Regency At Bluffs Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure showers were offered and completed per resident preference for one out of four residents (Resident #30). Findings include: Resident #30 (R30) Review of the medical record reflected R30 was admitted to the facility on [DATE], with diagnoses that included difficulty in walking. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/19/25, reflected R30 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 4/15/25 at 10:30 AM, R30 was observed in her room resting in bed. R30 expressed frustration with the lack of communication at the facility. R30 stated that she has had several room changes and typically, staff would not give her any notice and would state that they were moving her that day. R30 also stated that due to the constant room changes, she believes her shower days were mixed up, therefore, R30 had missed some of her scheduled shower days.…

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 prevention of a fall for one (Resident #10) of two reviewed for falls. Findings include: Resident #10 (R10) R10 admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included muscle wasting and atrophy and anoxic brain damage. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/2/25, reflected R10 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R10's Care Plan revealed R10 was dependent on two staff members with the use of a mechanical Hoyer lift for transfers. On 4/15/25 12:35 PM, R10 was observed in his room, sitting on a motorized wheelchair. R10 had a seatbelt across his lap. R10 reported that he fell out of chair recently. R10 explained that staff had transferred him to his wheelchair and after being placed in his wheelchair, staff had forgotten to put the armrest on his chair down. R10…

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 Occupational Therapy (OT) services as ordered for one (R22) of two reviewed. Findings include: Review of the medical record reflected R22 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included fusion of the spine and dependence on renal dialysis. At the time of review, R22's Admission/Medicare 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/10/25 was In Progress. On 4/15/25 at 10:50 AM, R22 was observed in bed, wearing a Miami J cervical collar (type of neck brace). R22 reported they were supposed to receive Physical Therapy (PT) and OT five times per week, for one hour per day, but were receiving less. R22 reported the facility was discussing discharge due to lack of progress and stated, how can I progress if they don't work with me more? In an interview on 4/17/25 at 9:48 AM, Physical Therapist (PT) E reported there were times therapy was unable to work with R22 during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to 1) ensure appropriate use of Personal Protective Equipment (PPE) for one (R7) of three reviewed for Transmission-Based Precautions (TBP); and 2) ensure appropriate hand hygiene. Findings include: Resident #7 (R7): Review of the medical record reflected R7 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included pain in thoracic spine and chronic obstructive pulmonary disease. The admission/Medicare 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/2/25, reflected R7 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 04/15/25 at 12:20 PM, R7's room door was observed to be open, with a droplet precaution sign and PPE hanging on the exterior of the door. Two staff members were observed in the room, each wearing a gown, gloves and an N95 mask. Neither of the staff members were observed wearing eye protection. At 12:23 PM,…

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 MI00149652. Based on observation, interview, and record review, the facility failed to provide the necessary supplies to perform oral care for one (R5) of three reviewed. Findings include: Review of the medical record revealed R5 was admitted to the facility on [DATE]. The Brief Interview Status (BIMS-a cognitive screening tool) dated 1/31/25 revealed R5 scored 15 out of 15 (cognitively intact). On 2/3/25 at 11:34 AM, R5 was observed self-ambulating back to bed from the bathroom. R5 reported they had been in the facility for five days and had not been provided a toothbrush, toothpaste, or mouth wash and therefore had not had oral care since admission. On 2/4/25 at 9:16 AM, R5 was observed sitting on the edge of their bed. R5 reported they still had not received the necessary supplies to complete oral care. In an interview on 2/4/25 at 9:18 AM, Certified Nursing Assistant (CNA) F reported R5 required very light assistance with activities of daily living (ADL) and did most care…

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 MI00149652. Based on interview and record review, the facility failed to follow-up on a change in vital signs for one (R2) of three reviewed. Findings include: Review of the medical record revealed R2 was admitted to the facility on [DATE] with diagnoses that included infection and inflammatory reaction due to cardiac and vascular devices, chronic obstructive pulmonary disease (COPD), history of cardiac arrest, and acute respiratory failure with hypoxia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/6/24 revealed R2 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Physician's Order dated 5/1/24 revealed an order for oxygen at 2 liters per minute continuously to maintain an oxygen level of 90% or better. This order was discontinued 6/24/24 as R2 was weaned off oxygen. Review of the Physician's Order dated 5/31/24 revealed check pulse ox (oximetry) on room air. Try to wean…

