Greenfield Rehab and Nursing Center

Inspectors wroteThis citation pertains to intake 3020087. Based on observation, interview and record review, the facility failed to maintain the exterior dumpster area in a clean/sanitary manner. This deficient practice had the potential to affect all residents, staff and visitors.

Inspectors wroteThis citation pertains to intake 3020087. Based on observation, interview and record review, the facility failed to ensure an environment free from accident hazards (broken/sharp handrail). This deficient practice has the potential to affect multiple residents who are independently ambulatory with, or without an assistive device.

Inspectors wroteThis citation pertains to intake 3021235. Based on interview and record review the facility failed to ensure that the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) was provided and completed for one (R303) of one resident reviewed for beneficiary notification, resulting in the residents and/or their representatives not being informed timely of private pay charges for continued services while they remained in the facility.

Inspectors wroteThis citation pertains to intake: 3018571. Based on interview and record reviews the facility failed to accurately assess the nutritional status and obtain weights per the facility's policy for one (R302) of one person reviewed for nutrition.

Inspectors wroteThis citation pertains to intake: 3018535 & 3018571. Based on interview and record reviews the facility failed to ensure Physical & Occupational Therapy (PT/OT) services were provided as ordered by the Physician in the residents therapy plan for one (R302) of one resident reviewed for therapy services.

Inspectors wroteThis citation pertains to Intake 2992499. Based on interview and record review, the facility failed to report an allegation of verbal abuse by staff to the State Agency for one (R801) of two residents reviewed for abuse.

Inspectors wroteThis citation pertains to intake #2796374Based on observation, interview, and record review, the facility failed to implement a facility wide activity and recreation program with varied interests and taking into account resident's preferences and their individual cognitive and physical abilities for three residents (R507, 509, and 510) of three residents reviewed for activities and recreation, resulting in verbalized complaints of boredom and dis-satisfaction with the facility's activity programming. This citation had the potential to affect multiple residents who reside in the facility.

Inspectors wroteThis citation pertains to intake #2785249. Based on interview and record review, the facility failed to thoroughly perform a skin assessment and implement treatments for wounds upon admission for one resident, (R502) of one resident reviewed for skin impairments, resulting in concerns with wound healing and complaints with quality of care.

Inspectors wroteThis citation pertains to Complaint #2633707. Based on observation, interview, and record review, the facility failed to prevent a significant medication error when they did not administer insulin according to physician's orders for one (R801) of three residents reviewed for medication administration, resulting in the resident being hospitalized in the intensive care unit (ICU) for low blood sugar after they received 100 units of short acting insulin instead of the ordered three units.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from neglect for one (R93) of two residents reviewed for death by neglecting to adequately assess/monitor a resident with an identified change in condition, timely notify the physician of resident's status and timely transfer the resident to a higher level of care, resulting in a delay in identifying and treating the resident with a history of respiratory distress leading to death in the facility. The deficient practice resulted in the increased likelihood of serious harm, serious injury and /or death to occur.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Activity Director had the minimum qualifications to perform duties of the position affecting all residents in the facility.

Inspectors wroteConcern with facility staffing has the potential to affect to all residents Based on interview and record review facility failed to ensure sufficient nursing staff were available to meet the needs of residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the facility assessment staffing was revised upon the reopening of a previously identified closed unit. This has the potential to affect all 87 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) Assessments were completed accurately for one (R68) of residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident's call light was within reach for one (R48) one of resident reviewed for call lights, resulting in the potential for unmet response for care needs or fall(s) etc.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the window air conditioning (AC) unit was properly sealed to maintain a safe, clean, comfortable environment for two (R15 and R77) of four residents reviewed for environmental concerns.

Inspectors wroteBased on observation, interview and record review the facility failed to report an injury of unknow origin to the State Agency (SA) for one R10 out of three residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to conduct a care planning review in coordination with a significant change Minimum Data Set (MDS) assessment for one (R62) of one resident reviewed for hospice, resulting in the lack of opportunity for the resident, legal representatives, and hospice to participate in review of interventions which pertained to their care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure showers and/or nail care were provided to one (R50) of four residents reviewed for activities of daily living (ADL's).

