Optalis Health and Rehabilitation of Ann Arbor

This citation pertains to Intake MI00147863 Based on interview and record review, the facility failed to develop a comprehensive care plan for 1 (R203) of 4 residents reviewed which would include intervention for communication and coordination with endocrinology for management of diabetes resulting in the potential for a lack of needed care. Findings include: Review of the Electronic Medical Record (EMR) revealed that R3 had an admission date of 10/10/22. R3 had the following pertinent diagnoses: Type II Diabetes (a condition due to a problem with the way the body regulates and uses glucose), Malignant Neoplasm of the left kidney (a cancerous tumor), Malignant Neoplasm of the lung, Malignant Neoplasm of the Pancreas, and Malignant Neoplasm of the bone. According to the EMR R3 was receiving cancer treatment and also was under the care of an endocrinologist (a specialist who diagnoses and treats conditions related to hormones and endocrine glands). The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/4/24 revealed R201 scored 15 out of 15 indicating intact cognition…

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

This citation pertains to Intake MI00147863 Based on interview and record review the facility failed to follow physician's order for communication and coordination with endocrinology for management of diabetes care for 1 (R3) of 4 residents reviewed resulting in high glucose levels. Findings include: Review of the Electronic Medical Record (EMR) revealed that R3 had an admission date of 10/10/22. R3 had the following pertinent diagnoses: Type II Diabetes (a condition due to a problem with the way the body regulates and uses glucose), Malignant Neoplasm of the left kidney (a cancerous tumor), Malignant Neoplasm of the lung, Malignant Neoplasm of the Pancreas, and Malignant Neoplasm of the bone. EMR R3 was receiving cancer treatment and also was under the care of an endocrinologist (a specialist who diagnoses and treats conditions related to hormones and endocrine glands). The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/4/24 revealed R201 scored 15 out of 15 indicating intact cognition on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).…

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 Pertaining to Intake MI00145739: Based on interview and record review the facility failed to administer medications as ordered for one (R2) of three reviewed, resulting in R2's strong dissatisfaction with care, final refusal of continued stay, and resident leaving the facility to obtain medical care. Findings include: On 8/2/24 record review of the electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE] with pertinent diagnoses of Infection following a Procedure, Presence of Aortocoronary Bypass Graft, and Presence of Prosthetic Heart Valve. According to an MDS dated [DATE] R2 had a Brief Interview for Mental Status (BIMS) of 15/15 indicating intact cognition. On 8/2/24 at 11:20 AM a telephone interview with R2 was held. R2 explained I had C Difficile. (Clostridioides Difficile is a bacterium which causes diarrhea and colon damage). R2 explained the medicine for C Difficile was supposed to be given every 6 hours and that throughout the stay at least 3 doses were missed. R2 expressed…

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 sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 130 residents who receive meal services (1 nothing by mouth residents, or NPO) out of the facility's total census of 131 residents. Findings include: 1. On 3/19/24 at 10:24 AM, an accumulation of dust and debris was observed on the interior utensil drawer adjacent to the clean dry storage rack. On 3/19/24 at 10:35 AM, an accumulation of dust, hair, as well as pink and green colored debris was observed on the interior utensil drawer on the on the kitchen's main prep line. At this time upon interview with the Dietary Manager, staff K, the surveyor inquired if the facility had any policies in place regarding cleaning related job duties for staff to follow to which they stated, Yes. I will have someone clean out this whole drawer. On 3/19/24 at 10:24 AM, the surveyor requested a copy 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 Resident #55 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE], R55 was admitted to the facility on [DATE] with diagnosis that included seizure disorder. R55 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) assessment. On 03/19/24 at 12:45 pm during an interview with R55, he reported he had a concern with the staffs chronic use of cell phones while providing care was upsetting to him. R55 elaborated that he believes the fact most staff do not wear name tags, exacerbates the issue. On 03/21/24 09:12 AM, during an interview with Registered Nurse (RN) V reported she was aware of complaints that staff talk on their phones/watches, and utilize the use of ear buds to try to conceal it. RN V stated for the most part this was agency staff. Based on observation, interview, and record review, the facility failed to demonstrate respect and dignity for 2 (Resident #55 and #78) of 2 residents reviewed for dignity, and 5 of 7 in the confidential group…

