Springcreek 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 ensure respiratory care, including tracheal suctioning was provided consistent with professional standard of practice for one Residents (#6) of three Residents reviewed for respiratory care. Findings Included:Resident #6 (R6)Review of the medical record revealed R6 was admitted [DATE] with diagnoses that include dysphagia (difficulty swallowing), cerebral infarction (stroke), tracheostomy (a surgical opening in the trachea), gastrostomy (a feeding tube inserted through the abdomen directly into the stomach to provide nutrition), chronic respiratory failure, pressure injury to right heel, anxiety, insomnia, abnormal posture, lack of coordination, language deficits, paralysis right side of body, type 2 diabetes, hypertension, gastro-esophageal reflux, and protein-calorie malnutrition. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/06/2023, revealed R6 had a Brief Interview of Mental Status (BIMS) 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 and interview the facility failed to remove all expired medications from two of four medication administration carts used to administer medications to residents with the potential to affect half of the facility census of 93. Findings Include During observation and interview on 03/25/2026 at 8:16 AM, writer asked to look through medication cart labeled Hall A. Writer found Allergy Relief 24 hr. 180mg tab expired 01/26. Naproxen Sodium 220mg tab expiration date has been removed, all white with no date.During observation and interview on 03/25/2026 at 8:36 AM, writer asked to look through medication cart labeled Hall B. Writer found Cetirizine HCI 10 mg tab- Expiration date had been removed, wiped off, plain white area where expiration date was.During observation and interview on 03/25/2026 at 10:45 AM, writer asked to look through the medication room at the nurses' station. No outdated medications found, refrigerators and freezer temperatures were present and within normal range.During an interview on 03/26/2026 at10:29 AM, DON B stated it would be the expectation…

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 the published menu was served as planned to six residents and residents were consistently informed in advance of any menu changes affecting all residents consuming food from the kitchen resulting in resident dissatisfaction with their meal experience and feelings of frustration related to meals voiced in confidential resident group the the potential to effect all 93 residents. Findings include:During an observation and interview on 3/24/2026 at 9:19 AM, tour of kitchen with Kitchen Manager (KM) Y. Menus were reviewed and KM Y reported residents had option related to menus and reported if residents did not prefer main dish they had option for alternative option and also had options for always available items. During an observation, interview and record review on 3/25/2026 at 11:15am, this surveyor observed tray line services. KM Y and cook verified posted menu that included roast beef, potatoes, butter carrots, roll, and beverages. Observed several resident meal tickets with request for grilled cheese…

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 palatable and appetizing food was served to two (Resident #2 and Resident #49) of 2 residents reviewed for receiving palatable and appetizing food, resulting in potential for decreased oral intake.Findings include:During an observation on 3/25/2026 7:21 AM, this surveyor observed a full uninsulated tray cart located on Hall C (secure memory unit) with no staff delivering trays at that time. Two nurses were observed at medication cart and several residents were observed wandering the hall and six residents were sitting at the dining room table at the end of the hall with no staff in the dark. Continued observation on 3/25/2026 at 8:08 AM, Certified Nurse Aid (CNA) LL entered R2 room with breakfast tray. (about 45 min after arrival of tray) Continued to observe and at 8:15 AM R49 was served first bite of breakfast with staff assist. (almost one hour after tray delivered). Observed 11 residents in secure memory dining room with 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.

Based on observation, interview, and record review the facility Arbitration Agreement failed to explicitly state that neither the resident nor his or her representative was required to sign an agreement for binding arbitration as a condition of admission, or as a requirement to continue to receive care at the facility and state that the binding arbitration agreement allows the resident or anyone else to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health departement employees and representatives of the Office of the State Long Term Care Ombudsman for one resident (#73) of three Resident reviewed for Arbitration Agreements. Findings Included:Resident #73 (R73) Review of the medical record revealed R73 was admitted to the facility 02/01/2023 with diagnoses that include atherosclerotic heart disease (plaque build-up in artery walls), polyneuropathy (wide spread peripheral nerve damage), insomnia, contracture (long lasting tightening of muscle) of left elbow, lack of coordination, muscle weakness, dementia, abnormal…

