Majestic Care of Battle Creek

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food in the kitchen. Findings include: During an initial tour of the kitchen, at 9:12 AM on 10/27/24, observation of the two door Delfield refrigeration unit found the following items: a container of hot dogs dated 10/24 to 11/7, an open container of sliced smoked ham with no date, a saran wrapped chunk of ham with no date, an open container of strawberry sauce dated 10/13 to 10/19, a ziplock bag of bratwurst dated 10/18 to 11/18, and a bag of shredded lettuce dated 10/26 to 11/1 with a manufacture best by date of 10/28/24. An interview with [NAME] F, at 9:15 AM on 10/27/24, asking how many days are usually given to items like brats and hot dogs, [NAME] F stated it should be seven days, I would throw them away. According to the 2017 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, 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 This Citation Pertains to Intake #M00145852 Based on observation, interview and record review the facility failed to provide consistent and accurate activity calendars and failed to provide meaningful, diverse and engaging activity programs for one resident (#30) of three residents reviewed and 6 of 8 residents from confidential group meeting. Resident #30 Review of the clinical record including the Minimum Data Set (MDS) dated [DATE] Resident # 30 (R30) was admitted to the facility on [DATE] with diagnoses that included, major depression, hemipelaigia and hemiparesis. Review of the MDS reflected R30 scored 15 out of 15 (cognitively intact) on the Brief Interview Mental Status (BIMS), further review of the MDS reveled R30 had clear speech and adequate hearing. On 10/27/24 at 11:23 AM, during a bedside interview R30 was observed in bed and reported he was bored as the facility offers little to no activities, R30 reported there had been no Activity Director or Activity Aid in a month and they were employed at the…

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

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing and failed to protect clean and sanitary supplies from possible wastewater contamination. This deficient practice has the potential for the growth and transmission of Legionella in the circulating water of the building and the spread of Legionella infections, and potential contamination of clean supplies, affecting all residents. Findings include: During a tour of the facility, at 10:10 AM on 10/27/24, an observation of the small shower room found a shower fixture on the wall with no direct spigot or faucet found to dispense the water. Upon momentarily turning on the handle, water could be heard coming out of a fixture in the wall. During an interview with Maintenance Director (MD) H,at 11:08 AM on 10/27/24, it was found that he flushes all empty rooms on a weekly basis. During a tour of the nourishment room behind the nurse's station, at 11:10 AM on 10/27/24, it was observed that two…

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 required transfer and discharge documentation was completed for one (Resident #20) of two residents reviewed for discharge. Resulting in the potential for ineffective or mismanaged continued care, as care plan goals were omitted from the transfer paperwork. Findings include: Resident #20 (R20) Review of the medical record reflected R20 was an initial admission to the facility on [DATE] with a readmission on [DATE]. Diagnoses of Parkinsons Disease, Diabetes Mellitus, Dementia, Cardiac Arrhythmias, Anxiety, Chronic Pain and weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/2024, revealed R20 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R20 requires minimal assistance with personal care. During an interview on 10/27/24 at 12:27 PM, R20 stated the last time she was in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a written copy to one (Residents #20) of two residents of the reason for transfer/discharge to the hospital in a language that was understandable, resulting in potential for lack of understanding and knowledge. Findings Include: Resident #20 (R20) Review of the medical record reflected R20 was an initial admission to the facility on [DATE] with a readmission on [DATE]. Diagnoses of Parkinsons Disease, Diabetes Mellitus, Dementia, Cardiac Arrhythmias, Anxiety, Chronic Pain and weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/2024, revealed R20 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R20 requires minimal assistance with personal care. During an interview on 10/27/24 at 12:27 PM, R20 stated the last time she was in the hospital, she was admitted with a urinary tract…

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 a written copy to one (Resident #20) of two residents reviewed for bed hold notification in a language that was understandable, resulting in potential for lack of understanding and knowledge for and what the bed hold policy entailed. Findings include: Resident #20 (R20) Review of the medical record reflected R20 was an initial admission to the facility on [DATE] with a readmission on [DATE]. Diagnoses of Parkinsons Disease, Diabetes Mellitus, Dementia, Cardiac Arrhythmias, Anxiety, Chronic Pain and weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/2024, revealed R20 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R20 requires minimal assistance with personal care. During an interview on 10/27/24 at 12:27 PM, R20 stated the last time she was in the hospital, she was admitted…

