South Haven Nursing and Rehabilitation Community

Inspectors wroteThis citation pertains to intake number 3031211. Based on interview and record review, the facility failed to protect the resident's right to be free from staff to resident physical mistreatment for 1 (Resident #100) of 3 residents, resulting in Resident #100 experiencing physical injury, emotional distress, and fear.

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

Inspectors wroteBased on observation and interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment resulting in an increased potential for contamination and a possible decrease in the satisfaction of living for all residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1. a dignified dining experience for 2 (Resident #1 and Resident #19); 2. an environment that promoted resident dignity in 1 (Resident #25) of 16 residents reviewed for dignity, resulting in the potential for a reasonable person to experience feelings of embarrassment, loss of self-worth, and a negative psychosocial outcome for the residents impacting their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to address and resolve grievances reported in Resident Council Meetings as stated during a confidential Resident Council meeting resulting in unresolved concerns, unmet resident needs and frustration.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify residents of where to find grievance forms and how to file a grievance as stated during a confidential Resident Council meeting resulting in unresolved concerns, unmet resident needs and frustration.

Inspectors wroteBased on interview and record review, the facility failed to employ an Activity Director who possessed the required qualifications resulting in the potential for unmet met psychosocial needs, feelings of boredom, isolation, and a lack of person-centered activities. This citation has the potential to impact any resident who relies on the activities program to support their leisure involvement.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food at a palatable temperature to 1 (Resident #75) of 4 residents and all residents who consume food resulting in the potential for decreased food consumption and potential nutritional decline.

Inspectors wroteThis citation pertains to intake #2563732Based on interview and record review the facility failed to ensure as needed (PRN) psychotropic medications (a medication that alters a person's mental state) included a stop date not exceeding 14 days for 1 (Resident #68) of 6 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement care plan interventions for 1 (Resident 7) of 16 sampled residents reviewed for care plan intervention implementation resulting in the potential for the development of pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of nursing practice for physician notification of a change in condition and medication administration for 1 of 1 residents (Resident #2) reviewed for medication administration resulting in the withholding of a medication without a physician's order and the potential for affected resident not maintaining or achieving their highest practical physical well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide individualized activities based on resident preferences, needs, and abilities for 1 resident (Resident #59) of 16 residents for activities, resulting in potential for social isolation, decreased connectedness to the resident's environment, and decreased overall well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure services and assistive devices were provided to maintain adequate vision in 1 (Resident #24) of 1 resident reviewed for vision services resulting in inadequate glasses, outdated prescription, and the potential for vision strain.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper treatment to maintain good foot health for 1 (Resident #5) of 1 resident reviewed for foot health, resulting in the potential for injury, unmet care needs and/or complications from chronic conditions that affect foot health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hydration was readily available for 1 resident (Resident #25) of 1 resident, resulting in the potential for decline in function, fluid and electrolyte imbalance, dehydration, the development of skin breakdown, urinary tract infections, and altered mental status.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered at the correct dose per the physician's order for 1 (Resident #2) of 2 residents reviewed for significant medication errors, resulting in the potential for adverse effects.

Inspectors wroteBased on observation and interview the facility failed to properly store controlled substance medications in a secure manner in 1 of 2 medication rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident food choices were obtained and honored for 1 (Resident #75) of 4 residents reviewed for meal services, resulting in resident dissatisfaction with their meal experience and the potential for inadequate food/fluid intake.

Inspectors wroteBased on interview and record review, the facility failed to complete accurate assessments for 1 of 16 residents (R#75) reviewed for assessments, resulting in an inaccurate reflection of the resident's status and the potential for impaired medical, functional, and psychosocial problems due to unidentified needs.

Inspectors wroteThis citation pertains to intake: MI00151221 Based on observation, interview, and record review the facility failed to ensure the safety and prevent an elopement of 1 (Resident #1) of 2 residents who were assessed to be at risk for elopement, resulting in an Immediate Jeopardy when Resident #1 left the premises alone, unbeknownst to staff, and was later observed (by a staff member who happened to drive by) walking along the road on 2/28/25, and was returned to the facility at approximately 3:30 pm. The elopement placed Resident #1 at risk serious harm, serious injury, and/or death.