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 MI00149652. Based on interview and record review, the facility failed to completed bladder scans and intermittent straight catheterization as ordered by the physician for one (R2) of two reviewed. Findings include: Review of the medical record revealed R2 was admitted to the facility on [DATE] with diagnoses that included retention of urine. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/6/24 revealed R2 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Physician's Order dated 6/14/24 revealed PVR [post void residual/bladder scan] q 6 hours [every 6 hours]. ISC [intermittent straight catheter] if greater than 250 cc [cubic centimeter/1 cc is equal to 1 milliliter] and notify [Nurse Practitioner]. Review of the Physician's Order dated 6/18/24 revealed Bladder Scan PVR Q6hours, if unable to void and greater than 250cc then straight cath and place note in [doctor] book. Review…

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 MI00149652. Based on interview and record review, the facility failed to notify the physician of urine culture results for one (R2) of one reviewed. Findings include: Review of the medical record revealed R2 was admitted to the facility on [DATE] with diagnoses that included retention of urine. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/6/24 revealed R2 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R2's urinalysis dated 6/3/24 revealed a urine culture was pending. Review of the Nurse Practitioner Note dated 6/4/24 revealed Urine positive for LE [leukocyte esterase] - Await culture as patient is asymptomatic. On 2/4/25 at 10:44 AM, R2's urine culture results were requested from Nursing Home Administrator (NHA) A. Review of the urine culture results collected 6/3/24 and resulted 6/6/24 revealed R2's urine culture was positive for over 100,000 cfu/mL (colony forming…

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 MI00149652. Based on interview and record review, the facility failed to ensure urine culture results were in the medical record for one (R2) of one reviewed. Findings include: Review of the medical record revealed R2 was admitted to the facility on [DATE] with diagnoses that included retention of urine. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/6/24 revealed R2 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R2's urinalysis dated 6/3/24 revealed a urine culture was pending. Review of the Nurse Practitioner Note dated 6/4/24 revealed Urine positive for LE [leukocyte esterase] - Await culture as patient is asymptomatic. R2's medical record did not include urine culture results. Review of the medical record revealed no documentation that R2's urine culture results were received. On 2/4/25 at 10:44 AM, R2's urine culture results were requested from Nursing Home Administrator…

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

Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting the facility's total census of 54 residents who receive meal services (2 nothing by mouth residents, or NPO) out of the facility's total census of 56 residents. Findings include: On 4/23/24 at 11:26 AM, at 11:32 AM and at 12:11 PM, Dietary aide, staff DD, was observed not using a hand barrier to shut off the faucet when done washing their hands. On 4/23/24 at 11:54 AM, the surveyor requested the facility's hand hygiene policy from Dietary Manager, staff AA, to review. At this time the surveyor asked staff AA if they had conducted any trainings with staff on the proper procedure to wash their hands to which they stated, Yes, and we have a sign posted at our sinks. On 4/23/24 at 11:37 AM, and at 11:58 AM, Chef, staff CC, was observed not using a hand barrier to shut off the faucet when done washing their hands. On 4/23/24 at 11:43 AM, Registered Dietitian,…

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 sufficient staff to meet residents' needs, as voiced by 6 resident and family interviews (Resident #19, 41, 42, 50, 167, and 323), from a total sample of 14 residents, resulting in unmet needs. Resident #19 Review of the Face Sheet revealed Resident #19 (R19) was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included difficulty in walking, shortness of breath, repeated falls, and paralytic gait. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/3/24 revealed R19 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). In an observation and interview on 04/23/24 at 2:59 PM, R19 was in her room watching television. R19 reported that she felt staffing was an issue. When asked to explain, R19 stated that at home, her normal routine was to wake up at 6:00 AM, rest in the recliner until 9:00 AM when her home health…

