Pinnacle Care of Battle Creek

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes 1194799 and 2564904.Based on observation, interview and record review, the facility failed to protect the resident's (R1's) right to be free from sexual abuse by R2.Findings include: R1:Review of the medical record reflected R1 admitted to the facility on [DATE], with diagnoses that included Parkinson's and dementia. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/9/25, reflected R1 scored zero out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and required supervision or touching assistance for walking. On 9/10/25, at 9:12 AM, R1 was observed lying in bed, awake. She acknowledged having friends at the facility but did not know their names. R2 denied concerns pertaining to interactions with other residents.R2:Review of the medical record reflected R2 admitted to the facility on [DATE], with diagnoses that included Alzheimer's. The Annual MDS, with an ARD of 6/20/25, reflected R2…

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: (1) effectively clean and maintain food service equipment, and (2) effectively date mark all potentially hazardous ready-to-eat food products effecting 61 residents who consume food, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness. Findings include: On 05/05/25 at 09:10 A.M., An initial tour of the food service was conducted with Dietary Head [NAME] (DHC) K. The following items were noted: One gallon (one-sixteenth full) of Kemps Select 2% Milk was observed, within the Arctic Air 2-door reach-in cooler, without an effective open or discard date. The manufacturer's use-by-date read 5-15-25. One gallon (one-eighth full) of Kemps Select Whole Milk was observed, within the walk-in cooler, without an effective open or discard date. The manufacturer's use-by-date was observed to read 5-15-25. The 2022 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12,…

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 maintain an effective Quality Assurance and Performance Improvement program that identified areas of focus and improvement in a current facility census of 61 residents. Findings Included: During the survey a concern was identified at an Immediate Jeopardy level regarding hot water temperatures in which the facility was unaware off. Also, it was identified during the survey a concern of accommodation of resident needs regarding call light accessibility. Review of resident council meeting minutes, dated 3/5/2025, revealed a concern was brought up regarding not having hot water in the resident rooms. The facility's response was to check the hot water temperatures, and to also check them weekly. Review of QAPI minutes revealed no further discussion of weekly hot water temperatures, nor were any documented logs noted. In an interview on 5/08/2025 at 2:35 PM, Administrator A was not able to verify that a QAPI meeting had been held for the month of April 2025. Administrator A stated that she had no idea if there had been QAPI…

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

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 61 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased air quality, and potential cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies. Findings include: On 05/06/25 at 09:20 A.M., A common area environmental tour was conducted with Environmental Services Director (ESD) E. The following items were noted: South Unit Occupational Therapy/Physical Therapy: The wall mounted grab bar, located directly in front of the wheelchair scale, was observed loose-to-mount. 2 of 2 oval shaped mobile swivel chair cushions were also observed (etched, scored, particulate). 1 of 2 chair cushions were additionally observed with green duct tape covering the damaged vinyl surface. (ESD) E indicated she would have staff repair the loose-to-mount grab bar and remove the damaged chairs as soon as possible. Shower Room: 2 of 2 shower wand assemblies were observed missing an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure six out of 15 residents (Resident # 4, 7, 23, 26, 46 & 134) had call lights that were accessible. Findings Included: Resident #4 (R4): During an interview on 5/05/2025 at 10:42 AM, Resident #4 (R4) was observed in bed. The call light was observed to be hanging out of reach of R4. R4 was alert and able to answer questions. R4 stated that he does not have a call light, but there was one hanging on the wall. It was then observed that a call light was wrapped around the call light outlet box that was on the wall. The call light was not within reach of R4, and R4 stated he was not able to reach the call light, and also stated he never used that call light. During the same interview it was observed that a bell was on R4's over the bed table, and upon asking R4 the reason for the bell, R4 stated it was so he could ding it to get someone to come in his room when he needed assistance. R4 said, but said they (staff) never hear it, so he gets…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #67 (R67) Review of the medical record revealed R67 was admitted to the facility on [DATE] with diagnoses that included diabetes, quadriplegia, anxiety, and atrial fibrillation. The Discharge Minimum Data Set (MDS) with an Assessment Reference Date of 4/6/25 revealed R67 was independent with cognitive skills for daily decision making and had an unplanned discharge to the hospital with a return not anticipated. Review of hospital records from prior to admission revealed a wound assessment dated [DATE] which revealed an abdominal wound to the left lower quadrant. The wound measured 3.5 centimeters (cm) long x 15 cm wide x 1 cm deep. The wound had moderate serous: thin, water, clear drainage. Wound management was listed as Negative Pressure Wound Therapy (NPWT/wound vacuum assisted closure [vac]). Another assessment dated [DATE] revealed a second wound on the midline abdomen measuring 12 cm long. The wound was approximated with sutures and moderate amount of serosanguineous: thin watery, pale red/pink…

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 On 5/7/25 at 12:24 PM, during a confidential Resident Council meeting, when asked if the residents get the help and care they need without waiting a long time and if staff respond to their call lights timely, responses included: One resident laughed and replied not on nights Usually takes at least a half an hour. Staff turn off call lights and don't take care of the need. It depends on who is working, with certain people I have to wait 45 minutes When asked if there is enough staff, 10 of 10 residents responded no and provided the following responses: We are always short that is why we have to wait so long for call lights. Nights is worse. Good luck getting something done after 6pm (resident mentioned specific concerns with delay in getting brief changed) Based on observation, interview and record review, the facility failed to ensure sufficient nursing staff to respond to resident needs timely for three (R2, R25 and R37) and the Resident Council, from a census of 61 residents. Findings include: Resident #2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #9 (R9): Review of the medical record reflected R9 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included dementia, major depressive disorder, insomnia, Alzheimer's and psychotic disorder with delusions. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/31/25, reflected R9's cognition and mood were not assessed. R9's medical record did not reflect evidence that monthly Pharmacy Medication Regimen Reviews had been conducted for July 2024, August 2024, September 2024, October 2024 and March 2025. On 05/07/25 at 12:59 PM, an email request was sent to Nursing Home Administrator (NHA) A and Director of Nursing (DON) B for monthly Pharmacy Medication Regimen Reviews, Pharmacy recommendations and follow-up actions for R9 since 5/1/24. On 05/07/25 at 2:28 PM, DON B reported if the Pharmacy Medication Regimen Reviews were not in the medical record, they did not have them. During a phone interview on 05/08/25 at 11:59 AM, Pharmacist Z reported their…

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 medications were properly labeled and stored per professional standards of practice for two residents (R35 and R36) and a medication cart in a current facility census of 61 residents. Findings Included: During an observation of a medication administration on 5/06/2025 at 8:10 AM, Registered Nurse (RN) EE was observed to obtain an iron pill from a bottle to administer to a resident. RN EE was asked why was the observed handwritten date on the bottle there, RN EE stated she did not know other than the nurse were to write the date of the bottle being opened, but stated it meant nothing. A review of the bottle of iron revealed the bottle did not have a manufacture's expiration date on the bottle. RN EE was asked what needed to have been done with the bottle of iron, seems it was not possible to know the expiration date of the iron pills, in which RN EE stated that she would give the iron to the resident because that was what she was…

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

Based on interview and record review the facility failed to consistently offer bedtime snacks to nine of ten residents who attended the confidential Resident Council Meeting. Findings include: On 5/7/25 at 12:24 PM, during the confidential Resident Council meeting, when asked if residents were offered snacks at bedtime, nine of ten reported that snacks were not offered and they would like them. Responses included: No bedtime snacks. They do not offer every night, it is rare when they come in and offer (several residents nodded in agreement or verbalized agreement) They don't always have snacks available. I use to get cottage cheese but they don't have a variety of snacks anymore, mostly only peanut butter sandwiches. The previous kitchen staff use to be really good at asking and offering snacks every night. A review of the resident council meeting minutes revealed the following: January 2, 2025 Please describe the concern: snacks at night February 5, 2025 Please describe the concern: not getting snacks at night On 5/8/25 at 10:48 AM, during an interview with dietary cook JJ, she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to effectively maintain the resident call system effecting 61 residents, resulting in the increased likelihood for delayed emergency response and/or negative resident outcomes. Findings include: On [DATE] at 02:01 P.M., The resident call system was monitored for functionality for the following resident rooms: South Unit Resident room [ROOM NUMBER]: Functioning Resident room [ROOM NUMBER]: Functioning Resident room [ROOM NUMBER]: Functioning Resident room [ROOM NUMBER]: Functioning Resident room [ROOM NUMBER]: Functioning Resident room [ROOM NUMBER]: Functioning Resident room [ROOM NUMBER]: Functioning Resident room [ROOM NUMBER]: Functioning Resident room [ROOM NUMBER]: Functioning Resident room [ROOM NUMBER]: Functioning On [DATE] at 02:55 P.M., An interview was conducted with R25 regarding the resident call system provided by the facility. R25 stated: I wish I had the old call system to push. On [DATE] at 12:06 P.M., An interview was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one resident (R38) was treated with dignity and respect out of one reviewed. Findings include: Review of the medical record revealed R38 was admitted to the facility on [DATE] with diagnoses that included: legal blindness, muscle weakness, need for assistance with personal care, anxiety disorder, and depression. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/18/25 revealed R38 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 5/5/25 at 12:34 PM, R38 was observed lying on his back in his bed, speaking with a soft/quiet voice with his eyes closed during most of the interview. R38 reported that his roommate R35 calls him names (dumb son of a b*tch) and is not friendly at all. R38 reported that the facility is aware and that staff have been in the room and witnessed R35 calling him names. On 5/7/25 at 10:32 AM, R35 was asked what he could…

