Optalis Health & Rehabilitation of Bloomfield Hill

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to report an injury of unknown origin to the Administrator in a timely manner for one (R80) of five residents reviewed for abuse. Findings include: On 1/12/25 at 11:48AM, R80 was observed lying in bed. A dark purple bruise that appeared to be squarish, approximately 1 inch x 1 inch was observed on the outside of R80's left upper arm. R80 was asked how she got the bruise. R80 explained an aid was rough with her care a couple days ago. When asked if she had told anyone about the rough care, R80 explained she had told the nurse.Review of the clinical record revealed R80 had been admitted into the facility on 3/30/23 and readmitted [DATE] with diagnoses that included: rheumatoid arthritis, ankylosing spondylitis [type of arthritis that fuses the spine] and muscle weakness. According to the Minimum Data Set [MDS] assessment dated [DATE], R80 was cognitively intact and required the assistance of staff for all activities of daily living…

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 There are two deficient practice statements. Deficient Practice Statement (DPS) #1. This citation pertains to Intake 2703853.Based on interviews and record reviews the facility failed to complete accurate assessments, document accurate vitals in the medical charts, complete labs as ordered, administer medications/intravenous fluids as ordered, and report accurate assessments to the Physician for timely treatment, care and/or transfer to a higher level of care, for three (R's 122, 99 and 4) of four residents reviewed for a change in condition.Findings include: R122 A review of a complaint submitted to the State Agency (SA) documented a concern of the facility's negligence that resulted in the death of R122. A review of the hospital record Discharge Summary dated 12/5/25 at 8:55 PM, noted in part . presented for a few days of decreased oral intake, fatigue, lethargy. having poor oral intake and coughing when attempting to eat. Per wife, he was prescribed diltiazem on 11/29 for documented tachycardia. Per EMS…

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 2690703. Based on observation, interview, and record reviews the facility failed to ensure interventions and treatment were implemented and/or applied consistently for two (R's 120 & 4) of four residents reviewed for pressure wounds. Findings include:R120 On 1/13/26 at 9:52 AM, an observation of R120's feet revealed white gauze bandages wrapped on both feet and dated 1/10. R120 stated the nurse is supposed to change their feet dressings before they were to be discharged that day. A review of the medical record revealed R120 was admitted on [DATE], with diagnoses that included: end stage renal disease, moderate protein-calorie malnutrition dependence on dialysis, and prediabetes. A review of the physician orders revealed the following: Cleanse left heel with wound cleanser, apply moist betadine gauze apply to left heel with abd (abdominal) pad and wrap with kerlix. Every night shift every Mon (Monday), Wed (Wednesday), Fri (Friday) for DTI (Deep Tissue Injury). Cleanser right…

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 2711600. Based on observation, interview, and record review, the facility failed to ensure interventions were implemented to prevent falls for one (R85) of five residents reviewed for accidents, resulting in additional falls from bed. Findings include: On 1/12/26 at 10:20 AM, R85 was observed lying in bed on a regular mattress. R85 did not speak English and was unable to answer questions. A review of R85's clinical record revealed R85 was admitted into the facility on [DATE] with diagnoses that included: dementia, osteoporosis, and essential hypertension. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R85 had moderately impaired cognition, required substantial/maximal assistance to go from lying to sitting on the side of the bed and when transferred from the chair to the bed or the bed to the chair. The assessment noted R85 was always incontinent of urine and stool and did not have any falls since admission into the facility. A review of R85's progress…

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 2711600Based on observation, interview and record review the facility failed to ensure accurate weights were obtained and accurate assessments were completed for one (R64) of six residents reviewed for nutrition resulting in R64's actual weight being 29.6 pounds [Lbs] less than the documented weight indicating severe weight loss. Findings include:On 1/12/26 at 10:45 AM, R64 was observed lying in bed. R64 appeared very thin, and as R64 was not wearing a shirt or slacks, he was only clothed in a brief, the definition of ribs was noticeable along with thin arms and legs. Review of the clinical record revealed R64 was admitted into the facility on 3/22/24 and readmitted on [DATE] with diagnoses that included: quadriplegia, major depressive disorder and anxiety disorder. According to the Minimum Data Set [MDS] assessment dated [DATE], R64 was cognitively intact and was dependent on staff for all activities of daily living [ADL's].Review of R64's weights revealed monthly weights…

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 reviews the facility failed to ensure coordination with meals around dialysis services for one (R120) of two residents reviewed for dialysis. Findings include: On 1/12/26 at 11:05 AM, R120 was observed sitting in a wheelchair in their room. R120 stated they have a chair time at 6:30 AM every Monday, Wednesday & Friday. R120 stated they had not received breakfast on any Monday, Wednesday or Friday since being admitted to the facility. R120 stated they had yet to receive breakfast (at the time of the interview) and was hungry. After the interview the Unit Manager (UM) HH was alerted of the resident in need of a meal.A review of the medical record revealed R120 was admitted on [DATE], with diagnoses that included: end stage renal disease, moderate protein-calorie malnutrition and dependence on dialysis.On 1/13/26 at 10:05 AM, UM HH was interviewed and asked whose responsibility it was to ensure the dialysis residents meals are coordinated around their dialysis…

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 reviews the facility failed to ensure the timely review of a pharmacist recommendation for one (R65) of five residents reviewed for unnecessary medications. Findings include:On 1/12/26 at 3:05 PM, R65 was observed lying in bed. R65 did not awaken with verbal stimuli.A review of the medical record revealed R65 was initially admitted to the facility on [DATE], with a readmission date of 2/26/25. R65 was admitted with diagnoses that included: dementia and heart failure and depended on staff assistance for all Activities of Daily Living (ADLs). A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 8 (that indicated moderately impaired cognition).A review of the medical record revealed no documentation of the monthly pharmacist medication reviews to have been conducted.On 1/14/26 at 11:43 AM, the monthly pharmacist medication reviews were requested from the Director of Nursing (DON) and the Administrator.A review of…

