Optalis Health and Rehabilitation of Allen Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate coordination of care between the facility and the contracted dialysis center for one resident (R15) out of one resident reviewed for dialysis services, resulting in the potential for resident to experience fluid overload. Findings include: On 6/2/25 at 1:03 PM, R15 was observed asleep in bed. A 20 oz. sized cup was observed on R15's overbed table. On 6/3/25 at 10:55 AM, R15 was observed awake in bed. A 20 oz. sized cup was observed on R15's overbed table. R15 was able to reach and shake the cup which appeared to be half full. R15 said that she enjoys drinking water. On 6/4/25 at 10:31 AM, an observation of R15 was conducted with Registered Dietitian (RD) F. R15 was observed awake in bed. RD F indicated R15 had a 20 oz. cup on the overbed table. R15 was able to reach and shake the cup which appeared to be full of ice. A review of the clinical record for R15 documented an admission date of 1/27/25 with diagnoses 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 Based observation, interview and record review the facility failed to ensure prescription medication was properly stored for one resident (R21) of 27 residents reviewed for medication administration, resulting in unsecured medication and the potential for access to unauthorized persons to the medication. Findings include: On 6/3/2025 at 8:40 a.m. during a morning medication administration (Med Pass) on the Mackinaw unit with Licensed Practical Nurse (LPN) M a cup with two pills was observed on R21's bedside table. LPN M was interviewed regarding the medication at bedside. LPN M stated, I have no idea who put the pills on the resident's table near her breakfast tray. I just pulled my medications. LPN M verified the two pills as (Faxiga and Levothyroxine) and the R21 does not self-administer medication. LPN M stated, This was 6 a.m. scheduled meds and medication should not be left at bedside. On 6/3/2025 at 8:50 a.m. R21 was interviewed regarding the medications left at bedside. R21 stated, I don't know who sat…

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 dental services were provided in a timely manner for one resident (R19) out of three residents reviewed for dental services. Findings include: On 6/2/25 at 10:44 AM, R19 was observed with crooked and uneven teeth. An interview was conducted with R19, the resident reported having broken teeth. R19 reported past dentist appointments, but had not heard anything else since last appointment. R19 stated, I have been waiting a long time to get dentures. Review of electronic medical record (EMR) revealed resident was admitted into the facility on 3/6/23 with a diagnosis of Parkinson's Disease (disorder that affects central nervous system). According the R19's Brief interview for Mental Status (BIMS) dated 3/12/25, R19 scored 14 out of 15 (intact cognition). Further review revealed resident required substantial/Maximal assistance with Activities of Daily Living (ADLs). Record review of Dentist Consultation dated 6/17/24 revealed R19 had a referral to have all teeth extracted. Further review of electronic medical…

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 complete and accurate medical records for one resident (R45) out of 27 sampled residents resulting in unmet resident care. Findings include: On 6/03/25 at 2:45 PM, R69 was observed in bed and stated, The staff are not changing my tube feed dressing. The tube feed dressing was observed with a date of 5/24/25. On 6/03/25 at 2:55 PM, R69's tube feed dressing was observed with Licensed Practical Nurse/Unit Manager LPN C. LPN C said the dressing was dated 5/24/25 and explained that was the date that the dressing was last changed. LPN C said the dressing should be changed daily on the night shift and there is a risk for infection if the site is not kept clean. On 6/04/25 at 8:57 AM, R69's May and June of 2025 Medication Administration Record (MAR) and Treatment Administration Records (TAR) were reviewed with LPN C. LPN C said R69's MAR/TAR was incorrect from 5/25/25 to 6/2/25 since the wound care and bandage change last occurred 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 This citation pertains to intake MI00149552. Based on interview and record review the facility failed to prevent verbal abuse for one resident (R3) of three residents reviewed for abuse, resulting in staff to resident verbal abuse. Findings include: Review of the Clinical Record revealed resident (R3) was re-admitted to the facility on [DATE] with pertinent diagnoses of chronic respiratory failure, malignant neoplasm of the left breast, quadriplegia, hypertensive heart disease with heart failure, type 2 diabetes mellitus with diabetic, chronic kidney disease, major depressive disorder, morbid (severe) obesity, anxiety disorder, polyneuropathy (peripheral nerve disorder). Review of the Minimum Data Set (MDS) assessment with a reference date of 2/5/2025 revealed, R3 had a BIMS (Brief interview for mental status) score of 15/15, which indicated R3 was cognitively intact. Further review of the MDS indicated R3 was incontinent of bowel and bladder and was dependent on staff for toileting, hygiene and transfers.…

