Resthaven Care Center

Inspectors wroteBased on interview and record review, the facility failed to prevent significant medication errors in 1 (Resident #14) of 7 residents reviewed for medication errors, resulting in Resident #14 receiving a mood stabilizing medication at a dose greater than the physician had ordered for 26 days.

Inspectors wroteThis citation pertains to intake # 2574196Based on interview and record review the facility failed to ensure the safety of 1 resident (Resident #1) of 3 residents reviewed for accidents/hazards resulting in Resident #1 having a fall in the facility parking lot while she was left unattended and as a result suffered frontal and temporal lobe hemorrhages, a 4th left rib fracture and a change in capacity.

Inspectors wroteBased on interview and record review, the facility failed to provide quarterly resident trust fund financial statements to 8 of 8 residents utilizing resident trust accounts resulting in the residents not being systematically informed about personal funds.

Inspectors wroteBased on observation, interviews and record review, the facility failed to maintain a comfortable ambient temperature between 71-81 degrees for 20 residents within a memory care unit (Rooms 401-415), resulting in resident's experiencing ambient room temperatures higher than 81 degrees and a potential for overheating and dehydration.

Inspectors wroteBased on observation, interview, and record review the facility failed provide a dignified environment and assist residents with care needs in 1 (Resident #52) of 2 residents reviewed for dignity, resulting in feelings of frustration and the potential for depression, loss of self-worth, and an overall deterioration of psychological well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure accurate documentation of advance directives - code status (resident wishes for life sustaining interventions an emergency) for 1 (Resident #389) of 28 residents reviewed for advance directive - code status documentation resulting in the lack of an order or other documentation for the first 5 days of Resident #389's stay.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening (PAS) / Annual Resident Review (ARR) Level I Screening Form DCH-3877 was completed annually for 1 (Resident #37) of 2 residents reviewed for preadmission screening / annual resident review screening, resulting in the potential for unmet mental health care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure professional standards of nursing were followed for treatment of a skin tear for 1 (Resident #43) of 1 resident reviewed for professional standards of nursing practice.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to prevent, treat, and promote healing of pressure ulcers in 1 of 2 residents (Resident #126) reviewed for pressure ulcers, resulting in the lack of repositioning and implementation of care planned interventions, delayed healing of pressure ulcers for the resident, and the potential for infection and the development of new ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and ensure appropriate transfer techniques were implemented for 2 (Resident #96 and Resident #102) of 9 residents reviewed for accidents resulting in an increased risk for falls and injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received food items within their preferences for 1 (Resident #27) of 2 residents reviewed for food, resulting in dissatisfaction and the potential for nutritional decline and gastrointestinal upset.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly sanitized resident shared equipment, specifically a glucometer between uses during medication administration for 1 (Resident #129) of 5 residents observed for medication administration, resulting in the potential for the spread of infection, cross-contamination, and disease transmission.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include: 1. During the initial tour of the main kitchen, at 11:09 AM on 6/4/24, observation of the Blueair Refrigeration unit found the digital thermometer on the outside stated it was 34F. Upon opening the door it was noticed that the ambient temperature of the unit felt warm and there was no ambient air thermometer in the unit. A temperature of an open half gallon of fat free milk was taken with a digital rapid read thermometer and found to be 55F. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1.) ensure resident shared equipment was properly cleaned and sanitized between each use, 2.) ensure personal protective equipment (PPE) was worn by staff and visitors in care units where required and by staff when caring for 1 (Resident #119) of 29 sampled residents, 3.) ensure clean laundry bins used for transport were free from dirt and debris; and 4.) ensure 1 (Resident #91) of 2 residents sampled for dialysis had a dressing applied to their dialysis access site (an indwelling device). These deficient practices resulted in the increased potential for the spread of infection, bacterial harborage, cross contamination, and disease transmission for residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to provide a written notice of transfer for 1 of 2 residents (Resident #98) reviewed for hospitalization, resulting in the potential of residents and/or resident representatives being uninformed of the reason for transfer and their rights, and failed to provide timely notification to a representative of the Office of the State Long-Term Care Ombudsman for emergency transfer of residents being discharged , residents left without an advocate to inform them of their rights, and for the Office of the State Long-T erm Care Ombudsman to be unaware of the facilities practices related to transfers and discharges.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the bed hold policy upon transfer to the hospital for 1 of 2 residents (Resident #98) reviewed for transfer and discharge requirements, resulting in the potential for residents and/or their representatives to be unaware of their rights in regard to facility bed holds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of practice for physician orders were obtained/followed for two residents (R91 and R291) of two residents reviewed for professional standards of care, resulting in the lack of documentation, 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 follow orders for monitoring of blood sugars for 1 resident, (R292), and to follow orders for dressing changes for 1 resident, (R119) resulting in the lack of monitoring and the resident not receiving appropriate interventions with the potential of worsening health status.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure services to maintain and prevent further decrease in ROM (range of motion) for 1 of 2 residents (Resident #7) reviewed for limited ROM, resulting in the potential for decreased ROM, contractures (hardening of the muscles, tendons, and other tissues) and pain.