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

Based on observation, interview and record review, the facility failed to ensure a medication error rate less than five percent when two medication errors out of 27 opportunities for error were observed for two (R110 and R70) of three residents reviewed during the medication administration observation, resulting in a 7.41% error rate. Findings include:On 1/13/26 at 8:16 AM, Licensed Practical Nurse [LPN] 'I' was observed as part of the medication administration task. LPN 'I' prepared seven medications for R110, including one Senna Plus [a combination constipation medication including senna and docusate] 8.6-50 mg [milligrams]. LPN 'I' was observed to enter R110's room and administer all seven medications to R110.On 1/13/26 at 8:31 AM, LPN 'H' was observed preparing eleven medications for R70, including one Geri-Kot [a senna laxative] 8.6 mg (milligrams). LPN 'H' was observed to enter R70's room and administer all eleven medications to R70.On 1/13/26 at 3:30 PM, R70's physician orders were compared to the medications observed to have been given by LPN 'H'. The reconciliation 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 This citation pertains to intake: 2662635.Based on observation, interview, and record review the facility failed to consistently notify and update R502's family of newly identified wounds for one (R502) of one resident reviewed for notification/plan of care. Findings include:A review of a complaint submitted to the State Agency (SA) noted concerns of the resident to have been identified with multiple wounds at the hospital that the family was unaware of. On 12/3/25 at 12:57 PM, R502 was observed in their room lying on their back in bed. The resident did not wake up with verbal stimuli. At approximately 1:15 PM, a skin observation was conducted with the Assistant Director of Nursing (ADON) C and Certified Nursing Assistant (CNA) D. A review of the medical record revealed that R502 was admitted to the facility on [DATE] with diagnoses that included: cerebral infarction and multiple myeloma. Further review of the medical record revealed R502 was dependent on staff for all Activities of Daily Living (ADLs). A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: 2662635. Based on observation, interview and record review the facility failed to report a decline of a sacral/sacrum wound to the physician and implement treatment to an infected wound, for one (R502) of two residents reviewed for pressure wounds. Findings include: On 12/3/25 at 12:57 PM, R502 was observed lying on their back in bed. The resident did not awake with verbal stimuli. A review of the medical record revealed R502 was admitted to the facility on [DATE] with diagnoses that included: cerebral infarction and multiple myeloma. Further review of the medical record revealed R502 was dependent on staff for all Activities of Daily Living (ADLs). A review of a wound consultation dated 10/24/25, documented in part . Wound #1 - sacral 4 (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer), exudate is Moderate. Patient complains of pain level none. Infection or Inflammation is None. Residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: 2662635.Based on observation, interview and record review the facility failed to provide indwelling catheter care for one (R502) of one resident reviewed for catheter care. Findings include:On 12/3/25 at 12:57 PM, R502 was observed sleeping on their back in bed. Observed on the right side of the bed lower bed frame was a urinary foley bag with a privacy cover. Observed in the tubing was bright yellow cloudy urine. R502 did not wake with verbal stimuli. A review of the medical record revealed R502 was admitted to the facility on [DATE] with diagnoses that included: cerebral infarction and multiple myeloma. Further review of the medical record revealed R502 was dependent on staff for all Activities of Daily Living (ADLs). A review of the physician orders revealed the following: Start Date- 6/28/25 Catheter care has been provided every shift for management routine. Discontinued The medical record did not note the date the order was discontinued. The review of the medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: 2662635.Based on observation, interview, and record review the facility failed to ensure consistent Percutaneous Endoscopic Gastrostomy (PEG) care was completed for one (R502) of two residents reviewed for PEG maintenance/care. Findings include:Review of a complaint submitted to the State Agency (SA) documented concerns of the facility's failure to maintain R502's PEG care and noted the hospital found a . whole pill lodged in it (PEG). A review of the medical record revealed R502 was admitted to the facility on [DATE] with diagnoses that included: cerebral infarction and multiple myeloma. Further review of the medical record revealed R502 was dependent on staff for all Activities of Daily Living (ADLs). A review of the progress notes revealed the following: On 10/28/25 at 11:49 PM, a nurse's note documented in part . Residents peg-tube clogged, with several attempts to unclog writer unsuccessful. Physician notified and verbal orders to start hypodermoclysis with sodium chloride…

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 2564545Based on observation and interview, the facility failed to provide a sanitary homelike environment among the first and second floor residential common areas including the second-floor dining rooms, first floor community room, and first floor residential community shower room, resulting in an unkempt environment and potential for resident dissatisfaction with their living conditions and failure to maintain a clean healthcare environment.Findings include: On 7/14/25, the State Agency received a complaint alleging the facility is not maintaining a clean environment.During an initial environmental tour of the facility on 9/16/25 at 12:30 PM, the Two-West dining room was observed and revealed areas of beige colored dried substances spillage incorporated into the carpeting entering the room and near two front resident dining tables. Food crumbs and debris were noted amongst the entire dining room including the entire perimeter of floor, under dining tables and chairs, windows,…

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 Complaint #1191844.Based on interview and record review, the facility failed to provide access or copies of the resident's medical records to the resident representative within the required timeframe for one (R705) of two residents reviewed for access to medical records. Findings include:A review of a complaint submitted to the State Agency in May 2025, revealed an allegation that the resident representative had been waiting to receive R705's medical records for two months. It was documented the resident representative requested the most recent care plan, physical therapy and occupational therapy notes, medication lists, and the last three Kardex (the resident's care guide). It was alleged the resident representative was verbally told by the Administrator that he would follow up regarding the medical records, but there was no follow-up. A review of a Grievance and Satisfaction Form dated 5/20/25 revealed the former Administrator (Administrator 'H') received a grievance regarding R705…

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 1191435 and 1191855. Based on observation, interview and record review, the facility failed to ensure medications were available for administration and arrange a dermatology consultation per the Physician's order for two residents (R701 and R703) of two residents reviewed for Physican orders/Medications. Findings include:R701 Clinical record review revealed R701 had a medical diagnosis including diabetes, morbid obesity, heart disease, seborrheic dermatitis (chronic inflammatory skin condition), and schizoaffective disorder, bipolar type (bouts of hypomania, mania, and depression) On 9/16/25 at 9:30 AM, during an interview, R701 confirmed they had chronic dermatology concerns and had informed the Providers and Nurses at the facility for the last few months requests to be seen by a Dermatologist (doctor that specializes in the treatment of skin disorders). Clinical record review revealed on 7/22/2025 at 11:16 AM, Nurse Practitioner (NP) “G” ordered R701 to be consulted by a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Complaint #1191844.Based on interview and record review, the facility failed to provide medically related social services related to obtaining consent for psychotropic medication use and coordination of psychiatric services for one (R705) of four residents reviewed for medications. Findings include:A review of a complaint submitted to State Agency revealed allegations that the resident representative requested multiple times that Physician 'K' not be assigned to evaluate or change medications orders for R705 due to changing the resident's antipsychotic medication (Seroquel) order without consent of the resident representative (RR 'J'). It was alleged on 8/17/25, nursing staff contacted R705's resident representative and notified them that he was more verbally combative and attempted to hit staff. On 8/20/25, the Director of Nursing (DON) called to report a change in condition with exacerbated behaviors. A behavioral health evaluation and medication review was requested due to R705…