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 address and resolve grievances reported in Resident Council Meetings as stated during a confidential Resident Council meeting, resulting in unresolved concerns and unmet needs of residents. Findings include: During a confidential Resident Council meeting on 3/21/2024 at 12:45 PM, four of seven residents reported that call light concerns have been brought up for months in Resident Council meetings and the facility doesn't follow up on the resolutions and the problem isn't fixed. Six of seven residents stated that call lights have been an issue for at least 6 months. They stated that afternoons, midnights, and weekends are bad where they have to wait for 1 1/2 to 2 hours to get help. One resident said, Staff don't seem to care and they say that they will be right back and they don't come back or they go to get another aide and turn off the light and forget. Five of seven residents reported that staff talk on their phones with ear buds on when they are working and in resident rooms. They stated that they also have watches 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 interview and record review, the facility failed to ensure the accuracy of one discharge Minimum Data Set (MDS) assessment for one resident (resident #122) of 2 reviewed for discharge. Findings include: According to the clinical record, including the Minimum Data Set (MDS) dated ARD 2/16/24- completed 3/1/24 reflected R122 was admitted to the facility on [DATE]. The discharge MDS reflected section A0310 question F and G reflected R122 had a planned discharge and return to the facility was not anticipated. Question A.2105 of the MDS reflected R122 was transferred to the hospital. Review of the Nurses progress notes dated 2/16/24 reflected R122 was discharged home with his wife. On 03/26/24 at 10:01 AM, during an Interview with Registered Nurse (RN) U she confirmed R122 was discharged home and MDS that was completed 03/01/24 was coded incorrectly.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to confirm that the Pre-admission Screening (PAS)/Annual Resident Review (ARR) (PASARR) Level I determination request was sent to the Community Mental Health Service Program (CMHSP) for a level II Omnibus Budget Reconciliation Act (OBRA) evaluation for one (Resident #26 ) of two reviewed for PASARR, resulting in the potential for delayed mental health services and unmet psychosocial needs. Findings include: Resident #26 (R26) Review of the medical record revealed Resident #26 (R26) was initially admitted to the facility on [DATE] with diagnoses that included unspecified Dementia with psychotic disturbance and Schizophrenia. According to Resident #26 (R26)'s Minimum Data Set (MDS) dated [DATE], revealed R26 scored 06 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R26 required assistance with toileting, showering/bathing, getting dressed and personal hygiene. R26 can…

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 comprehensive care plans for 2 (Resident #78 and Resident #110) of 26 residents reviewed, resulting in the potential for unmet care needs, weight loss and increased injury risk with recurrent falls. Findings include: Resident #78 Review of the medical record revealed that Resident #78 (R78) was admitted to facility on 1/26/24 with diagnoses including gastrointestinal tumor, malignant neoplasm of prostate, unspecified dementia, psychotic disorder with hallucinations, and adult failure to thrive. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/31/24 revealed a Brief Interview for Mental Status (BIMS) score of 8 (moderate cognitive impairment). Section F reflected that it was very important to have R78 to choose what clothes to wear. Section GG of the same MDS revealed that R78 required setup assist with eating; moderate assistance with toileting and upper body dressing; and maximal…

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 assistance with activities of daily living (ADLs) for 1 (Resident #78) of 3 residents reviewed, resulting in unmet care needs and the potential for a decline in emotional and physical health. Findings include: Review of the medical record revealed that Resident #78 (R78) was admitted to the facility on [DATE] with diagnoses including gastrointestinal tumor, malignant neoplasm of prostate, unspecified dementia, psychotic disorder with hallucinations, and adult failure to thrive. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/31/24 revealed a Brief Interview for Mental Status (BIMS) score of 8 (moderate cognitive impairment). Section F reflected that it was very important to R78 to choose what clothes to wear. Section GG of the same MDS revealed that R78 required setup assist with eating; moderate assistance with toileting and upper body dressing; and maximal assist with bathing, lower…

