part . It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls .
Refrigerated medications are kept in closed and labeled containers, with internal and external medications separated, and separate from fruit juices, applesauce, and other foods used in administering medications.
Other foods (e.g., employee lunches, activity department refreshments) are not stored in this refrigerator .
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
was made for one resident (R20) of one residents reviewed for dental services.
Findings include:
On 8/27/24 at approximately 11:03 a.m., R20 was observed in the group meeting and indicated that they were supposed to have their tooth taken out in January but had no assistance from the facility in getting the procedure completed.
On 8/27/24 at approximately 3:04 p.m., R20 was observed in the hallway, up in their wheelchair and expressed concerns about their tooth hurting and needing to be pulled. R20 indicated again that nobody was going to do anything about it.
On 8/27/24 the medical record for R20 was reviewed and revealed the following: R20 was initially admitted to the facility on [DATE] and had diagnoses including Pain and Dysphagia. A review of R20's MDS (minimum data set) with an ARD (assessment reference date) of 7/20/24 revealed R20 needed assistance from facility staff with most of their activities of daily living. R20's BIMS score (brief interview for mental status) was 15 indicating intact cognition.
A Dental evaluation dated 2/15/24 revealed the following: Confirmed with facility patient is Covid-19 negative and afebrile.; Reviewed Medical History; Patient has plaque and calculus build-up, recommend cleaning and exam every 6 months; Patient masticating well.; Stressed brushing twice per day to maintain health of teeth and tissues.; Patient has discomfort from fractured teeth #2, #19.
Refer to oral surgeon for extractions due to need for surgical extractions and health issues.
Tooth #8 DFL caries .Action required by Nursing home staff: Referral to oral surgeon for extraction of teeth #2, #19 surgical extractions .
A second dental evaluation dated 4/26/24 revealed the following: Treatment notes: Patient complains of pain in lower left and upper right .#19 is non-restorable and causing the patient pain, irreversible pulpitis and/or symptomatic apical periodontitis.
Both #2 and #3 have fractures with caries in them, and due to the communication issues with the patient, it is not possible at this moment to discern which tooth is bothering him. He gives no concrete answer to the presence of cold in his mouth on these teeth and percussion and palpation do not yield anything useful.
Patient unable to effectively communicate.
Note to hygiene: please take PA (posterior-anterior) of #2 and #3, so that it may be possible to find out which tooth is causing the patient discomfort .Action required by Nursing home staff: Refer to MD/OS (medical doctor/oral surgeon) for extraction of tooth; Please refer for extraction of #19 .
A progress note dated 7/8/202410:00 Nurses' Notes: Resident LOA (leave of absence) to dentist appt (appointment) via harmony transportation accompanied by cena (certified educated nurse assistant).
A second progress note dated 7/8/2024 revealed the following: Resident returned back to the facility.
Unable to be seen without guardian present with him.
Appointment needs to be rescheduled.
On 8/27/24 at approximately 3:25 p.m., during a conversation with the Administrator (providing social service oversight) the Administrator was queried regarding the lack of oral surgeon referral being made and they indicated that they have been without a social worker who would usually make those referrals and had recently hired a new one.
The Administrator indicated that they would have to make R20 a dental appointment to get their tooth extracted.
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
According to the 2017 FDA Food Code section 3-501.13 Thawing Except as specified in (D) of this section, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be thawed: 1. (A) Under refrigeration that maintains the FOOD temperature at 5 ºC (41ºF ) or less; or
- (B) Completely submerged under running water: 1. (1) At a water temperature of 21 ºC
(70ºF ) or below, 3. (3) For a period of time that does not allow thawed portions of READY-TO-EAT FOOD to rise above 5 ºC (41ºF ).
On 8/26/24 at 9:20 AM, in the walk-in cooler, there was an undated pan of leftover enchiladas, an undated pan of white sauce, an undated pan of gravy, an opened undated package of bologna, an opened undated 1 gallon container of Italian dressing and ranch dressing, and a 1 gallon container of creamy Caesar dressing dated 6/17-7/17.
Dietary Staff M confirmed the items should have been dated when opened.
According to the 2017 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days.
Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
will arrange for the provision of hospice services.
hospice services being provided was coordinated and documented in the resident's clinical record for
of comprehensive services and incorrect code status.