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 Arbitration Agreement failed to explicitly state that the agreement provided for the selection of a neutral arbitrator agreed upon by both parties for one resident (#73) of three Resident reviewed for Arbitration Agreements. Findings Included:Resident #73 (R73)Review of the medical record revealed R73 was admitted to the facility 02/01/2023 with diagnoses that include atherosclerotic heart disease (plaque build-up in artery walls), polyneuropathy (wide spread peripheral nerve damage), insomnia, contracture (long lasting tightening of muscle) of left elbow, lack of coordination, muscle weakness, dementia, abnormal posture, chronic obstructive pulmonary disease (COPD), dysphagia (difficulty swallowing), hypertension, cognitive communication deficit, alcohol abuse, gastro-esophageal reflux, and chronic hepatitis (inflammation of the liver). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/13/2026, revealed R73 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out…

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 coordination of care for hospice services for one resident (R7) of one reviewed for additional services above and beyond the facilities provides.Findings IncludeResident #7 (R7)Review of the medical record reflected that R7 was admitted to the facility on [DATE] and signed onto hospice 02/12/2026.Diagnoses of Huntington's disease, dementia, other disorders of the muscles, emotional deficit related to cerebrovascular disease, protein-caloric malnutrition, weakness and repeated falls.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/26/2025 revealed R7 had a Brief Interview of Mental Status (BIMS) of 10 (moderate cognitive impairment) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance revealed R7 was dependent on toileting, showering, lower body, sit to stand and transferring from one surface to another with a mechanical device.Record review revealed R7 was admitted on…

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 that appropriate hand hygiene was conducted during dressing changes for two residents (#63, #88) and during medication administration observation with the potential to affect facility census of 93. Findings included:During an observation on 03/25/2026 at 8:04 AM, LPN OO was preparing medications for R57, writer did not see LPN OO perform hand hygiene prior to getting in the medication cart. LPN OO did not perform hand hygiene before going into the R57's room nor after administering R57's medication. No hand hygiene in R57's room or prior to returning back to the medication cart. During an interview with Infection Preventionist D stated she would expect the nurses to use hand hygiene between each resident. She did education on hygiene as well as an annual skills fair. During an interview on 03/26/2026 at10:29 AM, DON B stated it would be the expectation that all nurses use hand hygiene between residents and after administration of…

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 implement the Comprehensive Care Plan for one (R6) of three reviewed.Findings include:Review of the medical record reflected R6 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included fracture of unspecified part of neck of left femur (6/8/25), seizures, difficulty walking, diabetes, dementia and impulse disorder. The modification of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/11/25, reflected R6 scored six out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had two or more falls since admission or the prior assessment. On 12/30/25 at 12:57 PM, R6 was observed up in their wheelchair, in a common area, with shoes on both feet. Anti-rollback brakes, rear anti-tip bars and a drop seat (seat tilted back) were observed on R6's wheelchair. R6's bed height was observed to be in a low position, with a standard…

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 2697023.Based on interview and record review, the facility failed to 1) ensure the accuracy of medication orders for one (R4); and 2) administer medication according to Physician Orders for one (R4) of three reviewed.Findings include:Review of the medical record reflected R4 admitted to the facility on [DATE], with diagnoses that included rheumatoid arthritis, pain, diabetes, atrial fibrillation and fibromyalgia. The Medicare 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/15/25, reflected R4 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). According to the medical record, R4 discharged from the facility on 12/15/25. R4's December 2025 Medication Administration Record (MAR) reflected Alendronate Sodium 70 milligrams (mg) by mouth, once daily, every Sunday, for Osteoporosis was due to be administered on 12/14/25 at 6:00 AM. The medication was not documented as administered. Progress…

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 prevent the development of a pressure ulcers for two resident (#2, #8) of three residents reviewed for the development of pressure ulcers. Findings Included: Resident #2 (R2) Review of the medical record revealed R2 was admitted to the facility 11/21/2024 with diagnoses that included acute kidney failure, Alzheimer's disease, lack of coordination, difficulty walking, Peripheral Vascular Disease (PVD), stage 3 kidney disease, cognitive communication deficit, abnormal posture, protein-calorie malnutrition, congestive heart failure (CHF), insomnia, obesity, anxiety, depression, type 2 diabetes, hypertension, hyperlipidemia (high fat content in blood), atrial fibrillation, and arthropathy (any disease of the joints). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/02/2025 demonstrated R2 had a Brief Interview for Mental Status (BIMS) of 08 (moderate cognitive impairment). During observation and interview on 05/28/2025 at 07:28 a.m. R2 was observed sitting up in her wheelchair…

