Optalis Health and Rehabilitation of Ann Arbor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2801978.Based on observation, interview and record review, the facility failed to prevent missing controlled substance medication for one (R2) and maintain accurate controlled substance records for five (R6, R7, R8, R9, R10) in two of seven medication carts reviewed.Findings include:R2:Review of the medical record reflected R2 admitted to the facility on [DATE], with diagnoses that included low back pain, chronic pain and systemic lupus erythematosus. On 5/12/26 at 12:13 PM, R2 was observed in bed, watching TV, and declined to be interviewed. The January 2026 Medication Administration Record (MAR) included a Physician Order for 10 milligrams (mg) of oxycodone by mouth, every six hours, as needed, for ANALGESICS [pain relief]. A Facility Reported Incident investigation file reflected a blister pack of R2's oxycodone 10 mg went missing between the 7:00 AM and 7:00 PM nursing shift on 1/30/26. A Controlled Drug Receipt/Record/Disposition Form reflected 30 tablets of oxycodone 10 mg…

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 134 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, reduced air quality, and inadequate sanitization of dishware and utensils. Findings include: On 04/07/25 at 09:20 A.M., An initial tour of the food service was conducted with Dietary Manager G. The following items were noted: The ceiling mounted return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. The soiled ventilation grill plate measured approximately 3-feet-wide by 4-feet-long. 6 of 25 food production kitchen overhead light assembly plastic lens covers were observed soiled with accumulated (dust/dirt/dead insect carcasses). Dietary Manager G indicated he would contact maintenance for necessary repairs as soon as possible. The 2022 FDA Model Food Code section 6-501.12 states: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is…

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 effecting 138 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and reduced air quality. Findings include: On 04/07/25 at 03:50 P.M., An environmental tour of the facility Laundry Service was conducted with Director of Maintenance H and Director of Housekeeping and Laundry Services I. The following items were noted: Two 4-feet-wide by 6-feet-long padded floor mats were observed (etched, scored, particulate), adjacent to the three commercial dryers. The worn padded floor mats were also observed attached to the flooring surface with maroon colored duct tape. Director of Maintenance H indicated he would have staff remove and replace the worn floor mats as soon as possible. The flooring surface was observed (etched, scored, particulate), adjacent to the three commercial washers. The damaged flooring surface measured approximately 7-feet-wide by…

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 honor a resident's choices regarding his daily routine and failed to facilitate the ability to go outside when requested, in one of two residents reviewed for choices (Resident #117). Findings include: Resident #117 (R117) Review of the medical record reflected R117 was admitted to the facility on [DATE], with diagnoses that included multiple sclerosis, depression, bipolar disorder, and anxiety. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/3/25, reflected R117 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 04/08/25 at 10:45 AM, R117 was observed dressed and seated in a motorized wheelchair. During the observation, R117 shared that he had always been a busy body and, for many years, was up and at work by 7:00 AM. He expressed that having to wait until after lunch for staff assistance to get out of bed kills something in my soul.…

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 oral care was provided to one (R81) of two reviewed. Findings include: Review of the medical record reflected R81 admitted to the facility on [DATE], with diagnoses that included atherosclerotic heart disease and essential tremor. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/20/25, reflected R81 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), had impairment on one upper extremity and one lower extremity and required setup or clean-up assistance for oral hygiene. On 04/08/25 at 11:18 AM, R81 was observed lying in bed. R81 stated their teeth had not been brushed since admitting to the facility, and staff did not provide supplies for them to be able to brush their teeth. R81 reported they would have been able to brush their own teeth, if they had the supplies. On 04/09/25 at 2:06 PM, R81 was observed in bed, watching TV. R81…

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 review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act in one (R102) of four residents reviewed for abuse. Review of the medical record reflected R102 was admitted to the facility on [DATE], with diagnoses that included anxiety disorder, vascular dementia, and dementia with behavior disturbances. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/20/25, reflected R102 scored 11 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of a Nursing-Progress Note dated 3/8/25 at 4:26 PM revealed Resident [R102] verbally abusing resident. Resident stated he would smack another resident. The note author was identified as Licensed Practical Nurse (LPN) T. In an interview on 3/19/25 at 1:14 PM, LPN T stated that she was familiar with R102. LPN T stated that she did write the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to, investigate allegations of abuse for one out of four residents (Residents #102). Findings Include: Review of the medical record reflected R102 was admitted to the facility on [DATE], with diagnoses that included anxiety disorder, vascular dementia, and dementia with behavior disturbances. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/20/25, reflected R102 scored 11 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of a Nursing-Progress Note dated 3/8/25 at 4:26 PM revealed Resident [R102] verbally abusing resident. Resident stated he would smack another resident. The note author was identified as Licensed Practical Nurse (LPN) T. In an interview on 3/19/25 at 1:14 PM, LPN T stated that she was familiar with R102. LPN T stated that she did write the Progress Note on 3/8/25, however, could not recall details of the verbal abuse allegation and that R102 gets into…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for two (Resident #102 and #103) of three reviewed. Review of the medical record reflected R102 was admitted to the facility on [DATE], with diagnoses that included anxiety disorder, vascular dementia, and dementia with behavior disturbances. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/20/25, reflected R102 scored 11 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R102's Care Plan revealed R102 ambulated independently with the use of a walker. Review of the medical record reflected R103 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included aphasia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/9/25, reflected R103 was rarely understood. On 3/17/25 at 10:47 AM, R102 was observed in his room sleeping. In an interview on 3/19/25 at…

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 showers per care plan for two (Resident #104, #105) of three reviewed for activities of daily living. Findings include: Resident #104 (R104) Review of the medical record reflected R104 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included muscle weakness and dislocation of internal left hip prothesis. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/28/25, reflected R104 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 3/17/25, at 11:26 a.m., R104 was observed in bed watching television. R104 was wearing a hospital gown and appeared ungroomed. R104 stated that she was unimpressed with the care she was receiving at the facility. She expressed concerns about not receiving showers consistently and call lights not being answered in a timely manner, sometimes waiting over an hour for assistance. R104…

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 numbers MI00150030 and MI00150146. Based on observation, interview, and record review the facility failed to maintain sufficient staff to meet residents' needs timely and provide scheduled showers for three (Resident #101, #104, #105) of seven reviewed for staffing. Resident #101 (R101) Review of the medical record reflected R101 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included muscle weakness and contractures of the left and right hand. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/9/25, reflected R101 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R101's Care Plan reflected she required assistance of two staff members via mechanical lift for transferring. On 3/17/25 at 11:09 AM, R101 was observed in bed watching television. R101 reported that staffing sucks and often experience call light responses that are up to an hour. R101 also…

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 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.