Woodward Hills Health and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Physician ordered laboratory diagnostics (labs) were completed and reported to the Physician in a timely manner for one resident (R52) of one resident reviewed for laboratory diagnostics. Findings include: On 3/2/26 the medical record for R52 was reviewed and revealed the following: R52 was initially admitted to the facility on [DATE] and had diagnoses including Pneumonia and Sepsis. A Physician's order dated 2/20/26 revealed the following: CBC (complete blood count) and CMP (comprehensive metabolic panel) Dx (diagnosis): New Admit A review of R52's laboratory results in the electronic medical record did not reveal any lab results for R52's labs ordered on 2/20/26. On 3/4/26 at approximately 11:54 a.m., Nurse Manger R (NM R) was queried regarding the lab results for 2/20/26. NM R reported that new admission residents have baseline labs ordered and drawn upon admission, and that they would check for the results. On 3/4/26 at approximately 12:02…

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 and interview, the facility failed to provide proper hand hygiene procedures during medication administration for three (R128, R53, R215) residents of four reviewed for medication administration.Findings include:On 3/3/26 at 8:12 AM, a medication administration observation was conducted with Registered Nurse (RN) C for R128. RN C donned a pair of clear gloves at the 600-hallway cart without cleaning their hands. RN C proceeded to touch items on top of cart including a stack of clear plastic cups, poured a brown liquid supplement into a plastic cup, retrieved a pen from the top of cart, and opened the top drawer, donned with the same gloves, RN C proceeded to remove the medicine cup of opened medications and liquid supplement for R128 and proceeded to administer at bedside.On 3/3/26 at 8:58 AM, a medication administration observation was conducted with Licensed Practical Nurse (LPN) B for R53 and was observed not performing hand hygiene prior to medication preparation and not performing hand hygiene prior to medication administration to R53.On 3/3/26 at 9:09 AM,…

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 #2577284.Based on observation, interview, and record review, the facility failed to provide a safe, clean, homelike environment, in multiple resident rooms and throughout the hallways on the 100, 400, 500, 600, and 700 units. Findings include:Review of concerns reported to the State Agency on 7/31/25 included: the building smells like mildew, the facility is dirty, rain is coming down from the second-floor ceiling, which was not a new issue and happened every time it rains, and there was black mold on the pipes and in the ceiling.On 8/5/25 between 8:30 AM - 10:05 AM, observations of the facility revealed the following environmental concerns:At 8:30 AM, upon entry into the facility's main lobby, there was a strong mildew odor present, as well as in hallway towards the conference room.At 9:11 AM, there were three ceiling tiles off the main dining room towards the long-term care side of the facility that were heavily stained with water damage.At 9:15 AM, the end of the 500 hallway…

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: MI00151510. Based on interview and record reviews the facility failed to address the concerns reported to the facility for one (R202) of three residents reviewed for grievances. Review of a complaint submitted to the State Agency (SA) documented multiple concerns that the complainant attempted to get resolved with the facility staff unsuccessfully. The complainant noted the facility's failure to follow up and the lack of communication to resolve any of their concerns. A review of R202's medical record revealed the resident was admitted to the facility on [DATE] and transferred out to the hospital on 3/27/25. R202 admitted with the primary diagnosis of hypokalemia and required staff assistance with all Activities of Daily Living (ADLs). A review of the progress notes revealed the following: On 3/26/25 at 9:35 AM, a Social Worker (SW) note documented in part . CM (case manager) had some concerns regarding the resident. SW asked appropriate parties to follow up . This note was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation relates to Intake #MI00151329. Based on observation, interview, and record review, the facility failed to protect the resident's rights to be free from physical abuse during two resident-to-resident incidents for two Residents (R205, R206) of three residents reviewed for abuse. Findings include: R206 Review of R206's Minimum Data Set (MDS) assessment, dated 12/13/25, revealed R206 was admitted to the facility on [DATE], with diagnoses including heart failure, lung disease, and arthritis. R206 required set up with eating, and maximal assistance with toileting and transfers. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, which showed R206 was cognitively intact. On 5/27/25 at 12:54 p.m., R206 was observed dressed, seated in a bariatric wheelchair. On 5/27/25 at 12:56 p.m., R206 reported they had a concern with another resident. R206 reported they transferred to R205's room from another facility room a couple months ago, and the room was torn apart (messy) .so bad…