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 catheter orders for catheter care for one (Resident #3) of one reviewed for catheters, resulting in the potential for increased risk of infection. Findings Include: According to the facility's policy titled Catheter Care with an issued date of 8/24/23 It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. General Guidelines: Catheter care will be performed every shift and as needed by nursing personnel . Review of the face sheet revealed R3 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included post-polio syndrome (deterioration of nerve cells called motor neurons over many years that leads to loss of muscle strength and dysfunction), major depressive disorder, anxiety disorder, bipolar disorder, adjustment disorder with anxiety,…

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 nutritional and hydration needs were met and failed to obtain weights per policy for resident (Resident #110) of 5 residents reviewed for nutrition, resulting in the potential for altered nutrition status and unmet needs. Findings Include: Review of the facility's policy titled Weights with a revision date of 2/1/24 reflected the guidelines for obtaining weights. The policy stated .weights are obtained upon admission and then weekly for a total of four weeks . Review of an medical record revealed Resident #110 (R110) admitted to the facility on [DATE] with diagnoses which included repeated falls, muscle weakness, depression, pressure ulcers, severe protein-calorie malnutrition, and other drug induced secondary Parkinsonism. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/18/24, reflected R110 scored 11 of out 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide sufficient staff to meet resident needs as reported in a confidential Resident Council meeting and Resident #'s (2,8,49, 55, 59 and 80) resulting in anger, frustration, increased risk of falls and the potential for unmet care needs. Findings include: During a confidential Resident Council meeting on 3/21/2024 at 12:45 PM, six of seven residents stated that call lights have been an issue for at least six months. They stated that afternoons, midnights, and weekends are bad where they have to wait for 1 1/2 to 2 hours to get help. One resident said, Staff don't seem to care and they say that they will be right back and they don't come back or they go to get another aide and turn off the light and forget. Three of seven residents also stated that the facility was supposed to have two staff present when using the hoyer lift (allows a person to be lifted and transferred with minimal physical effort) and sometimes there was only one staff available.…

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 opened medications were appropriately labeled and stored (R17, R60, R33) and that expired medications were disposed of in 4 of 8 medication carts reviewed for labeling and storage, resulting in the potential for decreased medication efficacy and adverse side effects. Findings include: On 3/21/24 at 7:58 AM, [NAME] Unit Medication Cart 2 was reviewed in the presence of Licensed Practical Nurse/Unit Manager (LPN/UM) D. During the review, an uncapped Albuterol Inhaler with dried, crusty brown material at the inhaler mouthpiece was observed lying in the top right medication cart drawer. A peeling pharmacy label on the inhaler reflected R60's name with no open date indicated. LPN/UM D confirm that the Albuterol Inhaler was an active medication, that the brown debris had to be some sort of food particle from not being cleaned after use, and that she would be disposing of and obtaining a new one. LPN/UM D stated that the inhaler should…

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 #MI00142268 Based on interview and record review the facility failed to thoroughly investigate an allegation of abuse, and report the findings to the State Agency for one resident (Resident #3) of three residents reviewed for abuse and neglect. Findings include: Review of the clinical record reflected Resident #3 (R3) was an [AGE] year old female admitted to the facility on [DATE] and transferred back to the hospital on [DATE] with diagnosis that included end stage renal disease. Review of the facility grievance log dated 01/24/24 reflected a concern for R3, the concern was identified as nursing/customer service. Review of R3's concern form reflected the concern was received on 01/16/24. The concern form reflected R3 was evaluated at the hospital/out patient clinic on 01/12/24 for a concern related to her fistula. Review of the Nurse Practitioner progress notes at the out patient clinic reflected (R3) was .Very upset about going back to the rehab facility. She notes it is very…