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 MI00145468. Based on observation, interview, and record review, the facility failed to provide a proper bed frame extender for one (R405) of five residents reviewed for falls resulting in R405 rolling out of bed during patient care. Findings include: On 7/16/24 at 12:35 PM, R405 was observed in her room, lying in a 42-inch bed watching TV. R405 was asked about her fall out of bed and replied, I fell out of bed last month. I was getting help from a CNA (certified nursing assistant) to get cleaned up and I rolled towards the door, and right out of bed. The mattress slipped right off the bed. I have chronic back pain, but the fall didn't make it worse, I didn't get injured. The bed should have had a bed frame extender on it, but it didn't. After the fall maintenance came in and put on the bed extender. R405 then pointed to the bed extenders and stated, I haven't had any problems with the bed since then. Record review of electronic medical records revealed R405 was admitted into 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 that a proper sanitizing product was used to kill Clostridium difficile (C. diff - a bacteria that can cause diarrhea) resulting in the potential spread in infection and disease, potentially affecting all residents who resided in the facility. Findings include: On 6/25/24 at 9:50 AM, Licensed Practical Nurse (LPN) I indicated the resident in room [ROOM NUMBER] was on transmission-based precautions because of a C. diff. infection. On 6/26/24 at 11:08 AM, signage outside of room [ROOM NUMBER] documented that staff were to used transmission-based precautions upon entering and exiting the room. On 6/26/24 at 11:16 AM, Housekeeper F was observed entering room [ROOM NUMBER] without donning PPE (personal protection equipment) with the exception of gloves. Housekeeper F mopped the floor in room [ROOM NUMBER]. Upon exiting the room, Housekeeper F took the gloves off, removed the mop bottom, and put it in a bag. Housekeeper F then used hand…

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 ensure proper completion of Advanced Directive information was in place for one (R8) of 19 residents reviewed for Advanced 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 an Electronic Health Record (EHR) revealed, R8 had a code status of Do Not Resuscitate/No code (DNR). R8's Do-Not-Resuscitate (DNR) Order was signed by the guardian on 6/15/23. The document was signed by the Physician on 6/26/23 and two witnesses on 6/28/23. Review of an admission Record revealed, R38 admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included dementia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R8 had mild cognitive impairment with a Brief interview for Mental Status (BIMS) score…

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 complete an annual OBRA (Omnibus Budget Reconciliation Act) Level II Evaluation for one (R3) of seven residents reviewed for PASARRs (Preadmission Screen and Resident Review), resulting in the potential for unmet mental health services. Findings include: Review of the clinical record revealed Resident #3 (R3) was initially admitted into the facility on 8/19/11 and readmitted on [DATE]. R3's diagnoses included adjustment disorder with mixed anxiety and depressed mood, unspecified dementia, bipolar disorder, and major depressive disorder. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment. The date of R3's most current Level II PASARR was 3/21/23. On 6/26/24 at 2:30 PM, a review of R3's most recent Level II PASARR, dated 2/20/23, was conducted with Social Worker (SW) K. SW K stated the local community mental health services modified the document on 3/21/23, and that we need to submit a new Level II. It was due 3/21/24. 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) provide wound care according to treatment orders for one (R49) of six residents reviewed for skin conditions, resulting in unmet skin treatment needs, 2) failed to follow-up on pharmacist recommendations in a timely manner, 3) consistently hold antihypertensive medication per physician's order, and 4) consistently check blood pressure prior to administration of antihypertensive medication for two (R104, R1) of 23 residents reviewed for quality of care resulting in unmet care needs. Findings include: R49 On [DATE] at 12:24 pm R49 was observed in bed with a bandage on his left forearm dated [DATE] and a bandage on his right hand dated [DATE]. When R49 was asked what happened to your arms R49 reported I fell and tore up my hand and arm. On [DATE] at 9:09 am R49's left forearm and right-hand bandages were observed with dates of [DATE]. On [DATE] at 9:19 am Licensed Practical Nurse (LPN) V was interviewed and said R49's bandages and wound…