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

Based on interview and record review, the facility failed to ensure the Preadmission Screening (PAS)/ Annual Resident Review (ARR) form for Mental Illness (MI)/ Intellectual Disability (ID)/ Related Conditions Identification (DCH-3877) document was timely completed and sent to the local state agency for an evaluation for a Level II determination for one residents (R18) of one residents reviewed for PASARRs. Findings include: Findings include: On 10/28/24 at 10:30 AM R18 was observed sitting in a wheelchair in the hallway; greeting staff and residents by name as they came by. Review of the Electronic Medical Record (EMR) revealed R18 had an original admission date of 3/8/23. R18 had the following diagnoses: Quadriplegia (a paralysis that affects all limbs), Schizoaffective Disorder; Bipolar Type (a psychotic condition which causes fluctuation of mood), Major Depressive Disorder, Anxiety Disorder, and Dementia (a chronic condition that causes a decline in mental abilities). The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/5/24 revealed R18 scored 15 out of 15…

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 baseline care plans were developed within 48 hours of admission for one of 13 residents (Resident #41) resulting in the potential for unmet care needs. Findings included: Per the facility R41 was admitted to the facility on [DATE]. Diagnoses included dyskinesia (disorder of the esophagus) and dysphasia (difficulty in swallowing). Record review of R41's nutrition care plan revealed that it wasn't until 10/1/2024, six days after R41 was admitted , that a plan of care was put into place. R41's nutritional care plan revealed, presents with potential for nutritional risk related to acute metabolic encephalopathy (brain disease), UTI (urinary tract infection) chronic dysphasia. DX: MDD (diagnosis major depression disorder), anxiety, seizures, CKD (kidney disease) HLD increase lipids), chronic gastritis, vit D deficiency, hypothyroidism, sarcopenia (loss of muscle/strength). Mechanically altered diet affecting her oral intake. Date Initiated:…

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 revise timely, individualized care plans for one (Resident #25) of 13 residents reviewed for care planning, resulting in the potential for inadequate/inappropriate care and this resident not maintaining or achieving their highest practical physical well-being. Resident #25 (R25) Review of the medical record reflected R25 was an initial admission to the facility on [DATE] with a readmission on [DATE]. Diagnoses of Diabetes Mellitus with foot ulcer, restless leg syndrome, non-pressure related ulcers of the right foot with necrosis, Peripheral Vascular Disease and Chronic Kidney Disease. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/30/2024, revealed R25 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R25 requires stand by assistance to independent with personal care. During an interview on 10/27/24 at 01:27…