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 1191435Based on interview and record review the facility failed to obtain requested and ordered services to be seen by an Oral Surgeon for two surgical teeth extractions to meet a needed escalation of dental care for one resident (R701) of one reviewed for dental services. Findings include:Clinical record review revealed R701 had a medical diagnosis including diabetes, morbid obesity, heart disease, seborrheic dermatitis (chronic inflammatory skin condition), and schizoaffective disorder, bipolar type (bouts of hypomania, mania, and depression)On 9/16/25 at 9:30 AM, during an interview , R701 stated they had two molars that need to be removed but the facility never followed through setting up an appointment.Requested medical records for R701 from March 2025 were reviewed and revealed on 3/5/2025 R701 was seen at bedside by a Dentist related to tooth pain in their lower right side. Treatment notes documented R701 had severely decayed teeth #30, #31 (Tooth number 30 is the lower right first molar; Tooth number 31 is the lower right second molar.) 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.

This citation pertains to intake #MI00150014 Based on interview and record review the facility failed to ensure medications were administered timely and per resident preference for one resident (R810) of three residents reviewed for medication administration, resulting in verbalized complaints and frustration with medications being administered late. On 3/19/25 at approximately 3:25 PM, an interview was conducted with R810. They verbalized complaints regarding late medication administration times. They said nurses go on their breaks prior to passing medications so they don't get them on time. They said the concern was worse at night and it made them, nervous to not get their seizure medications on time. On 3/20/25 at 10:45 AM, a review of R810's medication administration audit report (a report that shows the times medications were documented on the medication administration record) was conducted and revealed the following: 2/4/25 medications scheduled for 9 PM given at 10:33 PM. 2/7/25 medications scheduled for 9 PM given at 11:32 PM 2/8/25 medications scheduled for 9 AM given at…

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

This citation pertains to intake #MI00150014 Based on interview and record review the facility failed to notify the responsible party of a change of antipsychotic medication dosage for one resident (R801) of three residents reviewed for notification of changes resulting in complaints they were not informed of the resident's plan of care. Findings include: A complaint received by the State Agency alleged the responsible party is not notified for changes in the resident's condition. On 3/19/25 at 12:00 PM, a review of a facility provided document titled, Grievance and Satisfaction form dated 3/10/25 for R801 was reviewed and indicated their responsible party contacted the facility's Administrator with concerns regarding a medication increase without their knowledge. The form read, .Resident daughter says her and family are upset at this change that happened in December . The section on the form titled, Resolution was reviewed and read, (Psychiatric Service Provider) called to apologize for not notifying the resident daughter of this change . A review of Dr. 'B's psychiatric service…

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 #MI00150014 Based on interview and record review the facility failed to ensure care conferences were coordinated with the inclusion of their responsible party for one resident (R801) of three residents reviewed for care conferences resulting in complaints of not being informed of the resident's plan of care. Findings include: A complaint received by the State Agency alleged the resident's responsible party was not notified or included in care conferences. On 3/19/25 at 2:10 PM, an interview was conducted with Social Worker 'C' regarding documentation of care conferences. They said when a care conference occurred the Social Work Department would enter a progress note into the record. On 3/19/25 at 2:13 PM, a review of R801's Social Services Progress notes was conducted and revealed the last documented note making any mention of a care conference was dated 5/24/24. A review of R801's assessments was also conducted and revealed no evidence of care conferences. On 3/20/25 at 9:20 AM, the facility was requested to provide any documented evidence of R801's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #'s MI00150014, MI00150295 Based on observation, interview, and record review facility failed to provide appropriate supervision for one (R804) of one resident reviewed for accidents. This deficient practice had the potential to cause burns and or fire related accidents when facility staff applied a non-medical grade heating pad (brought from home) to R804 with no assessment and physician order. Findings include: Record review revealed R804 was a long-term resident of the facility. R804 was originally admitted to the facility on [DATE]. Recently R804 was admitted to the hospital on [DATE] and they were readmitted to the facility on [DATE]. R804's diagnoses included rheumatoid arthritis, ankylosing spondylitis, contractures of both knees, intractable pain, overactive bladder, with history of urinary tract infection and anxiety disorder, and major depressive disorder. Based on the Minimum data Set (MDS) assessment dated [DATE], R804 had a Brief Interview for Mental Status score…

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 MI150014, MI00150295, MI00148319 Based on observation, interview, and record review facility failed to provide timely incontinence care for one (R804) of 3 residents reviewed for incontinence care resulting in the potential for impaired skin integrity and urinary tract infection(UTI). Findings include: Record review revealed R804 was a long-term resident of the facility admitted on [DATE]. Recently R804 was admitted to the hospital on [DATE] and readmitted to the facility on [DATE]. R804's diagnoses included rheumatoid arthritis, ankylosing spondylitis, contractures of both knees, intractable pain, overactive bladder, with history of urinary tract infection and anxiety disorder, and major depressive disorder. Based on the Minimum data Set (MDS) assessment dated [DATE], R804 had a Brief Interview for Mental Status Score (BIMS) of 15/15 indicative of intact cognition. R804 needed extensive staff assistance with their mobility and Activities of Daily Living (ADLs) such 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake #MI00148866 Based on observation, interview and record review the facility failed to adhere to a resident's right to decline a urine toxicity test for one resident (R905) of three residents reviewed for resident rights. Findings include: A complaint was filed with the State Agency (SA) that alleged facility staff obtained a urine sample for an unexplained reason and without their permission. The complainant further alleged that the facility never divulged the results of the urine test. On 12/23/24 at approximately 9:28 AM, R905 was observed sitting in their wheelchair. The resident was alert and able to answer all questions asked. When asked about life and care in the facility, R905 reported that they felt they were discriminated against based of race and age. They noted that the facility took a urine sample without their permission, sent the results to the laboratory and never explained the reason why they did so. R905 further stated that at times staff would allege that 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 This citation pertains to intake #MI00148615 Based on observation, interview and record review, the facility failed to ensure freedom of movement was maintained for one resident (R903 as witnessed by R907 and R908) of three residents reviewed for involuntary seclusion. Findings include: On 12/23/24 a facility reported incident (FRI) was reviewed that alleged R903 was involuntarily secluded by facility staff on 11/20/24. On 12/23/24 at approximately 9:54 a.m., R903 was observed in their room, laying in their bed. R903 was observed to be dressed appropriately wearing a hair cap. R903 was observed to have a CNA (Certified Nursing Assistant) sitting in a chair in their room providing supervision. On 12/23/24 the medical record for R903 was reviewed and revealed the following: R903 was initially admitted to the facility on [DATE] and had diagnoses including Generalized anxiety disorder, Dementia and Delirium. A review of R903's MDS (minimum data set) with an ARD (assessment reference date) of 11/19/24 revealed R903…

