Adrian Bay Rehabilitation and Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to document blood sugars prior to holding or administering insulin for one (R10) of six reviewed for unnecessary medications. Findings include: Review of the medical record reflected R10 admitted to the facility on [DATE], with diagnoses that included type 2 diabetes. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/21/25, reflected R10 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 06/10/25 at 1:56 PM, R10 was observed in their room. R10 reported their insulin had been adjusted, and they were receiving long-acting insulin if their blood sugar was above 90 milligrams per deciliter (mg/dL) in the morning. R10's May 2025 and June 2025 Medication Administration Records (MAR) reflected an order, which was started on 5/28/25, for 25 units of insulin glargine to be administered subcutaneously (under the skin) in the morning. The insulin was to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

During an observation on 6/11/25 at 11:28 am hall A medication cart was unlocked with no staff in area. One resident observed in area able to self propel in wheelchair. During an interview on 6/12/25 at 1:35 PM, Unit Manager (UM) M reported would expect medication carts to remain locked when staff not present and computer closed. Director of Nursing (DON) B joined interview and reported would expect medication carts to remain locked if nurse not present. UM M reported often monitors for secure medications carts and occasionally observes unlocked and performs education with staff. Based on observation, interview, and record review the facility failed to ensure proper storage of medication for one residents (R60) of 18 sampled residents and one medication cart of two medication carts reviewed for medication storage. Findings Included: Resident #60 (R60) Review of the medical record demonstrated R60 was admitted to the facility 03/11/2025 with diagnoses that included osteomyelitis (bone infection) of sacral and sacrococcygeal region, sepsis, methicillin resistant staphylococcus aureus…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00149511. Based on interview and record review, the facility failed to ensure a complete and accurate medical record for one (R333) of 18 reviewed. Findings include: Review of the medical record reflected R333 admitted to the facility on [DATE], with diagnoses that included heart failure, atrial fibrillation, rheumatic mitral stenosis, nonrheumatic aortic valve stenosis, presence of prosthetic heart valve and atherosclerotic heart disease. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R333 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was dependent for transfers. R333's admission Record, dated [DATE] at 11:38 AM, reflected they were female, however, R333 was male. R333's medical record reflected they had a Do-Not-Resuscitate (DNR/no Cardiopulmonary Resuscitation/CPR) order in place, dated [DATE]. A Progress Note for [DATE] at 11:36 AM reflected R333…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to maintain use of personal protective equipment during resident care for three residents (#45, #60, #70) out of 80 residents at the facility. Findings Included: Resident #45 (R45) Review of the medical record demonstrated R45 was admitted to the facility 5/6/2025 with diagnoses that included hyperkalemia (high potassium levels), hypermagnesemia (high magnesium levels), acute kidney failure, altered mental status, cytomegaloviral disease (herpes virus), history of kidney transplant, type 2 diabetes mellitus, polyneuropathy (general term for peripheral nervous system disorder), immunodeficiency (weakened or compromised immune system), low back pain, muscle wasting, hypoxemia (low oxygen levels), hypertension, hyperlipidemia (high fat content in blood), urinary retention, constipation, sleep apnea, anemia (low red blood cell count) gastro-esophageal reflux, gout (inflammatory arthritis caused from high amounts of uric acid), stage 4 kidney disease, and cognitive communication deficit. Review of the Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to install and maintain backflow protection devices and air gaps, resulting in the potential contamination of the facility potable water system, affecting all residents in the facility. Findings include: On 7/17/24 at approximately 9:50 AM, during an inspection of the kitchen, the drain lines of the three-compartment sink, were observed to not be provided with an air gap to prevent backflow of gas, liquid, and solid contaminants into the sink basins if a backflow event were to occur. Additionally, the vegetable and fruit preparation sink was observed to not be provided with an air gap in the drain line. At this time, Dietary Manager D confirmed the finding. On 7/17/24 at approximately 9:55 AM, the steamer at the cookline was observed to not be provided with a backflow protection device to protect the potable water supply. According to the 2017 FDA Food Code Section 5-203.14 Backflow Prevention Device, When Required. A PLUMBING SYSTEM shall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services per standards of practice, facility policy, and per physician's orders for one resident (Resident #575) of one resident reviewed for respiratory services. This deficient practice resulted in respiratory distresss, increased anxiety, missed doses of physician orders nebulizer treatments, and the potential to result in hypoxia [below-normal level of blood oxygen], and respiratory/medical decline with the potential to effect a total of five residents who had nebulizer treatments in the facility. Findings include: Review of the facility, Nebulizer (SVN) Policy, dated 7/11/18, reflected, It is the policy of this facility that Small Volume Nebulizer (SVN) treatments will be administered by licensed nurse and/or respiratory therapist, as ordered by a physician .Supplies: Oxygen delivery system or compressed air and connector tube-Nebulizer-Prescribed medication . Resident #575 (R575) Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to serve the appropriate food consistency for one (Resident 44) of three reviewed for therapeutic diets, resulting in the potential for aspiration and/or choking and continued weight loss. Findings include: Resident #44 (R44) Review of the admission Record reflected that Resident 44 (R44) was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficultly swallowing) and cerebral infarction (stroke). The quarterly Minimum Data Set (MDS) assessment, dated for 6/24/24, reflected that R44 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) (a cognitive screening tool). The MDS also reflected that R44 received a soft, bite sized texture for meals. During an observation and interview on 07/16/24 01:58 PM, R44 was resting in bed and had a family member visiting. R44 explained that she had been experiencing some weight loss. R44 stated that she had a difficult time chewing her food and that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00140043 and MI00139259. Based on observation, interview, and record review, the facility failed to provide meals as planned and posted, in 2 of 11 residents reviewed for dining services (Resident #1 and #4), potentially affecting a census of 77 residents that received meal trays, resulting in decreased quality of life. Findings include: During a lunch meal observation on 10/23/23 at 11:30 AM, a posting in the dining room indicated lunch was at 11:30 AM, at 11:47 AM no trays had been passed and no beverages were being offered or served, some residents were noted to have brought soda and water cups from their rooms. Resident #1 (R1) R1's Minimum Data Set (MDS) assessment dated [DATE] introduced a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 15 (13-15 Cognitively Intact). During an observation and interview on 10/23/23 at 12:50 PM, R1 stated meals were never ready at the scheduled times including the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00139259. Based on observation, interview and record review, the facility failed to provide meals at scheduled times, in 3 of 11 residents reviewed for dining services (Resident #1, #3, & #5), potentially affecting 77 residents receiving meals from the kitchen (1 resident received nothing by mouth) , resulting in decreased quality of life, and the potential for weight loss and depression. Findings include: Resident #1 (R1) R1's Minimum Data Set (MDS) assessment dated [DATE] introduced a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 15 (13-15 Cognitively Intact). During an observation and interview on 10/23/23 at 12:50 PM, R1 stated meals were never ready at the scheduled times including the day of interview. Resident #3 (R3) R3's Minimum Data Set (MDS) assessment dated [DATE] indicated she admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS), a short performance-based…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

This citation pertains to MI00139259. Based on observation, interview, and record review the facility failed to ensure proper label and dating of foods, documentation of food and beverage temperatures, and wearing of hair restraints with 77 residents receiving meals from the kitchen (1 resident receives nothing by mouth) resulting in increased the risk of contaminated foods and the risk of food borne illness. Findings include: During an initial tour of the kitchen on 10/23/2023 at 9:45 AM, the following was observed in the refrigerator: Creamed corn in a pan, dated 10/18/2023 with no use by date Opened package of hot dogs wrapped in saran wrap with no label and date Opened block of cheese with no label and date Opened block of ham with no label and date Opened Sausage with no label and date Opened Salad bag with no label and date Opened sliced meat wrapped in saran wrap, dated 10/5/2023 with no label of what it was and no use by date Hot dogs in shallow pan, covered with foil with no label or date 3 evening (HS) snacks dated from the previous night (10/22/2023) were sitting on a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to promote dignity during meals in 5 of 11 residents reviewed for dietary services (Resident #3, #4, #5, #9 & #10), resulting in decreased quality of life and an unhomelike dining experience. Findings include: During a lunch meal observation on 10/23/23 at 11:30 AM, a posting in the dining room indicated lunch was at 11:30 AM. At 11:47 AM no meals had been passed and no beverages were being offered or served in the dining room; some residents were noted to have brought soda and water cups from their rooms. Residents were served meals on cafeteria like trays, the first resident was served their lunch at 11:56 AM. Resident #3 (R3) R3's Minimum Data Set (MDS) assessment dated [DATE] indicated she admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 06 (00-07 Severely Cognitively Impaired). R3's Nutrition risk/risk for dehydration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00140043. Based on observation, interview and record review, the facility failed to honor food preferences in 5 of 11 residents reviewed for food preferences (Resident #1, #3, #4, #5, & #8), resulting in resident dissatisfaction and the potential for weight loss. Findings include: During a lunch meal observation on 10/23/23 at 11:30 AM, a posting in the dining room indicated lunch was at 11:30 AM, the menu was posted in small print for entire week in the dining room. Lunch on 10/23/23 included spaghetti with meat sauce, Italian Blend Vegetables, Apple Crisp, Garlic Bread stick and beverage. At 11:47 AM no trays had been passed and no beverages were being offered or served, some residents were noted to have brought soda and water cups from their rooms. Residents were served meals on cafeteria like trays, the first resident was served their lunch at 11:56 AM. Resident #1 (R1) R1's Minimum Data Set (MDS) assessment dated [DATE] introduced a Brief Interview for Mental Status…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide therapeutic