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 obtain and document required informed consent from the resident's guardian prior to administering a psychotropic medication for two (Resident #33, #41) of five reviewed for unnecessary medications. Findings include: Resident #33 (R33) A review of the medical record indicated that Resident #33 was admitted to the facility on [DATE] with diagnoses including major depressive disorder and early-onset Alzheimer's disease. According to the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/31/25, R33 scored 0 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. During an interview conducted on 5/05/25 at 11:14 AM, family member (FM) FF reported concerns regarding the recent administration of the anti-anxiety medication Ativan (Lorazepam) to R33. The family member stated that she had questioned why he was receiving the medication and how long it had been prescribed, noting that the family,…

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 interview and record review, the facility failed to ensure the accuracy of code status information for one (R36) of one reviewed for advance directives. Findings include: Review of the medical record reflected R36 admitted to the facility on [DATE], with diagnoses that included hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, vascular dementia and chronic kidney disease. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R36's cognitive status was not assessed. According to the medical record, R36 was their own responsible party. Review of the medical record reflected R36's Physician's Order, dated [DATE], reflected they were a full code (full resuscitation/Cardiopulmonary Resuscitation-CPR). Further review of the medical record reflected R36 and two witnesses signed a Do Not Resuscitate (DNR/no CPR) form on [DATE]. 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 personal belongings were available for use for one (Resident #38) of one reviewed for personal belongings, resulting in misplaced personal items. Findings include: Review of the medical record revealed R38 was admitted to the facility on [DATE] with diagnoses that included: legal blindness, muscle weakness, need for assistance with personal care, anxiety disorder, and depression. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/18/25 revealed R38 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 5/5/25 at 12:52 PM, R38 reported that a DVD (digital optical disc) set (of episodes of Law and Order) had been purchased by his daughter and was stolen the same day that it was brought into the facility, the facility is aware and his daughter had completed a form to request the facility remedy the situation about 5 months ago. R38 reported being upset…

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 limit the duration of a PRN (as needed) psychotropic medication to 14 days and/or ensure the physician documented rationale to extend the duration of use for one (Resident #33) out of five reviewed for unnecessary medications. Findings include: Resident #33 (R33) Review of the medical record reflected R33 was admitted to the facility on [DATE], with diagnoses that included major depressive disorder and Alzheimer's with early onset. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/31/25, reflected R33 scored 0 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Medical Record revealed an active Physician order initiated on 3/6/25 for Lorazepam (Ativan-an antianxiety medication) Tablet 0.5 milligrams. Give 1 tablet by mouth every 4 hours as needed for Anxiety. On 05/08/25 at 11:27 AM, Director of Nursing (DON) B reviewed the as needed Ativan order 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 interview and record review, the facility failed to provide the resident/representative with a written notice of transfer/discharge and send a copy to the ombudsman for one (R67) of one reviewed. Findings include: Review of the medical record revealed R67 was admitted to the facility on [DATE] with diagnoses that included diabetes, quadriplegia, anxiety, and atrial fibrillation. The Discharge Minimum Data Set (MDS) with an Assessment Reference Date of 4/6/25 revealed R67 was independent with cognitive skills for daily decision making and had an unplanned discharge to the hospital with a return not anticipated. Review of the Health Status Note dated 4/6/2025 revealed R67 was transferred to the hospital. R67 did not return to the facility. There was no documentation that a written notice of transfer/discharge was provided. In an interview on 05/08/25 at 12:45 PM, Director of Nursing (DON) B reported a transfer/discharge notice would not have been sent to the ombudsman because they were unaware that was 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 accurately complete a comprehensive assessment for one (Resident #20) of 15 residents reviewed. Findings include: Review of the medical record reflected that Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included muscle weakness, contractures of both right and left legs, pressure-induced deep tissue damage of the left heel, dementia, and acute and chronic respiratory failure with hypoxia. The Minimum Data Set (MDS), with an Assessment Reference Date of 02/10/25, reflected that Resident #20 scored 3 out of 15 on the Brief Interview for Mental Status, indicating severe cognitive impairment. Resident #20 was not interviewable. On 05/05/25 at 10:07 AM, Resident #20 was observed seated in the dining room wearing pressure-relieving ankle-foot orthosis (PRAFO) boots on both feet. However, the right boot was nearly detached from Resident #20's foot. During an interview conducted on 05/05/25 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to perform a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for one (R11) of 15 reviewed. Findings include: R11: Review of the medical record reflected R11 admitted to the facility 7/3/14 and readmitted [DATE], with diagnoses that included vascular dementia, dependence on wheelchair and diabetes. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/31/25, reflected R11's cognition and mood were not assessed. The same MDS reflected R11 did not walk, was dependent for transfers and required substantial/maximal assistance with personal hygiene and partial/moderate assistance with rolling left and right. On 05/06/25 at 9:21 AM, R11 was observed seated in a wheelchair, in the hallway, without a seating cushion in the wheelchair. On 05/07/25 at 8:12 AM, R11 was observed seated in a wheelchair, in the hallway, without a seating cushion in the wheelchair. On 05/07/25 at 2:52 PM, R11 was observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #9 (R9): Review of the medical record reflected R9 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included dementia, major depressive disorder, insomnia, Alzheimer's and psychotic disorder with delusions. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/31/25, reflected R9's cognition and mood were not assessed. On 05/06/25 at 1:12 PM, R9 was observed seated in a wheelchair, in their room, watching TV. Section C (Cognitive Patterns) of the Quarterly MDS, with an ARD of 3/31/25, reflected questions C0100 through C1000 were marked with responses of dashes and Not assessed. Section D (Mood) of the same MDS was marked with responses that included Not assessed and Not assessed/no information. In an interview on 05/07/25 at 11:21 AM, Social Worker (SW) C reported R9 could be cranky and unwilling to do things, and their behaviors included refusal of care and lashing out at others. In an interview on 05/08/25 at 10:49 AM, Certified Nurse Aide…

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 a comprehensive Care Plan for one (R11) of 15 reviewed. Findings include: Review of the medical record reflected R11 admitted to the facility 7/3/14 and readmitted [DATE], with diagnoses that included vascular dementia, dependence on wheelchair and diabetes. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/31/25, reflected R11's cognition and mood were not assessed. The same MDS reflected R11 did not walk, was dependent for transfers and required substantial/maximal assistance with personal hygiene and partial/moderate assistance with rolling left and right. On 05/06/25 at 9:21 AM, R11 was observed seated in a wheelchair, in the hallway. Gripper socks were observed on both feet. Rear anti-tip bars and anti-rollback brakes were observed on the wheelchair. A seating cushion was not observed in the wheelchair. Upon entering R11's room, a standard mattress was noted on their bed, 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 conduct a quarterly care conference for one (resident 33) of three residents reviewed for careplanning. Findings include: Review of the medical record reflected R33 was admitted to the facility on [DATE], with diagnoses that included major depressive disorder and Alzheimer's with early onset. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/31/25, reflected R33 scored 0 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). During an interview conducted on 5/5/25, at 11:14 AM, Family Member FF reported recent inconsistencies regarding the care conferences, which are typically scheduled on a quarterly basis. A review of R33's care conference records showed that the last quarterly care conference was held on 12/9/24. The subsequent conference was due in March 2025, however, documentation confirmed that it was not conducted. In an interview on 5/8/25 at 10:56…

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 consistent and meaningful activities, ensure adequate staffing and staff engagement, and maintain accountability for the implementation of scheduled activities for one (Resident #33) out of one reviewed for activities. Findings include: Resident #33 (R33) Review of the medical record reflected R33 was admitted to the facility on [DATE], with diagnoses that included major depressive disorder and Alzheimer's with early onset. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/31/25, reflected R33 scored 0 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). During an interview on 5/05/25 at 11:14 AM, Family Member (FM) FF reported that resident R33 was previously a very active person. The FM expressed concern regarding the current level of activity and engagement available to R33, stating that they were concerned about the activities. FM FF stated…

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 properly adhere to the physician's order for double protein portions for one resident (Resident #20) out of one reviewed for nutrition. Resident #20 A review of the medical record indicates that Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses include heart failure and both acute and chronic respiratory failure with hypoxia. On 05/05/25 at 11:54 AM, Resident #20 was observed seated in the dining room, where their lunch consisted of two chicken tenders, potatoes, and coleslaw. Upon further observation, it was noted that the portion size of Resident #20's meal was consistent with that of the other residents in the dining room. The medical record shows that Resident #20's weight was recorded on the following dates: 2/28/25, 3/1/25, 3/14/25, 4/18/25, and 5/2/25. The recorded weights were as follows: 222.0 pounds on 3/14/25, 211.5 pounds on 4/18/25, and 210.2 pounds on 5/2/25. A Physician's Order dated…

