Harmony Village of Beverly Hills

This citation relates to Intake 1291048. Based on interview and record review, the facility failed to report an abuse mistreatment incident for one Resident (R204) of two residents reviewed for abuse. Findings include:Review of the Facility Reported Investigation Summary/Actions Taken revealed, Reported Event: On 6/26/25, the Abuse Coordinator was informed by Social Worker (SW) A, of an alleged incident of staff-to-resident physical intimidation, involving R204 and Certified Nurse Assistant (CNA) C. The incident was reported to have occurred on 6/22/25, between 3:00 - 4:00 p.m. and allegedly involved the staff member retrieving an object from her car and reentering the building to confront the resident after a verbal altercation.Background: Upon notification, the facility suspended the staff member (CNA C) pending investigation, contacted the (Name of) Police Department, and initiated a full investigation . Further review of the report further revealed, (Staff E) submitted a statement dated 6/27/25, stating he witnessed (R204) tell (CNA C) to 'shut the f* up and then saw (CNA C)…

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

Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices, hand hygiene, during medication administration observations for five (R4, R6, R10, R25, R27) of five residents resulting in the increased likelihood for the spread of infection. Findings include: On 6/10/25 at 9:12 AM, Registered Nurse (RN) A was observed for medication administration for R27 and was not observed performing hand hygiene prior to the preparation of the medications and prior to administering the medication. At 9:23 AM, Unit Manger Licensed Practical Nurse (LPN) C was observed whispering into RN A's ear at which time RNA made an audible comment to R27 that they need to do hand hygiene and proceeded into the residents restroom. On 6/10/25 at 9:25 AM, RN A provided a medication pass to R25 and was observed entering the room without performing hand hygiene. R25 placed a cup of medications on the side table, then proceeded to readjust the resident pressing the controls of the electronic control pad, call light, bedside table, and blankets with bare…

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 the development of a pressure ulcer, ensure the facility accurately assessed/identified the wound timely and accurately implemented treatment for one (R27) of two residents reviewed for pressure ulcers, resulting in the development of a Stage IV (full-thickness skin and tissue loss) pressure ulcer to the bilateral buttocks that required an extensive hospital stay and a diagnosis of osteomyelitis (bone infection). Findings include: On 6/10/25 at approximately 10:12 AM, R27 was observed lying in bed. The resident was resting and did not answer questions asked. Prior to the observation, the facility provided information that noted R27 was the only Hospice resident at the facility. A review of R27's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Cerebral Infarction, Dysphasia, Adjustment Disorder and Moderate Protein-Calorie Malnutrition. A review of R27's Minimum…

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 related to Intake #: MI00150321. This citation has two deficient practice statements. Deficient Practice Statement #1 Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent two physical resident-to-resident incidents for three Residents (R7, R13, R23) of three residents reviewed for incidents. Findings include: Review of a Facility Report Investigation (FRI) report, dated 2/11/25 through 2/13/25, revealed there was a resident-to-resident incident which occurred on 2/10/25. The incident began as a verbal altercation when R7 removed a chair from the hallway for their guest to be seated, which R13 believed was their own personal chair. There was a subsequent disagreement between R7 and R13, with an exchange of words, which resulted in R13 kicking R7 in the left ankle. The report conveyed R7 initially reported pain and was later found not injured. Review of R7's Minimum Data Set (MDS) assessment, dated 1/14/25, revealed R7 was admitted to 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 that one (R25) of one resident reviewed for nutrition received nutritional supplements as ordered, resulting in the potential for weight loss and overall decline in their condition. Findings include: Record review revealed R25 was a long-term resident of the facility admitted to the facility on [DATE]. R25 was most recently re-admitted to the facility after hospitalization on 6/7/25. Review of R25's admission history revealed that R25 had multiple hospitalizations between 1/12/25 and 6/10/25. R25's admitting diagnoses included stroke, bladder cancer, difficulty swallowing, left ankle pressure ulcer and malnutrition. Based on the Minimum Data Set (MDS) assessment dated [DATE], R25 had a Brief Interview for Mental Status (BIMS) score of 4/15, indicative of significant cognitive impairment. An initial observation was completed on 6/10/25 at approximately 9:30 AM. R25 was observed laying on their bed. R25's bed on the right side 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 observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent. Two medication errors were observed for R10 from a total of 30 opportunities reviewed during medication administration, resulting in an error rate of 6.67%. Findings include: On 6/11/25 at 8:29 AM, record review of a medication reconciliation was conducted for R10 and two medications: Metoprolol (medication for lowering blood pressure and heart rate) 25 milligram (mg) and Thiamine (Vitamin B1, essential nutrient for brain, heart, and nervous system function) 100 mg were documented as administered at 9:00 AM and were not observed prepared or administered. On 6/11/25 at 8:37 AM, RN M was questioned if the two medications in question were administered after the survey observation, at which time they reviewed the Electronic Medical Record (EMR) for R10 and apologized I am sorry for that and acknowledged they documented the Thiamine was given but it was not and RN M was observed providing Thiamine to R10. RN M was questioned about the Metoprolol medication…