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 and interview the facility failed to provide a safe, functional, and sanitary environment for the facilities census of 56 residents and its staff resulting in an increased potential for harm. Findings include: On 4/23/24 between 2:22 PM, and 2:48 PM, during an environmental tour of the facility the following observations were made: An accumulation of dust and debris was observed on the flooring of the [NAME] Hall's dietary storage closet. Two physical therapy cold compresses were observed stored in the activity room's freezer designated for food storage only. Lift batteries and charging stations were observed being stored in the first and second floor's soiled utility rooms. On 4/23/24 at 2:26 PM, the surveyor inquired Housekeeping Supervisor, Staff EE, on if the lift batteries and charging stations would normally be stored in a soiled utility room to which they replied, I think they always have been, but we can move them to a cleaner area.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain the dignity for 2 (Resident # 42 and 50) of 2 residents reviewed resulting in anger, frustration and the potential for decreased self worth. Findings include: Resident #42 Review of the Face Sheet revealed Resident #42 (R42) was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included multiple fractures of ribs, muscle weakness, orthostatic hypotension (drop in blood pressure upon standing), hemiplegia and hemiparalysis following cerebral infarction affecting non dominant left side (weakness and/or total loss of function on left side of body after experiencing a stroke), bilateral chronic angle closure glaucoma (bulging of the iris resulting in fluid and pressure build up in the eye), and bilateral blepharitis (inflammation of the eyelids). Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/17/24 revealed R42 scored 15 out of 15 (cognitively intact) 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 upon observation, interview and record review, the facility failed to provide repair services for a power wheelchair in a timely manner for one (R19) of one residents reviewed for adaptive equipment, resulting in resident dissatisfaction and reduced resident independence with wheelchair mobility. Findings Include: Review of the Face Sheet revealed Resident #19 (R19) was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included difficulty in walking, shortness of breath, repeated falls, and paralytic gait. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/3/24 revealed R19 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Care Plan revealed R19 required assistance of one staff member for toileting and the use of a hemi walker. On 04/23/24 at 2:59 PM, R19 was observed in her room watching television. R19 was seated in a standard wheelchair. A power wheelchair 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 accurately complete a Minimum Data Set (MDS) assessment for 2 (Resident #s 5 and #22 ) of 14 reviewed for MDS assessments, resulting in the potential for inaccurate care plans and unmet care needs. Resident 5 (R5) Review of the clinical record, including the Minimum Data Set, dated [DATE] reflected R5 was a [AGE] year old female admitted to the facility on [DATE]. MDS section B question 0200 of the MDS reflected R5 had adequate hearing - no difficulty in normal conversation, social interaction, listening to TV. (with or without use of hearing aid or hearing appliances if normally used) and did not use a hearing aid. Section B 0300 Hearing aid or other hearing appliance used was coded as No. On 4/23/24 at approximately 11:00 am R5 was observed resting in bed, R5 initially did not respond to any questions, then stated I cant hear you. Multiple methods attempts were made to interview R5/getting closer, deeper tone etc however R5 was not able…

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 1 (Resident #42) of 14 reviewed, resulting in the potential for unmet care needs and continued falls. Findings include: Review of the Face Sheet revealed Resident #42 (R42) was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included multiple fractures of ribs, muscle weakness, orthostatic hypotension (drop in blood pressure upon standing), hemiplegia and hemiparalysis following cerebral infarction affecting non dominant left side (weakness and/or total loss of function on left side of body after experiencing a stroke), bilateral chronic angle closure glaucoma (bulging of the iris resulting in fluid and pressure build up in the eye), and bilateral blepharitis (inflammation of the eyelids). Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/17/24 revealed R42 scored 15 out of 15 (cognitively intact) on the Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure communication services were available and appropriately utilized by staff for one (Resident #42) of two residents reviewed for communication. Findings include: Review of the Face Sheet revealed Resident #42 (R42) was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included multiple fractures of ribs, muscle weakness, orthostatic hypotension (drop in blood pressure upon standing), hemiplegia and hemiparalysis following cerebral infarction affecting non dominant left side (weakness and/or total loss of function on left side of body after experiencing a stroke), bilateral chronic angle closure glaucoma (bulging of the iris resulting in fluid and pressure build up in the eye), and bilateral blepharitis (inflammation of the eyelids). Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/17/24 revealed R42 scored 15 out of 15 (cognitively intact) on the Brief…