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 consistently implement interventions to prevent the development of pressure wounds for one resident (R19) out of seven residents reviewed for pressure ulcers, resulting in the potential for the development of pressure wounds. Findings include: During an interview on 6/25/24 at 10:03 AM, Licensed Practical Nurse (LPN) O was identified as the wound care nurse. LPN O said Resident #19 (R19) had a facility acquired pressure ulcer on their left lateral leg. On 6/25/24 at 1:45 PM, Resident #19 (R19) was observed lying in bed. The heel of R19's left foot was lying directly on the sheeted mattress. R19 offered minimal response when greeted. On 6/28/24 at 10:38 AM, during an observation, interview, and record review with Licensed Practical Nurse (LPN) U, R19's left heel was resting directly on the bed. Only one heel lift boot was located in R19's room. LPN U said R19 does not like to wear the boots. A review conducted with LPN U of R19's Treatment…

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 obtain weekly weights and perform timely nutrition reviews for two residents (R1 and R19) who were determined to be at high nutritional risk, resulting in the potential for compromise in nutrition status to go undetected. Findings include: Resident #1 - Review of the clinical record for Resident #1 (R1) documented an initial admission into the facility on 1/9/24 and readmission on [DATE]. R1's diagnoses included moderate protein-calorie malnutrition (PCM), type 2-diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), irritable bowel syndrome (IBS) without diarrhea, end state renal disease, and heart failure. A Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition. Nutritional evaluation for R1 dated 5/28/24 documented in part the following: - Resident has a fluctuating weight history due to extreme swelling upon admission in February, was discharged and had fluid removed, currently in house 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 Based on observation, interview, and record review the facility failed to administer medications accurately for one resident (R38) out of three residents during medication pass, resulting in a medication error rate of 7.41%. Findings include: In an observation on 6/26/24 at 9:45 a.m., Licensed Practical Nurse (LPN) E prepared medications for R38. Medications included Flonase (nasal spray) and Symbicort (inhaler). In an observation on 6/26/24 at approximately 9:47 a.m., LPN E entered R38's room and performed hand hygiene. LPN E administered two sprays of Flonase in each of R38's nostrils and gave the inhaler. R38 requested to receive a PRN (as needed) breathing treatment. LPN E then exited the room and documented the medication administration. In an interview on 6/26/24 at 9:49 a.m., LPN E reported R38 administer the breathing treatment and has a PRN order is being requested. In an observation on 6/26/24 at 9:50 a.m., R38 began the breathing treatment with Albuterol. Review of an admission Record revealed, R38…

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 ensure two residents (R37 and R60) out of five residents reviewed for immunizations, were provided influenza and/or pneumococcal vaccination and education resulting in the potential for the development and spread of influenza and pneumonia among vulnerable residents in the facility. Findings include: On 6/28/2024 at 10:04 AM the Infection Preventionist (IP) G was interviewed and reported the following residents did not have documentation of a current influenza and/or pneumococcal immunization or refusal: -Review of the Electronic Health Record (EHR) for R37 admitted on [DATE] with diagnosis of Multiple Sclerosis and Parkinson's Disease. R37 did not have documentation to indicate that the influenza and/or pneumococcal vaccines were offered or was contraindicated. -Review of the EHR for R60 revealed admitted on [DATE] with a diagnosis of Heart Failure. R60 did not have documentation to indicate that the influenza and/or pneumococcal vaccines were offered…