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 #: MI00152670 Based on interview and record review facility failed to investigate (and follow-up) on an injury (skin tear) of unknown origin for one (R207) of three Residents reviewed for abuse resulting in the potential for further unidentified instances of injuries of unknown origin. Findings include: Review of the complaint received to the State Agency revealed that a family member/emergency contact regularly visited R207 during their stay at the facility. On 4/28/25 the family member discovered that R207 had a bandage on their arm when they removed the resident's jacket. When they removed the bandage they found bruises and a gash. They reported they were handling and assisting R207 with all their affairs. They did not receive any calls from the from the facility on how R207 sustained this injury. Record review revealed R207 was admitted to the facility on [DATE] for short-term skilled rehabilitation and nursing care. R207's admitting diagnoses included atrial fibrillation…

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: MI00151510. Based on observation, interview and record reviews the facility failed to consistently complete wound treatments (R202), failed to timely identify a left heel wound, timely implement treatment to the left heel wound and consistently completed weekly skin assessment (R209) for two of three residents reviewed for wounds. Findings include: R202 A review of a complaint submitted to the State Agency (SA) noted concerns of the facility failure to provide adequate and appropriate interventions to prevent and care for R202's wounds. A review of the R202's medical record revealed the resident was admitted to the facility on [DATE] and transferred out to the hospital on 3/27/25. R202 admitted with the primary diagnosis of hypokalemia and required staff assistance with all Activities of Daily Living (ADLs). A review of an admission Evaluation dated 3/13/25 at 12:38 AM, documented the following in part, . Sacrum- unstageable . Left heel- Dry . Coccyx- 2 stage twos next 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: MI00151510. Based on interview and record reviews the facility failed to ensure an initial comprehensive consultation was completed by a Physician for one (R202) of three residents reviewed for quality of care. Findings include: A review of the R202's medical record revealed the resident was admitted to the facility on [DATE] and transferred out to the hospital on 3/27/25. R202 admitted with the primary diagnosis of hypokalemia and required staff assistance with all Activities of Daily Living (ADLs). Review of the medical record revealed the following: A Physician Team - Progress Note dated 3/13/25 at 4:16 PM, that documented in part . DATE OF EXAM 3/12/2025 . initial visit post hospitalization . of multiple medical problems . This progress note contained an assessment and evaluation of care for the resident. The progress note was documented by Nurse Practitioner (NP) L. Further review of the medical record revealed no documentation of an initial comprehensive visit to have been…

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 #MI00149390. Based on interview and record review, the facility failed to ensure treatment in a dignified manner for one resident, (R801) of three residents reviewed for dignity, resulting in feelings of frustration and being ignored. Findings include: A complaint received by the State Agency alleged R801 was moved from one unit to another and staff did not retrieve and deliver their personal hygiene wipes as requested. A review of R801's progress notes revealed a note entered into the record by Nurse 'B' on 1/12/25 at 11:18 PM that read, .Patient needs wipes from priar <sic> room on brae burn <sic> (unit) please relay message to day shift supervisor or maintenance . On 3/11/25 at 2:35 PM, an interview with the facility's Director of Nursing (DON) was conducted regarding the resident's request for their wipes and the nurses progress note in response. The DON indicated the nurse should have went to R801's previous room, retrieved the wipes and delivered them to their new room. A review of a facility provided policy titled, Resident Rights issued…

