Corewell Health Rehabilitation & Nursing Center -

Inspectors wroteThis citation pertains to intake #3094708Based on observation, interview, and record review the facility failed to ensure ADLs (Activities of Daily Living) specifically, nail care, for dependent residents, were completed for 2 (Resident #101 and Resident #104) of 4 residents reviewed for ADLs resulting in an unkept appearance and the potential for the spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the kitchen/kitchenettes' food contact and/or non-food contact surfaces were consistently maintained in a clean and sanitary manner and failed to consistently date, label, and discard food items appropriately with the potential to effect any resident out of the census of 98 who consumed food/beverages from the kitchen resulting in the potential for foodborne illness, physical food contamination, and/or pest issues.

Inspectors wroteBased on observation, interview, and record review the facility failed to honor food preferences for 1 (Resident #121) of 20 sampled residents reviewed for food preferences resulting in feelings of frustration and anger.

Inspectors wroteThis citation pertains to intake: 2568667. Based on interview and record review, the facility failed to prevent the use of unnecessary psychotropic medications without adequate indication for use and without resident monitoring in 1 of 1 resident (Resident #101) reviewed for psychotropic medications, resulting in an Immediate Jeopardy when on [DATE] Resident #101 was prescribed a psychotropic medication, who then sustained a fall with a impacted acetabulum (hip socket) and pelvic fracture on [DATE] and subsequent death.

Inspectors wroteThis citation pertains to intake: 2614764Based on interview and record review, the facility failed to ensure residents maintained their right to self-determination in 1 of 1 resident (Resident #100) reviewed for choices, resulting in frustration with not being able to go to sleep at a preferred bedtime, an altercation with staff and a left fractured humerus.

Inspectors wroteThis citation pertains to intake: 2568667Based on interview, and record review, the facility failed to obtain informed consent for psychotropic medications for 1 of 7 (Resident #101) residents reviewed for psychotropic medications, resulting in the resident/resident representative's inability to make decisions on risk vs benefit of medication use and alternative treatment options.

Inspectors wroteBased on record review and interview, the facility failed to implement care plan interventions and the facility policy to prevent falls in 1 of 7 residents (Resident #102) reviewed for fall prevention, resulting in the potential for falls and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the risk of urinary tract infection and ensure urinary catheter tubing and drainage bag were not resting on the floor in 2 of 2 residents (Resident #102, #105) reviewed for urinary catheter use, resulting in the potential of a urinary tract infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.

Inspectors wroteThis citation has two Deficient Practice Statements DPS A Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility.

Inspectors wroteBased on interview, and record review the facility failed to complete advance directives completely and accurately for 3 residents (Resident #37, Resident #312, Resident #60) of 22 residents reviewed for advance directives resulting in the potential for resident preferences for medical care to not be followed by the facility staff.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a clean comfortable environment with clean, sanitized medical equipment for 1 resident (Resident #75) of 2 residents, resulting in the potential for cross contamination and bacterial harborage.

Inspectors wroteBased on interview and record review, the facility failed to transmit Minimum Data Set (MDS) discharge assessments timely for 2 residents (Resident #82, Resident #93) of 2 reviewed for MDS transmission resulting in the potential for inaccurate tracking of discharges.

Inspectors wroteBased on interview and record review the facility failed to ensure that PASARR (Preadmission Screening and Resident Review) Level II (a comprehensive evaluation completed by the local (state mental health aruthority) was completed for 1 (Resident #16) of 4 residents reviewed for PASARR Level II screening resulting in the potential for unmet mental health care needs.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan related to Hospice care for 1 resident (Resident #58) of 22 reviewed for person centered care plans resulting in the potential for unmet care needs of the resident.

Inspectors wroteBased on observations, interview, and record review the facility failed to provide activities of daily living (ADLs) specifically nail care to a dependent resident for 1 (Resident #52) of 5 residents reviewed for activities of daily living, resulting in an unkept appearance and the potential for the spread of infection. Resident #52 Review of a Face Sheet revealed Resident #52 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: cognitive deficits following a non-traumatic intracerebral hemorrhage (bleeding in the brain), hemiparesis (paralysis) on the left non-dominate side, and debility. Review of a Minimum Data Set (MDS) assessment for Resident #52, with a reference date of 12/4/2024 revealed a Brief Interview for Mental Status (BIMS) score of 2/15 which indicated Resident #52 was severely cognitively impaired. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received care in accordance with physician orders for medications and professional standards in 1 resident (Resident #49) of 22 residents reviewed for quality of care, resulting in a delay in treatment and worsening of a medical condition, and the potential for residents not attaining or maintaining their highest practicable level of wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide preventative care, consistent with professional standards of practice for 2 residents (Resident #98 & #65) of 5 residents reviewed for at risk for the development of pressure injuries, resulting in the potential for worsening of pressure wounds, the development of an avoidable pressure ulcer, infection, and overall deterioration in health status.