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

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5% for three observed medication errors out of 25 opportunities, resulting in a medication error rate of 12%. Findings Included: During an observation of a medication administration on 5/06/2025 at 8:10 AM, Registered Nurse (RN) EE was observed to obtain an iron pill from a bottle to administer to a resident. RN EE was asked why was the observed handwritten date on the bottle there, RN EE stated she did not know other than the nurse were to write the date of the bottle being opened, but stated it meant nothing. A review of the bottle of iron revealed the bottle did not have a manufacture's expiration date on the bottle. RN EE was asked what needed to have been done with the bottle of iron, seems it was not possible to know the expiration date of the iron pills, in which RN EE stated that she would give the iron to the resident because that was what she was supposed to do, but said she did not know the expiration date of the iron pills. RN EE was observed to…

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 oxygen tubing was changed every seven days for one out of two residents (Resident #61). Findings Included: In an observation on 5/05/2025 at 12:25 PM, an oxygen concentrator (tank that delivers oxygen) was observed to be on. Tubing was observed to go from the tank to Resident #61's (R61) nose and was administering oxygen to the R61. The tubing was observed to have a tapped label on it which had a date of 4/20/2025. In another observation on 5/07/2025 at 3:07 PM, R61 was observed to have the same oxygen tubing in place as observed on 5/5/2024 and was still labeled 4/20/2025. In an interview on 5/07/2025 at 3:45 PM, Infection Control Preventionist (ICP), who was also a Registered Nurse (RN) J stated that she did not monitor and track the use of oxygen tubing via the infection control program. ICP/RN J stated she did not perform audits to ensure oxygen tubing was being changed every seven days. In an interview on 5/07/2025 at 3:59 PM, the Director of Nursing (DON) B stated the oxygen tubing was to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document education provided regarding the benefits and potential side effects of the pneumococcal immunization for two (R2 and R22) of five reviewed. Findings include: Resident #22 (R22) Review of the medical record revealed R22 admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD) and diabetes. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/23/25 revealed R22's cognitive skills for daily decision making were not assessed. The MDS with an ARD of 12/21/24 revealed R22 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Pneumonia Vaccine Consent Form revealed R22 declined the pneumonia vaccine on 5/9/24. Review of the Nurses Note dated 8/28/24 revealed PCP [primary care physician] ordered pneumonia immunization, resident consented . R22 received the pneumonia vaccine on 8/30/24. The medical record…

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 MI00150826. Based on observation, interview, and record review, the facility failed to provide activities of daily living (ADL) assistance for two residents (Resident 14 and Resident 21) of three residents reviewed. Findings include: Resident #14 (R14) Review of the medical record revealed Resident #14 (R14) was admitted to the facility on [DATE] with diagnoses that included depression, need for assistance with personal care, reduced mobility, and muscle weakness. The Minimum Data Set (MDS) with an Assessment date (ARD) of 12/15/25 revealed R14 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) and required substantial/maximal assistance with showering. On 4/9/25 at 12:38 PM, R14 was observed sitting in his power scooter, with stubble on his face and food/debris on his shirt and coat. R14 reported that he had been trying to get staff to shave him for at least 3 days and that he gets a shower about once per week, which he reported is an improvement…

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 MI00151617 and MI00150826 Based on observation, interview, and record review, the facility failed to obtain orders for catheter care and failed to properly maintain urinary catheters for two (Resident 10 and Resident 14) of three reviewed. Findings include: Resident #10 (R10) Review of the medical record revealed R10 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, depression, neuromuscular dysfunction of bladder and paraplegia. The Minimum Data Set (MDS) with an Assessment date (ARD) of 12/29/24 revealed R10 scored 15 out of 15 (intact cognition) on the Brief Interview for Mental Status (BIMS) and had an indwelling catheter. On 4/9/25 at 1:13 PM, R10 was observed lying in bed on her left side, with a urinary drainage bag observed hanging from the edge of her bed. R10 reported having problems with her suprapubic catheter frequently and that she needs to remind staff to flush it daily. R10 further reported being frustrated that she recently has had to…

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

This citation refers to intake MI00148755. Based on observation and interview, the facility failed to maintain an effective Pest Control Program effecting 64 residents, resulting in complaints regarding rodents, the presence of rodent activity in multiple areas of the facility, and the potential to cause cross-contamination and resident discomfort. Findings include: On 12/18/24 at 10:30 AM, an observation of R2's Room (104) was conducted. Several rodent droppings were observed in the hallway right outside resident's door. Rodent droppings were observed along the floor/wall junctures, behind the door and garbage cans. Additional activity was observed in both resident closets. Approximately 20 droppings were found in/around R2's room. On 12/18/24 at approximately 10:40 AM, upon exiting right from R2's room, an outside exit door was observed not to be tightly sealed. Rodent droppings were observed along the floor/wall junctures of the hallway leading to the exit door. Droppings were noted in front of the exit door and windows in this area. Further observation of the exit door (outside…

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 MI00147038. Based on observation, interview and record review, the facility failed to report an allegation of resident to resident physical abuse to the State Agency for two (Resident #4 and #5) of five reviewed. Findings include: Resident #4 (R4): Review of the medical record reflected R4 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included hemiplegia and hemiparesis following unspecified cerebrovascular disease and mild cognitive impairment of uncertain or unknown etiology. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/30/24, reflected R4 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 9/25/24 at 9:52 AM, R4 was seated in a wheelchair, in his room. R4 denied any verbal or physical incidents with other facility residents. A Progress Note for 9/12/24 at 7:25 PM reflected R4 was in his wheelchair and attempted to roll around…

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 management and monitoring of diabetes for one (Resident #1) of four reviewed. Findings include: Review of the medical record reflected Resident #1 (R1) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included type 2 diabetes without complications (11/17/23) and type 2 diabetes mellitus with hyperglycemia (9/11/24). On 9/25/24 at 10:31 AM, R1 was lying in bed. R1 reported his Trulicity (dulaglutide/medication used to treat type 2 diabetes and help control blood sugar) was discontinued a couple months prior due to insurance no longer covering the cost of the medication. R1 reported the facility had not found an alternative medication that insurance would cover the cost for. R1 reported a recent hospitalization and being placed on short-acting and long-acting insulin. Review of R1's Physician's Orders reflected he had been prescribed Trulicity, to be administered weekly for type 2 diabetes, with a start…

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: (1) date mark all potentially hazardous ready-to-eat food products, (2) maintain the mechanical dish machine, and (3) maintain ventilation hood lighting effecting 53 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, resident foodborne illness, and decreased illumination. Findings include: On 03/12/24 at 09:23 A.M., An initial tour of the food service was conducted with Dietary Manager L. The following items were noted: One gallon of Mooville Whole Milk 1/4 full was observed within the Arctic Air 2-Door Refrigeration Unit without an effective date mark on the container. The manufacturer's use-by-date was observed to read 3-18-24. One quart of Glenview Farms Heavy Cream was also observed without an effective date mark on the container. The manufacturer's use-by-date was observed to read 4-14-24. One 5lb container of Glenview Farms Cottage Cheese was additionally observed with a manufacturer's use-by-date of 3-4-24. The date mark label was also observed to read:…

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 for all 46 residents, who resided in the facility, effective administration oversite of the facility's plan of correction for the survey dated 3/19/2024, and bringing the facility into compliance for 10 identified deficient practices. Findings Included: Review of the facility's plan of correction (POC) for survey dated 3/19/2024 revealed that the POC was not completed by 4/22/2024, the facility's alleged POC date, nor by 5/9/2024 upon exit of the revisit survey for the following tags, F561, 565, 582, 625, 656, 657, 684, 740, 761, and 812. Further review of the facility's POC revealed: F561, the facility did not perform audits to monitor and ensure continued compliance for resident self-determination, and did not provide education for all staff. The facility's POC revealed that all residents were determined to have the potential to be affected by the deficient practice, however the facility did not assess all residents who resided at the facility for self-determination. F565, the facility identified per…

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, through the facility's Quality Assurance and Performance Improvement (QAPI) program, monitoring of corrective action for 10 deficiencies that were identified on the previous survey, dated 3/19/2024, were in compliance by 4/22/2024 the facility's alleged compliance date. Findings Included: Review of the facility's plan of correction (POC) for survey dated 3/19/2024 revealed that the POC was not completed by 4/22/2024, the facility's alleged POC date, nor by 5/9/2024 upon exit of the revisit survey for the following tags, F561, 565, 582, 625, 656, 657, 684, 740, 761, and 812. Further review of the facility's POC revealed: F561, the facility did not perform audits to monitor and ensure continued compliance for resident self-determination, and did not provide education for all staff. The facility's POC revealed that all residents were determined to have the potential to be affected by the deficient practice, however the facility did…

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 maintain an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one of eight residents reviewed for medications (Resident #18), affecting a census of 53 residents, resulting in inappropriate antibiotic use and increased risk of adverse events associated with antibiotic use. Findings include: Infection Control Preventionist (ICP) U was interviewed on 3/14/24 at 11:11 AM and stated the facility did not use McGeer's or Loeb criteria to determine if the resident likely had an infection, in which an antibiotic was indicated. Director of Nursing (DON) B was interviewed on 3/19/24 at 8:07 AM and stated the facility followed McGeer's criteria. DON B was not able to produce education provided to facility nurses regarding McGeer's or Loebs criteria. Antibiotic Stewardship Program Policy dated 12/01/23 revealed the program included antibiotic use protocols and a system to monitor antibiotic use. Nursing…