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 #MI00148615 Based on interview and record review, the facility failed to report an allegation of involuntary seclusion in a timely manner to the Administrator and the State Agency for one resident (R903) of three residents reviewed for abuse. Findings include: On 12/23/24 a facility reported incident (FRI) was reviewed that alleged R903 was involuntarily secluded by facility staff on 11/20/24. Further review of the FRI revealed it was received by the State Agency on 11/21/24. On 12/23/24 at approximately 9:54 a.m., R903 was observed in their room, laying in their bed. R903 was observed to be dressed appropriately wearing a hair cap. R903 was observed to have a CNA (Certified Nursing Assistant) sitting in a chair in their room providing supervision. On 12/23/24 the medical record for R903 was reviewed and revealed the following: R903 was initially admitted to the facility on [DATE] and had diagnoses including Generalized anxiety disorder, Dementia and Delirium. A review of R903's…

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

Based on observation, interview, and record review, the facility failed to maintain the kitchen and the 1st and 2nd floor pantry refrigerators in a sanitary manner. This deficient practice had the potential to affect all residents in the facility that consume food. Findings include: On 9/30/24 between 8:50 AM-9:20 AM, during an initial tour of the kitchen with Dietary Manager (DM) K, the following items were observed: In the walk-in cooler, there was pooled milk on the floor near the milk crates. DM K stated that staff would get the spilled milk cleaned up when they began putting stock away. According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean. The shelving rack used to store spices and various food items, was observed with a heavy buildup of grease, food debris and dust. DM K confirmed the soiled rack and stated staff would clean it right away. According to the 2017 FDA Food Code section 4-602.13 Nonfood-Contact Surface, Nonfood-contact surfaces of equipment shall…

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 employ a qualified social worker on a full-time basis to meet the psychosocial, mental, and behavioral health care needs of the residents. This deficient practice had the potential to affect all residents that reside within the facility. Findings include: During the recertification survey conducted [DATE] to [DATE], substandard quality of care was identified regarding the facility not having a qualified social worker to provide medically related social services full-time to the 122 residents who resided in the facility. The facility was certified for 159 beds. Deficient practices were identified during the survey related to social services, specifically concerns with lack of assessment and monitoring for resident's psychosocial, mood and behavioral needs, and coordination of guardianship. Review of the facility's documentation provided for Social Work job description included: Revised [DATE], Job Title: Social Services Director .Location: All MI…

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 establish an effective Quality Assessment and Assurance (QAA) and Quality Assurance and performance Improvement (QAPI) plan that identified systemic issues that resulted in sub-standard quality of care from failure to employ a qualified full time social worker and failure to provide medically related social services. This deficient practice had the potential to affect all 120 residents of the facility. Findings include: Facility failed to employ a qualified social worker on a full-time basis and failed to identify the ongoing concern. Facility was unaware of this concern until the concern was brought to the attention of the Administrator. The facility was previously determined to be out of compliance for concerns with providing medically related social services to address psychosocial needs, including guardianship during an abbreviated survey conducted on [DATE] with an alleged compliance date of [DATE]. On [DATE] at 8:32 AM, the Administrator 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.

On 10/01/24 at 12:20 PM, an observation of the second-floor [NAME] dining room revealed four residents sitting at three different tables. The tabletops were dirty and appeared sticky. The entire carpeted floor was unkept with moderate amounts of crumbs and debris throughout. The kitchen counter displayed areas of brown colored, dried food substance, and debris. Two mirrors on the far wall in between the windows were smudged with fingerprints. Left window vertical blinds were observed broken and bent. Two blue colored fabric lounge chairs were observed with large stains on both seats and arm rests. The middle cabinet of a credenza containing board games was opened and revealed used white Kleenex tissue, a white sheet rolled up with yellow-colored stains and a dirty white bath towel. Lying on the floor next to the credenza, a dusty single black sock was observed. On 10/1/24 at 8:33 AM, observation of the 2 [NAME] dining room revealed two residents, one with family members present, sitting at tables waiting for the breakfast trays to be served. A tray was observed on the counter along…

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 R25 On 10/2/24, clinical record review revealed R25 was admitted to the facility on [DATE] with a medical history of Parkinson's disease, heart disease, and diabetes. Psychiatric diagnoses included dementia, and schizophrenia. R25 had a BIMS score 9/15 indicating moderate cognitive impairment. Record review revealed on 8/20/24, R25 was evaluated determined unable to make medical treatment or financial decisions and guardianship was recommended. Progress note dated 8/16/24 revealed social services contacted R25's daughter and recommended guardianship. The progress note dated 8/21/24 documented social services informed R25's daughter about the results of the capacity evaluation and the determination of inability to participate in complex decision making. The family expressed they will proceed with guardianship. The progress note dated 8/30/24 documented that social services met with R25's daughter and provided the letter of decision-making capacity and the daughter would be filing for guardianship soon. Social…

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 resident prescribed psychotropic medication had adequate documentation to support continued use, as well as identify and monitor resident specific targeted behaviors and approaches for one (R22) of five residents reviewed for unnecessary medication, resulting in prolonged unnecessary use of psychotropic medication and the inability to monitor the effectiveness of the prescribed treatment due to lack of supporting documentation. Findings include: On 9/30/24 at 11:23 AM, R22 was observed seated in a wheelchair behind the nursing desk reading a magazine with staff. The resident began to repeatedly yell out loudly, in which another resident was observed yelling out to the resident to shut up several times. On 9/30/24 at 2:00 PM, an interview was conducted with R22's daughter in the resident's room. At that time, when asked about the resident's behaviors of yelling out, the daughter reported they felt that was due to concerns with 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 This citation pertains to intake #s MI00146078 and MI00147295. Based on observation, interview and record review, the facility failed to provide an environment that promoted and enhanced residents' dignity for one (R22) of five residents reviewed for dignity. Findings include: Review of complaints reported to the State Agency included allegations that residents were not being treated with dignity and respect. Review of the facility's policy titled, Dignity and Respect dated 7/11/2018: .It is the policy of this facility that all residents be treated with kindness, dignity and respect .The staff shall display respect for Resident's when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings .Violations of the Resident's right to dignity and respect should be promptly reported to the Director of Nursing Services and/or the Administrator. On 9/30/24 at 11:23 AM, R22 was observed seated behind the nursing station with several nursing staff 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 facility failed to provide an appropriate wheelchair/Geri-chair (a reclining chair with wheels) for one (R107) of two Residents reviewed for accommodation of needs. Findings include: Record review revealed R107 was originally admitted to the facility on [DATE] with diagnoses of respiratory failure, stroke with right hemiplegia (sided weakness), left craniectomy (is a surgical procedure in which a portion of the skull is removed), major depressive disorder, and anxiety. R107 had a tracheostomy tube (a surgical opening created through the neck into the trachea/windpipe to allow air to fill the lungs). Based on the Minimum Data Set (MDS) assessment dated [DATE], R107 had a Brief interview for Mental Status (BIMS) score of 00/15, indicative of significant cognitive impairment. R107 was dependent on staff assistance for their mobility in bed and transfers. R107 was receiving part of their nutrition through Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube…

