Mission Point Nursing & Physical Rehabilitation Ce

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were transferred following care planned interventions for 2 residents (Residents #66 and #78) out of 3 residents reviewed for falls. Findings: Resident #66 (R66) Review of an admission Record revealed R66 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Huntington's Disease and history of falling. Review of R66's Care Plan revealed, I am at an increased risk for falls r/t (related to) Confusion, Huntington's Disease with Gait/balance problems, History of Falls .Unaware of safety needs secondary to HD (Huntington's Disease) with spontaneous chorea (involuntary) movements .TRANSFERRING: 2 person assist Please use gait belt, as he allows. Date Initiated: 08/15/2024 .Revision on: 10/17/2024. Review of R66's Nursing Progress Note dated 2/15/25 and written by Registered Nurse (RN) P revealed, This nurse heard a noise and heard a CNA (Certified Nursing Assistant) calling out…

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 thoroughly explain the arbitration agreement and complete paper work accurately for two of three residents ( Resident #58 and Resident #88) reviewed for arbitration. Findings: Resident #58 (R58) Review of an admission Record revealed R58 was [AGE] year old cogently intact female, originally admitted to the facility on [DATE] with pertinent diagnoses of glaucoma. During an interview on 04/03/25 at 8:50 AM, R58 stated that she did not recall signing an arbitration agreement at admission. After describing the agreement to R58, she stated that she did not recall anything of that nature. After requesting and receiving a copy of the signed arbitration agreement for R58, it was shown to the resident. R58 indicated that she cannot see, has had multiple eye surgeries, and was unable to see at the time of admission. R58 also indicated that staff sat in a chair in the room and went through the admission paperwork and R58 had given permission for Administrative…

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

This citation pertains to intake #MI00147642 and #MI00148721. Based on interview and record review, the facility failed to report alleged resident abuse within the two-hour required timeframe for 4 residents (R101, R102, R103, and R104), of 5 residents reviewed for abuse. Findings include: Review of the facility investigation of MI-FRI 00057973 revealed an incident of alleged staff to resident abuse involving R101 and R102 on 10/6/2024 was reported to the Nursing Home Administrator (NHA) by facility staff at 1:30 PM on 10/10/2024. Further review revealed this alleged resident abuse was reported to the state survey agency on 10/10/2024 at 3:50 PM. In an interview on 2/6/2025 at 9:20 AM, the NHA reported former Certified Nursing Assistant (CNA) C informed him of the allegation of staff abuse of R101 and R102 on 10/10/24 and four days after the allegation took place on 10/6/2024. The NHA reported staff are expected to report allegations of abuse immediately. Review of the facility investigation of MI-FRI 00058491 revealed an incident of alleged resident to resident abuse that took…

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 a dignified dining experience for 8 of 11 residents, 7 of the residents including (R70 and R29) were being assisted by staff standing over them and one Resident (R82) watched residents eat for 20 minutes prior to being served his meal, resulting in an undignified dining experience for residents. Findings include: During lunch meal service on 4/1/24 at 12:04 PM, Certified Nurse's Aide (CNA) D was observed standing over three Residents while assisting them with their lunches. CNA D would assist one resident with a few bites, she would then stop/turn and assist another resident while the others watched. R70 A review of R70's admission Record, dated 4/4/24, revealed R70 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, Resident 70's admission Record revealed multiple diagnoses that included depression, anxiety, and alcohol dependence with alcohol-induced persisting dementia. A review of R70's Minimum Data…