Inspectors wroteThis citation pertains to intake #'s 1214456 and 2569467. Based on observations, interviews and record reviews, the facility failed to timely and accurately assess, treat and follow up with a medical provider for change in condition for one resident(R83) of one resident reviewed for a change in condition,resulting in R83 being transferred to the hospital for a cellulitic scalp wound.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure timely interventions and treatments for one (R6) of three residents reviewed for pressure ulcers, resulting in R6 acquiring a Stage 3 (full-thickness skin loss) pressure ulcer.

Inspectors wroteThis citation pertains to Intake #1214313Based on interview and record review the facility failed to provide proper care for one (R87) out of three residents reviewed for falls, resulting in R87 being transferred to the hospital and examined for injuries.

Inspectors wroteBased on observations interview and record review the facility failed to ensure that oxygen was administered according to physician's orders for one resident (Resident #39) of one reviewed for respiratory care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the timely acquisition and administration of medication for one (R13) of one resident reviewed for pharmacy services.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control practices related to implementation of enhanced barrier precautions (EBP) upon identification of a new wound for one (R62) of three residents reviewed for pressure ulcers.

Inspectors wroteThis citation pertains to Intake Number(s): MI00152130. Based on observation, interview, and record review, the facility failed to ensure call lights were within reach of five (R605, R606, R607, R608, and R609) of six residents reviewed for accommodation of needs.

Inspectors wroteThis citation pertains to Intake Number: MI00149259. Based on observation, interview, and record review, the facility failed to ensure a resident bathroom was maintained in a clean, comfortable, and safe manner for one (R803) of three residents reviewed for the environment, resulting in the resident having to change their clothing often due to leaking water, having to wait for a community bathroom, and feeling frustrated.

Inspectors wroteThis citation pertains to intake #MI00149259 Based on observation interview and record review, the facility failed to ensure medications were administered per the Physician's orders for one resident (R801) of two residents reviewed for medication administration.

Inspectors wroteThis citation pertains to Intake Number: MI00148850. Based on observation, interview, and record review, the facility failed to ensure recommendations from the orthopedic specialist were implemented for one (R802) of one resident reviewed for coordination of care to outside appointments.

Inspectors wroteThis citation pertains to intake #MI00147465 Based on observation, interview, and record review the facility failed to ensure freedom from staff neglect for one resident, (R903) of three residents reviewed for abuse, resulting in a significant delay of administration of an anti-anxiety medication and feelings of sadness, frustration, anger, anxiety, fear, and disappointment with care.

Inspectors wroteThis citation pertains to Intake(s): MI00147253 and MI00147444 Based on observation, interview and record review, the facility staff failed to timely report allegations of sexual abuse to the Administrator/Abuse coordinator to ensure timely reporting to the State Agency for one (R901) out of three residents reviewed for abuse.

Inspectors wroteThis citation pertains to intake # MI00146550. Based on observation, interview, and record review, the facility failed to maintain an effective pest control program, resulting in the presence of gnats, house flies and sewer flies throughout the facility. This deficient practice had the potential to affect all residents in the facility.

Inspectors wroteThis citation pertains to intake # MI00146550. Based on observation, interview and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment, affecting multiple residents throughout the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a portable oxygen tank was properly secured while left unattended for one (R405) of one resident reviewed for oxygen use, resulting in the potential for the tank to be knocked over, causing a potential rocketing of the cylinder and injury to residents in the immediate area.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident medications were not left at the bedside for one (R406) of one resident reviewed for medication storage.

Inspectors wroteThis citation pertains to intake # MI00145182. Based on observation, interview, and record review facility failed to complete appropriate assessment(s) and provide appropriate interventions and follow the standard(s) of care for Activities of Daily Living (ADL's) resulting in a fall from bed for one (R801) of one Resident reviewed for falls.

Inspectors wroteThis citation pertains to Intake Number(s): MI00138288, MI00140123, and MI00144352. Based on observation, interview, and record review, the facility failed to protect three (R33, R35, and R21) residents' rights to be free from physical and verbal abuse by staff and other residents (R50 and R61).