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 number MI00141165. Based on observation, interview, and record review the facility failed to ensure care plan interventions were followed for one out of eight residents (Resident #3), resulting in a right and left tibia (shinbone) and right femur (upper leg bone) fracture from a fall out of bed. Findings Included: Per Resident #3's (R3) Minimum Data Set (MDS), R3 was discharged to the hospital on [DATE] with an anticipated return to the facility. Review of an MDS dated [DATE], revealed R3 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 (moderately impaired cognition). The assessment revealed that both of R3's legs were impaired, and also R3 was totally dependent on staff for rolling right to left while in bed. Review of R3's list of diagnoses revealed R3 had multiple sclerosis (MS-a disease that affects the central nervous system). Record review of a care plan that was in place for activities of daily living (ADLs) dated 11/30/2018 and revised on 10/17/2023,…

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 that five Certified Nursing Aides (K, L, M, CC, and GG) of five Certified Nursing Aides personnel records had the required annual competency evaluation in skills and techniques necessary to care for residents, resulting in the potential for staff to lack the necessary training to adequately meet the needs of the 114 Residents that currently reside at the facility. Findings Included: Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) K was hired 02/24/2003. CNA K 's last skills and techniques evaluation for Nursing Assistants was completed 03/08/2022. Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) L was hired 10/05/2012. CNA L 's most recent skills and techniques evaluation for Nursing Assistants was completed 11/15/2021. Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) M was hired 01/23/2014. CNA M 's last skills and techniques evaluation for Nursing Assistants was completed 01/31/2022.…

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 that four Certified Nursing Aides (K, L, M, CC) of four Certified Nursing Aides in-service records reviewed had the 12 hours of in-service education per year, resulting in the potential for staff to lack the necessary in-service education to adequately meet the needs of the 114 residents that currently reside at the facility. Findings Included: Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) K was hired 02/24/2003. CNA K 's Inservice education record revealed that CNA K only had 5.56 training hours for the dates of 04/16/2022 through 10/06/2022. Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) L was hired 10/05/2012. CNA L 's Inservice education record revealed that CNA L only had 8.33 training hours for the dates of 04/13/2022 through 1/14/2023. Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) M was hired 01/23/2014. CNA M 's Inservice education record revealed that CNA M only had 6.57…

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 observations, interviews, and record reviews, the facility failed to: (1) effectively clean and maintain food service equipment, and (2) maintain physical plant drywall surfaces effecting 113 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased interior food service equipment illumination. Findings include: On 04/03/23 at 01:21 P.M., An initial tour of the food service was conducted with Food Service Manager C. The following items were noted: The Victory one-door reach-in refrigerator interior light bulb was observed non-functional. The 2017 FDA Model Food Code section 6-303.11 states: The light intensity shall be: (A) At least 108 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry FOOD storage areas and in other areas and rooms during periods of cleaning; (B) At least 215 lux (20 foot candles): (1) At a surface where FOOD is provided for CONSUMER self-service such as buffets and salad…

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 observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant affecting 114 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 04/05/23 at 08:50 A.M., a common area environmental tour was conducted with Director of Maintenance F and Director of Housekeeping and Laundry Services G. The following items were noted: Cypress Unit (100-200) Cypress Lounge: 9 of 23 overhead recessed light assemblies were observed non-functional. Director of Maintenance F indicated he would have staff replace the faulty bulbs as soon as possible. The overhead light assembly directly outside of the Central Bath was observed non-functional. Maple Unit (300-400) Central Bath Restroom: The toilet seat was observed etched, scored, particulate, and worn. Director of Housekeeping and Laundry Services G indicated she would have maintenance replace the worn toilet seat as soon as possible.…