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 #MI00147295. Based on interview and record review facility failed to document and promptly resolve grievances reported to the facility staff for one (R104) of one Resident reviewed for grievances. Findings include: A complaint received by the State Agency revealed the facility failed to follow-up on a medication concern that was brought up to the attention of the facility administration and attending physician on multiple occasions by the R104 and family member(s). R104 was a long-term resident of the facility originally admitted on [DATE]. R104 had multiple hospitalizations in the recent past that included 12/14/23; 4/5/24; 8/28/24; and 9/6/24. R104's admitting diagnoses included chronic normocytic anemia (low hemoglobin level), CKD (chronic kidney disease), respiratory failure, dry gangrene right 5th toe, and diabetes. Based on the Minimum Data Set (MDS) assessment dated [DATE], R104 had a Brief Interview for Mental Status (BIMS) score of 14/15, indicative of intact cognition.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete an annual OBRA (Omnibus Budget Reconciliation Act) Level II Evaluation for one resident(R33) of one resident reviewed for PASARR (Preadmission Screen and Resident Review). Findings include: Clinical record review revealed R33 was admitted to the facility on [DATE] with hemiparesis following a stroke, heart failure, diabetes, and hypertension. Psychiatric history included vascular dementia and bipolar disorder. A Brief Interview for Mental Status (BIMS) evaluated on 07/03/24 score totaled 15/15 indicating R33 was cognitively intact. On 10/2/24, review of the available PASARR form revealed there were two 3877 forms, one was submitted on 7/27/24 and another on 9/12/24. There was no evidence of R33 having the 3878 (dementia exemption) completed for both dates, as well as evidence that there was a level II evaluation completed (given the resident's recent mental status exam which indicated intact cognition, R33 would likely require a level II…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop resident-specific comprehensive care plans for one (R22) of three residents reviewed for care planning related to behavior-emotional needs and use of psychotropic medications. Findings include: On 9/30/24 at 11:23 AM, R22 was observed seated in a wheelchair behind the nursing desk reading a magazine with staff. The resident began to repeatedly yell out loudly, in which another resident was observed yelling out to the resident to shut up several times. Staff reported the resident's daughter was out of town and usually visited daily, but these behaviors were frequent and not new. Review of the clinical record revealed R22 was admitted into the facility on 1/29/24, discharged on 7/26/24 and readmitted on [DATE] with diagnoses that included: unspecified dementia, unspecified severity, with mood disturbance, altered mental status, generalized anxiety disorder, depression, adjustment disorder with mixed disturbance of emotions 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 citations pertains to intake: MI00146611 Based on observation, interview, and record review, the facility failed to secure the smoking materials for one (R15) of one Resident reviewed for smoking resulting in the potential to cause burns from smoking/smoking materials that were unsecured. Findings include: During the entrance conference with the facility administrator on 9/30/24 at 9:58 AM, the administrator reported that the facility was a non-smoking facility and they did not have any current smokers at the facility. Record review revealed R15 was originally admitted to the facility on [DATE] with diagnoses of cancer of the urinary bladder, peripheral vascular disease, nicotine dependence, Chronic Obstructive Pulmonary Disease (COPD), diabetes, and heart disease. Based on the Minimum Data Set (MDS) assessment dated [DATE], R15 had a Brief Interview for Mental Status (BIMS) score 14/15, indicative of intact cognition. An initial observation was completed on 10/1/24 at approximately 9 AM. R15 was observed…

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

This citation pertains to intake #s MI00146249 and MI00147295. Based on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent. Three medication errors were observed from a total of 36 opportunities for three out of three residents (R19, R03, R83) resulting in an error rate of 8.33%. Findings include: Review of a complaints filed with the State Agency included allegations that medications were not being properly administered. On 10/01/24 at 8:28 AM, a medication administration observation was conducted with Licensed Practical Nurse (LPN) L. R19 R19 had an order for one tablet of chewable Aspirin 81 milligrams (mg). LPN L was observed preparing an enteric coated aspirin 81 mg and crushed the medication for administration. R03 R03 had an order for one tablet of chewable Aspirin 81 milligrams (mg). LPN L was observed preparing an enteric coated aspirin 81 mg, crushed the medication, then administered it. R83 On 10/01/24 at 9:38 AM, LPN L obtained an order for one tablet chewable aspirin 81 mg. LPN L was observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number(s): MI00145592 Based on observation, interview, and record review, the facility failed to promote self-determination and allow one (R802) of three residents reviewed for resident rights, who was his own responsible party, to make his own decision to go on a leave of absence in the community, resulting in the resident feeling angry and distressed about possible loss of personal items in a storage unit after police were called and the facility staff threatened commitment to a psychiatric unit if he tried to leave the facility. Findings include: A review of a complaint submitted to the State Agency revealed allegations that noted, .(R802) attempted to leave the facility around 12/30/2023 but was told he could not leave without a guardian's permission. Veteran (R802) states he does not have a legal guardian, was not provided with any information regarding this guardian, and a quick check of (county) probate court records did not reveal any open guardianship cases for 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 This citation pertains to Intake Number: MI00145554 and MI00145592. Based on observation, interview, and record review, the facility failed to conduct a thorough and accurate skin assessment, clarify discharge instructions from the hospital and facility orders for wound treatment, implement and administer wound treatment according to hospital discharge instructions, and ensure coordination between the wound provider and the surgeon for one (R802) of one resident reviewed for wounds, resulting in infection and the need for antibiotics. Findings include: A review of a complaint submitted to the State Agency revealed an allegation that R802's wound care was not provided daily. A review of a second complaint submitted to the State Agency revealed an allegation that R802 had wounds and cellulitis (a bacterial skin infection) that were not being addressed. On 7/29/24 at approximately 11:30 AM, an interview was conducted with R802. R802 was observed in his room. His lower legs were discolored. R802 reported prior 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 This citation pertains to Intake Number(s): MI00145554 Based on observation, interview, and record review, the facility failed to ensure one (R802) of one resident reviewed for foot care, received physician ordered treatment from a podiatrist. Findings include: On 7/29/24 at 11:30 AM, R802 was interviewed in his room. R802 stood for the interview. He was observed to be wearing sandals and his toenails were very long, yellow, and thick. A large, thick, yellow bump was observed on the bottom edge of R802's left foot. R802 reported he needed to see a foot doctor and did not understand why it had not happened yet. R802 reported his toenails got stuck on things due to the length and it was very painful. R802 pointed out the large, raised area on the bottom of his foot and said it was painful. R802 took off one of his sandals to exposed the raised area on the bottom of his foot. He had difficulty putting the sandal back on due to the length of this toenails. Review of an After Visit Summary provided by the hospital 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 This citation pertains to Intake Number(s): MI000145412, MI00145592. Based on observation, interview, and record review, the facility failed to provide medically related social services related to competency evaluation, guardianship, discharge planning, and coordinating ancillary services for two (R802 and R804) of three residents reviewed for social services. Findings include: A review of a complaint submitted to the State Agency revealed allegations that included concerns with guardianship and medical issues not being addressed. It was alleged that R802, who was a Veteran, made complaints to the facility social worker who did not follow up or resolve his concerns. A review of a second complaint submitted to the State Agency revealed an allegation that the facility did not allow R804's legal guardian to sign a do not resuscitate order for the resident. R802 On 7/29/24 at approximately 11:30 AM, R802 was interviewed. R802 answered questions appropriately, despite some tangential thinking (thinking/thoughts that…