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 ensure one resident (R37) out of five residents reviewed for immunizations, were provided a Covid 19 vaccination and education resulting in the potential for the development and spread of Covid 19 among vulnerable residents in the facility. Findings include: On 6/28/2024 at 10:04 AM the Infection Preventionist (IP) G was interviewed and reported the following resident did not have documentation of a current Covid 19 immunization or refusal: -Review of the Electronic Health Record (EHR) for R37 admitted on [DATE] with diagnosis of Multiple Sclerosis and Parkinson's Disease. R37 did not have documentation to indicate that the Covid 19 vaccine was offered or was contraindicated. On 7/2/2024 at 9:07 AM the Director of Nursing (DON) was interviewed and agreed R37 should have been educated and offered the Covid 19 vaccine. Review of the facility policy titled Infection control Program revised 3/1/22 revealed in part . Residents will be offered the Covid 19…

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 MI00144351. Based on observation, interview, and record review, the facility failed to provide adequate supervision during delivery of care for one (R803) of three residents reviewed for falls resulting in R803 rolling out of bed and sustaining a skin tear to her left knee area. Findings include: The State Agency received a complaint that R803 rolled out of bed during a bed bath because only one staff member was present and there should have been two. On 5/8/24 at 11:30 AM, R803 was observed in her room, lying in bed watching TV. R803 was asked about her fall out of bed and replied, Yes, I was getting a bath, and the CNA (certified nursing assistant) told me to roll over towards the wall. I help with my good hand, and I rolled right out of bed. No one was on the other side. I should have two CNAs. R803 said x-rays were done and no fractures were seen. R803 said there was a skin tear on her left knee after the fall, but no other injuries. According to the Electronic Health Record…

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 intakes numbers MI00143609 and MI00143610. Based on observation, interview and record review, the facility failed to provide timely incontinence care for one resident (R102) of three residents reviewed for Activities of Daily Living (ADL). Findings include: Review of an admission Record revealed, R102 admitted to the facility on [DATE] with pertinent diagnoses which included Dementia and Hemiplegia and Hemiparesis affecting left non-dominant side (weakness on one side of the body). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R102 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 13, out of a total possible score of 15. In an observation and interview on 4/11/24 at 9:13 a.m., R102 laid in bed and wore a gown. R102 reported having a wet brief and not being changed since midnight. R102 then reported being told staff should do rounds every two hours to assist residents that needed their briefs changed. In an observation on 4/11/24…

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 MI00143287 Based on observation, interview and record review, the facility failed to implement a comprehensive, person-centered care plan regarding vision impairment and chronic urinary tract infection for one resident (R202) of five residents reviewed, resulting in the potential for unmet care needs and the potential for injury. Findings include: On 3/19/24 at 10:20 PM R202 was observed sitting upright in bed. R202 was interviewed and described ongoing problems with a burning sensation within the bladder. R202 said there have been many falls and further explained the staff have instructed resident to await help. I can't wait that long. R202 was queried about vision and responded by putting on a pair of glasses explaining they are new having gotten them about a month ago. R202 explained prior to that she did not have glasses. With the new glasses resident said vision has improved. Record review revealed that R202 was admitted into the facility on 7/26/23 with diagnoses 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 Based on interview and record review, the facility failed to obtain a physician's order in a timely manner for one resident (R201) of three residents reviewed for an ostomy, resulting in unmet care needs. Findings include: According to the electronic medical record, R201 was initially admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis, ileostomy status (part of the small bowel, is brought through the abdominal wall via a surgically-created opening called a stoma, to evacuate stool from the body), and enterostomy malfunction (The frequent complications associated with enterostomy formation are prolapse, retraction, stenosis or necrosis of the stoma, parastomal hernia and breakdown of the skin). R201's admission Minimum Data Set (MDS) with a reference date of 2/21/24 indicated R201 had severe cognition impairment with a BIMS (brief interview for mental status) score of 0/15. Review of the medical record on 3/19/24 at 10:31 a.m. revealed, R201's Activity Daily Living (ADL) care plan…

