Corewell Health Grand Rapids Hospitals Rehabilitat

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a resident comprehensive care plan (placement of pillow behind the neck to reduce/prevent contractures) for 1 of 23 residents (Resident #7) reviewed for care plan implementation, resulting in the potential for breathing complications and increased contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity during meals and ensure residents are treated with respect in 3 of 5 residents (Resident #13, #56, & #21) reviewed for dignity/respect, resulting in the potential for feelings of embarrassment, frustration, and impaired self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with fingernail grooming/hygiene for 2 of 5 residents (Resident #21 and #19) reviewed for activities of daily living (ADL's), resulting in the potential for diminished dignity, alteration in skin integrity, nail infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that thorough documentation of a death in the facility was completed and fingernail issues were recorded for 1 of 23 residents (Resident #113 ) reviewed for accurate and complete medical records, resulting in insufficient details related to death in the facility for Resident #113.

Inspectors wroteThis citation pertains to intake #MI00142952. Based on interview and record review, the facility failed to report an allegation of neglect facility staff did not follow a resident care plan to prevent falls to the State Agency for 1 of 3 residents (Resident #103) reviewed for falls, resulting in the potential for continued violations involving neglect and/or abuse going undetected, unreported, or without thorough investigation.

Inspectors wroteThis citation pertains to intake #MI00142952 Based on interview, and record review, the facility failed to implement care plan interventions, and perform safe transfers in 1 of 3 residents (Resident #103) reviewed for falls, resulting in a fall and the potential for harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain professional standards of care and provide timely incontinence care in 2 of 4 residents (Resident #106 and #108) reviewed for bowel and bladder incontinence, resulting in an increased risk for UTI (urinary tract infection) and the potential for skin breakdown.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions to prevent skin breakdown for residents at risk for pressure ulcers, for 2 of 2 residents (Resident #106 and #108) reviewed for pressure ulcer prevention, resulting in the potential for the development of an avoidable pressure ulcer, infection, and overall deterioration in health status.

Inspectors wroteThis citation pertains to intake #MI00142371 and #MI00142124. Based on observation, interview, and record review, the facility failed to ensure residents were free from accident hazards for 3 of 4 residents (Resident #101, #108 and #109) reviewed for falls, resulting in the potential for serious injury from a fall when care plan interventions were not implemented for bed mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe infection control practices in regard to hand hygiene (glove use), and consistently implement enhanced barrier precautions in 3 of 4 residents (Resident #106, #108 & #109) reviewed for infection control, resulting in the potential for cross-contamination and the development and spread of multi-drug resistant bacteria.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect in 5 (Residents #30, #477, #480, #25, and #54) of 7 residents reviewed for dignity, resulting in staff not respecting privacy for Resident #30, long call light wait time following incontinence episode for Resident #477, staff speaking disrespectfully about Resident #480 in his presence during incontinence care as well as long call light wait time following incontinence episode, and staff not promoting dignity and self-determination for Resident #25 and Resident #54.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain and/or honor meal preferences for 4 (Residents #4, #106, #123, and #73) of 29 sampled residents reviewed for meal services, resulting in resident dissatisfaction with their meal experience, feelings of frustration related to meals, and the potential for inadequate food/fluid intake and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure an annual PASARR II (PASARR Level II is a comprehensive evaluation by the appropriate state-designated authority and determines whether the individual has mental disability, intellectual disability, or a related condition, determines the appropriate setting for the individual and recommends what, if any, specialized services and/or rehabilitative services the individual needs) assessment was completed timely for 1 resident (R21) of 2 residents reviewed for PASARR, resulting in the potential for the resident to not maintain or achieve their highest practicable psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure maintenance, cleaning, and sanitary storage of CPAP (continuous positive airway pressure) and BIPAP (bilevel (alternating) positive airway pressure) respiratory equipment in accordance with physician orders and professional standards 4 of 6 residents (Resident #1, #54, #3, #7) reviewed for respiratory care, resulting in an increased potential for respiratory infection and respiratory distress.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform a thorough assessment for past trauma, identify post-traumatic stress disorder (PTSD) triggers and develop individualized care plan interventions to mitigate triggers for 2 (Resident #5 and Resident #7) of 3 residents reviewed for trauma informed care, resulting in the potential of re-traumatization due to staff not being informed and knowledgeable of the resident's past trauma and Resident #7 did not receive direct care that could trigger PTSD.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist a resident with legal matters and follow up regarding acquisition of guardianship and/or potential discharge to a lower level of care1 of 29 residents (Resident #79), resulting in Resident #79 feeling frustrated and helpless related to his placement.

Inspectors wroteBased on interview and record review, the facility failed to discontinue psychotropic as needed (PRN) medications after 14 days and/or document clinical rationale and indicate a timeframe for extended prn psychotropic medication use in 1 of 5 residents (Resident #18) reviewed for unnecessary medications, resulting in the potential for unnecessary medication use and inability to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence.

Inspectors wroteBased on observations and interviews, the facility failed to ensure proper infection control measures were implemented for cleaning and disinfecting resident shared equipment, resulting in the increased potential for the development and transmission of communicable diseases and infection in a vulnerable population.