Findings include: On 8/25/24 at 10:20 AM, R315 was observed lying in bed with a family member present. An interview was held with R315. R315 was then asked how the care was received at the facility and stated that they were only here for a short period of time because they were a hospice respite patient (at the facility for a short period of time).
On 8/27/24 at 3:00 PM, the Director of Nursing (DON) was interviewed and asked how the facility communicated with the hospice company for R315. DON replied that we have been doing everything verbally, there is no actual book or log (to communicate with hospice) at this moment.
The DON continued by stating , I have told the administrator (about the communication concern), and they will communicate to the hospice company about our requirements and expectations.
There was no additional information provided by the exit of the survey.
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
During an onsite annual recertification survey conducted from 8/26/24 through 8/28/24 deficient practices were identified in multiple areas of social services, including the failure to provide the following: effective coordination of advance directives to ensure the residents' desired code status was properly documented in the clinical record, discharge planning resulting in an unsafe discharge without home health care services, completion of PASRR, and facilitation of ancillary services including dental and audiology, and assessment of residents for their social service needs.
A review of a Facility Assessment Tool provided by the facility revealed the facility was licensed to provide care to 126 residents.
On 8/27/24 at 9:44 AM, an interview was conducted with Human Resources Director (HR) 'E' and Corporate HR 'F'.
According to HR 'F', the facility had a change in ownership on 8/1/24 and there was no qualified social worker employed at that time. HR 'F' reported the facility did hire a social worker who was starting on 9/4/24. At that time, documentation of the last day the previous social worker worked in the facility was requested.
When queried about whether there are anyone providing full-time social services in the facility after the previous social worker resigned, HR 'F' reported various people were helping out since 8/1/24, but not onsite and not full time.
A review of Termination Information for the former social worker, SW 'G', revealed SW 'G' last day worked in the facility was 3/28/24 with a termination date of 4/17/24.
Cross-Reference F-F578, F-F645, F-F660, F-F685, F-F745, and F-F791
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
corrective plans of action.
and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) plan that identified
Findings include: A review of a facility provided policy titled, Quality Assessment & Assurance Program revised 9/18/29 was conducted and read, .Quality Assurance is a continuous process towards quality management .Each person's effort contributes to improving resident outcomes .The Quality Assessment and Assurance (QAA) Committee provides leadership and guidance for ongoing continuous quality and performance improvement .
On 10/9/24 at 12:27 PM, an interview was conducted with the facility's Director of Nursing regarding concerns identified with pressure ulcers.
The DON acknowledged the concerns and the facility's ongoing audits that indicated no concerns despite concerns identified during the re-visit survey.
On 10/9/24 at 1:00 PM, an interview with the facility's Administrator was conducted regarding the facility's Quality Assurance process and they acknowledged the concerns with pressure ulcers.
Cross-reference F-F686.
235036 08/28/2024
The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
On 8/26/24 at 10:34 AM, R58 was observed positioned on his back in bed with a tracheostomy tube
Endoscopic Gastrostomy (PEG) tube (a tube inserted into the stomach to directly provide nutrition).
When spoken to, R58 did not make eye contact and did not verbally respond to questions.
A review of R58's clinical record revealed R58 was admitted into the facility on 6/10/24, and readmitted on [DATE] with diagnoses that included: diffuse traumatic brain injury with loss of consciousness, acute respiratory failure with hypoxia, type 2 diabetes, and seizures. A review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed R58 had severely impaired cognition, was dependent on staff all activities of daily living, received all nutrition via a PEG tube, and had a tracheostomy tube to assist with breathing.
On 8/27/24 at 11:06 AM, the skin underneath R58's foam trach collar tie was observed with Licensed Practical Nurse (LPN) 'A'.
Upon lifting up the trach tie, a large amount of secretions was observed on R58's neck. At that time, LPN 'A' reported he was going to clean the secretions from R58's neck. LPN 'A' donned gloves located outside of the room and a sterile trach kit was opened that contained supplies and sterile gloves. LPN 'A' removed the gloves he was wearing and donned the gloves in the sterile kit without performing hand hygiene in between the glove change. LPN 'A' then used the gauze in the kit to wipe the secretions from R58's neck and underneath the trach mask.
