Glacier Hills

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to: (1) effectively maintain 1 of 2 outdoor waste receptacles, (2) clean the concrete receptacle pads and adjacent grounds, and (3) effectively clean the outdoor waste grease receptacles and adjacent concrete receptacle pad surfaces effecting 35 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and pest attraction/harborage. Findings include: On 03/17/25 at 12:20 P.M., 1 of 2 outdoor waste receptacles were observed missing a drain plug. 1 of 2 outdoor waste receptacles were also observed with a severely bent mounting rod, allowing the receptacle lid to not close completely. The exterior surface of 1 of 2 outdoor waste receptacles were further observed bent inward. The damaged surface area measured approximately 24-inches-wide by 36-inches-long. The outdoor waste compactor assembly and adjacent ground surfaces were additionally observed soiled with accumulated and encrusted dirt and debris (dead…

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 call light was kept within resident reach for one resident (#12) out of twelve residents reviewed. Findings Included: Review of the medical record revealed R12 was admitted to the facility 11/14/2018 with diagnoses that included chronic obstructive pulmonary disease (COPD), hypertension, Hemiplegia (paralysis one side of the body) left side, multiple sclerosis, atrial fibrillation, bullous pemphigoid (skin condition causing large fluid-filled blisters), hyperlipemia (high fat content in blood), depression, dementia, pain, overactive constipation, neuromuscular dysfunction of bladder, anxiety disorder, osteoarthritis (tissue at end of bones wears down), and malnutrition. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/13/2025, revealed R12 had a Brief Interview of Mental Status (BIMS) of 12 (moderate cognitive impairment) out of 15. During observation and interview on 03/17/2025 at 11:20 a.m. R12 was observed lying down in bed. R12 explained that staff frequently…

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

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 42 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 02/13/24 at 09:18 A.M., An initial tour of the food service was conducted with Executive Chef S. The following items were noted: Dry Storage Room: The individual white plastic disposable forks were observed unprotected. The inner plastic liner bag within the cardboard box container was also observed open, allowing potential contamination to enter the cavity opening. The 2017 FDA Model Food Code section 3-307.11 states: FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. Chemical Storage Room: The return-air-exhaust ventilation grill was observed soiled with accumulated dust and dirt deposits. The 2017 FDA Model Food Code section 6-501.14 states: (A) Intake and exhaust air ducts shall be cleaned, and filters changed so they are not a source 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.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 42 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 02/14/24 at 08:25 A.M., An environmental tour of the facility Laundry Service was conducted with Environmental Services Supervisor W. The following items were noted: Clean Linen Room: The wall mounted oscillating fan was observed soiled with accumulated dust and dirt deposits. Soiled Laundry Room: The drywall surface was observed (etched, scored, particulate). The damaged drywall surface measured approximately 12-inches-wide by 20-feet-long. Environmental Services Supervisor W indicated she would contact maintenance for necessary repairs as soon as possible. On 02/14/24 at 12:35 P.M., A common area environmental tour was conducted with Facilities Manager X, Maintenance Team Leader Y, and Environmental Services Supervisor W. The following items were noted: Storage Room (2111): The laminate flooring…

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 Physical and Occupational Therapy schedules upon request for three (Resident #25, 43, 151) out of three residents reviewed for accommodation of needs resulting in feelings of frustration. Findings Include: Resident #43 Review of the medical record revealed Resident #43 (R43) was admitted to the facility on [DATE] with diagnoses that included. A Social Work Progress Noted revealed R43 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). The medical record indicated that R43 was at the facility for a short term rehabilitation stay. In an observation and interview on 02/13/24 at 1:09 PM, R43 was seated in her reclining chair in her room with her feet elevated. R43 had a fiberglass cast on her left leg. A whiteboard was observed in R43's room which identified the care team assignment for the day, along with Physical and Occupational therapy times. R43 pointed out that the whiteboard does not get…