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 MI00142041 Based on observation, interview, and record review the facility failed to ensure meaningful Activities were provided to 1 facility residents directly (Resident #53 (R53)) and all facility residents in the S-1 and S-2 memory care units resulting in unengaged cognitively impaired resident not engaged in activities that a reasonable person would partake in to avoid boredom and to seek a sense of self-worth. Findings: R53 was originally admitted to the facility 3/7/19 and has current diagnoses that include Dementia, Anxiety, and Major Depressive Order. Review of the Minimum Data Set (MDS) dated [DATE] reflected R53 is severely cognitively impaired, is rarely or never understands or is understood, and has highly impaired vision. Review of the MDS section F for Preferences for Customary Routine and Activities reflected R53 enjoys Doing things with groups of people, and Participating in favorite activities. Review of the Care Plan for R53 revealed a Focus of I am here for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent repeated falls for 1 of 4 residents, Resident #82 (R82) reviewed for falls. The deficient practice resulted in R82 sustaining repeated falls with minor injury over a 60 day period. Findings include: The facility provided a copy of the Fall Reduction Policy dated 2/14/02, last revised date 4/2023 for review. The policy reflected, 2. The nurse will initiate interventions on the resident's baseline care plan, in accordance with the resident's identified risks .a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed . R82 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R82 was admitted to the facility on [DATE] with diagnosis of (but not limited to) Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), dementia (memory and safety impairment), and history of falls. Brief Interview for Mental Status (BIMS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1) safeguard the confidentiality of medical records for 1 of 27 facility residents [R25) and 2) maintain complete, accurate, and timely medical records for 3 of 27 residents (R70, R85, and R98), resulting in inaccurate medical records and delayed entry of vital medical record information by the physician provider, the potential for providers not having an accurate and complete picture of the resident's stay at the facility, the potential for unauthorized access to resident medical records, and the potential for the loss of resident privacy and confidentiality of their personal health information. Findings include: R25 During an observation on [DATE] at 11:00 AM, the computer screen on top of the North [NAME] Medication Cart was observed open to R25's electronic Medication Administration Record, (e-MAR), specifically to the medication diclofenac sodium. R25's personal and health identifying information (i.e., picture, name, 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.

Based on observation, interview, and record review the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) committee that identified care concerns, respond to deficiencies, and maintain compliance for all residents that resided at the facility. The deficient practices resulted in repeated identified deficiencies from the previous annual survey, and undesired outcomes for residents. Finding include: According to the CMS-2567 dated 2/17/23 with a date of correction of 3/17/23 the facility was found to be out of compliance with F-679 meeting the activity needs/interests of residents when the residents of the memory care unit were observed sitting around with lack of meaningful engagement. According to the plan of correction, the staff were educated to provide individual activities according to the resident assessment. The policy was reviewed. The activity calendars were updated and posted monthly. Results were to be presented by the Activities Director/designee to the Administrator who would present results at QAPI meeting monthly. Results 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 implement and utilize enhanced barrier precautions for 2 of 3 resident's (Resident #48 and Resident #502) reviewed for and who were currently placed on enhanced barrier precautions. Findings: Resident #48 (R48) Review of an admission Record revealed R48 was a [AGE] year old male, admitted to the facility on [DATE], with pertinent diagnoses of congestive heart failure, chronic kidney disease-stage 4, insulin dependent diabetes mellitus, and chronic wounds with previous osteomyelitis. Review of a Care Plan for R48 reflected .I require enhanced barrier precautions (EBP) due to increased risk of MDRO (multi-drug resistant organisms) acquisition due to wounds. Date initiated-05/21/24. During an observation on 05/28/24 at 12:15 PM, no sign hung on the door to alert staff that R48 was on EBP. There were no PPE (personal protective equipment) towers available near the room. During the same observation, Infection Control Preventionist (ICP) C 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 and interview, the facility failed to maintain ventilation, resulting in odors and uncirculated air, affecting all residents' in the North Hall's. Findings include: On 4/1/24 at 9:43 AM, the North halls were observed to have stagnant, humid air. The [NAME] hall shower room exhaust vent was tested using a paper towel to test the exhaust function and no suction was observed. On 4/1/24 at 9:45 AM, the bathroom of resident room [ROOM NUMBER] was tested using a paper towel and no suction was observed from the vent. On 4/1/24 at 9:48 AM, the bathroom of resident room [ROOM NUMBER] was tested using a paper towel and no suction was observed from the vent. During an interview on 4/1/24 at 10:14 AM, Maintenance Director R was queried on the frequency of preventative maintenance inspections for the ventilation system and stated that they are inspected twice a year. Maintenance Director R continued to say that the North halls are equipped with a rooftop unit separate from the South Halls.