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 revise the Care Plan for one (Resident #33) of 18 reviewed. Findings include: Review of the medical record reflected Resident #33 (R33) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included unspecified dementia, Alzheimer's Disease with early onset, major depressive disorder and anxiety disorder. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/8/24, reflected R33 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 12/19/24 at 11:22 AM, R33 was observed seated at a dining table, drinking a beverage. On 12/19/24 at 2:52 PM, R33 was observed lying in bed, with their eyes closed. Snacks and a beverage were observed on the over-bed table. A Psychiatric visit note for 10/16/24 reflected R33 had dementia with violent behaviors, which was not related to their terminal hospice diagnosis. According 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure nephrostomy tube care was ordered and completed for one (Resident #47) of one residents reviewed for nephrostomy care. Findings include: Resident #47 (R47) Review of the medical record revealed Resident #47 (R47) was admitted to the facility on [DATE] with diagnoses that included tubulointerstitial nephritis (inflammation of the tubules of the kidneys), hydronephrosis with renal and ureteral calculus obstruction (kidney and ureter obstruction due to stones), and obstructive and reflux uropathy (urine unable to flow due to obstruction). R47 was unable to participate in an interview due to an intellectual disability. On 12/17/24 at 12:09 PM, R47 was observed in bed, peering around the room. R47 was not conversant. A nephrostomy bag was observed on the left side of R47, laying flat on the mattress at the left elbow level of R47. Urine was observed in the bag and in the entire length of the nephrostomy bag tubing. 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.

Based on observation, interview and record review the facility failed to initiate intervention for the prevention of repeated falls at bedside for 1 resident (R38) of 3 residents reviewed for falls resulting in the potential for repeated falls at bedside. On 12/17/24 at 3:53 PM during observation and interview R38 pointed at her eye which appeared bruised extending around the entire eye. R38 responded, uh huh when asked if she had fallen. R38 was quite busy in her room, moving place to place independently in the wheelchair. A nurse on the unit said that R38 had recently fallen twice in one day. Review of the electronic medical record (EMR) revealed that R38's original admission date was 3/27/23 and recent admission date was 4/15/23. R38 had the following pertinent diagnoses: Dementia (a neurological condition affecting the brain which can cause loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Aphasia (a language disorder affecting the ability to communicate), Transient Ischemic Attack and Cerebral Infarction…

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 water was available for 1 resident (R24) of 1 resident reviewed for hydration resulting in the potential for inadequate fluid intake. Findings Include: On 12/17/24 at 1:33 PM during observation and interview R24 was upright in bed and established strong eye contact and was able to participate in an interview. It was noted during observation that R24's water cup was on a bedside table positioned to the left side of the bed and up against the wall. This positioned the table and water to the left and behind her head and out of sight and reach. There was also a rolling type of bedside table near the bed, and within resident's reach, but no water cup on it. When asked if R24 enjoyed drinking water her response was, I love it. On 12/17/24 at 4:42 PM during observation and interview R24 smiled and said a few words. Her words were muffled as she spoke through a dry mouth. It was noted during observation that the water was in the same place…

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 communication with the dialysis center, pertaining to a fluid restriction, for one (Resident #42) of one reviewed. Findings include: Review of the medical record reflected Resident #42 (R42) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included dependence on renal dialysis. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/4/24, reflected R42 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 12/18/24 at 2:51 PM, R42 was observed in bed and reported having had a dialysis treatment that day. R42 was observed to be drinking from a bottle of Coca Cola. On 12/20/24 at 11:55 AM, R42 was observed asleep, in bed. A 20 ounce bottle of Sprite and a 16 ounce styrofoam beverage cup, with a straw, were observed on R42's over-bed table. Review of R42's medical record reflected a fluid restriction of…