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

Based on observation, interview, and record review the facility failed to ensure appropriate treatment and services for contracture management for one resident (#3) of one resident reviewed. Findings Included: Resident #3 (R3) Review of the medical record demonstrated R3 was admitted to the facility 02/22/2013 with diagnoses that included chronic kidney disease, morbid obesity, macular degeneration, insomnia, bradycardia, depression, hyperlipidemia (high fat content in blood), anxiety, dementia, amputation of the left leg above the knee, acquired club foot,(deformity of the foot when compromised nerve connections o irregular blood vessels in the lower extremity due to injury or illness), peripheral vascular disease (PVD), pain in right leg, atherosclerotic heart disease (buildup of plaque in vessels) , colostomy, hypertension, gastroesophageal reflux, atrial fibrillation, congestive heart failure (CHF), and chronic ischemic heart disease (damage or disease in the heart's major blood vessels). Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent falls for one (Resident #42) of 1 reviewed for falls, resulting in recurrent falls and the potential for serious injury. Findings include: Review of the Face Sheet revealed Resident #42 (R42) was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included multiple fractures of ribs, muscle weakness, orthostatic hypotension (drop in blood pressure upon standing), hemiplegia and hemiparalysis following cerebral infarction affecting non dominant left side (weakness and/or total loss of function on left side of body after experiencing a stroke), bilateral chronic angle closure glaucoma (bulging of the iris resulting in fluid and pressure build up in the eye), and bilateral blepharitis (inflammation of the eyelids). Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/17/24 revealed R42 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental…

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 pain medications were given as ordered for two (resident #45 and #269) of three reviewed, resulting in increased pain and the potential for unmanaged pain. Findings include: Resident #45(R45) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R45 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included breast cancer, bone cancer, secondary cancer of liver and bile duct, chronic pain, stage 3 pressure wound(full thickness tissue loss), hip fracture and malnutrition. The MDS reflected R45 had a BIM (assessment tool) score of 14 which indicated her ability to make daily decisions was cognitively intact. Continued review of the MDS reflected R45 described pain as severe, almost constant pain and received both scheduled and as needed pain medications During an observation on 4/23/24 at 10:05 AM, CNA staff entered R45 room and answered call light. R45 was overheard reporting…

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 proper storage of medications for two residents (Resident #7, 42) out of 56 residents, resulting in the potential for unauthorized access to medications, medication errors, and the potential for adverse reactions/side effects. Findings include: Resident #7 Review of the facesheet revealed Resident #7 (R7) admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnosis which included obstructive sleep apnea and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/22/24 revealed R42 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). In an observation and interview on 04/23/24 at 11:54 PM, R7 was observed in her room and looking out the window. Two inhalers were observed on the bed of R7. R7 reported that they are her inhalers. She has kept them in the top drawer for about 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 observation, interview, and record review, the facility failed to justify the use of an antipsychotic medication for one (Resident #5) of five reviewed. Findings include: Review of the medical record revealed Resident #5 (R5) was admitted to the facility on [DATE] with diagnoses that included, visual hallucinations, adjustment disorder with depressed mood, and dementia. The Minimum Data Set (MDS) with an Assessment Reference Date of 1/5/24 revealed R5 had modified independence with cognitive skills for daily decision making. On 04/24/24 at 2:40 PM, R5 was observed sitting in a wheelchair in her room. R5 was pleasant and carried on a conversation about what she had for lunch that day. Review of the Physician's Order history revealed on 3/30/23 R5 was prescribed 75 mg of Quetiapine (Seroquel-antipsychotic medication) at bedtime for depression with delirium. On 4/11/23, the dose was reduced to 50 mg at bedtime for depression and delirium. On 5/24/23, the dose was further reduced to 25 mg at bedtime for…

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 remove/discard expired ready-to-eat food products, effecting 59 residents that consume meals from the facility kitchen, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness. Findings include: On 01/30/23 at 09:13 A.M., A tour of the food production kitchen was conducted with Chef C, the walk in cooler was observed to have cottage cheese with a Best by used date of 1/15/23 individual cottage cheese cups pre made and ready for delivery were made from that container per Chef C. A large container of Italian dressing was labeled with an open date of 11/23 and a discard date of 12/23. Opened applesauce container with handwritten date of 1/15, box of onions dated 1/17, box oranges dated 12/20, box lemons dated 12/13, box of cucumbers dated 1/24, box pork hand written on outside of the box dated 1/17, in the box 4 separate vacuumed packed packages pf pork was observed. An undated wrapped pre made salad was observed along with a clear plastic container…