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 preserve the dignity of 5 residents (Resident #14, Resident #31, Resident #36, Resident #40 and Resident #76) of eight residents reviewed for dignity, resulting in feelings of anger, embarrassment, and decreased self-worth. Findings include: Resident #31: According to the clinical record, including the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/23/23, Resident # 31 (R31) was admitted to the facility on [DATE] with diagnoses that included anxiety, bi-polar disorder and depression. Further review of the MDS reflected R31 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). During an interview with R31 on 04/04/23 at 1:30 pm, she reported staff often talk on phone while providing care, they use an ear piece. R31 went on to say that recently one of the nursing staff was in R31's room providing care and the staff person started talking into their wrist. R31 stated she had 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to revise care plans for 8 residents (#12, #15, #22, #28, #34, #48, and #92) of 24 residents reviewed resulting in the potential of unmet care needs. Findings included: Resident #12 (R12): Review of the medical record revealed R12 was admitted to the facility 12/5/2020 with diagnoses that included congestive heart failure (CHF), hypertension, chronic respiratory failure, type 2 diabetes, atherosclerotic heart disease, occlusion (blockage) and stenosis (narrowing) of carotid artery, atrial fibrillation, vascular dementia, anxiety, psychotic disturbances, mood disturbance, insomnia, gout (buildup of uric acid in bone joints) , dysphagia (difficulty swallowing), and anemia (low blood count). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/09/2023, revealed R12 had a Brief Interview for Mental Status (BIMS) of 99 (unable to participate in assessment). During observation on 04/05/2023 at 08:00 a.m. R12 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure sufficient nursing staff for four residents (Resident #10, Resident #14, Resident #67, and Resident #84) and the confidential residents attending Resident Council resulting in the potential of all 114 residents residing at the facility being unable attain or maintain their heights practicable physical, mental, and psychosocial well-being related to showers and unmet needs. Finding Included: Resident #10 (R10): Review of the medical record revealed R10 was admitted to the facility 02/08/2023 with diagnoses that include B-cell lymphoma (cancer of the lymph nodes), pancytopenia (problem with blood-forming stem cells in bone marrow), hypertension, hyperlipidemia (increase fat in blood), osteoporosis (brittle and fragile bones), glaucoma, and depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/14/2023, revealed R10 had a Brief Interview for Mental Status (BIMS) of 11 (moderately cognitively…

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 safe and secure medication storage for two out of 16 medication carts, and three out of three residents (Resident #28, Resident #62, and Resident #77) resulting in the potential for loss of medications, and other residents having access to medications. Findings Included: Resident #28 (R28): In an observation and interview on 4/03/2023 at 2:41 PM, with R28 it was observed that in a medication cup (small plastic cup used to place medications in) there was a purple scored (dented line to break apart pill) oval shaped pill with an M on one side and L10 on the other side, and another round scored white pill with the number 120 on it. The two pills were identified be a thyroid pill and a Baclofen (muscle relaxer) pill. R28 stated that the two pills were brought in to her at around 6:00 AM this day (4/3/2023). R28 stated that she finished her lunch at approximately 2:00 PM and needed to wait three hours after she ate to take her thyroid…

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 food preferences were honored and alternative menu options were offered to Resident #489 and the 111 of 114 residents who are served food from the kitchen. This deficient practice resulted in meal dissatisfaction, decreased appetite, and frustration when disliked foods continued to be served on meal trays. Findings include: Findings include: Resident #489 (R489): Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R489 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), calculus of gallbladder with acute cholecystitis with obstruction, reduced mobility and weakness. The MDS reflected R489 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required two-person assist with bed mobility, transfers and toileting and one-person physical assist with locomotion on unit,…

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 accurate reasoning and advanced written notice prior to a room change for one resident (Resident #36) of one resident reviewed for room changes, resulting in frustration with the potential for increased anxiety, misinformation of the reason for the room change and lack of opportunity to for resident questions. Findings include: Resident #36: According to the clinical record, including the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/21/23, Resident # 36 (R36) was a [AGE] year old resident with diagnoses that included major depression and anxiety. Review of the Brief Interview for Mental Status (BIMS) reflected R36 scored 15 out of 15 (cognitively intact). On 04/04/23 at 08:43 AM, R36 was interviewed at bedside and reported last December she was moved to her current room which was located on a locked unit designated for dementia. R36 stated she did not have dementia, was not an elopement risk, was not given an…