Inspectors wroteBased on interview, and record review the facility failed ensure physician orders were in place for dialysis treatment (the process of removing excess fluid and toxins in people with insufficient kidney function) and monitoring, and post dialysis assessments were documented for 2 residents (Resident #65 and #91) of 2 residents reviewed for dialysis care, resulting in the potential for the resident to not meet their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post required nurse staffing information on a daily basis, for all 135 residents in the facility, resulting in a lack of available staffing information for residents and visitors.

Inspectors wroteThis citation pertains to intake: MI00136097, MI00136440, MI00137896, MI00139274 Based on observation, interview, and record review, the facility failed to provide an environment that promoted a dignified experience and respond to resident call lights timely for 2 residents (Resident #100, Resident #103) of 8 residents, resulting in the feelings of humiliation, embarrassment, concern about receiving a timely response in the event of a medical emergency and a negative psychosocial outcome for the residents impacting their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident safety during a Hoyer (mechanical life) transfer in 1 of 8 residents (Resident #103), resulting in a fall with minor injury.

Inspectors wroteThis citation pertains to intake number MI00133713 Based on observation, interview, and record review the facility failed to: 1. Ensure proper working order of the dish machine; 2. Datemark and discard potentially hazardous foods; 3. Store raw animal product in a manner that decreases contamination of ready to eat foods; and 4. Properly store clean and sanitary items and equipment. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 142 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the main kitchen, at 12:20 PM on 4/24/23, it was observed that the pressure indicator for the rinse cycle was reading between 50 and 55 pressure per square inch (psi). Observation over the course of three cycles, found the rinse pressure stayed in the 50-55 psi range when engaged. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff received all required doses of COVID-19 vaccine and maintain complete and accurate records of the COVID-19 vaccination status for all required facility staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents maintained their right to self determination for 1 of 29 residents (Resident #37), reviewed for choices, resulting in frustration with not being able to go to sleep at a preferred bedtime, due to waiting for medication administration and catheter (tube inserted into bladder to drain urine from the body) care to be completed. Findings Include: Resident #37 Review of a Minimum Data Set (MDS) assessment for Resident #37, with a reference date of 2/13/23 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #37 was cognitively intact. Review of Preferences for Customary Routine and Activities with a reference date of 8/14/22 revealed that Resident #37 indicated that being able to choose a bedtime, was very important. [...]

Inspectors wroteThis citation pertains to intake numbers MI00133713 and MI00134025 Based on observation, interview, and record review, the facility failed to provide appropriate Activities of Daily Living (ADL) care for 2 of 29 residents (Resident #30 and #47 ) reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for resident's who are dependent on staff for assistance. Findings Include: Review of an admission Record revealed Resident #30 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: urinary incontinence and constipation. Review of a Minimum Data Set (MDS) assessment for Resident #30, with a reference date of 1/30/23 revealed a Brief Interview for Mental Status (BIMS) score of 7, out of a total possible score of 15, which indicated Resident #30 was cognitively impaired. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the development of pressure ulcer for 1 (Resident #52) of 2 sampled residents reviewed for pressure ulcers, resulting in the development of a facility acquired pressure ulcer.

Inspectors wroteThis citation pertains to intake numbers MI00135243 and MI00134025. Based on observation, interview, and record review, the facility failed to ensure a safe environment and implement safety interventions for 3 (R191, R134, and R91) of 29 residents reviewed for accidents and hazards, resulting in feelings of being scared (R191), a fall with injury (R134), unsafe transfer (R91), and the increased potential for further feelings of being scared, and falls with injuries.

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 2 of 29 sampled residents (Resident #62 and #80) reviewed for Advance Directives / Code Status, resulting in an incomplete/inconsistent reflection of the resident records and the potential for care wishes not being honored as desired.