Based on interview and record review the facility failed to ensure Certified Nurse Aides had completed a minimum of twelve hours of in-service training annually. Findings: On 4/8/24 at 9:34 AM the Director of Nursing (DON) was asked to provide documentation of completed annual in-service training for Certified Nurse Aide (CNA) D, CNA E, CNA Q, and CNA X. Review of the information provided by the facility reflected CNA D had 5.25 hours of training at the start of this survey, 4/1/24, to include abuse training. Dementia training was not completed at the onset of the survey. Review of the information provided reflected CNA E had a hire date of 6/5/23 and had no record of in-service hours to include no record of Abuse training at the start of this survey. Review of the information provided reflected CNA Q had 1 hour of in-service training at the start of this survey. Abuse training was not listed, and Dementia training was not initiated until after the onset of the survey. Review of the information provided by the facility reflected CNA X had 2 hours of training at the start of 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 obtain informed consent from the residents' responsible parties prior to administration of the medications for 2 of 5 residents reviewed (R70 and R87), resulting in the potential for the responsible parties not being informed that R70 and R87 were on psychotropic medications, not being informed of the indications for use of the psychotropic medications, the risks and benefits of the use of psychotropic medications, and the opportunity to decline the use of the psychotropic medications prior to administration. Findings include: R70 A review of R70's admission Record, dated 4/4/24, revealed R70 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, Resident 70's admission Record revealed multiple diagnoses that included depression, anxiety, and alcohol dependence with alcohol-induced persisting dementia. In addition, R70's admission Record revealed he had a legal (court appointed) guardian. A review of R70's Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a clean, comfortable and home like environment to ensure that Resident #44's room was clean and uncluttered to allow safe access to the bed and oxygen concentrator, resulting in the potential for falls and the inability to provide appropriate oxygen therapy. Findings Include: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #44 was admitted to the facility on [DATE] with diagnoses: Bipolar disorder, heart disease, Chronic obstructive pulmonary disease, dependence on oxygen, chronic respiratory failure. The MDS assessment dated [DATE] indicated the resident was independent with most care and had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 15/15. On 4/01/2024 at 12:39 PM, during a tour of the facility, Resident #44 was observed sitting on her bed. She had a variety of personal possessions piled on the floor from the wall towards the end of the bed. There…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement it's abuse and neglect prohibition policy and procedure for 1 resident (R82) out of 14 residents reviewed, resulting in a failure to identify and investigate an allegation of abuse. Findings: Review of a facility policy Abuse, Neglect and Exploitation reflects It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy specified C. Possible indicators of abuse include but are not limited to 1. Resident, staff or family report of abuse; 4. Resident reports of theft of property, or missing property. Resident #82 (R82) Review of an admission Record revealed R82 admitted to the facility on [DATE] with diagnoses that included mild dementia with mood disturbance, Parkinsonism, dysthymic disorder and anxiety. The admission 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 The facility provided a copy of the Fall Reduction Policy dated 2/14/02, last revised date 4/2023 for review. The policy reflected, 2. The nurse will initiate interventions on the resident's baseline care plan, in accordance with the resident's identified risks .a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed . R82 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R82 was admitted to the facility on [DATE] with diagnosis of (but not limited to) Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), dementia (memory and safety impairment), and history of falls. Brief Interview for Mental Status (BIMS) reflected a score of 3 out of 15 which represented R82 had severe cognitive impairment involving short and long term memory deficits. R82 had a resident representative for all medical decision making. During an observation and interview on 4/4/24 at 3:26 PM, R82 was observed seated 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 Based on observation, interview and record review, the facility failed to ensure medications were administered per standards of practice for 3 residents (#'s 60, 93 and 405) reviewed for medication administration, resulting in the lack of nursing presence during medication administration for two residents (#'s 60 and 93) without assessment for self-administration of medication and administering medications outside of the physician prescribed orders for Resident #405, which could lead to adverse effects. Findings Include: Resident #60 A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #60 was admitted to the facility on [DATE] with diagnoses: History of a stroke, history of brain and ovarian cancer, Alzheimer's Dementia, heart disease, history of falls with vertebral fracture, anxiety, depression, diabetes and lymphedema. The MDS assessment dated [DATE] revealed the resident had severe cognitive loss and needed assistance with all care. On 4/02/24 at 9:00 AM, observed Nurse…