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 comfortable room temperatures for 8 residents (#'s1, 39, 114, 117, 118, 119, 256, 268 ) of 8 reviewed for ambient room temperatures and room [ROOM NUMBER]-2, resulting in discomfort of feeling cold and anger. Findings include: Resident#114 According to the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/18/23, Resident 114 (R114) scored 15 of 15 (cognitively intact) on the Brief Interview for Mental Status. During the initial screening process on 1/30/23 that started at approximately 10:00 am, R114 reported his room had not had heat all weekend and he was told by staff that the heating system had been out for days. R114 stated he ate meals in his room and would like to sit near the window for the scenery (there was a fresh snow fall), but could not sit there due to the already frigid room temperature. Upon this surveyor leaving R114's room he requested to leave the door open in the hopes if there was any heat…

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 accurate completion of advance directive information for 1 (Resident #268) of 2 residents reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time) resulting in the potential for a resident's preferences for medical care to not be followed by the facility. Findings include: Review of the MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT, Act 193 of 1996 (Revised 3-25-14), revealed that, An order executed under this section shall be on a form described in section 4. The order shall be dated and executed voluntarily and signed by each of the following persons: (a) The declarant, the declarant's patient advocate, or another person who, at the time of the signing, is in the presence of the declarant and acting pursuant to the directions of the declarant. (b) The declarant's attending physician. (c) Two witnesses [AGE] years of age or older, at least 1 of whom is not the declarant's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake M100134151 Based on observation, interview, and record review, the facility failed to timely identify, investigate, and report an injury of unknown origin to the Nursing Home Administrator, and failed to report the injury of unknown origin to the State Agency for 1 (resident # 8) of 2 residents reviewed for abuse resulting in delayed investigation, identification, and treatment of a fracture and the potential for further injuries of unknown origin to go unreported. Findings include: Resident # 8 (R8) initially admitted to facility 8/4/2021 with most recent facility readmission 1/11/23 with diagnoses including COVID-19, unspecified fracture of left femur, muscle weakness, unspecified atrial fibrillation, embolism and thrombosis of arteries of the upper extremities, and cognitive communication deficit. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/17/23 revealed that R8 had unclear speech, was usually understood and understands, and that a Brief…

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 timely completion of an annual Minimum Data Set (MDS) assessment for one (Resident #5) of 17 reviewed for MDS, resulting in a late MDS assessment and the potential for further late assessments. Findings include: Review of the medical record reflected Resident #5 (R5) admitted to the facility on [DATE], with diagnoses that included delusional disorder and insomnia. On 02/01/23 at 02:20 PM, review of R5's MDS history reflected the annual MDS, with an Assessment Reference Date (ARD) of 8/10/22, was completed on 9/3/22. During an interview on 02/06/23 at 01:10 PM, MDS Licensed Practical Nurse (LPN) FF reported an annual MDS was to be completed within 14 days after the ARD. LPN FF acknowledged R5's annual MDS with an ARD of 8/10/22 was late and was completed on 9/3/22. According to the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October, 2019, .Annual Assessment .The MDS…

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 complete a Significant Change in Status Assessment (SCSA) for one (Resident #13) of 17 reviewed for Minimum Data Set (MDS), resulting in the potential for inaccurate Care Plans and unmet needs. Findings include: Review of the medical record reflected Resident #13 (R13) admitted to the facility on [DATE], with diagnoses that included urinary tract infection, unspecified hearing loss (bilateral/both sides), unspecified dementia and major depressive disorder. On 01/30/23 at 12:28 PM, R13 was observed seated in a recliner, in her room, with her head down and eyes closed. A meal tray was in front of her with the plate cover still on. The plastic wrapper was still covering her plate with cheesecake. Lids were observed on her beverage cups. The Admission/Medicare 5 day MDS, with an Assessment Reference Date (ARD) of 6/26/22, reflected R13 scored 11 out of 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 ensure the Minimum Data Set (MDS) assessment was coded to accurately reflected the resident's status for one (Resident #5) of 17 reviewed for MDS, resulting for the potential for inaccurate Care Plans and unmet needs. Findings include: Review of the medical record reflected Resident #5 (R5) admitted to the facility on [DATE], with diagnoses that included delusional disorder and insomnia. R5's medical record revealed a Preadmission SCREENING (PAS)/ANNUAL RESIDENT REVIEW (ARR) Level I Screening (form DCH-3877), dated 3/14/22, which reflected R5 was marked as having a current diagnosis of mental illness and had received treatment for mental illness. A Comprehensive Level II Evaluation, with a submission date of 3/21/22, was noted in R5's medical record. An attached letter reflected a Level II Evaluation was needed by 3/27/23 if R5 remained in the nursing facility. R5's annual MDS, with an ARD of 8/10/22, revealed question A1500 for, Preadmission Screening…