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 have an emergency tracheostomy readily available for 1 (R9) of 1 resident reviewed for tracheostomy care, resulting in the potential for a delay in needed action in the event of an emergency tracheostomy dislodgement. Findings include: On 10/27/24 at 10:42 AM R9 was observed resting in bed with a relaxed facial expression and breathing quietly through a tracheostomy which appeared intact and clean. Review of the electronic medical record (EMR) revealed R9 had an original admission date of 1/11/23 and a last admission date of 4/6/23. R9 had the following pertinent diagnoses: Chronic Respiratory Failure with Hypercapnia (breathing difficulty due to a high level of carbon dioxide) and Tracheostomy status (dated 2023). (A tracheostomy is a surgically created opening in the neck for access to the windpipe) On 10/28/24 at 9:25 AM during observation of tracheostomy care and after completion of care, Licensed Practical Nurse (LPN) J searched for the emergency tracheostomy. LPN J searched through the equipment on R9'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 Based on interview, observation and record review, facility failed to ensure one (resident#20) of one resident was assessed to safely self-administer medications. Resident #20 (R20) Review of the medical record reflected R20 was an initial admission to the facility on [DATE] with a readmission on [DATE]. Diagnoses of Parkinsons Disease, Diabetes Mellitus, Dementia, Cardiac Arrhythmias, Anxiety, Chronic Pain and weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/2024, revealed R20 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R20 requires minimal assistance with personal care. During an interview and observation on 10/28/24 at 09:00am, R20 had her morning medication brought into her room by Licensed Practical Nurse (LPN) N, who handed R20 a med cup with 14 pills in it. R20 asked LPN N for some applesauce to swallow the one of the large pills. LPN N left the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure proper communication/documentation of Hospice services provided to one (Resident #45) of one residents reviewed for Hospice services, resulting in a lack of coordination of comprehensive services and care provided Resident #45 (R45) Review of the medical record reflected R45 was an initial admission to the facility on [DATE] with a readmission on [DATE] and then signed up for hospice services on 08/26/24. Diagnoses of Chronic Kidney Disease, Bacteremia, Osteomyelitis, Methicillin Susceptible Staphylococcus, Diabetes Mellitus, Pressure Ulcer of Sacral Region. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/16/2024, revealed R45 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R45 requires maximum assistance to dependent with personal care. During an interview and observation on 10/28/24 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 This citation pertains to MI00143615. Based on observation, interview and record review, the facility failed to ensure bathing and grooming was provided according to resident preferences for three (Resident #1, #2 and #6) of eight reviewed for hygiene and grooming. Findings include: Resident #1 (R1): Review of the medical record reflected R1 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included unspecified dementia, diabetes and left side hemiplegia. The modification annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/14/24, reflected R1 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had upper and lower extremity impairments on one side of the body. On 4/25/24 at 10:37 AM, R1 was observed lying in bed, wearing a hospital gown. R1 reported she had gone for about one month without her hair being brushed by male staff members. Her hair then had to be cut with scissors, by a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to MI00143615. Based on observation, interview and record review, the facility failed to ensure safe smoking practices for three (Resident #8, #9 and #14) of three reviewed for smoking. Findings include: Resident #8 (R8): Review of the medical record reflected R8 admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/11/24, reflected R8 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 4/26/24 at 10:03 AM, R8 was observed seated on the left side of his bed, with a bag of tobacco in his lap, rolling cigarettes. He stated he knew it was a non-smoking facility, but they did allow him to roll cigarettes inside when it was windy or rainy. R8 reported he kept the tobacco in the top drawer of his night stand. R8 stated his lighter stayed in his pocket at all times. He reported he used to have to turn his cigarettes and lighter in, but the facility lost two packs 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 provide sufficient staff to meet residents needs in seven of eight reported during a confidential Resident Council meeting, and in four of 14 sampled residents (Resident #8, #14, #18 & #252), in a census of 46 residents, resulting in the potential for unmet care needs. Findings include: During a confidential resident council meeting held on 10/16/2023 at 1:30 PM, six of eight residents reported that staff did not respond to call lights timely, sometimes they turn it off without helping or saying anything and they leave. These residents stated that this occurred mainly in the evening and these staff say they don't want to do it and it's not my job. The residents also stated that sometimes the light was on, and staff stand around talking and didn't respond timely. Seven of eight residents reported that they have waited for 30 minutes or more for their call light to be answered, especially on evenings or weekends after management goes home.…

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: (1) effectively date and label cooked food put in the refrigerator, (2) effectively testing and maintaining the three-sink log with correct temperatures and sanitizing times and date effecting 46 residents, resulting in the increased potential for resident foodborne illness. During an observation and interview on 10/15/23 at 09:18 AM with the initial tour of the kitchen, a bowl of a brown substance was located in the refrigerator without a label and no date on the clear wrap over the bowl. Bowl was removed and disposed of by [NAME] L. During this same observation and interview, the three-sink dish washing log was already filled out with all three temperature checks for the whole day under date of 10/15/23. Dietary aide K stated, Oh I must have got confused when I was checking the off the water temperature and sanitation solution levels. Observed K tape the testing trip to the log, then getting some white white-out solution to white out the latter two entries for the day that he had documented on without…