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): MI00144743 and MI00144492 Based on observation, interview, and record review, the facility failed to maintain an environment that was clean, sanitary, and homelike for four (R505, R508, R509, and R510) of five residents reviewed for the environment with the potential to affect all residents who resided on the second floor of the facility. Findings include: A review of complaints submitted to the State Agency revealed allegations that the facility was dirty and unsanitary. On 6/17/24, an unannounced onsite investigation was conducted. On 6/17/24 from 10:19 AM and 10:32 AM, an observation of the second floor was conducted and the following was observed: Upon entrance to the 2 [NAME] Unit, a strong odor that smelled like dirty feet was observed. The air smelled stale. A portable vital sign machine was observed in the hallway of the 2 [NAME] Unit. The base was rusted and coated with various dried substances and stuck on debris. The hallway of the 2 [NAME] Unit appeared…

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): MI00144772. Based on interview and record review, the facility failed to report an allegation of resident to resident abuse to the State Agency within the required time frame for two (R501 and R502) of four residents reviewed for abuse. Findings include: A review of a complaint submitted to the State Agency revealed .On 05/27/2024 around 4 AM, (R501) was assaulted by (R502) .(R502) attacked (R501) twice by going into (R501's) room and punching her in the face. Night shift was present and did nothing to stop the assault. (R502) continued to enter the room of (R501) two more times. Day shift staff (Registered Nurse - RN 'H') .called the local police regarding the matter around 10:30 AM .It is unknown why staff did not report the allegations or intervened to prevent further harm to (R501) . On 6/17/24, an unannounced onsite investigation was conducted. A review of R501's clinical record revealed R501 was admitted into the facility on 5/10/24 and discharged home on 6/7/24.…

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): MI00144772. Based on interview and record review, the facility failed to implement adequate supervision for one (R502) of four residents reviewed for supervision, who had a history of wandering into other residents' rooms and aggressive behaviors, resulting in R502 entering R501's room multiple times, attempting to get into her bed, and punching her in the face multiple times. Findings include: A review of a complaint submitted to the State Agency revealed .On 05/27/2024 around 4 AM, (R501) was assaulted by (R502) .(R502) attacked (R501) twice by going into (R501's) room and punching her in the face. Night shift was present and did nothing to stop the assault. (R502) continued to enter the room of (R501) two more times. Day shift staff (Registered Nurse - RN 'H') .called the local police regarding the matter around 10:30 AM .It is unknown why staff did not report the allegations or intervened to prevent further harm to (R501). (R501) does not have visible bruises 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 pertains to Intake# MI00142366 Based on observation, interview and record review the facility failed to ensure resident's medications were stored securely, administered as ordered and documented according to professional nursing standards for five (R802, R804, R812, R813 and R816) out of sixteen residents reviewed for professional standards. Findings include: A Complaint was filed with the State Agency (SA) that alleged a resident did not receive their pain medication and was told by Staff that their pain medication had been given to other residents. R812 A review of R812's clinical record documented the resident was admitted to the facility on [DATE] with diagnoses that included: aftercare following joint replacement surgery. The resident initial assessment indicted the resident was cognitively intact. A review of the resident's Medication Administration Record (MAR) noted that that the following controlled substance/narcotic medications were administered on 1/18/24: Morphine Sulfate Extended…

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: MI00142560, MI00144323 Based on observation, interview and record review, the facility failed to administer a pre-procedural medication per physician orders for one resident (R813) resulting in termination of a diagnostic procedure. Findings include: On 5/7/24, a clinical record review revealed R813 was admitted to the facility on [DATE] for history of a stroke resulting in left hemiparesis (unable to move left side of body), requiring a suprapubic catheter (tube surgically placed into the bladder to remove urine), chronic kidney disease, hypertension, enlarged prostate, and a psychiatric history of depression. A Brief Interview for Mental Status (BIMS) conducted on 4/22/24 revealed R813 scored a total of five, indicating severe cognitive impairment. On 5/7/2024 at 11:40 AM, upon initial introduction, R813 was observed in a contracted position laying in bed watching television, orientated, and conversing appropriately. On the bedside table, a large clear bottle, half full with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00143440. Based on observation, interviews, and record reviews the facility failed to ensure an accurate placement of a urinary catheter foley for one R803 of two residents reviewed for a urinary catheter. Findings include: Review of a complaint submitted to the State Agency (SA) documented in part, . Resident's foley catheter was improperly inserted on 3/14/2024 and resident had to be transported to hospital on 3/15/2024. This is the 2nd time this has occurred . On 5/8/24 at approximately 2:30 PM, R803 was observed lying on their back in bed sleeping. R803 was observed to have a pink tie-dyed shirt with a green comforter covering their lower body. R803 did not open their eyes to verbal stimuli and continued to sleep. A urinary catheter bag was observed on the lower right side of the bed, draining clear yellow urine. Review of the medical record revealed R803 was initially admitted to the facility on [DATE], a readmission date of 4/9/24, with diagnoses that included: 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 Intake #MI00142366 Based on interview and record review the facility failed to ensure a resident received ordered pain medication in a timely manner for one (R812) out of one resident reviewed for pain, resulting in a significant increase in pain (10/10). Findings include: A complaint was filed with the State Agency (SA) that alleged R812 did not receive scheduled pain medication and after telling the nurse they were in extreme pain, the nurse noted told them honey you can make it through the night. A review of R812's clinical record documented the resident was admitted to the facility on [DATE] with diagnoses that included: aftercare following joint replacement surgery. The resident's initial assessment indicted the resident was cognitively intact. Continued review of R812's clinical record revealed, in part, the following: Medical Practitioner Note (1/18/24 at 6:38 PM): .Pt (patient) comes to this facility for rehab therapy and medical management. Pt. seen today and examined today. Pt…