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 appropriate medication storage and labeling for medications in two of two medication carts reviewed and one residential room. Findings include: On 6/10/25 at 9:12 AM, while observing a medication administration in room [ROOM NUMBER], a white round pill was observed lying on the floor along the baseboard near the bathroom. Attention to the pill was brought to Unit Manager Licensed Practical Nurse (LPN) C at which time they were observed picking it off the floor with their bare hand. They were inquired if any identifiers were on the pill and LPN C confirmed there was nothing to identify the pill and it should not be on the floor. On 6/10/25 at 9:55 AM, a medication storage observation was conducted with Registered Nurse (RN) N for Medication Cart East and revealed in drawer one, one green colored oval shaped pill and one small peach colored pill both unidentifiable and not stored in containers and unidentified. Drawer two revealed one small green…

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 record review and interview, the facility failed to ensure laboratory services for a urine culture/sensitivity test were received timely resulting in administering a resistant antibiotic for a Urinary Tract Infection in one resident (R27) of one reviewed for laboratory services. Findings include: A clinical record review revealed R27 was admitted to the facility on [DATE] with a sacral (base of the spine) ulcer and osteomyelitis (infection in the bone) of the sacral region. As a result of a stroke, and intracerebral hemorrhage (brain bleed) R27 was incontinent of urine and stool, resulting in high risk for a Urinary Tract Infections (UTI). R27 had impaired mobility and was unable to communicate their needs and their Brief Interview for Mental Status (BIMS) score was 4/15 indicating severe cognitive impairment. On 2/21/25 at 11:10 AM, a Nursing progress note documented a Urinalysis and Urine Culture and Sensitivity (C/S) was obtained and sent to the lab. On 2/26/25 at 10:45 AM, Interdisciplinary Team…

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 assist and ensure timely dental services (to obtain replacement dentures) for an extended period (approximately 6 months) for one (R6) of one resident reviewed for dental services resulting in the potential for avoidable decline in nutrition, overall health and well-being. Findings include: Record review revealed R6 was admitted to the facility from another skilled nursing facility on 1/29/25. R6's admitting diagnoses included neck fracture (of unknown age), temporomandibular joint disorder (pain and tenderness in jaw joints and surrounding muscles and ligaments), anemia, vitamin deficiency, and protein calorie malnutrition. Based on the Minimum Data Set (MDS) assessment dated [DATE], R6 had a Brief Interview for Mental Status Score (BIMS) score 12/15, indicative of moderate cognitive impairment. R6 had a Durable Power of Attorney (brother) who was making healthcare and financial decisions for R6. An initial observation was completed on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure complete and accurate medication orders and clarify ambiguous orders with the physician for one (R16) of one resident reviewed for professional standards. Findings include: Review of the clinical record revealed R16 was admitted into the facility on 3/3/23 and readmitted [DATE] with diagnoses that included: diabetes, kidney disease and dementia. According to the Minimum Data Set (MDS) assessment dated [DATE], R16 was cognitively intact. Review of a Consultant Pharmacist's Medication Regimen Review dated 10/16/24 recommendation for nursing read in part, .Patient had an order for the Insulin Lispro 7 units SubQ (subcutaneous) TID (three times a day) with meals on discharge records but they are not present in (electronic medical record). Please clarify with prescriber if these therapies should continue and add orders if deemed appropriate . It was signed and marked Completed 10/16/24. Review of R16's physician orders revealed an active 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.