Inspectors wroteThis citation pertains to Intake Number(s): MI00140123 and MI00144352. Based on interview and record review, the facility failed to report actual and alleged physical and verbal abuse to the Abuse Coordinator, law enforcement, and/or the State Agency within the required time frame for six (R7, R21, R33, R35, R50, and R61) of 11 residents reviewed for abuse, resulting in an approximately six month delay in investigating physical abuse of R33 by a staff member who continued to work in the facility during that time.

Inspectors wroteThis citation pertains to Intake Number(s): MI00144325 and MI00143575. Based on observation, interview, and record review the facility failed to investigate witnessed and alleged resident to resident physical and verbal abuse and failed to thoroughly investigate a bruised eye of unknown origin for five (R21, R35, R50, R61, R66) of 11 residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident's active Durable Power of Attorney (DPOA) wishes for their family member's code status was accurately followed for one (R34) out of five residents reviewed for advanced directive/code status.

Inspectors wroteThis citation pertains to Intake# MI00142649 Based on observation, interview and record review the facility failed to inform the resident's family/legal guardian of a room change, physician recommendations and enquire as to vaccination recommendations for one (R38) out of two residents reviewed for change in condition.

Inspectors wroteBased on interview and record review, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) for one resident (Resident #76) of three residents reviewed for Beneficiary Notices, resulting in the resident and/or the representative not being informed of the right to appeal and the potential for undue emotional and financial hardships.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately store resident property for two residents (R9, R67) of two reviewed for personal property, allowing for the potential loss and or theft of personal possessions.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate assessments were completed for one (R50) of 32 residents reviewed for Minimum Data Set (MDS) assessments.

Inspectors wroteBased on interview and record review, the facility failed to ensure a level I Preadmission Screening (PAS)/Annual Resident Review (ARR) Mental Illness/Intellectual Disability/Related Conditions Identification was completed on admission and/or annually and sent to local community mental health for a level II OBRA (Omnibus Budget Reconciliation Act of 1993) evaluation for two (R7 and R67) of three residents reviewed for PASARR.

Inspectors wroteBased on interview and record review, the facility failed to consistently monitor blood pressure for one (R7) of one resident reviewed for a change in condition who was prescribed multiple medications to treat high blood pressure.

Inspectors wroteThis citation pertains to Intake MI00137192 and MI00140349 Based on observation, interview and record review, the facility failed to implement preventative interventions and timely assess and identify formation of pressure ulcers for one (R75) of five residents reviewed for pressure ulcers resulting in R75 acquiring one Stage 2 (partial-thickness loss of skin with exposed dermis) and two Stage 3 (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer) pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the recommendations and physician orders for assistive devices to maintain range of motion and positioning for two (R12 and R30) of three residents reviewed for positioning resulting in the potential for decline in range of motion and worsening of contractures.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate supervision and/or positioning during showers and therapy for cognitively impaired residents for two (R436 and R11) of four residents reviewed for falls, resulting in R436 sustaining a compression fracture to the thoracic vertebrae and R11 hitting their head.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement recommendations made by the contracted behavioral health provider for one (R67) resident reviewed for behavioral health services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to evaluate the competency and obtain guardianship for a resident with severely impaired cognition who did not have a resident representative for one (R35) residents reviewed for social services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document and reconcile two controlled medications observed in a random surveillance of the narcotic drawer for one resident (R9) of one reviewed during medication storage and labeling observation.

Inspectors wroteBased on observation, interview and record review, the facility failed to schedule follow up dental services for one resident (R236) of two residents reviewed for dental services.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely skilled rehabilitation (physical therapy) services as ordered for one (#33) of one sampled resident reviewed for rehab/restorative services resulting in the delay in evaluation for physical therapy services to address the change in mobility and feelings of frustration.