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 review, the facility failed to provide an effective Pest Control Program effecting 53 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, insect/rodent infestations, and resident discomfort. Findings include: On 03/12/24 at 10:30 A.M., An interview was conducted with Resident #2 regarding pest control concerns within his room. Resident #2 stated: I saw mice in my room last Thursday night (3-7-24). Three pest control glue boards and one plastic bait station containing bait were also observed strategically placed within Resident #2's room. On 03/13/24 at 11:28 A.M., Record review of the (Contractual Pest Control Company Name) pest control service invoices for the last 180 days revealed the last physical facility service date by a licensed pest control technician occurred on 8-24-23. On 03/13/24 at 11:33 A.M., An interview was conducted with Director of Maintenance N regarding no specific facility pest control service activity since 8-24-23. Director of Maintenance N stated: I believe lack of…

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

Based on interview and record review, the facility failed to address and resolve grievances reported in Resident Council Meetings as stated during a confidential Resident Council meeting resulting in unresolved concerns and unmet needs of residents. Findings include: During a confidential Resident Council meeting on 3/13/2024 at 10:48 AM which started late due to staff not assisting residents on time, five of seven residents reported that the facility didn't respond to grievances and/or suggestions brought to them from Resident Council and they weren't getting resolved. Four of seven residents said that staffing and call lights have been brought up monthly for several months in Resident Council meetings and there was no distinct resolution and they weren't happy with the resolution presented by the facility. Six of seven residents stated that the rationale presented by the facility was that they are working on it and they think the resolution is okay for them but it isn't okay with us. Six of seven residents reported that the facility doesn't listen to suggestions brought to them…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete accurate Minimum Data Set (MDS) assessments for two residents (#7 and #38) of 15 residents reviewed for MDS accuracy, resulting in inaccurate MDS assessments, and the potential for inaccurate care plans and unmet care needs. Findings Included: Resident #7 (R7): Review of the medical record reflected Resident #7 (R7) admitted to the facility 2/1/24, with diagnoses that included diabetes, angina pectoris (chest pain caused by reduced blood flow to the heart) and hypertension (high blood pressure). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/14/24, reflected R7 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R7 no longer resided in the facility at the time of the survey. A Progress Note for 2/27/24 at 11:37 PM reflected that upon taking her bedtime medication, R7 was noticeably altered. She was confused and oriented to herself only. R7 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 observations, interviews, and record reviews, the facility failed to: (1) effectively secure an active physical plant renovation site, (2) maintain flooring and wall surfaces, (3) maintain roofing and plumbing systems, and (4) secure electrical heating devices (crock pot) for 1 (#47) of 14 sampled residents effecting 53 residents, resulting in the increased likelihood for accidental resident falls and/or serious bodily injury. Findings include: On 03/12/24 at 02:13 P.M., An interview was conducted with Nursing Home Administrator (NHA) A regarding the current physical plant renovation site security awareness. (NHA) A stated: We have caution tape across the double doors. On 03/13/24 at 09:55 A.M., An environmental tour of the facility basement was conducted by this surveyor. The following item was noted: Electrical/Generator Panel Room: Pooling water was observed, adjacent to the Main Electrical and Generator Panel Disconnects. On 03/13/24 at 10:20 A.M., An interview was conducted with Director of…

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

Based on interview and record review, the facility failed to provide sufficient staff to meet resident needs as reported in a confidential Resident Council meeting resulting in the potential for unmet care needs. Findings include: During a confidential Resident Council meeting on 3/13/2024 at 10:48 AM which started late due to staff not assisting residents on time, six of seven residents reported that they had to wait a long time for help from staff and that waiting for one hour was not unusual. One resident stated that the aides leave and say they will be back and sometimes don't come back. Six of seven residents said weekend staffing was worse. One resident said that he waited for help for over 2 ½ hours on a weekend. Another resident said they don't have enough staff to properly take care of them. Four of seven residents said that staffing and call lights have been brought up monthly for several months in Resident Council meetings and there was no distinct resolution and they aren't happy with the resolution presented by the facility. Six of seven residents stated that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the attending physician documented in the medical record that identified medication review irregularities were reviewed, the action taken, and the rationale for no changes to the medications for four (R2, R25, R38 and R44 ) of six reviewed for unnecessary medications Finding include: Resident #25(R25) Review of the Face Sheet and Minimum Data Set (MDS) date 1/3/24, reflected R25 was admitted to the facility on [DATE] related to dementia, heart disease, hypertension (high blood pressure), diabetes (DM), stroke, depression, psychotic disorder(other than schizophrenia), and anxiety . The MDS reflected R25 had a BIMS (assessment tool) score which indicated her ability to make daily decisions was severely impaired. The MDS reflected R25 did not have behaviors. Review of the Electronic Medical Record (EMR) on 3/13/24 at 2:38 PM, reflected R25 had monthly Pharmacy Reviews that indicated recommendations for May, June, July, November of 2023 and February…

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

This citation has 2 Deficient Practice Statements (DPS), #1 and #2. DPS #1 Based on observation, interview, and record review, the facility failed to ensure eye drops were removed from use according to manufactures instructions, in one of two medication carts reviewed, resulting in risk of decreased efficacy. Findings include: On 3/14/24 at 12:15 PM a bottle of Latanoprost (Xalatan, used to treat increased eye pressure/glaucoma) was observed in a medication cart located on south hall with an opened date of 1/02/24. Licensed Practical Nurse (LPN) G stated she thought Latanoprost was good for 60 days after opening. According to the Xalatan website at Xalatan.com, once the bottle was opened, it may be stored at room temperature for 6 weeks. The Director of Nursing (DON) B was interviewed on 3/19/24 at 8:10 AM and stated the facility's policy indicated to follow manufactures instructions for storage of eye drops. Deficient Practice Statement #2 Based on observations, interviews, and record reviews, the facility failed to ensure enteral food products were provided with current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to effectively maintain the facility resident call system effecting 29 residents, resulting in the increased likelihood for delayed emergency response and/or negative resident outcomes. Findings include: On [DATE] at 03:20 P.M., An interview was conducted with Director of Maintenance N regarding an unmarked illuminated light upon the South Unit Nursing Station call system panel board. Director of Maintenance N stated: The light is coming from room [ROOM NUMBER]. On [DATE] at 03:25 P.M., An interview was conducted with Certified Nursing Assistant (CNA) P regarding the facility resident call system. (CNA) P stated: You have to cancel Bed 1 and then Bed 2 to stop the noise in 148. (CNA) P also stated: Sometimes people forget to cancel Bed 2. On [DATE] at 08:57 A.M., Director of Maintenance N stated: The call system went down yesterday (3-13-24) at (05:15 PM) on South Unit. Director of Maintenance N also stated: We have provided bells to each…

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 maintain the physical plant, including floor wall junctures and lighting, resulting in unsanitary and unsafe conditions for any residents residing in or traversing through the North Hall and open areas of the South Hall. Findings include: On 5/7/24 at approximately 12:50 PM, the over sink light in the toilet room of room [ROOM NUMBER] was observed very dim and flickering. Interview at this time with Staff I was conducted. Staff I stated that the lighting comes and goes. On 5/7/24 at approximately 1:00 PM, a hole approximately 6 inches by 12 inches was observed in the wall behind the toilet in the visitor toilet room. On 5/7/24 at approximately 3:00 PM, on the North Hall between rooms [ROOM NUMBERS], and under the radiator near room [ROOM NUMBER], observed gaps at the floor/wall juncture of approximately an inch, between the floor and the cove base. Dirt and debris accumulation could be seen in the gaps. The cove base was observed missing at the exit door…

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 dignity for one resident (R11) of two residents reviewed for dignity, resulting in the likelihood of feelings of embarrassment and humiliation based on the reasonable person concept. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R11 was a [AGE] year old female admitted to the facility on [DATE] related to Alzheimers disease, bipolar disorder, traumatic brain injury, hypertension (high blood pressure), depression and anxiety. The MDS reflected R11 had a BIMS (Brief Interview for Mental Status) score which indicated her ability to make daily decisions was severely impaired. Review of the MDS, revealed she was dependant on care and required substantial/maximal assist (helper does more than half the effort) with toileting, bathing, dressing, and personal hygiene. The MDS reflected R11 did not have behaviors including refusal of care. The Face Sheet reflected a picture of R11 with long…

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 resident choices were honored for two of two residents (Residents #4 and #206) reviewed for choices and as reported by four of seven residents during a confidential Resident Council meeting resulting in frustration and distress. Findings include: During a confidential Resident Council meeting on 3/13/2024 at 10:48 AM which started late due to staff not assisting residents on time, four of seven residents reported that they were unaware of their rights at the facility and that their rights are not encouraged. One resident reported that he doesn't even know what his rights are. One resident said that the facility staff doesn't follow rules since the residents buy food items to be kept in the resident refrigerator at the nurses' station and staff won't get things for them when they ask for it. Another resident stated that Sometimes we don't get our items until a week later such as pop or unopened sandwich meat. Seven of seven residents…

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 1) issue a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) to one (Resident #56) of three reviewed for Beneficiary Notification; and 2) ensure the SNF ABN included the estimated cost of items and services for which the resident may be charged for two (Resident #14 and #47) of three reviewed for Beneficiary Notification. Findings include: Resident #56 (R56): Review of the medical record reflected R56 admitted to the facility on [DATE], on Medicare Part A services. R56's last covered day under Medicare Part A services was 10/1/23. R56 remained in the facility, until discharged on 11/21/23, and was not provided with an SNF ABN upon discharge from Medicare Part A services. During an interview on 03/15/24 at 08:52 AM, Business Office Manager (BOM) K reported R56 should have received an SNF ABN. Resident #14 (R14): Review of the medical record reflected R14 readmitted to the facility on [DATE], on Medicare Part A services. R14'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.