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 1) failed to ensure justification for an increase in psychotropic medications and 2) failed to attempt nonpharmacological interventions for two (Resident #9, Resident #33) of five reviewed for unnecessary medications. Findings include: Resident #9 (R9) Review of the medical record revealed Resident #9 (R9) was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included vascular dementia, bipolar disorder, and depression. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/29/24, reflected R9 scored four out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 12/17/24 at 2:21 PM, R9 was observed in his room watching television. Review of a Psychiatric Visit note dated 5/13/24 recommended a gradual dose reduction (GDR) of R9's Trazodone. The GDR recommendation was to reduce R9's Trazodone 150 milligrams (mg) 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.

Based on observation, interview and record review, the facility failed to, 1) ensure appropriate storage of medications, including narcotics; and 2) ensure one medication cart was free of expired medications. Findings include: On 12/18/24 at 1:36 PM, several medications were observed at the nurse's station unattended and readily accessible to staff, ambulatory resident's, and visitors. The medications included fentanyl Transdermal Patch (opioid medication), Bumetanide (water pill) Oral Tablet 2 milligrams (MG), Sinemet (Parkinson medication) Oral Tablet 25-100 MG, Carvedilol (used to treat high blood pressure) Oral Tablet 25 MG, Gabapentin (treatment for nerve pain and/or seizures) Oral Capsule 100 MG, Potassium Chloride Oral Tablet Extended Release, Spironolactone (treatment of high blood pressure/water pill) Oral Tablet 25 MG, Levothyroxine (thyroid hormone) Sodium Oral Tablet, and Omeprazole (treatment of acid reflux) Oral Tablet Delayed Release 20 MG. On 12/18/24 at 1:45 PM, Nursing Home Administrator A identified the unattended medication and removed the medication from 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 coordinate hospice services for one resident (#56) out of one resident reviewed for coordination of hospice services. Findings Included: Resident #56 (R56) Review of the medical record revealed Resident #56 (R56) was admitted to the facility on [DATE] with diagnoses that included senile degeneration of brain. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/1/24, reflected R56 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS revealed that R56 was utilizing hospice services. On 12/18/24 at 12:23 PM, R56's Hospice Communication binder was reviewed. R56's Hospice Care Plan was not located in the binder. On 12/18/24 at 1:14 PM, the electronic medical record was reviewed which revealed a hospice care plan dated October 2023. No current care plan could be located. On 12/20/24 10:17 AM, Director of Nursing (DON) B was asked 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: (1) effectively date mark all potentially hazardous ready-to-eat food products, (2) effectively don hair and beard restraints, (3) effectively clean and maintain food service equipment, and (4) monitor food for safe temperatures prior to serving and maintain temperature logs effecting 74 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness. Findings include: During a kitchen observation on 10/11/23 at 8:35 AM, vegetable soup was observed in a refrigerator in a 4-liter container dated 10/09/23. Dietary Manager (DM) F was interviewed at the same date and time and stated the vegetable soup was homemade and did not have cooling temperatures from 10/09/23 or any other cooling log records. DM F stated he didn't know if the soup was placed in the refrigerator in the same container or after cooling in shallow pans. On the right side, on the bottom of the same refrigerator,…

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 maintain a safe, clean, and comfortable bathroom for one of 19 sampled residents (Resident #42), resulting in an environment in disrepair. Findings include: Resident #42 (R42) On 10/09/23 at 10:35 AM R42 was observed sleeping in bed. R42's sink bowl was observed pitted and stained. R42 shared a bathroom with two other residents; peeling paint and several cobwebs were observed on the walls and flaked paint was noted on the floor, to the right of the toilet. R42'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 for nursing home residents, score of 03 (00-07 Severe Cognitive Impairment); and required extensive assistance in toileting. The same MDS assessment revealed R42 had the diagnoses of Dementia, Diabetes Mellitus, Aphasia (unable to comprehend or formulate language), and a seizure disorder. On…