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 one (Resident #36) of 17 residents reviewed, resulting in the potential for additional skin breakdown as well as unmet care needs and services. Findings include: Resident # 36 (R36) was initially admitted to facility 12/20/22 with diagnoses including osteomyelitis of vertebra, dysphagia, COVID 19, muscle weakness, age related osteoporosis, type 2 diabetes mellitus, unspecified severe protein-calorie malnutrition, malignant neoplasm of female breast, and malignant neoplasm of esophagus. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/26/22 revealed that resident was understood and understands with a Brief Interview for Mental Status (BIMS) score of 14. Section G of MDS revealed that R36 required 2-person extensive assist with bed mobility and toilet use, 2-person limited assist with transfers, 1-person extensive assist with dressing, eating, and personal…

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 and interview, the facility failed to ensure one of six medication carts and two of four medication rooms reviewed were free of expired medications resulting in the potential for decreased medication efficacy and adverse side effects. Findings include: On 2/1/23 at 10:29 AM, [NAME] Hall Medication Cart was reviewed in the presence of Licensed Practical Nurse (LPN) FF. During the review, it was noted that R26 had an Insulin Lispro (Humalog) Kwikpen with the date opened indicated to be 12/26/22 and an Erythromycin 0.5% (percent) Eye Ointment with the date opened indicated to be 10/13/22. In an interview with LPN FF at the time of the medication cart review, LPN FF referenced the Omnicare Insulin Storage Recommendation Sheet that was found within a white binder on the medication cart that indicated that a Humalog Kwikpen was good for 28 days at room temperature after opening. During the same interview, LPN FF stated that she would have to double check but believed that all eye ointments were…

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.

During observation, interview, and record review the facility failed to change oxygen tubing and nebulizer oxygen mask for one resident (#26) and failed to keep a urinary collection bag off the floor for one resident (#6) out of a facility census of 67 residents reviewed for infection control standards resulting in an increased risk of residents acquiring facility acquired infections. Findings included: Resident #26 (R26) Review of the medical record revealed R26 was admitted to the facility 09/11/2020 with diagnoses that include abdominal aortic aneurysm (enlargement of aorta) , disorder of bone, dysphagia (difficulty swallowing),hematuria (blood in urine), anemia (low red blood cells), hypomagnesemia (low magnesium levels in blood), anxiety, type 2 diabetes, epilepsy (disrupted nerve cell activity in brain), neuromuscular dysfunction (dysfunction of muscle), morbid obesity, sever protein-calorie malnutrition, depression, thoracic aortic ectasia (enlargement of aorta), chronic pulmonary edema, chronic respiratory failure, diverticulosis (small pouches in digestive tract), abscess…

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 offer COVID-19 Immunization and obtain complete declination for COVID-19 Immunization for one resident (#4) out of 5 residents reviewed for vaccinations resulting in the potential for miscommunication and misunderstanding of resident COVID-19 Immunization preferences. Findings Include: Resident #4 (R4) Review of the medical record revealed R4 was originally admitted to the facility [DATE] and re-admitted to the facility [DATE] with diagnoses that include senile degeneration of brain, vertigo (feeling of spinning), arthropathic psoriasis (form of arthritis), encephalopathy (brain disease), sever protein calorie malnutrition, angina pectoris (chest pain), neuromuscular dysfunction of bladder, atherosclerotic heart disease, hypotension (low blood pressure), congestive heart failure (CHF), insomnia, type 2 diabetes, hyperlipidemia (high levels of fat in the blood), major depression, anxiety, atrial fibrillation, and gastro-esophageal reflux disease. 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.