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 Restorative nursing services for one Resident (#60) of 2 residents reviewed for range of motion, resulting in the potential for a decline in condition. Findings Include: Resident #60 A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #60 was admitted to the facility on [DATE] with diagnoses: History of a stroke, history of brain and ovarian cancer, Alzheimer's Dementia, heart disease, history of falls with vertebral fracture, anxiety, depression, diabetes and lymphedema. The MDS assessment dated [DATE] revealed the resident had severe cognitive loss and needed assistance with all care. On 4/02/24 at 9:13 AM, Resident #60 was observed sitting in a wheel chair in her room. Her hands were placed on the arm rests of the wheelchair and her right hand was visibly swollen with edema. She was eating breakfast with assistance from Confidential Person O. He said she had a history of a stroke and also…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess and monitor weight changes for 1 of 27 residents (Resident #101) reviewed for weight loss. The deficient practice resulted in Resident #101 (R101) sustaining a significant weight loss. Findings include: R101 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R101 admitted to the facility on [DATE] with diagnosis of (but not limited to) acute gastric ulcer, kidney disease, and blood clot to right leg. Brief Interview for Mental Status (BIMS) reflected a score of 12 out of 15 which represented R101 was cognitively intact. During an observation and interview on 4/2/24 at approximately 12:40 PM, R101 was seated in her wheelchair in the dining room. R101 was observed feeding herself and stated the food here is okay. According to the Nutritional assessment dated [DATE] reflected that R101's current body weight was 164.4 lbs. and reported that it was stable for her. The assessment reflected, 16a. My nutrition goals…

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 follow accepted standards of practice for a peripherally inserted central catheter (PICC line) dressing change for 1 Resident (#405) of 2 reviewed for IV catheters, resulting in a lack of proper hand hygiene, use of a sterile barrier and measurement of the external catheter length, which could result in complications including infection and migration of the catheter. Findings Include: Resident #405 A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #405 revealed an admission date to the facility on 2/1/2024 and readmission on [DATE] with diagnoses: Meningitis, brain abscess, brain and lung cancer, diabetes, chronic kidney disease, history of pulmonary embolism. The MDS assessment dated [DATE] indicated the resident had moderate cognitive impairment with a Brief Interview for Mental Status/BIMS score of 11/15. On 4/02/24 at 8:22 AM, during a tour of the facility, Resident #405 was observed to have an IV…

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 unobstructed access to an oxygen concentrator and provide oxygen humidification for one Resident (#44), resulting in the potential for the resident to receive an inadequate amount of oxygen to meet their needs, and discomfort without humidification, which could lead to adverse effects including respiratory distress. Findings Include: Resident #44 A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #44 was admitted to the facility on [DATE] with diagnoses: Bipolar disorder, heart disease, Chronic obstructive pulmonary disease, dependence on oxygen, chronic respiratory failure. The MDS assessment dated [DATE] indicated the resident was independent with most care and had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 15/15. On 4/01/2024 at 12:39 PM, during a tour of the facility, Resident #44 was observed sitting on her bed. She had a variety of personal…