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 MI00140803. Based on interview and record review, the facility failed to follow standards of practice in the administration of medication for one resident (R112) out of four residents reviewed for medication administration resulting in the application of a nicotine patch without adequate indication for use. Findings include: Complainant states the resident was given a nicotine patch without consent. A review of the admission Record for Resident #112 (R112) documented an initial admission date of 3/30/23 and readmission date of 4/27/23. R112's diagnoses included moderate protein-calorie malnutrition, obstructive and reflux uropathy, unspecified dementia, and type 2 diabetes mellitus. A quarterly MDS assessment dated [DATE] documented moderate cognitive impairment. The initial MDS assessment dated [DATE] documented no current tobacco use. A review of R112's care plans revealed no identified concerns related to smoking or smoking cessation. A review of physician orders for R112 documented…

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 catheter tubing was properly anchored/secured for an indwelling urinary catheter for one resident (R113) out of three residents reviewed for urinary catheters, resulting in the potential for discomfort due to excessive tension and pulling. Findings include: During an observation on 11/29/23 at 12:06 PM with Licensed Practical Nurse (LPN) F, Resident #113 (R113) was observed with an indwelling catheter that did not have a securement device. LPN F noted that R113's catheter tubing was not anchored to his leg. LPN F stated, It (the catheter tubing) should be (anchored). I'll go get one now. A review of the admission Record for R113 documented an admission date of 12/31/22. R113's diagnoses included neuromuscular dysfunction of the bladder and retention of urine. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. A review of R113's care plan documented the following: Focus: Use of suprapubic urinary…

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 MI00140013. Based on interview and record review, the facility failed to create a comprehensive skin tear care plan for one resident (R601) of three residents reviewed for Pressure Ulcers/ Skin Integrity resulting in the potential for unmet care needs. Findings include: A review of R601's EMR (Electronic Medical Record) revealed R601 was admitted to the facility on [DATE] and readmitted on [DATE]. R601 had the following medical diagnoses: Disorder of Muscle, Protein-calorie Malnutrition, Type 2 Diabetes Mellitus, and Peripheral Vascular Disease. A review of R601's MDS (Minimum Data Set) dated 8/28/23 revealed R601 had a BIMS (Brief Interview of Mental Status) score of 15/15 (cognitively intact). R601 required extensive two-person assistance with bed mobility and toileting. R601 required extensive one person assistance with toilet use. R601 had urinary and bowel incontinence. R601 had no pressure ulcers. A review of a nursing progress note dated 8/30/23 at 4:14 PM by LPN (Licensed…

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 document wound care/interventions in the TAR (Treatment Administration Record) for one resident (R603) of three residents sampled for Pressure Ulcers/ Skin Integrity, resulting in the potential missed treatments and worsening of pressure ulcers. Findings include: A review of R603's EMR (Electronic Medical Record) revealed R603 was admitted to the facility on [DATE]. R603 had the following medical diagnoses: Disorder of Muscle, Sepsis (infection in the blood), Venous Insufficiency (back flow of blood in the veins resulting in pooling of blood in the peripheral extremities), and Cellulitis. A review of R603's MDS (Minimum Data Set) dated 9/14/23 revealed R603 had a BIMS (Brief Inteview of Mental Status) score of 13/15 (cognitively intact). R603 required extensive two-person assistance with bed mobility. R603 required extensive one person assistance with toilet use. R603 had an indwelling catheter and had occasional bowel incontinence. R603 had one stage…

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 M100132796. Based on interview and record review the facility failed to prevent misappropriation of a wedding band for one resident (R101) of three reviewed for misappropriation of property resulting in the feelings of anger and sadness. Findings include: Review of the Facility Report Incident (FRI) dated [DATE] at 7:00 PM revealed (R101) reported having a missing ring lost or stolen when R101 was moved to another room for isolation. R101 kept the ring in a lockbox. When R101 was returned to the original room after isolation the ring was gone. Record Review of the face sheet revealed R101 was admitted to facility on [DATE] with a diagnosis of congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) (a brief cognitive test) of 13/15, which indicated intact cognition. Record review of the resident item inventory was not dated and incomplete. There was no police report/investigation provided…