After the secretions were cleaned, LPN 'A' proceeded to apply clean gauze under the trach mask without changing gloves and performing hand hygiene.
On 8/27/24 at approximately 2:45 PM, an interview was conducted with the Director of Nursing (DON).
When queried about when hand hygiene and gloves changes should occur during trach care, the DON reported whenever you are going from dirty to clean.
The above observation was shared with the DON.
The DON reported LPN 'A' should have removed his gloves, performed hand hygiene, and donned clean gloves between cleaning the secretions and applying clean gauze.
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
replied McGeers criteria. ICN J was then asked how they identified if the infection met criteria and
the software would inform them if it met criteria. ICN J was then asked how they confirm the
orders and notes. ICN J was asked where they or the physician document if an infection met criteria and the appropriateness of prescribed antibiotics and ICN J replied they had not document it in the past, however, will implement it moving forward.
Additional documentation was provided by ICN J and reviewed, however the concerns of infections meeting criteria and concern of the appropriateness of antibiotics remained.
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
Review of R26's medical record revealed no documentation of the resident and/or representative to have been educated and offered the pneumococcal immunization.
Further review of the medical record revealed no documentation of the immunization to be medical contraindicated or noted the resident to already be immunized. R26 was admitted to the facility on [DATE].
R58 Review of 58's medical record revealed no documentation of the resident and/or representative to have been educated and offered the pneumococcal immunization.
Further review of the medical record revealed no documentation of the immunization to be medical contraindicated or noted the resident to already be immunized. R58 was admitted to the facility on [DATE] and had a readmission date of 7/23/24.
Review of the facility's policy titled Pneumococcal Vaccine dated 8/1/24, documented in part . It is the policy of this facility that all residents will be offered the pneumococcal vaccines to aid in preventing pneumonia .
Upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccines and when indicated, will be offered the vaccinations, unless medically contraindicated or the resident has already been vaccinated .
Before receiving the pneumococcal vaccines, the resident or responsible party shall receive information and education regarding the benefits and potential side effects of pneumococcal vaccines .
On 8/28/24 at 11:37 AM, the Infection Control Nurse (ICN) J who oversees the Pneumococcal vaccinations in the facility was interviewed and asked the facility's process on educating and the administration of the Pneumococcal vaccine. ICN J stated the vaccine is offered upon admission. ICN J stated they have a new process in place under the new ownership that will bundle the education and consents for all immunizations. ICN J was asked to provide the education and consents provided to the R's 26 & 58 and/or their representatives. ICN J stated they would look into it and follow up. A short time later ICN J returned and stated they were unable to find the requested documentation, however both residents/representatives will be educated and offered today 8/28/24.
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
Review of R26's medical record revealed no documentation of the resident and/or representative to have been educated and offered the Covid-19 Vaccine.
Further review of the medical record revealed no documentation of the vaccine to be medical contraindicated or noted the resident to have already received the vaccine and/or booster. R26 was admitted to the facility on [DATE].
R58 Review of 58's medical record revealed no documentation of the resident and/or representative to have been educated and offered the Covid-19 Vaccine.
Further review of the medical record revealed no documentation of the vaccine to be medical contraindicated or noted the resident to have already received the vaccine and/or booster. R58 was admitted to the facility on [DATE] and had a readmission date of 7/23/24.
Review of a facility policy titled COVID-19 Vaccine dated 9/23/23, documented in part . It is the policy of this facility that all residents will be offered the COVID19 vaccines to aide in preventing COVID19 infections and outbreaks .
Residents will be assessed for eligibility to receive COVID19 vaccines and when indicated, will be offered the vaccinations, unless medically contraindicated or the resident is up to date with vaccination, as recommended by CDC (Centers for Disease Control and Prevention) .
Before receiving the COVID19 vaccines, residents or responsible parties shall receive information and education regarding the benefits and potential side effects .
On 8/28/24 at 11:37 AM, the Infection Control Nurse (ICN) J who oversees the COVID-19 vaccinations in the facility was interviewed and asked the facility's process on educating and the administration of the COVID-19 vaccinations and/or boosters. ICN J stated the vaccine is offered upon admission. ICN J stated they have a new process in place under the new ownership that will bundle the education and consents for all immunizations. ICN J was asked to provide the education and consents provided to the R's 26 & 58 and/or their representatives. ICN J stated they would look into it and follow up. A short time later ICN J returned and stated they were unable to find the requested documentation, however both residents/representatives will be educated and offered today 8/28/24.