Inspectors wroteThis citation pertains to Intake MI00142547 Based on interview and record review, the facility failed to ensure vaccine consent/declination was signed by a resident's legal guardian, and ensure accurate tracking and administration of the pneumococcal vaccinations for residents residing in the facility for three (R38, R1 and R216) of five residents reviewed for influenza and pneumococcal vaccinations.

Inspectors wroteThis citation pertains to intake(s): MI00144245 & MI00144212. Based on observation, interviews, and record reviews the facility failed to protect the resident's right to be free from physical restraints and/or mistreatment during care for one (R704) of five residents reviewed for mistreatment and/or abuse by Certified Nursing Assistant (CNA) K, resulting in R704 to have a fracture of the fourth digit to their right hand.

Inspectors wroteBased on interviews and record reviews the facility failed to consistently implement their Compliance and Ethics Program, for two (R's 704 and 705) of five residents reviewed for abuse/mistreatment and had the potential to affect all 81 residents that resided in the facility, Resulting in the failure of the Administration staff to report suspected violations, prohibit the retributions of employees who report suspected violations (Unit Manager- UM I), failed to consistently identify and respond to violations, and implemented appropriate disciplinary mechanisms for reportable violations (Certified Nursing Assistant- CNA K).

Inspectors wroteThis citation pertains to intake: MI00144245. Based on interviews, and record reviews the facility failed to ensure the signage of employee rights related to retaliation against the employee for reporting a suspected crime was posted in the facility and failed to prohibit and prevent the retaliation of one employee (Unit Manager- UM I) who was terminated during the investigation conducted for an alleged allegation of abuse for (R704) and an alleged verbal allegation of abuse for (R705) two of five residents reviewed for Abuse/Mistreatment, resulting in the likelihood for mistreatment and/or abuse to occur, the termination of UM I and the likelihood of unreported mistreatment and/or abuse to be reported by the facility staff in fear of retaliation from the facility Administration.

Inspectors wroteThis citation pertains to intake(s): MI00144212 & MI00144245. Based on interviews, and record reviews the facility failed to develop and/or implement policies and procedures for ensuring the timely reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act, for an injury of unknown origin (R704), failed to report an allegation of a suspicion of verbal abuse (R705), failed to report an allegation of physical abuse (R708) and failed to report an accurate investigation to the State Agency regarding an injury of unknown origin (R704), for three of five residents reviewed for abuse.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide appropriate and consistent interpreter and/or translation services for three (R's 704, 708 & 711) of five residents reviewed for abuse/mistreatment.

Inspectors wroteThis citation pertains to intake: MI00144212. Based on observation, interviews, and record reviews the facility failed to consistently implement preventative interventions to prevent falls for one (R708) of one resident reviewed for falls.

Inspectors wroteThis citation pertains to intake #MI00144005. A complaint was received by the State agency that alleged a Certified Nurse Aide (CNA) neglected their patients. Based on interview and record review the facility failed to ensure an allegation of abuse by a staff member was reported to the abuse coordinator for two residents (R#'s 602 and 603) of seven residents reviewed for abuse.

Inspectors wroteThis citation pertains to intake #MI00144005 A complaint was received by the State Agency a resident was improperly transferred and suffered a fall. Based on observation, interview, and record review the facility failed to ensure a proper transfer for one resident (R606) of three residents reviewed for accidents resulting in a fall.

Inspectors wroteThis citation pertains to intake #MI000133364 Based on observation, interview and record review, the facility failed to ensure a resident was treated with dignity and respect and provided an environment that promoted and enhanced the resident's autonomy for two (R70 and R24) of nine residents reviewed for self-determination/dignity, resulting in the loss of autonomy and expressions of extreme frustration, loss of self-worth and helplessness.