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 M100132796. Based on interview and record review the facility failed to thoroughly investigate an allegation of misappropriation for one resident (R101) of three reviewed for misappropriation of property resulting an unresolved investigation of a missing wedding band and the potential for further mistreatment. Findings include: Review of the Facility Report Incident (FRI) dated [DATE] at 7:00 PM revealed (R101) reported having a missing ring lost or stolen when R101 was moved to another room for isolation. R101 kept the ring in a lockbox. When R101 was returned to the original room after isolation the ring was gone. Record Review of the face sheet revealed R101 was admitted to facility on [DATE] with a diagnosis of congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) (a brief cognitive test) of 13/15, which indicated intact cognition. Record review of the resident item inventory was not…

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 sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting all residents who receive oral food meal services (109 residents, with 2 NPO) out of the facility's total census of 111 residents. Findings include: 1. On 7/10/23 at 12:14 PM, Dietary Manager, staff A, was observed with gloved hands taking a sanitizing towel out of a wiping cloth bucket, wiping off the steam table's serving board, placing the towel back into the wiping cloth bucket and with the same gloves began assembling grilled cheese sandwiches. At this time the surveyor inquired with staff A on if they would normally use the same gloves to prepare sandwiches after handling a sanitizing towel to which they replied, No. I'll change them now. On 7/10/23 at 12:16 PM, staff A was observed removing their gloves, washing their hands, donning new gloves, and continuing to assemble grilled cheese sandwiches. On 7/10/23 at 11:44 AM, surveyor inquired with…

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 ensure the Infection Preventionist completed specialized training in infection prevention and control, resulting in the potential for knowledge deficits pertaining to current infection prevention and control standards and infectious disease outbreaks. Findings include: In an interview on 7/10/23 at approximately 11:00 am, the Director of Nursing (DON) reported Infection Preventionist H was responsible for infection control and due to her absence the unit managers have been assisting. Review of an training certificate provided by the facility revealed IP H only received specialized training in COVID-19 training for frontline nursing home staff. In an interview on 7/10/23 at 2:00 p.m. Regional Clinical Service Director (RCSD) I reported all nurse managers are registered to take the infection prevention training and acknowledged that IP H did not have the Invention Preventionist specialized training. In an interview on 7/12/23 at 1:20 p.m., the DON reported she did not receive the Invention Preventionist training because 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 follow the standards of infection control for proper gloves use and hand hygiene, resulting in the potential for increased cross-contamination of diseases. This deficient practice had the potential to affect all residents within the facility. Findings include: In an observation and interview on 7/10/23 at 10:27 a.m., Certified Nursing Assistant (CNA) N wore gloves in hall and carried bags of soiled linen. CNA N reported care was performed in the resident's room. CNA N reported she was wearing gloves because the linen was dirty. In an observation and interview on 7/10/23 at 10:30 a.m., Housekeeper O exited a resident room and wore gloves. Housekeeper O reported she was aware that gloves should not be worn in the hall. Housekeeper O then removed the gloves and did not perform hand hygiene. In an observation on 7/10/23 at 11:15a.m. Housekeeper's O and P exited a resident's room wearing gloves and stood by a housekeeping cart near the resident room. In an observation and interview on 7/10/23 at 12:18 p.m., CNA Q…

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 resident room [ROOM NUMBER] measured at least 80 square feet per each resident residing in the room (three residents), resulting in the potential for inadequate space. Findings include: On 7/10/23 at 11:22 a.m. during the initial pool process, room [ROOM NUMBER] was entered. There were three male residents, all laying in bariatric sized beds. A family member was also visiting. The family member complained of there not being much room to move around while visiting. The family member also complained of not being able to open the closet door due to the limited room space. The family attempted to open the closet the door and asked the resident in the first bed (closest) to the closets to move wheelchair. The closet door was only able to open part ways. The family member stated, I dont understand why they are cramped in this small room when there are other rooms that would better accommodate them. It's a good thing the other…