This citation is pertains to Intake #MI00145426. Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement elopement policies for one (R8) of one residents reviewed for elopement, resulting in a cognitively impaired resident being let out of a secured back door to the facility, unsupervised. R8 was found by the police, about two miles away from the facility. Findings include: On 6/11/24 the Facility reported an investigation that alleged R8 eloped from the facility, was found by police, and sent to the hospital for further evaluation. On 12/17/24 at 9:30 am, R8 was interviewed and they were asked did they remember leaving the facility in June and if so, why did they leave. R8 replied, Yes, I remember leaving the facility because they were trying to shock my heart and I got mad so I went through the back doors. I put the code in and left. I walked to 14 Mile and Southfield Road and picked a random house, it was green, and asked them if they could call the police for me. The residents of that home called the police for me 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 This citation pertains to intake #MI00145538. Based on interview, and record review, the facility failed to ensure all controlled substances were accounted for and accurately documented for one (R226) of five residents whose medications were reviewed, resulting in the unaccountability of the resident's controlled medications and the potential for diversion. Findings include: Review of complaints reported to the State Agency included allegations that R226's medications, including controlled medications were not properly managed at the time of discharge to another nursing facility. Review of the clinical record revealed R226 was admitted into the facility on 7/23/22 and discharged due to facility depopulation on 7/5/24 to a sister nursing home. As of this review, the resident did not return. Diagnoses included: Parkinson's disease without dyskinesia, polyneuropathy, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other chronic pain, and post-traumatic…

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 #s MI00141144, MI00141160, MI00142537, MI00143525, MI00143276, and MI00144073. Based on observation, interview and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment, affecting all 81 residents that reside in the facility, including R810, R814 and R815. Findings include: Review of multiple complaints reported to the State Agency included allegations that the facility was not clean, had offensive odors, bathrooms were moldy with lights not working, basement was flooded with mold concerns, there were electrical problems, and broken equipment. The facility was previously determined to be out of compliance for concerns with maintaining a safe, clean, comfortable environment during an abbreviated survey conducted on 3/14/24 with an alleged compliance date of 4/22/24. The observations identified during the current survey identified the facility was non-compliant at a widespread level, and was informed on 5/14/24 that the survey team had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00140360. Based on interview and record review the facility failed to implement their grievance policy and promptly address, investigate, follow up, and resolve concerns reported to the facility staff for one (R816) of two residents reviewed for grievances. Findings include: Review of a complaint submitted to the State Agency (SA) on 10/23/23, documented in part, the resident's entire wardrobe has come up missing after going to the laundry even though her name was on her clothes .complainant states she has been contacting the corporate office since June 2023 with no response and has been leaving messages for the facility administrator since August (2023) and hasn't received a return call or follow-up. Review of the clinical record revealed R816 was admitted into the facility on 8/9/23 with diagnoses that included Alzheimer's Disease and Aphasia. According to the Minimum Data Set (MDS) assessment dated [DATE], R816 scored 14/15 on the Brief Interview for Mental Status exam…

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 #MI00141144. Based on observation, interview and record review, the facility failed to maintain sanitary conditions in the kitchen, label/date food items, and discard expired food items. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: Review of a complaint reported to the State Agency included allegations with food and kitchen maintenance. On 5/14/24 at 9:30 AM, observation of the facility's kitchen was conducted with the Dietary Manager (DM 'B') who reported they had worked at the facility for 15 years, and had been in their current role for two years. The reach-in refrigerator contained a large plastic container of yellowish orange liquid that had a sticker on the top that read it was prepared on 5/8 and to use by 5/11. DM 'B' reported they had missed that when going through the refrigerator earlier. The walk-in freezer had a plastic tray stored on the top freezer shelf with three slices of cream pie that were uncovered and unlabeled/dated. DM 'B' reported that should not have…

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 #s MI00141144, MI00143525, and MI00144073. Based on observation, interview and record reviews, the facility failed to ensure appropriate infection control practices with regards to linen storage. This deficient practice has the potential to affect all residents in the facility. Findings include: Review of multiple complaints reported to the State Agency included concerns with infection control practices and linens. On 5/14/24 at 10:00 AM, the Administrator was asked to observe the environment. On the 1 East unit, there were three linen carts observed in the hallway. The medium sized linen cart was covered with a pink cover that was ill-fitted and there was a large rip which exposed the contents of the cart. Further observation of the contents stored inside the cart revealed multiple other non-linen items stored within the cart including briefs, gloves, wipes, lotions, and cleansers. The Administrator reported they had just received the new linen covering this week and reported the wrong size may have been ordered and proceeded to try to fit the cover…