diets as ordered in 2 of 11 residents reviewed for dietary services (Resident #8 & #11), resulting in risk of not meeting nutrition needs (Resident #11), and fluid overload (Resident #8). Findings include: Resident #8 (R8) R8's Minimum Data Set (MDS) assessment dated [DATE] revealed she admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 15 (13-15 Cognitively Intact). During an observation and interview on 10/24/23 at 7:40 AM, R8 was seated in her wheelchair and stated dining services have been a problem since she admitted to the facility in March 2023. R8 stated the food was always cold, she didn't receive what she ordered, dining times varied, and the always available menu was not always available. R8 stated she had diabetes, and she always received a regular diet. In review of R8's physician orders dated 9/25/23 a carbohydrate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 73 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 05/03/23 at 09:15 A.M., An initial tour of the food service was conducted with General Manager of Nutritional Services C and Registered Dietician (RD) D. The following items were noted: The Vulcan convection oven(s) interior and exterior surfaces were observed heavily soiled with accumulated and encrusted food residue. The Vulcan conventional oven(s) interior and exterior surfaces were observed soiled with accumulated and encrusted food residue. The Vulcan conventional stove top backsplash was observed heavily soiled with accumulated and encrusted food residue. The Vulcan griddle backsplash and side guards were observed heavily soiled with accumulated and encrusted food residue. General Manager of Nutritional Services indicated she would have dietary staff thoroughly clean and sanitize the convection and conventional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 73 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 05/04/23 at 08:45 A.M., A common area environmental tour was conducted with Director of Maintenance E and Environmental Services Director F. The following items were noted: Service Corridor Staff Break Room: The vinyl base coving was observed missing on 1 of 4 wall surfaces. The missing vinyl base coving measured approximately 16-feet-long. Director of Maintenance E indicated he would make necessary repairs as soon as possible. A-Hall Beauty Shop: Two 24-inch-long by 24-inch-wide acoustical ceiling tiles were observed stained from a previous moisture leak. B-Hall Soiled Utility Room: The two-door hand sink vanity base was observed etched, scored, bowed, and particulate. The vanity base lower shelf board was also observed severely warped and bent. Director of Maintenance E stated: We plan to replace the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to 1) ensure Do-Not-Resuscitate (DNR) documents were accurately and completely filled out for three (Resident #11, #28 and #42) of three reviewed; and 2) ensure updated and accurate letters of Guardianship were in the medical record for one (Resident #42) of one reviewed, resulting in the potential for code status wishes not being followed in an emergency situation and medical decisions not to be made by the legal Guardian of record. Findings include: Review of the MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT, Act 193 of 1996 reflected, .An order executed under this section shall be on a form described in section 4. The order shall be dated and executed voluntarily and signed by each of the following persons: (a) The declarant, the declarant's patient advocate, or another person who, at the time of the signing, is in the presence of the declarant and acting pursuant to the directions of the declarant. (b) The declarant's attending physician. (c) Two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to accurately complete Minimum Data Set (MDS) assessments for two (Resident #28 and Resident #29) of 18 reviewed, resulting in inaccurate assessments and the potential for unmet care needs. Findings include: Resident #29 (R29) Review of the medical record revealed R29 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer to the left heel, diabetes, and chronic kidney disease stage 3. Review of the MDS with an Assessment Reference Date (ARD) of 3/13/23 revealed R29 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), required extensive assistance of two people for bed mobility, was not on a turning/repositioning program, and had an unstageable pressure ulcer-suspected deep tissue injury present on admission. On 05/03/23 at 09:41 AM, R29 was observed sitting in a wheelchair in her room. Both feet were wrapped with kerlix and boots were in place. R29…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement comprehensive Care Plans for two (Resident #11 and #27) of 18 reviewed, resulting in the potential for unmet care needs and adverse events. Findings include: Resident #11 (R11): Review of the medical record reflected R11 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included cerebral infarction, flaccid hemiplegia affecting left non-dominant side and unspecified intellectual disabilities. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/24/23, reflected R11 scored nine out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R11 did not walk and required extensive assistance of one to two or more people for most activities of daily living. R11 was coded for fall with major injury. On 05/03/23 at 1:51 PM, R11 was observed in bed, with the head of the bed elevated and the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure 2 (Resident #13 and #34) out of 18 residents reviewed for care plans, had a comprehensive care plan that was revised for resident care needs, resulting in the potential for all care needs not being met. Findings Include: Resident #13 Review of an admission Record revealed Resident #13 (R13) admitted to the facility on [DATE] with pertinent diagnoses which included bilateral hearing loss, anxiety, osteoporosis, major depressive disorder, overactive bladder, delusional disorders, vascular dementia, and cognitive communication deficit. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/6/23, reflected R13 scored zero out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R13 did not walk and required extensive of two or more people for transferring and toileting. In an observation on 05/03/23 at 09:58 AM, R13 was observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to 1) follow their bowel management protocol for constipation; 2) ensure the accurate classification of a wound; 3) ensure comprehensive wound assessments were performed according to facility policy; and 4) ensure wound treatment and interventions were implemented timely and according to Physician recommendations for one (Resident #28) of 18 reviewed, resulting in constipation and the potential for delayed wound healing and/or worsening wounds. Findings include: Review of the medical record reflected R28 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included metabolic encephalopathy, adult failure to thrive, chronic kidney disease and diabetes. The Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/15/23, reflected R28 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R28…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure appropriate treatment and services for contracture management for one (Resident #27) of one reviewed, resulting in the potential for worsening contractures and pain. Findings include: Review of the medical record reflected R27 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cerebral vascular disease and diabetes. The Significant Change in Status MDS, with an ARD of 3/21/23, reflected R27 scored 15 out of 15 (cognitively intact) on the BIMS. The same MDS reflected R27 did not walk and required extensive to total assistance of two or more people for most activities of daily living. According to the MDS, R27 had upper and lower extremity impairment on one side that interfered with daily functions or placed her at risk for injury. R27 was not coded for receiving Restorative Nursing Programs for at least 15…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to justify rationale for clinically contraindicated gradual dose reductions (GDRs) of psychotropic medications for two (Resident #16 and #52) of five reviewed for unnecessary medications, resulting in the potential for unnecessary medications. Findings include: Resident #52 (R52): Review of the medical record reflected R52 admitted to the facility on [DATE], with diagnoses that included stage four chronic kidney disease, diabetes, anxiety disorder and major depressive disorder. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/4/23, reflected R52 scored 15 out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R52 was not coded for having behaviors and scored zero out of 27 on the PHQ-9 mood interview. On 05/03/23 at 2:10 PM, R52 was observed to sit herself up independently in bed. A bandage was observed on her left arm, which she reported was from dialysis that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent when two medication errors were observed from a total of twenty-seven opportunities for one resident (Resident # 374) of six reviewed for medication administration, resulting in a medication error rate of 7.41% and the potential for reduced efficacy of medications and increased risk of adverse reactions/side effects. Findings include: Review of the medical record revealed that Resident # 374 (R374) admitted to facility 4/20/23 with diagnoses including orthostatic hypotension, paroxysmal atrial fibrillation, essential hypertension, and type 2 diabetes mellitus. Active orders noted to include Insulin Glargine 30units daily and Metoprolol Succinate 25mg (milligrams), give 12.5mg daily, with a parameter to hold for blood pressure less than 100/60 or heart rate lower than 60. On 5/04/23 at 8:05 AM, Licensed Practical Nurse (LPN) GG was observed to prepare multiple oral medications and an insulin pen for administration to Resident #374 (R374). LPN GG entered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene practices during wound care for one (Resident #28) and proper catheter tubing placement for one (Resident #34) of 18 reviewed for infection control practices, resulting in the potential for cross contamination, the spread of infection and delayed wound healing. Findings Include: Resident #34 Review of an admission Record revealed Resident #34 (R34) admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnoses which included acute cystitis with hematuria, disorder of the muscle, bradycardia (slow heart rate), hearing loss, syncope, and dementia. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/29/23, reflected R34 scored nine out of 15 (moderately cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R34 required extensive of one person for toileting, transferring, and bed mobility. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to accurately track and document staff COVID-19 vaccination status and implement a process ensuring all staff were fully vaccinated for COVID-19, resulting in an inaccurate vaccination matrix, staff who were not vaccinated or partially vaccinated, and the potential for the transmission of COVID-19. Findings include: Review of the facility's Infection Control Manual: Chapter 10 Screening and Vaccinations revealed Both the annual influenza vaccine and the COVID-19 vaccines are mandatory for employees unless the individual has an approved medical contraindications or an approved religious exemption. Review of the COVID-19 Staff Vaccination Status for Providers provided by NHA A on 5/3/23 at 10:36 AM revealed the facility had 89 total staff of which 5 were partially vaccinated, 73 completely vaccinated, 0 pending exemptions, 8 granted exemptions, 9 were temporary delay/new hire, and 3 were not vaccinated without exemption/delay. Review of the COVID-19 Staff Vaccination Status for Providers provided by NHA A on 5/4/23 at 3:49 PM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.