Based on interview and record review, the facility failed to provide medical information to the hospital for one (Resident #7) of one resident reviewed for hospitalization. Findings include: Review of the medical record reflected Resident #7 (R7) admitted to the facility 2/1/24, with diagnoses that included diabetes, angina pectoris (chest pain caused by reduced blood flow to the heart) and hypertension (high blood pressure). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/14/24, reflected R7 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R7 no longer resided in the facility at the time of the survey. A late entry Progress Note for 2/26/24 at 9:30 PM reflected R7 was observed on a personal phone, contacting Emergency Medical Services (EMS), stating she was having diabetic complications and requesting assistance. Upon EMS arrival, there was no medical emergency, according to the note. The note reflected R7 was her own responsible party and was transferred for further evaluation.…

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 notify the resident and/or the resident's representative, in writing, of the reason for transfer/discharge to the hospital for one (Resident #7) of one reviewed for hospitalization. Findings include: Review of the medical record reflected Resident #7 (R7) admitted to the facility 2/1/24, with diagnoses that included diabetes, angina pectoris (chest pain caused by reduced blood flow to the heart) and hypertension (high blood pressure). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/14/24, reflected R7 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R7 no longer resided in the facility at the time of the survey. A Progress Note for 2/27/24 at 11:37 PM reflected that upon taking her bedtime medication, R7 was noticeably altered. She was confused and oriented to herself only. R7 was unable to communicate where she was. She was unable to complete full sentences and was confused to the time and day. R7's oxygen saturation was…

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

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative of the facility's policy for bed hold for one (Resident #7) of one reviewed for hospital transfer. Findings include: Review of the medical record reflected Resident #7 (R7) admitted to the facility 2/1/24, with diagnoses that included diabetes, angina pectoris (chest pain caused by reduced blood flow to the heart) and hypertension (high blood pressure). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/14/24, reflected R7 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R7 no longer resided in the facility at the time of the survey. A Progress Note for 2/27/24 at 11:37 PM reflected that upon taking her bedtime medication, R7 was noticeably altered. She was confused and oriented to herself only. R7 was unable to communicate where she was. She was unable to complete full sentences and was confused to the time and day. R7's oxygen saturation was 82 percent while…

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 complete a Significant Change in Status Assessment (SCSA) for one resident (#29) of 14 residents reviewed for Minimum Data Set (MDS), resulting in the potential for inaccurate care plans and unmet needs. Findings Included: Resident #29 (R29) Review of the medical record demonstrated R29 was admitted to the facility 10/08/2018 with diagnoses that included hemiplegia (paralysis) and hemiparesis (muscle weakness or partial paralysis) affecting left dominate side, type 2 diabetes, malnutrition, apraxia (difficulty with skill movement), weakness, chronic right hip pain, edema, depression, constipation, hearing loss, hypertension, and cerebral infarction (stroke). Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/12/2024, revealed R29 had a Brief Interview for Mental Status (BIMS) was not assessed because the resident is rarely never understood. Review of R29's medical record demonstrated a physician order written 12/09/2023 for hospice services. Review of R29's Minimum Data Set (MDS) history…

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 care plans for two of 14 residents (Residents #4, and #29) reviewed for Care Plan implementation for behavioral health and hospice services. Findings Include: Resident #4 (R4) Review of the medical record revealed Resident #4 (R4) was initially admitted to the facility on [DATE] with diagnoses that included heart disease with heart failure, supra-pubic catheter, neurogenic bladder (overactive). According to Resident #4 (R4)'s Minimum Data Set (MDS) dated [DATE], revealed R4 scored 10 out of 15 (Moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R4 required substantial/maximum assistance with toileting, showering/bathing, getting dressed and personal hygiene. During a record review, it revealed R4 did not have a Dementia diagnosis or any other diagnosis for cognitive impairment. R4 was not on any medications for cognitive impairment. Record…

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 care plan interventions were evaluated for effectiveness and updated in a timely manner, with new interventions, to prevent further decline in condition for one (Resident #4) of 14 sampled residents reviewed for care plan timing and revision. Findings Include: Resident #4 (R4) Review of the medical record revealed Resident #4 (R4) was initially admitted to the facility on [DATE] with diagnoses that included heart disease with heart failure, supra-pubic catheter, neurogenic bladder (overactive). According to Resident #4 (R4)'s Minimum Data Set (MDS) dated [DATE], revealed R4 scored 10 out of 15 (Moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R4 required substantial/maximum assistance with toileting, showering/bathing, getting dressed and personal hygiene. Record review did reveal visit notes from [name redacted] psychiatric services for dates of…

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

Based on observation, interview, and record review the facility failed to actively pursue discharge planning for one resident (#206) of one resident reviewed for discharge planning resulting in frustration with the facility discharge process. Findings Included: Resident #206 (R206) Review of the medical record demonstrated R206 was admitted to the facility 02/20/2024 with diagnoses that included central cord syndrome at the cervical spinal cord (causing impairment of upper limb motor function), abnormalities in gait and mobility, muscle spasm of back, rheumatoid arthritis, low back pain, overactive bladder, quadriplegia, hyperlipidemia (high fat content in blood), anxiety, constipation, insomnia, heart disease, hypertension, pain in upper left arm, and need for assistance with personal care. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/27/2024, revealed R206 had a Brief Interview for Mental Status (BIMS) of 14 (intact cognitive responses) out of 15. During observation and interview on 03/12/2024 at 02:20 p.m., R206 was observed lying in bed.…

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 During observation, interview, and record review the facility failed to ensure dependent residents receive showers according to their personal preferences for three residents (#206, #47, #4)) of four residents reviewed for hygiene and grooming, resulting in missed bath/showers. Findings Included: Resident #206 (R206) Review of the medical record demonstrated R206 was admitted to the facility 02/20/2024 with diagnoses that included central cord syndrome at the cervical spinal cord (causing impairment of upper limb motor function), abnormalities in gait and mobility, muscle spasm of back, rheumatoid arthritis, low back pain, overactive bladder, quadriplegia, hyperlipidemia (high fat content in blood), anxiety, constipation, insomnia, heart disease, hypertension, pain in upper left arm, and need for assistance with personal care. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/27/2024, revealed R206 had a Brief Interview for Mental Status (BIMS) of 14 (intact cognitive responses)…

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 provide assessment/intervention for bowel constipation for one resident (#206) of 14 residents reviewed for quality of care. Findings Included: Review of the medical record demonstrated R206 was admitted to the facility 02/20/2024 with diagnoses that included central cord syndrome at the cervical spinal cord (causing impairment of upper limb motor function), abnormalities in gait and mobility, muscle spasm of back, rheumatoid arthritis, low back pain, overactive bladder, quadriplegia, hyperlipidemia (high fat content in blood), anxiety, constipation, insomnia, heart disease, hypertension, pain in upper left arm, and need for assistance with personal care. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/27/2024, revealed R206 had a Brief Interview for Mental Status (BIMS) of 14 (intact cognitive responses) out of 15. During observation and interview on 03/12/2024 at 02:25 p.m. R206 was observed lying in bed. R206 explained that she had a history of constipation, and 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 appropriate treatment and services for contracture management for two residents (#32, #206) of two residents reviewed resulting in the potential for worsening contractures and pain. Findings Included: Resident #32 (R32) Review of the medical record demonstrated R32 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), hypertension, depression, anxiety, hyperlipidemia (high fat content in blood), Pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder), tachycardia, muscle spasm, cognitive impairment, psychosis (loss of external reality), conduct disorder, chronic pain, personality and behavior disorder, dysphasia (difficulty understanding spoken language), and muscle weakness. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/13/2024, revealed R32 had a Brief Interview for Mental Status (BIMS) of 11 (moderately…

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 one (Resident #4) out of four residents received the necessary behavioral health care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings Included: Resident #4 (R4) Review of the medical record revealed Resident #4 (R4) was initially admitted to the facility on [DATE] with diagnoses that included heart disease with heart failure, supra-pubic catheter, neurogenic bladder (overactive). According to Resident #4 (R4)'s Minimum Data Set (MDS) dated [DATE], revealed R4 scored 10 out of 15 (Moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R4 required substantial/maximum assistance with toileting, showering/bathing, getting dressed and personal hygiene. Record review did reveal visit notes from [name redacted] psychiatric services for dates of 01/17/24, 01/19/24, 01/26/24 and 02/07/24. [Name redacted] visit…