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 Resident #149 (R149): Review of the medical record reflected R149 admitted to the facility on [DATE] and with diagnoses that included heart failure and melanoma. R149's Treatment Preferences and Determination of Residents Wishes document reflected selection of, Code D-Comfort measures only. No cardiopulmonary resuscitation (CPR). No artificial nutrition and hydration. The document included a Presenter's Signature, and the resident's signature dated [DATE], the physician signed the document on [DATE]. The document did not include the required witness signatures or the Michigan do-not-resuscitate procedure act language. Based on interview and record review, the facility failed to ensure Do-Not-Resuscitate (DNR) documents were completed in accordance with the Michigan Do-Not-Resuscitate Procedure Act for three (Resident #17, #149 and #350) of three reviewed for Advance Directives, resulting in the potential for code status wishes not being followed in an emergency situation. Findings include: Review of the MICHIGAN…

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 a timely quarterly Minimum Data Set (MDS) assessment for one (Resident #17) of 13 reviewed for MDS, resulting in the potential for unrecognized and unmet care needs. Findings include: Review of the medical record reflected Resident #17 (R17) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included hemiplegia (paralysis on one side of the body), pain and unspecified dementia. The quarterly MDS, with an Assessment Reference Date (ARD) of 9/14/23, reflected R17 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), did not walk and required total assistance of one to two or more people for bed mobility, dressing, toilet use, personal hygiene and bathing. R17's MDS history included an annual MDS, with an ARD of 4/4/23; a quarterly MDS, with an ARD of 6/29/23 and a quarterly MDS, with an ARD of 9/14/23. Additional MDS assessments included a discharge return…

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 accuracy on a 5 day Minimum Data Set (MDS) assessment for one resident (resident #22) of one reviewed for Passar completion and discharge Minimum Data Set (MDS) assessment for one resident (resident #46) of 4 reviewed for discharge, resulting in the potential for unmet care needs. Findings include: Review of the clinical record reflected Resident 46 (R46) was an [AGE] year old male admitted to the facility on [DATE] with diagnosis that included right tibia fracture. Further record review reflected R46 had a planned transfer for inpatient rehab to the Veterans Affair (VA) on 12/05/23. There was no documentation in the clinical record that reflected R46 was hospitalized for an acute medical need/condition. Review of R46's discharge MDS dated [DATE] section A 0310 was coded 10 which indicated this was a planned discharge assessment and return was not anticipated. Section A 2105 was coded as a 4. Short-Term General Hospital (acute care hospital,…

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 a Preadmission/Annual Resident Review was completed after the 30-day exemption period and failed to notify the State Mental Health Authority for 1 of 1 resident (resident #22) reviewed for PAS/ARR, from a total sample of 13, resulting in the potential for unmet mental health treatment and services. Findings include: Review of the medical record revealed Resident #22 (R22) was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included [NAME] Disease, Fibromyalgia, Anxiety, Major Depression, Dysphasia, Speech Disturbances, Difficulty Walking, Muscles Spasms, after care following joint repair, and pain. According to Resident #01 (R01)'s Minimum Data Set (MDS) dated [DATE], revealed R22 scored 12 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R22 requires assistance with all care due to upper extremities having contractures…

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 #17) of 13 reviewed for Care Plans, resulting in inaccurate Care Plans and the potential for unmet care needs. Findings include: Review of the medical record reflected Resident #17 (R17) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included hemiplegia (paralysis on one side of the body), pain and unspecified dementia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/14/23, reflected R17 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), did not walk and required total assistance of one to two or more people for bed mobility, dressing, toilet use, personal hygiene and bathing. The same MDS was coded for upper extremity and lower extremity impairments on one side of the body. On 02/13/24 at 10:13 AM, R17 was observed lying in bed. His left hand was observed to be clenched…

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 MI00140950 Based on interview and record review, the facility failed to provide showers for one (Resident #48) of two reviewed for Activities of Daily Living (ADL) assistance, resulting in unmet care needs. Findings Include: Review of the medical record revealed Resident #48 (R48) was admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome, lumbar spinal fusion, hypertension (high blood pressure), connective tissue disease, and anemia. A Social Work Progress Noted dated 10/24/23 revealed R48 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). The Resident Summary with a date of 10/19/23 revealed R48 required staff assistance of two people for Activities of Daily Living Care, including showers. In a telephone interview on 2/13/24 at 10:15 AM, R48 reported that she went multiple days without receiving a shower which made her feel gross. R48 stated that staff would tell her that they were busy when she requested her…

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.