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 3 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
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