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 were free from unnecessary medications in three (Resident #12 and #18) of 8 reviewed for medications , resulting in increased risk of adverse drug reactions and R18's hospital admission related to sepsis due to urinary tract infection(UTI). Findings include: Resident #12 (R12) R12's annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/08/24, revealed she was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS), a short cognitive screener, score of 00 (00-07 Severe Impairment). R12's care plan dated 11/24/23 revealed she had the diagnoses of insomnia, depression, dementia, unspecified psychosis, and high cholesterol. In review of R12's physician orders, Levothyroxine 50 micrograms (mcg) was ordered on 8/14/23 for the diagnosis of hypothyroidism (thyroid gland does not produce enough thyroid hormones). R12 was also taking Seroquel (antipsychotic) 250…

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 were free from unnecessary medications in one of three reviewed for psychotropic medications (Resident #44), resulting in increased risk of adverse drug reactions. Findings include: Findings include: Resident #44(R44) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R44's admission date to the facility was on 7/21/2022 and she had diagnoses of Alzheimer's disease, anxiety, depression, psychotic disorder with delusions (fixed, false conviction in something that was not real or shared by other people). Brief Interview for Mental Status (BIMS) score was a 00 which indicated her cognition was severely impaired (00-07 severe impairment). R44 was receiving Hospice care as of 1/2/2024. Review of the Medication Administration Record (MAR) revealed that R44 received haloperidol lactate (Haldol) oral concentrate for agitation, 2 mg/ml (milligrams/milliliter) .5 ml by mouth every 4 hours as needed for agitation. This…

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 pneumococcal immunization in two of five residents reviewed for immunizations (Resident #12 & #18), resulting in an increased risk of acquiring, transmitting, or experiencing complications from pneumococcal disease. Findings include: Resident #12 (R12) R12's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 2/08/24, revealed she was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS), a short cognitive screener, score of 00 (00-07 Severe Impairment). In review of R12's immunization record, she was [AGE] years old, received the Prevnar 13 vaccine on 11/22/14. In review of R12's clinical record, there were no offering or education of the Pneumococcal 20-valent Conjugate Vaccine (Prevnar 20/PCV 20). Resident #18 (R18) In review of R18's clinical record, she was admitted to the facility on [DATE], was [AGE] years old and had the Prevnar-13 vaccine on 9/14/16. There was no consent or education…

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 maintain staff documentation of COVID-19 screening, education, offering and current COVID-19 vaccination status of one of one staff reviewed, resulting in increased risk for COVID-19 infections. Findings include: The employee file for Registered Nurse (RN) F was reviewed and did not contain documentation of COVID-19 vaccination screening, education, offering of COVID-19 vaccines and status. Human Resources Director J was interviewed on 03/14/24 at 12:02 PM and stated she was not aware the facility had to provide education on the COVID-19 vaccine and was not able to provide any COVID-19 documentation regarding RN F. COVID-19 Vaccination policy dated 12/01/23 indicated the facility would maintain documentation related to staff COVID-19 vaccination and include at a minimum: a. Education to the staff regarding the risks, benefits, and potential side effects of the COVID-19 vaccine; b. The offering of the COVID-19 vaccine or information on obtaining the COVID-19 vaccine; c. The COVID-19 vaccine status of staff and related…

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 and facilitate resident needs through support of resident choice in bathing, a toileting program, equipment needs, and services, in one of three residents reviewed for rehabilitation services (Resident #5), resulting in lack of progress in meeting resident goals for discharge. Findings include: Resident #5 (R5) R5 was observed lying in bed on his back on 2/08/24 at 10:50 AM. R5 stated he had not received therapy services he needed since he was admitted to the facility. R5 stated his goal was to return home and live independently as he did before he had back surgery a few months prior. R5 stated after his back surgery he transferred to a rehabilitation hospital for therapy, and bowel and bladder training. R5 stated he had not had a shower in over a month. R5 stated he had received bed baths, but preferred showers. R5 stated he had acne from not receiving a shower. R5 stated his pain was worse after the fall from the transfer lift…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 53 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased interior food service equipment illumination, and plumbing water leaks. Findings include: On 12/11/22 at 09:20 A.M., An initial tour of the food service was conducted with Food Service Director H. The following items were noted: On 12/11/22 at 09:23 A.M., An interview was conducted with Food Service Director H regarding rodent activity within the food production kitchen. Food Service Director H stated: One rodent was caught in a snap trap approximately one month ago. The True one-door reach-in freezer was observed missing the interior light bulb. One of two Garland convection oven interior light assemblies were observed non-functional. The 2017 FDA Model Food Code section 6-303.11 states: The light intensity shall be: (A) At least 108 lux (10 foot candles) at a…

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 MI00130932 Based on observation, interview and record review the facility failed to develop and implement comprehensive care plans for 6 (Resident #'s 14, 18, 21, 27, 48 and 50) of 15 reviewed for comprehensive care planning, resulting in the potential for unmet care needs and services. Findings include: Resident #50 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] and 10/10/22, Resident 50 (R50) was a [AGE] year old female admitted to the facility in July 2022 with diagnoses that included Alzheimer's disease. On 12/11/22 at 02:17 PM, R50 was observed in her room, she did not respond to simple questions, but did smile when surveyor greeted her. On the wall next to R50's bed , was notebook paper taped to the wall observed with key words from Spanish to English i.e. hola-Hello, aqua-water etc . Review of R50's medical record revealed R50 was born in Mexico and her primary language was Spanish, but at one point R 50 was bilingual. On 12/14/22 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise care plans for 4 (Residents #1, #14, #40, #21) of 15 reviewed for care plans resulting in the potential for inadequate/inappropriate care plan interventions and unmet resident needs. Findings include: Resident #1 Resident #1 (R1) initially admitted to facility 4/8/2016 with diagnoses including multiple sclerosis, anemia, right ankle contracture, left ankle contracture, osteoporosis, polyneuropathy, and urge incontinence. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/6/22 revealed that R1 had a Brief Interview for Mental Status (BIMS) score of 6 (severe cognitive impairment). Section G of MDS revealed that R1 required one-person extensive assistance with bed mobility, dressing, eating, and personal hygiene; one-person total dependence with toilet use; and two-person total dependence with transfer. Section H of MDS reflected that R1 was always incontinent of bowel and bladder. Section M of 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 This citation pertains to intake M100130932 Based on observation, interview and record review, the facility failed to ensure two residents of eight residents (R21and R40) receive the necessary care and services for activities of daily living resulting in potential unmet care needs. Findings Include: Resident #21(R21) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R21 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included dementia, coronary heart disease, heart failure, peripheral vascular disease, seizure disorder, schizophrenia, and mantic depression. The MDS reflected R21had a BIM (assessment tool) score which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with bed mobility, transfers, locomotion on unit, dressing, eating, toileting, hygiene, and bathing. During an observation on 12/11/22 at 9:07 AM, R21 was laying on an air mattress positioned low with hospital gown on with head…

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: MI00130932 Based on observation, interview and record review, the facility failed to provide meaningful activities for three Resident (R18, R21and R40) of seven residents reviewed for meaningful activities. This deficient practice resulted in the potential for boredom and decreased quality of life. Findings include: Resident #18(R18) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] reflected R18 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included hypertension, peripheral vascular disease, and mood disorder. The MDS reflected R18 had a BIM (assessment tool) score which indicated his ability to make daily decisions was cognitively intact. During an observation and interview on 12/11/22 at 10:27 a.m., R18 was sitting in wheelchair in room. R18 reported not a lot of interest in captivities offered at facility. R18 reported likes to watch TV but not many activities of interest for men. Review of the most recent Life…

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 has 2 Deficient Practice Statements: (A) & (B) (A) Based on observation, interview, and record review, the facility failed to complete routine post fall assessments and ensure timely completion of a stat x-ray order for 1 (Resident #20) of 15 residents reviewed for quality of care, resulting in delayed identification and treatment of a fracture, and increased pain. Findings include: Resident # 20 (R20) initially admitted to facility 8/5/21 with most recent facility readmission 9/22/22 with diagnoses including cerebral infarction, type 2 diabetes mellitus, chronic pain, displaced fracture of left femur, and morbid obesity. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/13/22 revealed that R20 had highly impaired hearing but had clear speech and was understood and understands with a Brief Interview for Mental Status (BIMS) score of 6 (severe cognitive impairment). Section G of MDS revealed that R20 required two-person extensive assistance with bed mobility, two-person…

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

This Citation Pertains To Intakes: MI00128361, MI00130337, MI00130932, MI00129672, Based on observation, interview, and record review the facility failed to ensure sufficient nursing staff for 8 of 9 resident council members, resulting in the potential for all 54 residents who resided at the facility to not attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of the facility's CMS-672 Resident Census and Conditions of Residents dated 12/11/22 revealed the facility's census was 54, of which 48 required assistance of one or two staff for bathing, 52 required assistance of one or two staff for dressing, 38 required assistance of one or two staff for transferring, 38 required assistance of one or two staff for toilet use, and 21 required assistance of one or two staff for eating. The CMS-672 also revealed 6 residents were dependent on staff for bathing, 0 were dependent on staff for dressing, 7 were depending on staff for transferring, 9 were dependent on staff for toilet use, and 2 were dependent on staff for eating.…