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 #MI00141144. Based on observation, interview and record review, the facility failed to maintain an effective pest control program, resulting in visible gnats in the rooms of R814, R815, and throughout the entire facility. Findings include: Observations included: On 5/14/24 at 9:25 AM, the exit door leading to the center courtyard was observed to have a bottom door seal that was broken (not properly sealed) which the outside light and walkway was visible from inside (approximate open area of one inch missing). There were multiple observations of gnats throughout the facility hallways, stairwells, resident rooms, kitchen, dining rooms, and employee offices. On 5/14/24 at 9:30 AM, an observation of the facility's kitchen was conducted with the Dietary Manager (DM 'B'). Throughout the entire kitchen, the flooring was observed to have several sticky areas (shoes sticking) and garbage debris, the walls near the juice machine were observed to have visible splatters on the surrounding wall tile and box of juice concentrate stored below the juice machine;…

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 #'s MI00141071, MI00142083 and MI00143861. Based on observation, interview and record review the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for five residents (R807, R808, R809, R810 and R819) of seven residents reviewed for abuse/neglect/mistreatment. Findings include: R807 and R808 On 5/14/24 a FRI (facility reported incident) submitted to the State Agency was reviewed which alleged R807 attempted to get into R808's bed, touch their leg and made inappropriate and sexual comments on 10/29/23. R807 On 5/14/24 the medical record for R807 was reviewed and revealed the following: R807 was initially admitted on [DATE] and had diagnoses including Dementia, Anxiety and legal blindness. R807's MDS with an ARD of 10/28/23 revealed a BIMS score of zero indicating severely impaired cognition. A Nursing progress note dated 10/29/23 revealed the following:…

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 R807 and R808 On 5/14/24 a FRI (Facility Reported Incident) submitted to the State Agency was reviewed which alleged R807 attempted to get into R808's bed, touch their leg and made inappropriate and sexual comments on 10/29/23. R807 On 5/14/24 the medical record for R807 was reviewed and revealed the following: R807 was initially admitted on [DATE] and had diagnoses including Dementia, Anxiety and legal blindness. R807's MDS with an ARD of 10/28/23 revealed a BIMS score of zero indicating severely impaired cognition. A Nursing progress note dated 10/29/23 revealed the following: Nursing Progress Note Late Entry: . Resident touched his roommate on his leg upsetting roommate who felt it was a sexual advance Responsible party notified , Physician notified, Administrator notified , DON (Director of Nursing) notified . Immediate intervention implemented: roommate moved to another room . R808 On 5/14/23 the medical record for R808 was reviewed and revealed the following: R808 was initially admitted on [DATE] and had…

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

This citation pertains to intake #MI00143431. Based on observation and interview, the facility failed to ensure that essential electrical equipment was maintained in safe operating condition. This has the potential to affect multiple residents throughout the facility. Findings include: On 5/14/24 at 9:25 AM, the exit signage on the ceiling was observed dangling by a wire and the entire sign hung down with the arrow to the exit pointing towards the inside of the facility (away from the exit door). On 5/14/24 at 9:30 AM, an observation of the kitchen was conducted with the Dietary Manager (DM 'B'). When asked if there were any electrical concerns, or equipment not working in the kitchen, the DM reported their steamer had been down, was waiting on a new part, and further reported this was previously cited during the annual survey in October 2023. Observation of an outlet on the wall located to the left of the steamer was observed to have brown stain on the top outlet with what appeared to be from electrical/fire damage. When asked about the outlet and whether it was used, DM 'B'…

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 #s: MI00141037 and MI00143377. Based on interview and record review the facility failed to inform a legal resident representative of changes in mental capacity and Physician ordered medication changes in a timely manner for one resident (R818) of one residents reviewed for notification of changes. Findings include: On 5/14/24 a concern submitted to the State Agency was reviewed which alleged R818's legal representative (LR) was not being informed of changes in treatments and mental capacity in a timely manner. On 5/14/24 the medical record for R818 was reviewed and revealed the following: R818 was initially admitted to the facility on [DATE] and had diagnoses including Heart failure, Dementia and Repeated falls. A review of R818's MDS (minimum data set) with an ARD (assessment reference date) of 2/13/24 revealed R818 required supervision with most of their activities of daily living. R818's BIMS score (brief interview for mental status) was 12 indicating moderately impaired…