Inspectors wroteDPS B Based on observation, interview, and record review, the facility failed to ensure resident safety with chair to bed transfers for 2 residents (Resident #98 & #65) of 5 residents reviewed for accident hazards, resulting in the potential for avoidable accidents and serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foley catheter (a tube inserted into the bladder through the urethra to drain urine) tubing was secured to prevent pulling and perform incontinence care per standards of practice in 2 residents (Resident #98 & #65) of 5 residents, reviewed for bowel and bladder incontinence, resulting in the potential for dislodgement of the catheter tubing with pain and urethral damage, and the potential for skin breakdown, cross-contamination and development/spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen delivery equipment was monitored for 1 (Resident #16) of 2 residents reviewed for oxygen administration resulting in the potential for ineffective performance of improperly maintained oxygen delivery equipment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician documented review of pharmacy recommendations/follow up occurred for 1 resident (Resident #15) of 5 residents reviewed for unnecessary medications resulting in the potential for medication side effects and/or unnecessary medications for residents.

Inspectors wroteThis citation pertains to intake #: MI00147147 Based on interview and record review the facility failed to ensure the safety and provide monitoring and/or supervision while eating in of 4 residents (Resident #1), reviewed for safety and supervision, resulting in Resident #1 choking on food and subsequent death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices to provide sanitary conditions for resident shared equipment, and implement enhanced barrier precautions for a resident with an MDRO (multi drug resistant organism) during care for 1 resident (Resident #19) of 4 residents reviewed for catheter care, resulting in the potential for the spread of infection, cross-contamination, and disease transmission for residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a person centered care plan for 2 (Resident #70 and #63) of 20 residents reviewed for care planning, resulting in Resident #70 using a wheelchair without the recommended safety features and aspiration risk for Resident #63.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise the person centered care plan in a timely manner with appropriate interventions for 2 residents (#63 and #90), with the potential for physical, mental, and psychosocial unmet care needs and harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for documentation of medication administration in 2 of 7 residents (Resident #17 & #43) reviewed for medication administration, resulting in the potential for medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assistance with activities of daily living (ADL) care was provided for 2 (Resident #13 and #63) of 4 residents reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for resident's dependent on staff for assistance.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were not to receive straws with fluids, did not receive them in 2 of 2 residents (Resident #63 and #28) reviewed for quality of care, resulting in the potential for aspiration and potential pneumonia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions were in place to prevent the worsening of contractures for 1 of 4 residents (Resident #63) reviewed for position and mobility, resulting in the potential for decreased range of motion, skin breakdown, pain and worsening of contractures (hardening of the muscles, tendons, and other tissues).

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1. provide adequate supervision and monitoring of a resident at risk for accidents for 1 resident (Resident #13) and 2. utilize wheelchair footrests for safe wheelchair transport for 1 resident (#92) of 2 resident reviewed for accidents and hazards, resulting in the potential for falls and injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician orders were in place and followed for a resident with a Foley catheter (a tube inserted through the urethra to drain urine out of the body from the bladder) in 1 (Resident #42) of 3 residents reviewed for catheter care, resulting in the failure to provide care and services to prevent blockage and infection, and the potential for serious complications and urinary tract infection (UTI).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were trauma survivors received care and services that addressed their psychosocial needs for 3 of 3 residents (Resident #68, Resident #13, and Resident #63) reviewed for trauma informed care, resulting in Resident #68 experiencing feelings of frustration, Resident #13 experiencing nightmares with no interventions to minimize his distress, and a potential for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to track and offer the pneumococcal vaccine for 5 (Resident #63, #363, #90, #11, #74) of 5 residents reviewed for immunizations, resulting in a delay in being given the opportunity to receive or decline the pneumococcal vaccination.