Inspectors wroteThis citation pertains to intake: MI00151221 Based on observation, interview, and record review the facility failed to develop and implement person centered care plans for 2 (Resident #1 and Resident #3) of 3 residents reviewed for care plan development and implementation resulting in Resident #1 exiting the facility unsupervised and the potential for Resident #3 to elope from the facility.

Inspectors wroteBased on observation and interview the facility failed to employ either a full time Registered Dietitian or Certified Dietary Manager to provide oversight of kitchen and clinical nutritional services. This deficient practice has the increased potential to result in food service sanitation failures, food borne illness, or inadequate assessment of high-risk residents among all residents.

Inspectors wroteDuring a tour of the kitchen, starting at 8:35 AM on 9/26/24, an interview with Dietary Supervisor (DS) S found that potentially hazardous foods get dated for a three-day discard. Observation of the walk-in cooler found an open container of sliced ham with no discard date. During a tour of the bunny patch resident refrigeration unit, at 10:06 AM on 9/26/24, an interview with DS S found that dietary, nursing, and activities takes care of this refrigeration unit for residents. When asked how long food product gets in the refrigeration unit, DS S stated three days. Observation inside of the unit found the following: [...]

Inspectors wroteDPS 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).

Inspectors wroteBased on interview and record review, the facility failed to 1.) Implement and operationalize an antibiotic stewardship program and 2.) failed to monitor to ensure appropriate use of an antibiotic for 1 (Resident # 368) of 5 residents reviewed for antibiotic use, resulting in the potential for inappropriate antibiotic utilization and antibiotic resistance.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain general cleanliness and repair of resident rooms, equipment, and aspects of the physical facilities for 5 of 38 residents (Resident #9, #50, #1, #8, and #10). Findings Include: During a tour of the facility, at 10:26 AM on 9/26/24, observation of resident room [ROOM NUMBER] found dust and debris under the bed and an accumulation of dirt debris around the perimeter and corners of the rooms vinyl coving. During a tour of the facility, at 1:54 PM on 9/26/24, it was observed that resident room [ROOM NUMBER] was found with increase staining and debris on the perimeter and corners of the room. Observation of shared resident bathroom found accumulations of dirt in the corners of the floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were in reach for 1 (Resident #8) of 20 residents reviewed for accommodation of needs, resulting in the inability to call for staff assistance and the potential for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for 1 (Resident #42) of 5 residents reviewed for medications, resulting in an incomplete reflection of the resident's care and monitoring needs for anticoagulant therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care plan interventions to prevent worsening of contractures for 1 (Resident #1) of 2 residents reviewed for range of motion resulting in the potential for worsening of contractures (a condition of shortening and hardening of muscles, tendons, or other tissue often leading to deformity and rigidity of joints).

Inspectors wroteThis citation pertains to intakes MI00145027 and MI00145248. Based on observation, interview, and record review, the facility failed to ensure a safe environment and implement safety interventions for 1 (R15) of 2 residents reviewed for accidents and hazards, resulting in a fall with facial bruising and laceration that required sutures, and the increased potential for further falls with injuries.

Inspectors wroteBased on interview and record review, the facility failed to attempt a required Gradual Dose Reduction (GDR) of antidepressant and antipsychotic medications for 1 (Resident #22) of 5 residents reviewed for unnecessary medications, resulting in the potential that the resident was receiving the medication at an unnecessary dose or for an unnecessary length of time.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents remained free from significant medication errors, when professional standards of medication administration were not followed for 1 (Resident #16) of 1 resident reviewed for insulin (works to lower blood sugar levels in your body) administration, resulting in the potential for serious adverse effects from an excessive dose of insulin.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were screened for eligibility to receive pneumococcal vaccinations and receive vaccination if eligible for 1 (Resident #22 ) of 5 residents reviewed for vaccinations, resulting in the potential of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia.

Inspectors wroteBased on interview and record review, the facility failed to ensure Covid-19 immunizations were offered to 1 (Resident #51) out of 5 residents, reviewed for Covid-19 immunizations, resulting in the increased likelihood of infection and complications from Covid-19.