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 #MI00142887 Based on observation, interview and record review the facility failed to prevent an unauthorized exit from the facility and appropriately assess for elopement risk for one resident (R813) of seven residents reviewed for accidents/supervision. Findings include: On 5/14/24 a facility reported incident (FRI) that was submitted to the State Agency was reviewed which alleged R813 eloped from the facility on 2/13/24 without knowledge of the facility staff and was found across a major five lane street displaying symptoms of intoxication. On 5/14/24 at approximately 11:55 a.m., R813 was observed in their room, laying in their bed. R813 was queried regarding their elopement on 2/13/24 and they reported that they wheeled themselves to the front desk and asked a staff person if they could go out and the staff person informed them that they did not care what they did so they signed out and left and indicated they did not remember much after that except the police were involved.…

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 MI00142652 Based on observation, and interview the facility failed to provide a clean homelike environment including for one Resident (R700), free from avoidable odors and gnats. Findings include: On 3/12/24 at 8:30AM, upon entrance to the facility dining room on the first floor by the entrance was observed, there was food all over the floor as well as three drinking cups located on the ground, and on the tables there were food and plates left. There was a strong urine odor at the main entrance nurses station. On 3/14/24 at 10:13 AM ,an interview was conducted with R700 in their room where there was a breakfast tray on the beside table. The food tray and resident were covered in gnats. Throughout the interview there was a constant waving away of the gnats as they were flying around the resident and this Surveyor. On 3/14/24 at about 1 PM, the administrator was interviewed and asked how do they keep the odors down in the facility and what were they doing about the gnats. The administer replied, We have house keepers that clean daily and as needed as…

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 MI00141246,MI00140964 Based on interview, and record review the facility failed to protect two resident's(R670 and R690) rights to be free from physical abuse by R680. Findings include: A record review of the Facility Reported Investigations (FRI) indicated that R680 hit R690 in the back of the head with a cane. On a separated reported FRI resident R680 and R670 had gotten into a physical altercation in the hallway where staff allegedly separated the two resident and maintained safety. A further review of the record revealed that in one progress note stating R689 hit R690 in the back of the head as R690 was attempting to get help because R680 would not let them get by to get in their room. On 3/13/24 at 1:00PM, an interview with the administrator was conducted and he was asked, being the abuse coordinator of the facility how does the administrator investigate allegations of abuse. The administrator replied ,when I am first notified of an allegation of abuse I immediately, investigate the situation, if it's a resident to resident, resident to staff or…

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 two Deficient Practice Statements (DPS) and pertains to intakes MI00141808 and MI00140623. DPS1 Based on observations, interview and record review the facility failed to ensure, monitoring, supervision and interventions for three of three residents (R600, R610 and R620) with known substance use disorders. Findings include: A record review revealed that R600 was observed in the bathroom on 12/20/23 with an insulin like syringe unresponsive on the toilet after a leave of absence. EMS (emergency medical services) arrived administered Narcan (a medication used to reverse narcotic adverse reactions) then transported the resident to the hospital. A record review revealed on 12/19/23, R610 was slow to respond and pupils were not reactive to light. The resident was sent to the hospital where they received 1mg (milligram) of Narcan IM (intramuscular) due to possible heroin overdose. A record review revealed R620 was observed on 12/18/23 unresponsive, 911 was called two dosages of Narcan for drug…

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 #MI00139279 This citation has three deficient practices Deficient Practice #1 Based on interview and record review the facility failed to establish a comprehensive infection control program that identified resident infections, calculated monthly infection rates, tracked and trended infections, utilized laboratory and pharmaceutical data, and ensured departmental surveillance and staff education on infection control. This deficient practice had the potential to affect all 87 residents who resided in the facility. Findings include: On 10/26/23 at 12:05 PM, a review of the facility provided infection control program was conducted. At that time, the facility's Director of Nursing (DON)/Infection Control Preventionist said they took over infection control when they started employment at the facility in September 2023. They said they would not be able to provide any infection control data prior to September 2023. The binder provided was reviewed and contained no monthly data including: monthly summaries, calculated infection control rates, line listings,…