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 the resident's representative information regarding the facility's bed hold policy for one resident (Resident #34) of two residents reviewed, resulting in the residents representative not being informed of the ability to hold the bed within the facility. Findings included: Resident #34 (R34): Review of the medical record revealed R34 was originally admitted to the facility 08/10/2022 and most recently re-admitted [DATE] (following a recent hospital stay on 02/19/2023) with diagnoses that included chronic ischemic heart disease, congestive heart failure (CHF), atherosclerotic heart disease of coronary artery, Alzheimer's disease, chronic obstructive pulmonary disease (COPD), atrial fibrillation, gastro-esophageal reflux, hypercholesteremia, chronic viral hepatitis C, hypertension, anxiety, depression, and benign prostatic hyperplasia (prostate enlargement). The most recent Minimum Data Set (MDS), with an Assessment Reference Date…

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 that a Preadmission/Annual Resident Review (PAS/ARR) was accurately completed upon admission and failed to ensure an accurate PAS/ARR level one OBRA (Omnibus Budget Reconciliation Act of 1993) was sent to Community Mental Health Services Program (CMHSP) for a level two OBRA evaluation for 1 resident (Resident #31) of 2 residents reviewed for PAS/ARR from a total sample of 24, resulting in the potential for unmet mental health needs. Findings include: Resident #31: According to the clinical record, including the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/23/23, Resident # 31 (R31) was admitted to the facility on [DATE] with diagnoses that included anxiety, bi-polar disorder and depression. Further review of the MDS reflected R31 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). Record review of both electronic medical record and paper medical record reflected R31's Pre…

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 #15 (R15): Review of the medical record revealed R15 was admitted to the facility 03/26/2016 with diagnoses that included seizures, stage 3 kidney disease, right knee pain, mood disorder, adjustment disorder, depression, traumatic brain injury, hydrocephalus (buildup of fluid in the brain), adult failure to thrive, osteoporosis (brittle/fragile bones), macular degeneration (degenerative condition affecting the retina), glaucoma (buildup of fluid in eye), gastro-esophageal reflux, and hyperlipidemia (high fat content in blood). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/16/2023, revealed R15 had a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact) out of 15. During observation and interview on 04/04/2023 at 11:38 a.m. R15 was observed lying in bed. R15 explained that wanted to be discharged from the facility but no one had assisted him with that plan. R15 explained that he had talked with Social Worker (SW) DD and SW J about his desire to be…

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 assistance to ensure ancillary services were arranged for 1 of 2 residents (Resident #49) reviewed for optical care, resulting in delayed care and treatment and anger and frustration. Findings include: Resident #49: According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident # 49 (R49) was an [AGE] years old and admitted to the facility with diagnoses of heart failure, diabetes and chronic obstructive pulmonary disease. R49 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) . On 04/03/23 at 02:04 PM R49 was observed sitting in a wheel chair, he was articulate and engaged in conversation easily. R49 reported having had cataracts and previously had cataract surgery. R49 stated he needed the cataracts removed and was told by staff he had and appointment in 4 months. R49 reported a 4 month wait time was not acceptable, and had reached out to Social Worker (SW) J…

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 #12 (R12): Review of the medical record revealed R12 was admitted to the facility 12/5/2020 with diagnoses that included congestive heart failure (CHF), hypertension, chronic respiratory failure, type 2 diabetes, atherosclerotic heart disease, occlusion (blockage) and stenosis (narrowing) of carotid artery, atrial fibrillation, vascular dementia, anxiety, psychotic disturbances, mood disturbance, insomnia, gout (buildup of uric acid in bone joints) , dysphagia (difficulty swallowing), and anemia (low blood count). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/09/2023, revealed R12 had a Brief Interview for Mental Status (BIMS) of 99 (unable to participate in assessment). During observation on 04/05/2023 at 08:00 a.m. R12 was observed setting on the side of her bed eating breakfast. She repeatedly was making grunting sounds and saying help. R12 did not respond to verbal stimulation. In an interview on 04/10/2023 at 10:34 a.m. Certified Nursing Aide (CNA) CC…