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 three Licensed Practical Nurses (LPN C, N, II) had specific competencies and skills necessary to meet resident needs, failed ensure two Certified Nursing Assistants (CNA GG and JJ) of two CNA's reviewed for nursing competencies had their required annual competency evaluation in skills and techniques necessary to care for residents, resulting in the potential for nursing staff to lack the necessary qualifications and training to adequately care for the needs of the residents, and failed to ensure one Hospitality Aide (E) ie. non-certified/ trained staff provide services within their scope of practice. Findings include: On 12/21/22 at 4:45PM, during a review of Personnel records, it was discovered LPN C with a hire date of 12/14/21, LPN N with a hire date of 3/19/14 and LPN II with a hire date of 5/19/20 did not have any nurse competencies and or performance reviews. Review of CNA personnel records for CNA GG hired 4/8/15 and CNA JJ with a hire date of 11/02/21 had no annual competency evaluation in skills and…

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, the facility failed to ensure staff were educated in behavioral care training for two of three residents (R40 and R49) reviewed for behavioral care resulting in the potential all 24 residents residing in the Dementia unit to receive adequate behavioral care. Findings Include; Resident #49 (R49) Review of the medical record reflected R49 was originally admitted to the facility 06/15/2022 with a diagnosis of Alzheimer's Disease. Record review on 07/29/2022 reflected behavior notes on R49 who continues 15-minute checks because other residents were wondering in his room. In an interview on 12/21/22 at 11:02 AM, Social Worker (SW) D stated the facility does not have a behavioral program. SW D was provided documentation showing 15-minute checks being performed on R49. SW D was asked why R49 was placed on 15-minute checks. SW D stated I am not sure why we put him on 15 mins checks. During an interview and record review on 12/21/22 at 02:05 PM, Human Resources (HR) 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 Resident #22 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed Resident 22 was admitted to the facility on [DATE], (R22) scored 00 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R22's monthly pharmacy reviews and recommendations reflected the January 27, 2021 pharmacy recommendation read Evaluated the patient immunological history in the chart and noticed this patient may be a candidate for pneumococcal vaccination. There was no written response from the Physician, and no signed consent or refusal from R22's legal guardian. It was requested that a signed physician copy of the pharmacy recommendation be provided on 12/20/22 On 12/14/22 at 11:41 AM, during an interview with Director of Nursing (DON) B she reported being new to her role and did not have an insight or knowledge how Pharmacy services work, along with the process and protocols. R22's signed pharmacy recommendation for January 2021…

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 includes two Deficiet Practice Statements A and B. DPS A Based on observation, interview, and record review the facility failed to review Infection Control Policies and Program annually resulting in the potential of not following the most current Infection Control Standards of Practice and resulting in the potential for the spread of infection for all 53 Residents that reside at the facility. Findings Included: During record review of the provided facility policies regarding Infection Control no documents listed a date that the policies were implemented and no date that the policies had been reviewed annually. In an interview on 12/21/22 08:43 a.m. Nursing Home Administrator A explained that the facility Infection Control Policies are reviewed annually in a QA (Quality Assurance) Committee meeting. When asked to provide documentation demonstrating that review of the facility Infection Control Policies had been completed annually, NHA A explained that she would have to locate that information and…

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 offer pneumococcal and influenza immunization for three Residents (Residents #22, #356, and #357) out of 6 reviewed and failed to provide written declination of those immunizations refused for two Residents (Residents #6 and #29) out of six Residents resulting in the potential for increased risk of acquiring, transmitting, or experiencing complications of pneumococcal or influenza disease and the potential for miscommunication and misunderstanding of Residents immunization preferences. Findings Included: Resident #6 (R6) Review of the medical record revealed R6 was admitted to the facility 05/22/2017 with diagnoses that included type two diabetes mellitus, paranoid schizophrenia, vascular dementia with behavioral disturbances, dysphagia (difficulty swallowing), chronic kidney disease, hypertension, atherosclerotic heart disease (buildup of cholesterol plaque on the walls of arteries), depression, kidney failure, hypermagnesemia (high…

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 offer COVID-19 Immunization, obtain complete declination for COVID-19 Immunization, provide COVID-19 Immunization education for five resident representatives or residents (residents #6,#29, #35, #356, and #357) out of five residents reviewed for COVID-19 Immunization resulting in the potential for miscommunication and misunderstanding of Resident COVI-19 Immunization preferences. Findings included: Resident #6 (R6) Review of the medical record revealed R6 was admitted to the facility 05/22/2017 with diagnoses that included type two diabetes mellitus, paranoid schizophrenia, vascular dementia with behavioral disturbances, dysphagia (difficulty swallowing), chronic kidney disease, hypertension, atherosclerotic heart disease (buildup of cholesterol plaque on the walls of arteries), depression, kidney failure, hypermagnesemia (high magnesium levels in the blood), and first-degree heart block (slow conduction of the atrioventricular node of the heart). The most recent Minimum Data Set (MDS), with an Assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 53 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased illumination, and plumbing leaks. Findings include: On 12/12/22 at 08:35 A.M., The drywall surface was observed bowed out between resident rooms [ROOM NUMBERS]. The damaged drywall surface alignment was observed to bow approximately 6-inches away from the remaining non-damaged symmetrical corridor drywall surfaces. On 12/12/22 at 08:40 A.M., The flooring surface was observed separated from the metal door frame, within Resident room [ROOM NUMBER]. The distance observed between the flooring surface and metal door frame was approximately 1.5 - 2.0 inches. On 12/12/22 at 08:45 A.M., The metal double door frame between Resident room [ROOM NUMBER] and Resident room [ROOM NUMBER] was observed separated from the flooring surface on the right-hand side. The distance observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and 6 of 9 from the confidential group meeting, the facility failed to provide effective pest control services effecting 53 residents, resulting in the increased likelihood for insect and rodent infestations. Findings include: On 12/11/22 at 09:23 A.M., An interview was conducted with Food Service Director H regarding rodent activity within the food production kitchen. Food Service Director H stated: One rodent was caught in a snap trap approximately one month ago. On 12/12/22 at 09:15 A.M., A gap, measuring approximately 1.0 - 1.5 inches wide, was observed between the metal emergency exit door surface and the metal weather stripping panel. The metal emergency exit door was located adjacent to Resident room [ROOM NUMBER] (Central Supply). On 12/12/22 at 10:42 A.M., An interview was conducted with Environmental Services Director F regarding the facility Pest Control Program. Environmental Services Director F stated: Our pest control contract is with (Pest Control…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #40 According to the clinical record including the Minimum Data Set (MDS) dated [DATE] resident 40 (R40) was a [AGE] year old female, admitted to the facility with diagnosis that include severe intellectual disabilities, early onset Alzheimer's, Bi-polar disorder, anxiety, Down syndrome unspecified. R40 scored 00 (severe cognitive impairment) on the Brief Interview for Mental Status. Of note, further record review revealed R40 had a court appointed guardian, no contact with family, and had no visitors. R40 was observed on 12/11/22 at approximately 12:00 pm, sitting alone at a table in the dining room, her hair had not been combed, she wore mismatched clothing and had a disheveled appearance. Unidentified staff delivered R40 her lunch and walked away to assist other residents. R40 was observed to eat with her fingers (there was a fork provided) no verbal or physical cueing was provided to assist R40 to use utensils, after several minutes passed, R40 was then observed to consume part of her meal by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide advanced written notice prior to a room change for one resident (#20) reviewed for room changes which resulted in reported frustration with the potential for increased anxiety, misunderstanding of the reason for the room change, and the lack of opportunity for resident questions. Findings include: Resident # 20 (R20) initially admitted to facility 8/5/21 with most recent facility readmission 9/22/22 with diagnoses including cerebral infarction, type 2 diabetes mellitus, chronic pain, displaced fracture of left femur, and morbid obesity. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/13/22 revealed that R20 had highly impaired hearing but had clear speech and was understood and understands with a Brief Interview for Mental Status (BIMS) score of 6 (severe cognitive impairment). Section G of MDS revealed that R20 required two-person extensive assistance with bed mobility, two-person total dependence…

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 that grievances were promptly documented, investigated, tracked and resolved for 9 of 9 members of the Resident Council resulting in unresolved complaints, anger and frustration. Findings Include: On 12/13/22 at 10:00 am, during the Resident Council meeting, 9 of 9 participants reported their complaints are frequently not addressed, responded to timely and/or go resolved without explanation. Members of the Resident Council reported they felt unheard, ignored and angry. Review of Resident Council Meeting Minutes dated 6/8/22 reflected concerns related to meal trays taking to long, dietary staff not reading tickets (resulting in food preference not being followed) , rooms not clean, lack of Nursing staff along with nursing staff being rude. Resolutions to the 6/08/22 Resident council meeting were to continue with tray audits, all staff to assist with passing trays, educate housekeeping staff and complete check off lists, and Staffing- staffing to get more staff. The 7/6/22 Resident Council Minutes…