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 dignity for four residents (R#'s 17, 28, 44, and 93) of four residents reviewed for dignity, three additional residents (R2, R49, and R58) and several members who participated in the group meeting who wished to remain anonymous. Findings include: R28 On 10/24/23 at 8:47 AM, upon entry to the building, R28 was observed being pushed into the shower room on the shower chair. R28 was nude, with a bedsheet covering only their genital area. The sheet was askew and R28's bare buttocks could be observed on the shower chair. R44 and R93 On 10/24/23 from 3:05 PM to 3:30 PM, R44 was overheard to be loudly and repeatedly yelling out I need help. At that, time, at least six staff members were observed clustered around the nursing station. Nurse 'N' was observed to walk past R44's room and did acknowledge R44. At 3:20 PM, Nurse 'P' was observed to pass by R44's room. At approximately 3:25 PM, R93 exited their room to the hallway 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 observation, interview and record review the facility failed to ensure fresh water was provided and water was within reach for eight residents (R#'s 32, 12, 90, 56, 75, 13, 37, 16, and 44) of 87 residents reviewed for accommodation of needs. Findings include: A review of a facility provided policy titled, Hydration revised 1/2021 was conducted and read, The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health . On 10/24/23 at 9:25 AM and 11:44 AM, R32 was observed in bed, no drinking water was observed in their room, within reach. On 10/24/23 at 9:28 AM, R12 was observed in their bed, no drinking water was observed in their room, within reach. On 10/24/23 at 10:16 AM, R90 was observed in their bed. A foam cup of water was on their bedside table and it was noted to be dated 10/23/23 for the day (7A-3P) shift. On 10/24/23 at 10:19 AM and 3:07 PM, R56 was observed in their bed. An empty foam cup for water was on their bedside table and it was noted to be 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 This citation pertains to Intake Number(s): MI00138819 and MI00139774. Based on observation, interview, and record review, the facility failed to provide a clean, comfortable, homelike environment for multiple residents (including R5, R23, R88, R35, R93,R18, R54, R17) in multiple resident rooms and hallways throughout the facility. Findings include: On 10/24/23 at 10:30 AM, the sink in the bathroom for room [ROOM NUMBER] was observed with an approximately 3 inch by 3 inch hole in the sink basin, with heavily rusted out edges. In addition, there was a strong urine odor in the bathroom. On 10/24/23 at 10:35 AM, the call light string in the bathroom for room [ROOM NUMBER] was observed to be short and did not extend down far enough to be accessible for a resident on the floor. In addition, the sink vanity particle board was warped and pulling away from the sink basin, leaving a large gap at the rear of the sink. On 10/24/23 at 10:40 AM, the bathroom for room [ROOM NUMBER] was observed. The grout around the toilet…

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 MI00138819 and MI00139871. Based on interview, and record review, the facility failed to ensure there was sufficient nursing staff to provide care and services to the residents. This had the ability to affect all residents in the facility. Findings include: Review of the facility's Payroll Based Journal (PBJ) Report revealed excessively low weekend staffing for the Second Quarter of the Fiscal Year, January 1, 2023-March 31, 2023. Review of the Daily Staffing Sheet revealed: 1/7/23 (Sunday) the census was 63 and from 7:00 AM-7:00 PM there were only two nurses for the whole facility. 3/4/23 (Saturday) the census was 65 and from 3:00 PM-11:00 PM there were only three Certified Nursing Assistants (CNA's) for the whole facility. 3/5/23 (Sunday) the census was 63 and from 3:00 PM-7:00 AM there were only three CNA's for the whole facility. 3/18/23 (Saturday) the census was 65 and from 11:00 PM-7:00 AM there were only three CNA's for the whole facility. 3/19/23 (Sunday) the census was 65 and from 11:00 PM-7:00 AM there were only three CNA's for the whole…

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 MI139844. Based on observation, interview, and record review, the facility failed to provide a functional call system that provides direct communication from the residents to the caregivers, in the [NAME] and East hall shower rooms. This deficient practice had the potential to affect all residents that utilize the [NAME] and East hall shower rooms. Findings include: On [DATE] at 10:30 AM, during an environmental tour of the building with the Nursing Home Administrator (NHA), the call lights in the [NAME] hall shower room and the East hall shower room were tested. When both call lights were activated, it was observed that there was no audible sound, the lights outside the shower room did not illuminate, and the call light panel located at the nurse's station did not light up to indicate the call light in the shower room had been activated. NHA confirmed the non-functional call lights and stated they would have maintenance address the issue. Review of the facility's policy Call…

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 to the State Agency for two residents (R93 and R252) of 15 residents reviewed for abuse/neglect/mistreatment. Findings include: R252 On 10/26/23 the medical record for R252 was reviewed and revealed the following: R252 was initially admitted to the facility on [DATE] and had diagnoses including adjustment disorder and chronic pain syndrome. A review of R252's MDS (minimum data set) with an ARD (assessment reference date) of 10/11/23 revealed R252 was independent with most of their activities of daily living. R252's BIMS score (brief interview for mental status) was 15 indicating intact cognition. A Nursing progress note dated 10/15/23 revealed the following: Approx. (approximately) 1330 writer was charting at east nurse's station heard verbal altercation down east hallway. While walking down hallway to see where altercation occurring, writer was approached by resident's roommate [R93] stating, 'Resident hit me in my back…