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 that the physician reviewed and acted upon identified medication regimen irregularities for one resident (Resident #76) of five residents reviewed for unnecessary medications, resulting in the potential for unnecessary medications and adverse reactions. Findings include: Resident #76: According to the clinical record, including the Minimum Data Set (MDS) dated [DATE], Resident 76 (R76) was originally admitted to the on 3/3/21 and readmit on 3/01/23 diagnosis of diabetes . Review of the medication administration record (MAR) for the month of April 2023 reflected 8 units of insulin was administered every night as ordered by the physician. Review of the Pharmacy recommendations dated 1/05/23 reflected R76 had been ordered Glargine 8 units in the evening , R76 was not on a sliding scale coverage and the most recent blood sugar from 11/18/22 20:15 was 135. milligrams. The Pharmacy recommended the current dose and need for accucheck or sliding scale…

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 adequate behavior monitoring during the use of psychotropic medication for two residents (Resident #34 and Resident #92) of five residents reviewed for psychotropic mediation usage resulting in the potential of residents receiving unnecessary psychotropic medication. Findings Included: Resident #34 (R34): Review of the medical record revealed R34 was originally admitted to the facility 08/10/2022 and most recently re-admitted [DATE] (following a recent hospital stay on 02/19/2023) with diagnoses that included chronic ischemic heart disease, congestive heart failure (CHF), atherosclerotic heart disease of coronary artery, Alzheimer's disease, chronic obstructive pulmonary disease (COPD), atrial fibrillation, gastro-esophageal reflux, hypercholesteremia, chronic viral hepatitis C, hypertension, anxiety, depression, and benign prostatic hyperplasia (prostate enlargement). The most recent Minimum Data Set (MDS), with an Assessment…

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 that ensure dental services were provided in a timely manner for 2 of 2 residents (Resident #49 and Resident #62) reviewed for dental care and services, resulting in anger, embarrassment and discomfort. Findings include: Resident #49: According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident # 49 (R49) was an [AGE] years old and admitted to the facility with diagnoses of heart failure, diabetes and chronic obstructive pulmonary disease. R49 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) . On 04/03/23 at 02:04 PM R49 was observed sitting in a wheel chair, he was articulate and engaged in conversation easily. R49 reported having had an attempt his dentures replaced/repaired at the facility in December 2022 and has not received them. R49 further stated that due to the delay he made a request to Social Worker J to see his long standing Dentist in the community, R49…

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 infection control guidelines for one resident (Resident #48) of one resident reviewed during urinary catheter care and contact isolation resulting in the potential to spread infection to all 114 residents in the facility. Findings Included: Resident #48 (R48): Review of the medical record revealed R48 was admitted to the facility 01/15/2020 with diagnoses that included chronic obstructive pulmonary disease (COPD), depression, type 2 diabetes, benign hyperplasia (enlarge prostate), obstructive and reflux uropathy (obstruction of urine flow), panic disorder, hypertension, cerebral infarction (ischemic stroke), obstructive sleep apnea, stage 4 kidney disease, coronary artery disease, and hyperlipidemia (high fat content in blood). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/20/2023, revealed R48 had a Brief Interview for Mental Status (BIMS) of 11 (moderately impaired cognition) out of 15. During observation and interview on 04/05/2023 at 10:02 a.m. R 48 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 interview and record review the facility failed to meet educational requirements for four (K, L, M, CC) of five Certified Nursing Aides related to required in-services education of dementia management resulting in the potential for improper and/or inappropriate care for 33 residents with dementia. Finding included: Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) K was hired 02/24/2003. CNA K 's Inservice education record revealed that CNA K only had 5.56 training hours for the dates of 04/16/2022 through 10/06/2022. The education record demonstrated no education regarding care for resident with Dementia that had been received in the last year. Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) L was hired 10/05/2012. CNA L 's Inservice education record revealed that CNA L only had 8.33 training hours for the dates of 04/13/2022 through 1/14/2023. The education record demonstrated no education on resident with Dementia that had been received in the last year. Record review of facility staff…

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.