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 #MI00149390. Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the State Agency for one resident (R801) of two residents reviewed for abuse. Findings include: A review of a complaint received by the State Agency alleged R801 was assaulted by a staff member. On 3/11/25 at approximately 10:30 AM, a review of a progress note entered into the record by Nurse 'D' on 12/28/24 was conducted and read, Nurse checked in with resident to see how he is doing and said he's doing better, and felt better knowing that the CNA (Certified Nurse Aide) that was working with him earlier was sent home . On 3/11/25 at 10:45 AM, in absence of the facility's Administrator (out of the facility) the Director of Nursing (DON) was requested to provide grievances, investigations, and facility reported incidents for R801. On 3/11/25 at 11:50 AM, a telephone interview was conducted with Nurse 'D' regarding their progress note on 12/28/24. They were asked about the note and why it documented a CNA had been sent home. They said…

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 #MI00149390. Based on interview and record review, the facility failed to prevent an avoidable fall for one resident (R801) of three residents reviewed for falls, resulting in the resident rolling out of bed. Findings include: On 3/11/25 at 8:50 AM, a review of R801's clinical record revealed they admitted to the facility on [DATE] and discharged [DATE]. R801's diagnoses included: paraplegia, spinal cord injuries, bipolar disorder, pain, foot drop, and post traumatic stress disorder. A Minimum Data Set assessment dated [DATE] revealed R801 had intact cognition, was non-ambulatory and dependent on staff for rolling left to right. R801's care plan for activities of daily living included an intervention dated 12/25/24 that read, .BED MOBILITY: 2 person assist . On 3/11/25 at 9:00 AM, a review of R801's progress notes revealed a note entered into the record by Nurse 'F' dated 1/27/25 at 6:13 AM that read, .CEna <sic> (Certified Nurse Aide) reports resident turning self for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00149390 and #MI00151121. Based on interview and record review, the facility failed to ensure pain was treated per resident request and physician's orders for one resident (R801) of two residents reviewed for pain, resulting in complaints with care and untreated pain. Findings include: A complaint received by the State Agency alleged the resident's pain was not treated per their request and physician's orders. On 3/11/25 at 8:50 AM, a review of R801's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: paraplegia, spinal cord injury, wounds, bipolar disorder, adjustment disorder, and post traumatic stress disorder. A review of R801's physician's orders revealed an order dated 12/31/24 for oxycodone (narcotic pain medication) 20 mg (milligrams) every four hours as needed for pain. R801's Medication Administration Record (MAR) for February 2025 was reviewed and revealed they received a dose of the medication on 2/16/25 at 10:47 AM. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen, failed to maintain the microwaves in the Cranbrook and [NAME] pantry in a sanitary manner, and failed to ensure food items were covered while transported through the hallways. This deficient practice had the potential to affect all residents in the facility that consume food. Findings include: On 12/2/24 between 8:40 AM-9:10 AM, during an observation of the kitchen with Dietary Director T, the following items were observed: There was a rolling cart with large portions of missing plastic edging. There was exposed porous particle board, and the surface was no longer smooth and easily cleanable. Dietary Director T confirmed the missing edging, but did not provide an explanation for why the cart was still in use. According to the 2017 FDA Food Code section 4-101.19 Nonfood-Contact Surfaces, NonFOOD-CONTACT SURFACES of EQUIPMENT that are exposed to splash, spillage, or other FOOD soiling or 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 Based on observation, interview and record review, the facility failed to provide an environment that promoted and enhanced resident's dignity for five residents (R53, R286, R292, R336, and R387) of seven residents reviewed for dignity. Findings include: R53 On 12/2/24 at 11:09 AM, R53 was interviewed about their stay in the facility. They said they recently received a shower and while in the shower the Certified Nurse Aide (CNA) squeezed the shampoo onto their head and told them they could, do it themselves. R53 said they were able to shampoo their own hair, but found the CNA's attitude and tone to be, unnecessary and, rude. R286 On 12/2/24 at 9:37 AM, R286 was observed from the hallway in their bed. They were not covered fully with a blanket and their upper thigh and buttock were visible. They were asked permission to enter the room, and they said they were on the bed pan. They were then asked if they would like the door closed for privacy and said they would. At that time, Certified Nurse Aide 'W' was…