Inspectors wroteThis citation pertains to intake MI00142836. Based on observation, interview, and record review, the facility failed to ensure timely care and services to promote dignity in 3 of 4 residents (Resident #200, #201, & #202) reviewed for dignity/respect, resulting in long call light wait times, cluttered rooms, and the potential for feelings of diminished self-worth, sadness, and frustration.

Inspectors wroteThis citation pertains to intake #MI00143198. Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse by staff for 1 of 3 residents (Resident #201) reviewed for abuse, resulting in the potential for a decline in physical, mental, and psychosocial well-being.

Inspectors wroteThis citation pertains to intake #MI00142836. Based on interview and record review, the facility failed to provide care and services in accordance with professional standards of practice to 1.) ensure physician orders were in place for scheduled pain medications and 2.) accurately document the administration of controlled medications in 1 or 3 residents (Resident #202), reviewed for quality of care, resulting in the potential for ineffective management of pain, and the potential for drug diversion of controlled substances.

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 implement enhanced barrier precautions (EBP) in 1 resident (Resident #200) 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: 1. Properly store, label, date mark, and discard potentially hazardous foods; 2. Ensure proper working order of dish machine prior to use; 3. Ensure proper thawing and cooling of potentially hazardous foods; 4. Clean food and non-food contact surfaces; 5. Monitor the sanitizer concentration of the three-compartment sink; and 6. Ensure proper air drying of sheet pans. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 61 residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the dignity for 4 residents (Resident #10, Resident #56,Resident #42 and Resident #49) of 5 residents reviewed for dignity, from a total sample of 17 residents, resulting in residents feeling anger, fear, frustration,anxiety, and embarrassment.

Inspectors wroteBased on observation and interview, the facility failed to provide comfortable environmental temperatures for 1 of 1 resident (Resident #46) reviewed for comfortable temperatures, resulting in decreased satisfaction with living environment and affecting the feeling of a homelike environment.

Inspectors wroteIn an observation on 10/16/23 at 9:07 AM, noted a sign on the exterior portion of the facility, near the front entrance, which stated to not lean on the white metal railing as it is weak. Observed tall, white metal railing surrounding the wheelchair ramp/stairs near front entrance. In an observation on 10/16/23 at 9:32 AM, observed room [ROOM NUMBER] had solid-colored dark blue carpet. Visible/extensive amount of debris/food particles and pieces of trash littered the floor. Observed a smeared, light brown substance on the floor in front of the armchair on the right side of the room. In an observation on 10/16/23 at 9:33 AM, observed room [ROOM NUMBER] had a tile floor with visible pieces of trash/food/debris scattered throughout. Noted a visible darkening along the perimeter of the room from dust buildup. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the call light within reach of the resident in 2 of 7 residents (Resident #14 & #55) reviewed for accommodation of needs, resulting in the inability to call staff for assistance and the potential for unmet care needs.

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 3 (Resident #24, #32, #37) of 3 residents 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 that professional standards of nursing practice were followed during medication administration and for the implementation of physician orders for 3 residents (Resident #15, Resident #22, and Resident #37) of 16 sampled residents reviewed for professional standards of nursing care resulting in a nutritional supplement not being administered, medication errors, and no monitoring of high risk medications.

Inspectors wroteBased on interview, and record review, the facility failed to obtain radiology services in a timely manner in 1 of 1 resident (Resident #37) reviewed for radiology services, resulting in delayed assessment and treatment for right quadrant pain.

Inspectors wroteBased on observation and interview the facility failed to perform proper hand hygiene during medication administration for 3 residents (Resident #22, Resident #28, and Resident #8) of 8 residents reviewed for medication administration, resulting in the potential for the spread of infection, cross contamination, and disease transmission.

Inspectors wroteBased on interview and record review, the facility failed to maintain professional standards of care for medication administration for 1 resident (Residents #108) of 4 residents reviewed for medication administration, resulting in the potential for mis-administration of medication and the diversion of narcotics.

Inspectors wroteThis citation pertains to intakes MI00139876 and MI00138198 Based on observation, interview, and record review the facility failed to maintain an environment free of accident hazards and provide adequate supervision for 2 residents (Resident #113 and #104) of 5 residents reviewed for accidents/hazards, resulting in Resident #113 falling while being transported in a facility van, and Resident #104 eloping from the building.