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The Springs at Rochester Hills Rehab and Nursing C 1480 Walton Blvd Rochester Hills, MI 48309
Review of the July 2024 antibiotic audit revealed three residents treated with antibiotics for a urinary tract infection and only one resident was identified on the facility's mapping.
On 8/28/24 at 11:12 AM, a meeting to review the facility's infection control program was conducted with ICN J. ICN J explained how they were hired three months prior and took responsibility of the facility's infection control program at that time.
When asked, ICN J stated they also had the responsibility of being the facility's staff development coordinator, unit manager and cart nurse when needed.
When asked how many hours out of the week they devoted to the Infection Control Program, ICN J stated . four hours out of every eight hour shift . ICN J was asked about the missing monthly analysis reports that are generated to oversee the facility's infections and present to the facility's QAPI (Quality Assurance Performance Improvement) program. ICN J stated they were unaware of what the analysis report was.
April 2024's analysis report was reviewed with ICN J and ICN J stated they had questions regarding the math and determining the infections for the report. ICN J stated they had not completed a report since resuming the role. ICN J stated the new corporation is implementing a new system for them to complete the infection surveillance and monthly analysis. ICN J was then asked how many QAPI meetings they attended since employment and ICN J replied they attended one meeting. ICN J stated the meetings are held monthly, however the facility had recently transitioned to a different corporation and had not been held monthly. ICN J was then asked about the inaccurate mapping of infections for July 2024. ICN J reviewed the program and stated they must have missed it.
Review of the facility's policy titled Infection Prevention and Control Program Overview last dated 8/1/24, documented in part .
The infection prevention and control program is comprehensive in that it addresses the prevention, identification, reporting, investigation and controlling of infections and communicable diseases among residents, employees, volunteers and visitors .
There is on-going monitoring for infections among residents .
Infection prevention and control is a component of the facility's quality assessment and assurance program and infection prevention and control reports are made to the QAA (quality assurance) committee .
No further explanation or documentation was provided by the end of the survey.
235036
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 235036 B.
Wing 08/28/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
The Springs at Rochester Hills Rehab & Nursing Ctr 1480 Walton Blvd Rochester Hills, MI 48309
235036
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 235036 B.
Wing 08/28/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
The Springs at Rochester Hills Rehab & Nursing Ctr 1480 Walton Blvd Rochester Hills, MI 48309
Review of the Morphine controlled form that was in use revealed the facility staff was only counting the opened morphine bottle and not accounting for the unopened Morphine bottle, creating opportunity for diversion. LPN A was then asked to provide the opened Morphine bottle and when compared to the Morphine controlled form in use, confirmed the facility staff were failing to account for all of the Morphine medication on hand for R315. LPN A was asked how they count each controlled medication with the off going or incoming nurse and LPN A replied they don't account for each controlled pill or liquid, they only count full and half cards of medications and document it as such. LPN A stated this is how they were trained to do it at the facility.
On 8/27/24 at 9:03 AM, the Administrator and Director of Nursing (DON) were asked to provide the facility's policy on the receipt, processing, count and maintenance of controlled medications.
Review of the facility's policy provided revealed the following:
Accepting Medication Delivery dated 8/1/24, was reviewed and contained no documentation for the receipt of controlled medications.
Medication Access and Storage dated 8/1/24, was reviewed and documented in part .
Schedule III and IV controlled medications are stored separately from other medications in a locked drawer or compartment designated for that purpose .
At 2:35 PM, the Administrator and DON were again asked to provide the policy for their protocol on receiving, disposition and reconciliation of the facility's-controlled medications in detail.
Review of the policy provided titled Controlled Medication - Ordering & Receipt dated 2/2024 documented in part . A controlled medication accountability record is prepared when receiving or checking in a controlled substance medication for a resident.
The following information is completed: Name of the resident, Prescription number, Drug name, strength . and dosage form of medication, Date received, Quantity received, Name of the person receiving the medication .
235036
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 235036 B.
Wing 08/28/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
The Springs at Rochester Hills Rehab & Nursing Ctr 1480 Walton Blvd Rochester Hills, MI 48309
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.