Inspectors wroteBased on interview and record review the facility failed to ensure sufficient nursing staff for the residents that resided in the facility on multiple dates in October 2022, resulting in the potential for unmet care needs, inadequate supervision and monitoring of the residents that resided in the facility at that time.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week resulting in the potential for inadequate coordination of emergent and routine care with negative clinical outcomes and clinical supervision of Licensed Practical Nurses (LPN) for the date of 10/7/22 affecting all 75 residents that resided in the facility at that time.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure potentially hazardous food items were cooled to 41 degrees Fahrenheit or less within 6 hours, and failed to ensure an open window in the kitchen area was screened. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure that five Certified Nursing Assistants (CNAs- Q, R, S, T & U) of five CNAs reviewed for the required annual in-service education, had the required 12 hours of in-service training within the required time period and/or the initial trainings of a new hire which included abuse prevention and dementia care, resulting in the potential for unidentified abuse, inadequate care and unmet resident care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure free movement throughout the building for four residents (R#'s 9, 17, 40, and 88) of four residents reviewed for self-determination, resulting in a complaint of not being able to leave the 2 North unit without staff keying in a door code. This deficient practice had the potential to affect all resident's on the 2 North unit. A review of a facility provided policy titled, Resident Rights under the Michigan Public Health Code dated 11/20/17 was reviewed and read, .The resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility, including those specified in this section . On 5/2/22, 5/3/22 and during the morning of 5/4/22 it was observed a numerical door code was required to enter and exit the 2 North unit. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure unrestricted, 24-hour visitation affecting all 87 residents residing in the facility, resulting in resident verbalizations of family/visitors unable to enter the facility to visit and potential for decreased psychosocial well-being and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement its policies and procedures related to screening procedures for work eligibility in a nursing home prior to employment for two (Certified Nursing Assistant- CNAs- Q & U) of five CNAs reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a meaningful program of activities for two residents (R#'s 82 and 83) of two residents revealed for activities. This deficient practice had the potential to affect all 17 residents on the 2 North unit. A review of a facility provided policy titled, Activities dated 1/2020 was conducted and read, It is the policy of this facility to provide an ongoing program of activities designed to meet the interest choice and preferences as well as to meet the interest of and support the physical, spiritual, mental and psychosocial well-being of each resident, encouraging both independence and interaction in the community . On 5/2/22, 5/3/22 and during the morning of 5/4/22 it was observed a numerical door code was required to enter and exit the 2 North unit. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff had the required certification and competency evaluations to provide nursing care and failed to follow up to ensure one (CNA- Certified Nursing Assistant Q) of five CNA's reviewed became registered, resulting in the potential for unmet care needs to have been provided by an uncertified and potentially incompetent nursing assistant.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate advance directive information was in place and all components of their Do-Not-Resuscitate (DNR) process was implemented for two (R70 and R43) of three residents reviewed for advance directives, resulting in the potential for unwanted or unmet health care decisions and the increased likelihood for the residents' end of life wishes and preferences not being considered and/or honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure a level I Preadmission Screening (PAS)/Annual Resident Review (ARR) Mental Illness/Intellectual Disability/Related Conditions Identification was completed accurately and sent to local community mental health for a level II OBRA (Omnibus Budget Reconciliation Act of 1993) evaluation for one (R21) of one resident reviewed for PASARRs. This deficient practice resulted in the potential for the resident to be excluded from receiving necessary care and services appropriate to meet their mental health and intellectual disability needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure coordination of care and timely communication with the hospice provider for the use of bed bolsters for one (R43) of two residents reviewed for hospice care, resulting in the the potential for discomfort and decline in quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents with limited mobility were assessed for appropriate assistive devices to maintain or improve functional mobility for one (R39) of three residents reviewed for mobility and assistive devices resulting in the potential to decline in bed mobility, decreased ability to assist during self-care,dissatisfaction and frustration with the care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment and services for indwelling urinary catheters for one resident (R82) of two residents reviewed for urinary catheters, resulting in the potential for injury and urinary tract infections.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure an opened Tuberculin solution vial was dated and/or discarded per the manufacturer's instructions from one of two medication rooms reviewed.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one (R70) of one resident reviewed for complete/accurate clinical record, resulting in the increased potential for delayed or omitted notification/involvement of the legal representatives and the potential for providers not having an accurate picture of the resident's condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents/resident's guardians understood the purpose of binding arbitration agreements (an out-of-court alternate form of dispute resolution) for two residents, (R#'s 41 and R55) of three residents reviewed for arbitration.