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

This Citation pertains to Intake MI00142983 Based on interview and record review the facility failed to timely document assessments and findings in the medical record by a medical provider and failed to ensure necessary monitoring, care, and medical treatment was ordered when changes in condition were noted by a Medical Provider but not acted upon for one facility Resident (Resident #85 (R85)) resulting in emergency Intensive Care hospitalization. Findings Include: Review of the electronic medical record (EMR) reflected R85 originally admitted to the facility 8/26/22 and had diagnoses that included: Pseudobulbar Affect (characterized by uncontrolled outburst of laughter or crying), Manic Depression (Bipolar Disease), Dementia and Anxiety. Review of the Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) dated 11/28/23 reflected a score of 2 out of 15 which indicated the Resident was severely cognitively impaired. Section GG of this MDS revealed R85 was functionally able to ambulate independently. Review of the EMR Progress Note dated 2/23/24 at 5:30 PM that R85 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 provide medically-related social services for 1 of 27 residents (R98), resulting in R98 not having current up-to-date guardianship documentation. Findings include: A review of R98's admission Record, dated [DATE], revealed R98 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included frontal lobe malignant neoplasm (brain cancer), cerebral edema (brain swelling), convulsions, delusional disorder, pulmonary embolism (blood clot in the lungs), and aphasia (difficulty verbally communicating). In addition, R98's admission Record revealed Guardian (GRD) K was R98's primary contact for healthcare needs and guardian. A review of R98's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 10 which revealed R98 was moderately cognitively impaired. A review of R98'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.

This Citation Refers to Intake Number MI00142983 Based on interview and record review the facility failed to properly monitor for psychotropic medication side effects and failed to identify and report signs that resulted from medication changes for one Resident (Resident #85 (R85)). Findings: Review of the electronic medical record (EMR) reflected R85 originally admitted to the facility 8/26/22 and had diagnoses that included: Pseudobulbar Affect (characterized by uncontrolled outburst of laughter or crying), Manic Depression (Bipolar Disease), Dementia and Anxiety. Review of the Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) dated 11/28/23 reflected a score of 2 out of 15 which indicated the Resident was severely cognitively impaired. Review of the EMR Progress Note dated 2/23/24 at 5:30 PM that R85 was to be transported to the hospital for Altered mental status and Functional decline. Review of the Emergency Medical Services (EMS) documentation revealed vital signs included a pulse of 135 beats per minute (BPM), respiratory rate of 34 breaths per minute, a blood…

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 MI00140722. Based on interview, observation, and record review, the facility failed to ensure elopement interventions were implemented for 2 of 3 residents (Resident #54 and Resident #57) reviewed for elopement. This deficient practice placed Resident #54 (R54) and Resident #57 (R57) at risk for elopement when prevention interventions were not in place and monitored. Finding include: The facility provided a policy for Elopements and Wandering Residents dated 3/2/08 and last revised on 4/2023 for review. The policy reflected, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their personal centered plan of care addressing the unique factors contributing to wandering or elopement risk. The facility provided a policy for the [Name of elopement guard] System (a system that alerts staff of a resident attempting to leave the building) dated 3/13/18…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake number MI00138957. Based on observation, interview, and record review, the facility failed to prevent misappropriation of resident property for 1 (Resident #1) of 3 residents reviewed for misappropriation. This deficient practice resulted in staff removing and taking resident personal property from Resident #1's body after she passed away and the potential for more resident items to be taken. Findings include: The facility provided a copy of the Abuse, Neglect and Exploitation policy/procedure with a last revised date of 6/23 reflected, Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Resident #1 (R1) A review of Resident #1's admission Record, dated 10/12/23, revealed R1 was admitted to the facility on [DATE] with multiple diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction, Multiple Sclerosis, Chronic…

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 MI00136719, MI00137186 and MI00139193. Based on interview and record review, the facility failed to prevent staff to resident abuse for two residents (#5, #7) which could result in further abuse of residents and cause pain, humiliation, embarrassment, fearfulness, frustration, and feelings of being unsafe in the facility based on a reasonable person standard for residents with impaired cognition. Findings include: The Abuse, Neglect and Exploitation Policy implemented 01/28/2023 and revised June 2023 was reviewed. The policy states the definition of verbal abuse as the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Under IV Identification C #9, the policy states, Evidence of photographs or videos of a resident that are demeaning or humiliating in nature, regardless of whether the resident…

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.