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 post the state agency hotline phone number in a manner accessible to residents and resident's representatives resulting in the inability of residents and resident's representatives to directly report complaints/concerns to the correct state agency. Findings include: On 7/11/23 at 10:33 a.m., during the Anonymous Confidential Resident Council meeting in which 13 alert and oriented to person, place, and situation residents participated. The residents were queried having access to the State Agency Complaint Hotline. Two of the resident's said they had the phone number, however the other participants said they did not have the number and wanted it. The group was also asked was the hotline number posted anywhere in the facility. The residents responded with No. One resident stated, I don't want to ask staff for the number. They may not give me right number and I don't want them to know I might call it. On 7/11/23 at 4:12 p.m. the State Agency Complaint Hotline was observed posted on the first floor back hall (not 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 This citation pertains to Intake MI136035. Based on observation, interview, and record review, the facility failed to provide scheduled showers for one (R105) out of 13 residents reviewed for activities of daily living, potentially resulting in the unmet hygiene needs, loss of dignity, and emotional distress. Findings included: Resident #105 On 7/10/23 at 11:14 a.m. R105 was observed resting in bed watching television in a hospital gown. R105 presented as alert and oriented to person, place, and situation. R105 expressed concerns of not getting scheduled showers, I have to give them hell to get my showers. The first shower I have gotten in weeks was a few days. ago. I get bed baths, but I did not get assistance. I was given the washcloth and told to do it myself. R105 was asked are they're times when showers are refused. R105 stated, No. I don't refuse showers. They tell me I can't get a shower because there is not enough staff, so I get bed baths instead, but I want showers. On 7/12/23 at 9:14 a.m. review 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 interview and record review the facility failed to follow McGreer's criteria to document antibiotic use for one resident (R58) out of eleven residents reviewed for antibiotic use, resulting in the potential to receive unnecessary doses of an antibiotic and/or the development of antibiotic resistance. Findings include: In an interview on 7/10/23 at 11:55 a.m., R58 reported he was taking an antibiotic for UTI (Urinary Tract Infection). Review of an admission record revealed, R58 admitted to the facility 8/27/22 with pertinent diagnosis which included Hemiplegia and Hemiparesis affecting Left non-dominant side (paralysis on one side of the body) and Benign Neoplasm of Brain (growth on brain). Review of a Minimum Data Set (MDS) assessment, with a reference date of 6/2/23 revealed R58 had mild cognitive impairment with a Brief interview for Mental Status (BIMS) score of 11 out of 15. R58 required extensive assistance of one staff with personal hygiene and toileting. Review of Physician orders revealed R58 had an order for Nitrofurantoin Macrocrystal (Macrobid used to treat…

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 provide a safe, functional, and sanitary, environment for the facilities census of 111 residents and its staff resulting in an increased chance of harm. Findings include: 1. On 7/11/23 at 9:22 AM, upon touring the laundry room multiple floor tiles were observed cracked and missing around the washing machines, along with an accumulation of dust and debris behind the units. At this time the surveyor inquired with Housekeeping Supervisor, staff B, on the current state of the floor in this area to which they replied, the tiles have been like that for as long as I can remember, and yeah, we can do a better job cleaning behind the washers. On 7/11/23 at 9:28 AM, an accumulation of dust and debris was observed on the duct work and piping above each of the dryers. Upon observation staff B stated, we have a company come out every six months to clean the tops and backs of the dryers, but I don't think they do what's overhead. I can talk to maintenance about cleaning these higher areas. On 7/11/23 at 9:30 AM, an overhead pipe above…

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 an effective pest control program so that the facility is free of pests potentially affecting six residents residing in rooms [ROOM NUMBERS]. Findings include: On 7/11/23 at 9:55 AM, during an environmental tour of the facility the surveyor inquired with the Housekeeping Supervisor, staff B, if the facility used the services of a pest control company to which they stated, yes, I know we have, but maintenance would know more about the specifics on it since we have new owners. On 7/11/23 at 11:00 AM, the surveyor knocked on the door of resident room [ROOM NUMBER], announced who they were, and asked permission to enter the room, to which three of three residents responded, yes. On 7/11/23 at 11:01 AM, upon interview with the residents the surveyor asked how they liked their room to which two of three residents stated, We have ants in the bathroom. At this time the surveyor investigated the residents claim but did not find any live or…

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.