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 care conferences were conducted regularly for one (R62) of 18 residents reviewed for care planning. Findings include: Review of R62's clinical record revealed R62 was admitted into the facility on 7/23/23 and readmitted on [DATE] with diagnoses that included: heart failure and Parkinson's Disease. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R62 had moderately impaired cognition and required extensive physical assist for bed mobility and toilet use and limited assistance with transfers. On 10/25/23 at 2:34 PM, an interview was conducted with Social Services Director (SSD) 'Y'. SSD 'Y' explained that resident care conferences were documented in the progress notes under care conference summary. Review of R62's Care Conference Summary progress notes revealed the last documented care conference was on 10/28/22. On 10/25/23 at 2:44 PM, an interview was conducted with SSD 'Y'. When queried about how often care conferences 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00139774. Based on interview and record review, the facility failed to address a change of condition and ensure a timely transfer to the emergency department after a fall for one resident, (R247) of one resident reviewed for transfer the the emergency room. Findings include: On 10/26/23 at approximately 1:00 PM, a review of a complaint to the State Agency was reviewed and indicated the local Police department responded to the facility on 9/11/23. The complaint further read, ' .dispatched .to (facility name) for a male fall victim with a head injury .spoke with (Nurse 'W) who stated she started her shift at 1900 hours (7PM), and the injury had already happened and had not been reported. She discovered the patient had apparently fallen out of his bed and hit his head causing a large laceration .(Nurse 'W') .called (Unit Manager 'X') who informed her to call (Ambulance Company) not 911 .We received the initial call @ 1025pm when the incident took place prior to 7 pm according 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure smoking supplies were securely stored for one (R45) of one resident reviewed for smoking. Findings include: On 10/24/23 at 1:10 PM, R45 was observed sitting in a wheelchair in their room. R45 was removing a pack of cigarettes out of the top drawer of the bedside nightstand. R45 was asked if they had a lighter. R45 pulled a lighter out of coat pocket they were wearing. When asked if they always kept their smoking supplies in their room, R45 explained the supplies were supposed to be kept in a locked box, but they kept them in their room. Review of the clinical record revealed R45 was admitted into the facility on 9/27/23 with diagnoses that included: diabetes, heart failure and kidney disease. According to the Minimum Data Set (MDS) assessment dated [DATE], R45 was cognitively intact and was independent for most activities of daily living (ADL's). On 10/26/23 at 8:40 AM, an observation residents smoking at the facility revealed…

