Covenant Village of the Great Lakes

Inspectors wroteBased on 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), resulting in the potential for increased risk of respiratory infection among all residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a person-centered baseline care plan for 1 (Resident #46) of 12 residents reviewed for person-centered baseline care plan resulting in the potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review the facility failed to revise a person-centered care plan for 1 resident (Resident #7) of 12 residents reviewed for care plan revision resulting in an inaccurate reflection of the resident's current care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent the development and worsening of pressure ulcers in 2 residents (Resident #13 and Resident #43) of 2 residents reviewed for pressure ulcers resulting in the development of a facility acquired pressure ulcer for Resident #13 and the potential worsening of an existing pressure ulcer for Resident #43.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist completed specialized training in infection prevention and control, resulting in the potential for knowledge deficits pertaining to current infection prevention and control standards and infectious disease outbreaks in a vulnerable population of 29 residents.

Inspectors wroteBased on interview, and record review, the facility failed to develop policies and procedures to include current standards of practice in regard to pneumococcal immunizations, resulting in the potential for eligible residents to not be offered either the PCV15 (15-Valent Pneumococcal Conjugate Vaccine) or PCV20 (20-Valent Pneumococcal Conjugate Vaccine), therefore increasing the risk of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia.

Inspectors wroteBased on interview and record review, the facility failed to provide showers per resident preference in 1 (Resident #17) of 1 resident reviewed for self determination, resulting in dissatisfaction with care and the potential for poor hygiene, skin breakdown, and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of practice for physician orders were followed for 1 of 8 residents (R9) reviewed for professional standards of care, resulting in the lack of following orders, and the potential for the worsening of a condition and a delay in treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adaptive dining equipment was provided consistently for 1 (Resident #179) of 2 residents reviewed for nutrition resulting in difficulty drinking, feelings of worry, and the potential for dehydration.

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate medical record related to Advance Directives / Code Status for 1 (Resident #17) of 1 resident reviewed for accurate medical records, resulting in the potential for the resident's care wishes not being honored as desired.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed to ensure appropriate PPE was worn during foley catheter care and brief change for two of 12 residents (R5 and R16) reviewed for infection control, resulting in the potential for the spread of disease to a vulnerable population.

Inspectors wroteBased on interview and record review, the facility failed to promote resident dignity for 2 residents (Resident #13 and #184) of 4 residents reviewed for dignity, resulting in feelings of diminished self worth and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well being.

Inspectors wroteThis citation is related to intake #MI00135955. Based on interview and record review, the facility failed to document resident concerns according to facility policy for 1 resident (Resident #182) of 13 residents reviewed for resolution of grievances, resulting in the potential for a decline in the physical, mental, and psychosocial well being of residents.

Inspectors wroteBased on interview and record review, the facility failed to complete and transmit a death tracking assessment and transmit the data to CMS for 1 (Resident #6) of 13 sampled residents.

Inspectors wroteBased on interview and record review the facility failed to ensure a Pre-admission Screening/Annual Resident Review (PAS/ARR) Level I screening for a Level II OBRA evaluation (DCH-3878) was completed for a resident who remained at the facility greater than 30 days following an exempted hospital stay for 1 (Resident #1) of 15 sampled residents reviewed, resulting in the potential for the resident to not receive appropriate mental health treatment and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement person-centered comprehensive care plans for 2 (Resident #7 and #17) of 15 residents reviewed for care plans, resulting in an incomplete reflection of the residents' care needs and the potential for a lack of resident-centered care planned goals and interventions.

Inspectors wroteBased on observations, interview, and record review the facility failed to provide activities of daily living to a dependent resident, including incontinence care, removal of facial hair and nail care in 1 (Resident #15) of 13 sampled residents resulting in the potential for the reasonable person to experience feelings of embarrassment and diminished self-esteem.

Inspectors wroteBased on observations, interview, and record review the facility failed to provide bed mobility and incontinence care for the prevention of skin breakdown in 1 (Resident #15) of 13 sampled residents resulting in the potential for skin breakdown and/or the development of pressure ulcers.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement gait belt use for safety during a transfer in 1 (Resident #10) of 13 residents reviewed for transfer status resulting in the potential for injury during transfer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to clean a CPAP (continuous positive airway pressure) mask (a treatment used for sleep apnea - pressurized air is provided through a mask to prevent collapse of the airway) according to the facility policy for 1 (Resident #25) of 1 resident reviewed for respiratory care, resulting in the increased potential for respiratory infection and respiratory distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1) date resident specific insulin when opened for use and 2) removed expired medication from the medication room, resulting in the potential for decreased potency and efficacy of medications and the exacerbation of resident medical conditions.

Inspectors wroteBased on interview and record review the facility failed to maintain accurate medical records for 1 (Resident #22) of 13 residents reviewed for medical records accuracy.