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 promote resident dignity while dining for two of 46 residents reviewed for dining (Resident #8 & #51) resulting in decreased quality of life. Findings include: Resident #8 (R8) On 10/15/23 at 11:52 AM, Certified Nurse Assistant (CNA) G was observed assisting R8 with lunch in the assisted dining room. CNA G was observed standing while feeding R8. R8's annual Minimum Data Set (MDS) assessment with an assessment reference date of 6/30/23 indicated she was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS), a short performance based cognitive screener, score of 07 (00-07 Severe Impairment). The same MDS revealed R8 had a diagnosis of Dementia and was independent in eating with set up help only. Resident #51 (R51) Review of the medical record revealed Resident #51 (R51) was initially admitted to the facility on [DATE] and then re-admitted on [DATE] with diagnoses that included Bilateral primary osteoarthritis…

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 level I Preadmission Screening/Annual Resident Review (PASARR) for one (Resident #22) of one residents reviewed for PASARR, resulting in the potential for lack of appropriate mental health treatment and services. Findings include: Resident #22 (R22) R22's annual Minimum Data Set (MDS) dated [DATE] revealed he was admitted to the facility on [DATE] and had a brief interview for mental status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 04 (00-07 Severe Impairment). The same MDS assessment indicated R22 had the diagnoses of Non-Alzheimer's dementia, depression, and Bi-polar disorder. Review of the physician signed 3878 dated 10/12/21, R22 was admitted to the facility on a 30-day exemption. There was no other documentation in R22's medical record. R22's PASARR Level 1 dated 10/11/21 indicated it was a Hospital exempted discharge and R22 was expected to require nursing home services 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.

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 2 (Resident #6 and #14) of 14 residents reviewed resulting in the potential for unmet care needs. Findings include: Resident #6(R6) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R6 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included alzheimers dementia, heart disease, hypertension (high blood pressure), diabetes, chronic obstructive pulmonary disease, and depression. The MDS reflected R6 had a BIM (assessment tool) score of 3 which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with bed mobility, dressing, toileting, eating, hygiene, bathing and two person physical assist with transfers. The MDS reflected R6 did not have any behaviors including rejection of care. During an observation on 10/15/23 at 10:42 AM, R6 was observed in bed with hospital gown on,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to revise resident care plans in three of 14 residents reviewed for care plans (Resident #12, #13, & #28), resulting in the potential for unment needs. Findings include: Resident #13 (R13) R13 was observed lying in bed on 10/15/23 at 1:47 PM, R13 was not wearing dentures, and stated he didn't have dentures. R13's Minimum Data Set (MDS) assessment with assessment reference date (ARD) of 9/30/23 indicated he admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 09 (08-12 Moderate Impairment). The same MDS indicated R13 was edentulous (did not have natural teeth or tooth fragments). In review of dental consult dated 7/12/23, R13 had ill fitting dentures, and recommended that the resident ask for some adhesive in the facility, to help with suction for the upper and lower denture. In review of R13's dental health problem care plan dated 10/14/23, R13 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 provide for one out of three Residents sampled (Resident #12), resulting in the potential for decline in skin integrity without ability to perform own activities of daily living (ADL's). Resident #12 (R12). Review of the medical record revealed Resident #12 (R12) was initially admitted to the facility on [DATE] and then re-admitted on [DATE] with diagnoses that included Chronic respiratory failure, heart failure, chronic obstructive pulmonary disease, obesity, diabetes, blind in both eyes and oxygen dependent. According to Resident #12 (R12)'s Minimum Data Set (MDS) dated [DATE], revealed R12 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R12 requires maximum assistance with all activities of daily living. During an observation on 10/16/23 at 07:54 AM, R12 was sleeping sitting in her wheelchair up against her bed, did not sleep in her bed. R12's had…

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 residents received assistance with care according to their care plans for 1 residents(R6) of 3 residents reviewed for activities of daily living (ADL's), resulting in the increased likelihood for inadequate hygiene and grooming and feelings of embarrassment. Findings include: Resident #6(R6) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R6 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included alzheimers dementia, heart disease, hypertension (high blood pressure), diabetes, chronic obstructive pulmonary disease, and depression. The MDS reflected R6 had a BIM (assessment tool) score of 3 which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with bed mobility, dressing, toileting, eating, hygiene, bathing and two person physical assist with transfers. The MDS reflected R6 did not have any behaviors…