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: MI00143426 and MI00144086. Based on observation, interview and record review the facility failed to ensure resident's received timely dental services, including denture replacement and tooth extractions for one (R802) out of three residents reviewed for dental care. Findings include: Complaints were filed with the State Agency (SA) that alleged residents were not receiving dental care and dentures were not replaced timely. R802 On 5/7/24 at approximately 10:05 AM, R802 was observed lying in bed. The resident was alert and could answer some questions asked. When asked about care provided in the facility R802 reported that they needed to seek services outside of the facility and further noted that they needed to have two molars removed. When asked if their teeth caused pain, R802 reported they hurt at times. R802 also noted that their dentures were stolen and needed to be replaced. A review of R802's clinical record revealed the resident was initially admitted to the facility…

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: MI00144086. Based on observation, interview, and record review, the facility failed to perform hand hygiene consistent with accepted standards resulting in the potential for transmission of infectious material. Findings include: A review of Intake MI00144086 indicated the complainant was concerned about cross contamination with R801's tracheostomy tube (a medical device surgically inserted into a hole in the neck to help a person breath).The staff touch everything in the room and then provide trach care . Further concerns included toe fungus, and skin breakdown on the buttock area. The complainant was present at the facility on 5/7/24 and confirmed the allegations. On 5/7/24, A clinical record review revealed R801 was recently readmitted to the facility on [DATE] for a history of stroke with intracerebral hemorrhage (bleeding in the brain), required a tracheostomy related to impaired breathing mechanics, and a Percutaneous Endoscopic Gastrostomy (PEG) Tube (surgically placed…

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 #MI00140379 and #MI00140532. Based on observation, interview, and record review the facility failed to ensure a patient assessment, a root cause analysis investigation, and timely clinical documentation of a fall for one resident (R902) of three residents reviewed for falls, resulting in the potential for undetected injuries and future incidences of falls. Findings include: A complaint received by the State Agency alleged R902 had a fall on 8/31/23, they were not assessed post-fall and clinical documentation of the fall had not been entered into the record in a timely manner. On 12/19/23 at approximately 10:15 AM, R902 was observed seated in their wheelchair at the nursing station. At numerous times on 12/19/23 R902 was also observed self-propelling through the hallway of the facility. A review of R902's clinical record was conducted and revealed they admitted to the facility on [DATE], with diagnoses that included: schizoaffective disorder, diabetes, dysphagia, dementia, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure physician visits/assessments were completed and/or documented timely for one (R81) of two residents reviewed for physician visits, resulting in delayed practitioner assessments, and the increased potential for lack of coordination of care. Findings include: Review of the clinical record revealed R81 was admitted into the facility on 2/24/20, readmitted on [DATE] with diagnoses that included: type 2 diabetes mellitus with other specified complication. According to the Minimum Data Set (MDS) assessment dated [DATE], R81 had intact cognition. Review of the physician and/or extender notes revealed from 8/22/22 to 10/10/23 there were a total of 27 physician/extender assessments documented for R81. 12 of these assessments were identified as late entry by Nurse Practitioner (NP 'B') and were not available timely to other disciplines of the interdisciplinary team for extended periods of time which had the potential to impact timely coordination of care.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure physician evaluations were alternated between the physician and extenders (Nurse Practitioner/NP) as required for one (R81) of two residents reviewed for physician visits. Findings include: Review of the clinical record revealed R81 was admitted into the facility on 2/24/20, readmitted on [DATE] with diagnoses that included: type 2 diabetes mellitus with other specified complication. According to the Minimum Data Set (MDS) assessment dated [DATE], R81 had intact cognition. Review of the physician and/or extender notes revealed from 8/22/22 to 10/10/23 there were a total of 27 physician/extender assessments documented for R81. Only one of these practitioner assessments were completed by a physician (Physician 'D') on 8/31/23. 22 of these practitioner assessments were completed by NP 'B' on 8/22/22, 8/25/22, 8/29/22, 9/12/22, 9/27/22, 11/8/22, 11/15/22, 12/16/22, 1/27/23, 2/24/23, 3/14/23, 3/16/23, 4/10/23, 4/21/23, 5/30/23, 6/19/23, 6/23/23,…

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 MI00137216 Based on observation, interview, and record review, the facility failed to ensure accurate, complete, and timely documented medical records for five residents (R#'s 336, 440, 636, 438, and 96) of five residents reviewed for accurate, complete, and timely documented records, resulting in Health Insurance Portability and Accountability Act (HIPAA) violations of privacy and the potential for additional privacy violations. Findings include: A review of a facility provided policy titled, Documentation adopted [DATE] that read, .All services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care . R440 and R336 On [DATE] at 12:05 PM, a review of R440's clinical record revealed they…

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 that two (R4 and R110) residents received a clear understanding of the facility's Binding Arbitration agreement prior to signing the document and ensure that facility staff had a clear understanding of the legal document. Findings include: During the entrance conference the facility reported that the Binding Arbitration was offered to all residents entering into the building. The facility provided a list of residents that had agreed to Binding Arbitration that included R4 and R110. Review of the facility Binding Arbitration Agreement was reviewed and documented, in part: .Except as otherwise expressly provided in any written agreement between the parties the parties agree that any and all claims and disputes arising out of or relating to Resident's stay .will be resolved through the dispute resolution process .Any covered claims not resolved by mediation will be settled by arbitration .Residents understand that by agreeing to the dispute…