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 catheter care for one resident (R21) of one resident reviewed for catheter care. Findings include: A request for a policy on catheter care was requested via e-mail on 10/26/23 at 12:35 PM, however; it was not provided by the end of the survey. On 10/24/23 at 9:43 AM, R21 was lying in their bed. It was observed they had a urinary catheter and the drainage bag. It was observed the drainage bag did not have a dignity bag and the bag and tubing were observed in contact with the floor. It was further observed the catheter tubing had a build-up of white sentiment. On 10/25/23 at 12:00 PM, a review of R21's clinical record revealed they most recently re-admitted to the facility on [DATE] with diagnoses that included: moderate protein calorie malnutrition, adult failure to thrive, anxiety disorder, major depressive disorder, diabetes, and dementia. R21's most recent Minimum Data Set assessment dated [DATE] revealed R21 had 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 observation, interview, and record review, the facility failed to ensure appropriate treatment and services for a feeding tube for one resident (R82) of three residents reviewed for feeding tubes. Findings include: A review of a facility provided policy titled, Care and Treatment of Feeding Tubes revised 6/2023 was conducted and read, Policy: It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible . On 10/24/23 at 9:33 AM, R82 was observed in their bed, with tube feeding being delivered via pump. A foam cup dated 10/22/23 contained a large, undated flush syringe submerged in water. An observation of R82's feeding tube site on their abdomen revealed an undated gauze with dried reddish, brown drainage. On 10/24/23 at 3:15 PM, the large flush syringe remained submerged in the cup of water dated 10/22/23. On 10/25/23 at 8:19 AM, an observation of R82's feeding tube site on 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 treatment and services for a tracheostomy for one resident (R82) of one resident reviewed for tracheostomy care. Findings include: A review of a facility provided policy titled, Tracheostomy Care revised 4/2023 was conducted and read, .4. Procedure: Licensed nurse or respiratory care personnel will perform trach care twice daily unless otherwise indicated by a physician order .5. Documentation a) Date, time, initials and any abnormalities b) All subjective and objective data c) Trach, condition of peristomal tissue, excessive or purulent or fetid trach secretions . On 10/24/23 at 9:33 AM, R82 was observed in their bed. They were observed to have a sterile tracheostomy care and cleaning kit and an open cup of sterile water on their bedside table. 10/24/23 at 11:45 AM and 3:15 PM, the open sterile tracheostomy care kit (the open kit exposed the sterile items within the kit to become contaminated) and sterile water remained on 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 This citation pertains to intake #'s MI00137712, MI00137726, MI00137731, MI00137802, MI00137848, and MI00137945. This citation has two deficient practices. Deficient Practice #1 Based on observation, interview, and record review, the facility failed to ensure a dignified existence for five resident (R#'s 902, 904, 909, 912, and 913 ) of six residents reviewed for dignity. Findings include: R902 A review of a complaint made to the state agency alleged R902 was observed sleeping on the floor, was being fed on the floor, and had a mattress placed on the floor that was soiled with blood. On 8/1/23 at 1:11 PM, an interview was conducted with former staff member 'B'. They said they reported to work on 6/11/23 and R902's mattress was covered in dried blood. They said around 12 PM, R902's family came to the facility to visit but were not allowed in R902's room because of the condition of the room and the bloody mattress. They said staff got R902 ready in their room and transported him by wheelchair to the day room for 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.

This citation pertains to intake #MI00137816. Based on observation, interview, and record review, the facility failed to ensure the privacy and confidentiality of private health information for three residents (R#'s 905, 909, and 910), as well as several residents who resided on the 1 East unit, resulting in the potential for identity theft and fraud. Findings include: A complaint was received by the State Agency that alleged the facility provided an unknown person R905's personal health information. On 8/1/23 at 12:38 PM, an interview was conducted with the complainant. They said on 6/15/23, R905 told them someone came to visit them, but they did not know who it was. The complainant was alarmed as they provided a strict list of visitors allowed to see R905 because of a pending criminal and civil matter involving R905. They said they asked R905's nurse who visited R905 on 6/15/23 and Nurse 'L' told them it was a Nurse Practitioner, but they did not know any other information about them. The complainant said Nurse 'L' provided the unknown nurse practitioner R905's face sheet (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.

This citation pertains to intake #'s MI00137731, MI00137816, and MI00137944. Based on interview and record review, the facility failed to ensure grievance follow-up and resolution for two residents (R903 and 905) of three residents reviewed for grievances, as well as address grievances resulting from resident council meetings, resulting in verbalized feelings of frustration. Findings include: R903 A complaint was made to the State Agency R903 had been sexually harassed by another resident and the facility did not address the family's concerns. On 8/1/23 at 2:47 PM an interview was conducted with the complainant. They said their husband had an audio recording of a resident threatening to sexually assault R903. They said it was also witnessed by other staff but staff did not address it so it was reported to Administration by her husband and he was concerned for R903's safety. On 8/1/23 at approximately 11:30 AM, review of a facility provided investigation was conducted revealed the facility substantiated the threat of sexual assault against R903. On 8/1/23 at approximately 2:20 PM,…

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

This citation pertains to intake #'s MI00137666 and MI00137731. Based on observation, interview, and record review, the facility failed to immediately suspend a staff member accused of physical abuse for one resident (R901) of six residents of abuse, resulting in the potential for further acts of staff to resident abuse. Findings include: A complaint was received by the State Agency that alleged a resident was abused by a staff member. On 8/1/23 at 3:20 PM, an interview was conducted with R901 regarding an incident that occurred on 6/6/23 on the midnight shift where they alleged Nurse 'A' grabbed their hand and forcefully, squeezed, twisted, and crushed it. trying to remove a cup of pills they were holding. They indicated the police were called, arrived to the facility and took their statement as well as Nurse 'A's statement. They said they had X-rays done at the hospital after the incident but they did not reveal any injury. At that time, R901 was asked if any facility staff were aware of the allegation and said the Director of Nursing (DON) and the Administrator were aware. On…

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