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 arrange ophthalmology services in one of one reviewed for vision services (Resident #14) resulting in decreased quality of life. Findings include: Resident #14 (R14) On 10/15/23 at 12:42 PM, R14 was observed sitting up in bed and stated she needed glasses and would like to see the eye doctor. R14 stated she had cataracts and that her vision was impaired. R14's Minimum Data Set (MDS) assessment, with assessment reference date (ARD) of 9/21/23 indicated she was admitted to the facility on [DATE]; and had a Brief Interview for Mental Status, a short performance-based cognitive screener for nursing home residents score of 15 (13-15 Cognitively Intact). During an interview on 10/16/23 at 10:02 AM, Social Services E was interviewed and stated R14 was on the list to see the eye doctor on the same day as the interview. In review of eye exam notes dated 03/06/23, R14 received a comprehensive eye exam and was referred to follow up with a cornea…

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 implement pharmacy recommendations in one of five residents reviewed for medication regimen (Resident #33), resulting in the potential for an oral infection. Findings include: Resident #33 (R33) R33's Minimum Data Set (MDS) dated [DATE] revealed she was admitted to the facility on [DATE] and had a brief interview for mental status (BIMS), a short performance based cognitive screener for nursing home residents, score of 02 (00-07 Severe Impairment). Note to Attending Physician/Prescriber dated 7/12/23 indicated R33 received Budesonide-Formoterol aerosol, 2 puffs twice daily for Asthma. Pharmacist recommended to consider adding to the order rinse mouth with water and spit back into cup after use to prevent an infection from the steroid component, the same document indicated the physician agreed with the pharmacist's recommendation and was signed by the physician on 7/17/23. In review of R33's physician orders and care plans, the pharmacist recommendation…

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 properly store and secure Schedule II controlled drugs in one of one medication room reviewed for medication storage, resulting in the increased likelihood medication errors and/or diversion. During an interview on 10/15/23 at 4:09 PM, Licensed Practical Nurse (LPN) U reported the facility had four medication carts and one medication room. During an observation on 10/16/23 at 1:44 PM, the Hall A treatment cart was located in the hall , unlocked with no staff in the area until 2:10 p.m. During an observation and interview on 10/17/23 at 9:36 AM, Registered Nurse(RN) T unlocked the medication room and reported nurses and the DON had keys to the medication room. An unlock box was observed in the unlocked refrigerator with a 30 mg bottle of liquid Xanax(controlled medication) for R 36. RN T verified the box was unlocked and should be locked because controlled medications were required to be double locked and was observed locking box with key. RN T reported central supply staff stocked medication room. During 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 interview and record review, the facility failed to ensure residents/resident's guardians understood the purpose of binding arbitration agreements (an out-of-court alternate form of dispute resolution) for 2 residents, (R37 and R252) of 4 residents reviewed for arbitration, resulting in the residents and/or their representatives to not be informed of their rights. Findings include: During an interview on 10/17/23 at 8:35 AM, NHA A reported residents not required to sign arbitration agreement but have the option to. Informed NHA A had requested list of residents who had signed but had not received list. NHA A reported was unsure how to obtain list but would follow up. NHA A reported no residents had entered into the agreement. NHA A reported the admission staff completed admission documents with each resident but was currently suspended. NHA A reported plan for Business office Manager to complete in her absence at that time. NHA A reported most recent admission was R252 from the the weekend. Review 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 in perform hand hygiene per Centers for Disease Control Prevention recommendations and administer eye drops using best practices, in 3 of a census of 46 residents reviewed for infection control practices (Resident #14, #18, & #32), resulting in the potential for the spread of infections. Findings include: Resident #18 (R18) Licensed Practical Nurse (LPN) Q was observed administering eye drops to R18 on 10/16/23 at 7:31 AM during medication pass. LPN Q placed the cap of artificial tears down on the over the bed table while administering the eye drops. There was no barrier placed or cleaning of the table prior to eye drop administration. Resident #14 (R14) R14's Minimum Data Set (MDS) assessment, with assessment reference date (ARD) of 9/21/23 indicated she was admitted to the facility on [DATE]; and had a Brief Interview for Mental Status, a short performance-based cognitive screener for nursing home residents score of 15 (13-15 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.