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

Based on interview and record review, the facility failed to establish an antibiotic stewardship program that failed to establish an antibiotic stewardship program that included consistent implementation of protocols for appropriate antibiotic use. This deficient practice affected multiple residents (including R42, and R637) at the facility. Findings include: Review of a facility policy titled, Antibiotic Stewardship dated 7/11/18 read in part, .training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community .If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: .f. Indications for use . Review of the facility's July 2023 infection control log book documented of the 36 antibiotic line listings, 12 of them did not meet criteria for antibiotic use. Including R637 receiving Ciprofloxacin 500 milligrams (mg) beginning 7/19/23. A progress note dated 7/18/23 at 5:46 PM by Nurse Practitioner (NP)…

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 MI00138955 and MI00137521. Based on observation, interview and record review the facility failed to honor preferences for the provision of caregivers for one resident (R101) of one residents reviewed for self-determination. Findings include: On 10/10/23 at approximately 10:25 a.m., R101 was observed in their room, laying in their bed receiving care. R101 was queried if they had any concerns regarding their care in the facility and they indicated they do not like having two people in the room while staff are providing care. R101 also indicated that they could not have male staff provide care to them, and they only wanted female caregivers. R101 reported the facility had recently assigned a male caregiver to them that went against their plan of care. On 10/10/23 the medical record for R101 was reviewed and revealed the following: R101 was initially admitted to the facility on [DATE] and had Bipolar disorder, Chronic pain and Muscle weakness. A review of R101's MDS (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 #MI00139363 Based on observation, interview and record review, the facility failed to ensure timely revision/updates to the comprehensive plan of care for one resident (R29) of one resident reviewed for wandering/elopement. Findings include: On 10/10/23 at approximately 9:37a.m., R29 was observed wandering in hallway, yelling out at nobody and appeared to be upset. On 10/12/23 the medical record for R29 was reviewed and revealed the following: R29 was initially admitted to the facility on [DATE] and had diagnoses including Dementia and Psychotic disorder with delusions. A review of R29's MDS (minimum data set) with an ARD (assessment reference date) of 9/21/23 revealed R29 needed supervision with most of their activities of daily living. R29 was documented as having severely impaired cognition. A review of R29's progress notes pertaining to their wandering behavior revealed the following: 8/29/2023 at 16:09 @ (at) 1:30 pm resident came into the hallway attempting to enter other…

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 contains two deficient practice statements DPS1 Based on observation, interview and record review the facility failed to ensure one resident (R34) was administered Lactulose, Nasal Spray and two as need(PRN) medications as requested according to professional standards of practice. Findings include: On 10/10/2023 at 10:03 AM a observation of medication administration was conducted. Nurse S began a medication pass with first identifying R34. Nurse S prepared medications sevelamer, vitamin c, nifedipine, losartan, Eliquis, Coreg, calcitriol, clopidogrel, paroxetine, vitamin D3 and gabapentin and signed them out. Nurse S entered the room with cup of medications and R34 asked Is my pain pill and muscle relaxer in here. Nurse S replied Yes. Handed resident cup of medications took them, we left residents room and went back to medication cart Nurse S was asked did resident receive a pain pill and muscle relaxer if so what was the pill named. Nurse S replied his gabapentin is the pain pill and no he did not…

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 wrist and hand orthotics were applied per therapy recommendations for one resident (R25) with contractures of six residents reviewed for range of motion and orthotics, resulting in the potential for worsening of contractures. Findings include: On the following dates and times, R25 was observed in their bed with no wrist or hand orthotic in place, but a wrist/hand orthotic marked with an 'L' for the left hand was observed on the shelf above the television: 10/10/23 at 10:13 AM, 10/10/23 at 12:50 PM, 10/10/23 at 2:35 PM, 10/11/23 at 9:00 AM, 10/11/23 at 12:10 PM, 10/11/23 at 2:40 PM, and 10/12/23 at 8:35 AM. A review of R25's clinical record was conducted and revealed they admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnoses that included: stroke with hemiplegia and hemiparesis, contractures, adjustment disorder, vascular dementia, seizures, dysphagia, lupus, falls and presence of a feeding tube.…

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 Physician orders for oxygen therapy were in place for one resident (R118) of two residents reviewed for respiratory care. Findings include: On 10/10/23 at approximately 10:15 a.m., R118 was observed in their room, up in their bed. R118 was observed to having oxygen infusing via nasal cannula at 3LPM (liters per minute) On 10/11/23 at approximately 9:51 a.m., R118 was observed in their room, laying in their bed with their nasal cannula applied with oxygen infusing at 3.5 liters per minute. R118 was queried if they knew how many liters of oxygen they should be provided and they reported they should be on four liters. On 10/11/23 at approximately 12:30 p.m., R118 was observed in their room with their nasal cannula infusing oxygen. R118 was still observed to be on 3.5 LPM. On 10/10/23 the medical record was reviewed and revealed the following: R118 was initially admitted to the facility on [DATE] and had diagnoses including 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 Based on observation, interview and record review, the facility failed to provide justification for the increase of an antipsychotic medication(Quetiapine/Seroquel) including identified targeted behaviors for one (R105) of five residents reviewed for unnecessary medications. Findings include: On 10/10/23 at 10:00 AM resident was observed in room in the Geri chair. Resident was nonverbal was able to make eye contact but could not answer questions asked. A review of R105's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Picks Disease (front-temporal dementia), aphasia and delirium. A review of the residents Minimum Data Set (MDS) documented that the resident had a Brief Interview for Mental Status (BIMS) score of 0 (severely cognitively impaired). Review of the behavior section of the MDS showed no behaviors. Further review of the clinical record revealed the following: 2/10/23 (Care Plan Progress Note): .met for quarterly care conference…

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 #MI00139363 Based on observation, interview and record review, the facility failed to provide timely laboratory services to two (R29 and R81) of two residents reviewed for laboratory services. Findings include: According to the facility's policy titled, Diagnostic Tests dated 7/11/2018: It is the policy of this facility to provide or obtain laboratory services .Ordered laboratory services .will be handled in a proficient manner to ensure timeliness, accuracy, and proper follow up . R81 On 10/10/23 at 1:30 PM, R81 was observed laying in bed. When asked about whether they had any concerns, they reported the were worried about having their blood sugar checked and stated, I've wanted to follow up to have them to a A1C (Hemoglobin A1C - a blood test that measures average blood sugar levels over the past three months) to see where I'm at cause I'm diabetic. I know I don't follow it (therapeutic diet for diabetes) but I'd still like to know. Review of the clinical record revealed R81…

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.