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. Dispose of expired eye drops; 2. ensure medications/treatment carts remained secured in 1 of 2 medication/treatment carts reviewed, resulting in the potential for medications given to residents to have decreased potency, reduced strength, effect, and medication errors. Findings include: During an observation on [DATE] at 11:00 AM, Hall C medication cart was observed unlocked in hall with no staff in area. At 11:10 AM, staff passed unlocked cart and nurse returned to Hall C medication cart at 11:11 AM and locked cart. During an observation on [DATE] at 11:52 AM, Hall B medication cart was observed unlocked in the hall with no staff observed in area. Nurse returned to the medication cart at 11:56 AM and locked the cart. During an observation and interview on [DATE] at 12:09 PM Licensed Practical Nurse (LPN) T unlocked Hall A odd medication cart. Review of the medication cart revealed an open bottle of latanopost 0.005%, eye drops dated…

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 updated and accurate advance directive information was in place for three residents (Resident #8, #18 and #52) of four reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers. Findings Include: Review of the MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT, Act 193 of 1996 revealed that, 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 witnesses [AGE] years of age…

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 care plans, for one of 19 residents reviewed for care plans (Resident #42), resulting in the potential for falls, pressure ulcers, and unmet needs. Findings include: Resident #42 (R42) R42'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 for nursing home residents, score of 03 (00-07 Severe Cognitive Impairment); and required extensive assistance in toileting. The same MDS assessment revealed R42 had the diagnoses of Dementia, Diabetes Mellitus, Aphasia (unable to comprehend or formulate language), and seizure disorder. On 10/09/23 at 10:35 AM R42 was observed lying in bed sleeping, lower legs were observed with edema (swelling). In review of R42's care plans, there were no goals or interventions to address R42's edema. In review of R42's risk for falls care plan dated 3/23/23;…

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 follow physician ordered parameters upon administration of blood pressure medications for 1 resident (Resident #37) of 5 reviewed for unnecessary medications, resulting in the potential for adverse drug consequences. Findings include: Review of the medical record reflected that Resident #37 (R37) was readmitted to facility 6/28/2023 with diagnoses including congestive heart failure, essential hypertension, myocardial infarction, and atrial fibrillation. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/25/23 reflected that R37 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Section G of the same MDS reflected that R37 required supervision for bed mobility, transfers, eating, and toilet use. In an observation and interview on 10/9/23 at 10:50 AM, R37 was observed sitting at edge of bed, dressed in black shirt and pants, with oxygen in place at 4 liters per minute via nasal cannula. R37 stated that he had been hospitalized a few months back as was…

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 less than five percent when 3 medication errors were observed from a total of 39 opportunities for one resident (R1) of nine residents observed during medication administration, resulting in a medication error rate of 7.69%. Findings include: During an observation on 10/11/23 at 7:49 AM, Licensed Practical Nurse(LPN) S prepared R1 medications at the C hall Medication cart located outside R1 room. LPN S prepared several oral medication and three respiratory medications that included Spiriva 18 mcg, Breyna(Symbicort) 160-4.5 mcg/act and Albuterol 108mcg/act. LPN S entered R1 room and administered R1 oral medications and instructed R1 to use respiratory medication Spiriva first. R1 inhaled twice and rinsed mouth. LPN S handed R1 the Breyna inhaler after attaching it to spacer. R1 was observed administering two puffs back to back with no time between puffs. LPN S did not provide guidance to R1 related to deep breathing, holding inhalation or waiting to administer second puff. LPN S…

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 food preferences were honored for 1 resident (Resident #30) of 3 reviewed for food preferences and for 9 of 9 residents in the confidential group, resulting in meal dissatisfaction and frustration when food choices were not honored and disliked foods continued to be served on meal trays. Resident #30 Review of the medical record reflected that Resident #30 (R30) was readmitted to facility 6/19/2023 with diagnoses including obesity, gastro-esophageal reflux disease, and diabetes mellitus. Review of the Minimum Data Set with an Assessment Reference Date (ARD) of 9/16/23 reflected that R30 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Section G of the same MDS reflected that R30 required two-person extensive assist with bed mobility, two-person dependent assist for transfers and toilet use, and supervision after set up for eating. In an observation and interview on 10/09/23 at 9:58 AM, R30 was observed lying in bed, on back, dressed in a long sleeve black shirt. R30 was…

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.