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 updated and accurate advance directive information was in place for three residents (Resident #7, #21, #27) of five 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, or other healthcare providers. 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…

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 were free of physical and verbal involving 2 residents (#40 and 25), of 6 residents that were reviewed for abuse, resulting in Resident 40 being verbally and physically abused. Findings include: Resident #25 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected Resident 25 (R25) was an [AGE] year old female admitted to the facility with diagnosis of dementia and bi-polar disorder. The MDS revealed R25 had long and short term memory impairment with severely impaired decision making skills. Resident #40 Review of Nursing progress notes dated 11/30/2022 reflected Certified Nursing Assistant (CNA) CC walked by R40's room at 12:30 am and observed R25 was slapping R40 and calling R40 names. Upon CNA CC trying to intervene, R25 then became verbally and physically aggressive with CNA CC, at which time CNA EE entered and separated R25 and R40. Review of the facility Incident report dated 11/30/22 reflected…

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 report an allegation of abuse for two of 6 residents reviewed for abuse (#25 and 40). Resulting in allegations of abuse not being reported to the State Agency and the potential for additional allegations of abuse to go unreported. Resident #25 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected Resident 25 (R25) was an [AGE] year old female admitted to the facility with diagnosis of dementia and bi-polar disorder. The MDS revealed R25 had long and short term memory impairment with severely impaired decision making skills. Resident #40 Review of Nursing progress notes dated 11/30/2022 reflected Certified Nursing Assistant (CNA) CC walked by R40's room at 12:30 am and observed R25 was slapping R40 and calling R40 names. Upon CNA CC trying to intervene, R25 then became verbally and physically aggressive with CNA CC, at which time CNA EE entered and separated R25 and R40. Review of the facility Incident report dated…

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 the accuracy of Minimum Data Set (MDS) assessments for three (Resident #21, #27, #50) of 15 reviewed, resulting in inaccurate MDS assessments and the potential for unmet care needs. Findings include: Resident #27 (R27) Review of the medical record revealed R27 was admitted to the facility on [DATE] with diagnoses that included chronic osteomyelitis, diabetes, anxiety, depression, and dementia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/22 revealed R27 scored 00 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), had an indwelling catheter in place, was always incontinent of urine, had one or more unhealed pressure ulcers, yet none were documented under each stage of pressure ulcers. R27's MDS was also not coded for any venous or arterial ulcers. On 12/20/22 at 9:55 AM, R27 was observed asleep in bed. R27 had an indwelling catheter in…

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 M100130932. Based on observation, interview, and record review, the facility failed to assess pressure injury risk, and failed to accurately and routinely assess and document pressure injury presentation in one of five residents (Resident #1) reviewed for pressure injuries resulting in the potential for delayed healing, wound deterioration, and the formation of additional pressure injuries. Findings include: Resident #1 (R1) initially admitted to facility 4/8/2016 with diagnoses including multiple sclerosis, anemia, right ankle contracture, left ankle contracture, osteoporosis, polyneuropathy, and urge incontinence. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/6/22 revealed that R1 had a Brief Interview for Mental Status (BIMS) score of 6 (severe cognitive impairment). Section G of MDS revealed that R1 required one-person extensive assistance with bed mobility, dressing, eating, and personal hygiene; one-person total dependence with toilet use; and…

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 completion of routine post dialysis monitoring, assessments, and documentation for one resident (Resident #14) of one reviewed for dialysis, resulting in the potential for unidentified change in condition and complications post dialysis treatment. Findings include: Resident #14 (R14) admitted to facility 10/1/19 with diagnoses including end stage renal disease, asthma, anemia, chronic obstructive pulmonary disease, acute lymphoblastic leukemia, and congestive heart failure. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/20/22 revealed R14 to have a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact). Further review of the medical record revealed that R14 received dialysis treatment, at an outpatient dialysis center, on Mondays, Wednesdays, and Fridays. During an observation and interview on 12/11/22 at 9:47 AM, R14 was observed sitting in a wheelchair at bedside with oxygen in place at 3 liters per minute via nasal cannula. R14 stated that her kidneys 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.

Based on interview, and record review, the facility failed to ensure that a Registered Nurse was on duty for 8 consecutive hours a day for seven days a week, resulting in the likelihood of inadequate coordination of emergency or routine care with negative clinical outcomes affecting all 53 residents residing in the facility. Findings include Review of the PBJ report, dated 4/1/22 through 6/30/22, reflected facility was triggered for failing to have Licensed Nursing coverage 24 Hours/Day for four or more days within the quarter. During an interview and record review on 12/21/22 at 3:40 PM, Requested staffing from Scheduler GG for following dates: 5/8/22 (Sunday), 5/21/22 (Saturday), 5/22/22 (Sunday), 5/30/22 (Monday), 6/4/22 (Saturday), 6/5/22 (Sunday), 6/19/22 (Sunday). Scheduler GG reported started as scheduler mid June 2022 and reported does not submit data for PBJ reports. Scheduler GG reported creates schedules according to census per direction of Facility Owner LL. Scheduler GG reported had been the owner since 7/1/21. Scheduler GG reported attempts to schedule Registered…

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

Based on interview and record review, the facility failed to ensure that two Certified Nurse Aides (CNA GG and JJ) whose in-service training files were reviewed, had the required 12 hours of in-service training, resulting in the potential for unmet educational needs and missed opportunity for improved quality of care and services provided to the residents. Findings include: Review of CNA personnel records for CNA GG hired 4/8/15 and CNA JJ with a hire date of 11/02/21 revealed there was not 12 hours of training, education and or in-service. On 12/21/22 at 2:05 pm, during an interview with Director of Nursing (DON) B and Human Resources (HR) S they reported they had a recent mandatory training in early December, HR S stated the training was approximately 2 hours in length and that was the only documented education, in-service training she had for any of the CNA's over the last 12 months. When queried why the requirement was not met, DON B reported the facility did not have time to train provide in-services upon orientation therefore the facility did not have time to do it on 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.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent when five medication errors were observed from a total of twenty-nine opportunities for two residents (Resident # 30 and # 8) of five reviewed for medication administration, resulting in a medication error rate of 17.24% and the potential for reduced efficacy of medications and increased risk of adverse reactions/side effects. Findings include: Resident #30 On 12/13/22 at 8:33 AM, Licensed Practical Nurse (LPN) C was observed preparing multiple medications for Resident #30 (R30) including one Aspirin 325milligram (mg) enteric coated tablet and one Docusate Sodium 100mg tablet. After preparing the medications, LPN C was observed to administer the medications to R30 and then proceeded to document the medications as given in the electronic medical record. On 12/13/22, a review of R30's medical record was complete. During the review, a physician's order dated 12/24/2020 read, Aspirin Tablet 325mg. Give 1 tablet by mouth one time a day . and a physician'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 observation and interview the facility failed to ensure nutritional supplements and over the counter medications were not expired and discarded. Resulting in the potential for altered potency and efficacy for the 53 residents receiving nutritional supplements and over the counter medications out of the medication room. During an observation and interview on [DATE] at 08:30 AM with LPN N regarding the number of medications. LPN N stated we have 2 med rooms, one on north and one on south. Med room- north-(Dementia unit) 3 bottles of Zinc 50mg expired on 08/22. On [DATE] at 08:45 A.M., A common area environmental tour was continued with Environmental Service Director F. The following item was noted: North Unit: Medical Supply Room: Two full cases of Glucerna Rich Chocolate nutritional supplement were observed with an expiration date that read [DATE]. One full case of Glucerna Creamy Strawberry nutritional supplement was also observed with an expiration date that read [DATE]. Environmental Services Director…

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 that a Certified Activities Director was employed at the facility, resulting in potential for all 53 residents to not be provided with meaningful activities. In an interview on 12/14/22 at 07:59 AM Activity Director certification. AD P stated she was not a certified as an activity director, but stated the facility set her up for an online program. however, the AD P had not started the program yet. Admin A sent an email that revealed that AD P was to start her training on 12/14/22 at 08:50 AM. On 12/14/22 at 09:58 AM and email was emailed was received from Admin A that AD P had not been signed up, until 12/14/22 Writer received second email from training site dated 12/14/22 at 09:58 AM reflecting AD P had been signed up for this online program at this date and time. In a continued interview with AD P on 12/14/22 at 07:59 AM, AD P stated she had been in her active role of AD for one year without training prior to this registration for the online certification program on 12/14/22.

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 the services that Hospice had provided to two of two residents (R48 and R21) reviewed for Hospice services, resulting in a lack of coordination of care between the facility and Hospice. Findings include: Resident #48 (R48) Review of R48's electronic medical record (EMR) upon R48 was admitted to the facility on [DATE] hospice services were already in place. Diagnoses included congestive heart failure (causes weakness and shortness of breath), Dementia, muscle weakness. Record review of a Minimum Data Set (MDS) assessment, dated 7/1/2022, revealed R48 had a Brief Interview for Mental Status (BIMS) score of zero out of 15, which indicated R48 had severely impaired cognition. Further review of the MDS R48 required use of a wheelchair for maximum assistance with all personal care. During an interview on 12/12/22 at 03:20 PM with Licensed Practical Nurse (LPN) N regarding care coordination with…

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.