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

Based on observation, interview, and record review, the facility failed to maintain comfortable ambient air temperatures in multiple resident rooms (Rooms 100, 101, 103, 105, 107, 111, 201, 203, 205, and 207). Findings include: On 12/2/24 between 12:34 PM-1:05 PM, the following resident room air temperatures were measured with Maintenance Director V: 100- 69 degrees Fahrenheit there was a pillow observed over the window to block the draft. 101- 65 degrees Fahrenheit the Resident in the room was observed sitting in a wheelchair, wrapped up in a blanket, wearing a winter hat and stated she was cold. 103- 60 degrees Fahrenheit 105- 64 degrees Fahrenheit 107- 65 degrees Fahrenheit 111- 62 degrees Fahrenheit (vacant room) 201- 68 degrees Fahrenheit 203- 66 degrees Fahrenheit (vacant room) 205- 68 degrees Fahrenheit 207- 69 degrees Fahrenheit On 12/2/24 at 1:25 PM, the room air temperature monitoring logs were requested from Maintenance Director V. Maintenance Director V stated that room temperatures are monitored, but that he does not record them. Review of the facility's policy…

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 all controlled substances were accounted for and accurately documented for one (82) of four residents reviewed for pain management. Findings include: On 12/2/24 at 12:56 PM, R82 was observed in their room. An interview was conducted with R82 regarding his care in the facility. R82 reported that they often run out of his pain medication, which included oxycontin and oxycodone (Schedule II Controlled Substances - Drugs that have a high potential for abuse and dependence). R82 reported that when they run out, he had to wait up to 14 hours to receive the next dose and in that time, he would experience pain. R82 reported the last time the facility ran out was a few days ago. A review of R82's clinical record revealed R82 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: hemiplegia and hemiparesis, charcot joint (a disease that attacks the bones, joints, and soft tissue in your feet, often…

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 prevent a significant med error for one (R20) of five residents reviewed for unnecessary medications, resulting in the resident receiving duplicate doses of a diuretic medication (furosemide) on three days. Findings include: A review of a document titled, Consultant Pharmacist Recommendations to Nursing dated 11/14/24 revealed the pharmacist made the following comments and recommendations regarding R20: The resident has duplicate orders on eMAR (Electronic Medication Administration Record) for: .Furosemide 20 mg (milligrams) once a day .Please clarify and discontinue one of the above orders . The document was signed off my the nurse which indicated it was reviewed. A review of R20's eMAR for November 2024 revealed the following: An order for furosemide 20 mg one time a day with a start date of 8/3/24. An order for furosemide 20 mg one time a day with a start date of 11/13/24. Both orders were active at the same time from 11/13/24 until 11/20/24. It was signed off on the MAR that both doses were administered on 11/17/24,…

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 Based on observation, interview, and record review, the facility failed to implement physician ordered transmission based precautions (TBP) for one (R20) of one resident reviewed for TBP. Findings include: On 12/2/24 at 10:38 AM, Certified Nursing Assistant (CNA) 'GG' was observed to enter R20's room and assist the resident with incontinence care and toileting. There was no signage observed on R20's door and no Personal Protective Equipment (PPE) outside of the room. At approximately 11:30 AM, R20 was observed near the nurse's station talking with another resident and they were later brought down to the dining room. A review of R20's Physician's orders indicated R20 was placed on Contact Precautions (TBP used to prevent spread of illness) for VRE (Vancomycin-resistant Enterococci - strain of bacteria resistant to the antibiotic Vancomycin) with a start date of 11/29/24. Further review of R20's clinical record revealed R20 was admitted into the facility on 5/13/23 and readmitted on [DATE] with diagnoses 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 Based on interview and record review, the facility failed to ensure a referral was made for a level II evaluation (a comprehensive evaluation completed by the local community mental health agency) in a timely manner for one (R24) of two residents reviewed for PASARR (Preadmission Screening/Annual Resident Review) screenings. Findings include: On 12/2/24 at 4:01 PM, a review of R24's clinical record revealed R24 was admitted into the facility on 5/6/20 and readmitted on [DATE] with diagnoses that included: paranoid schizophrenia, vascular dementia, schizoaffective disorder bipolar type, and major depressive disorder. A review of a Minimum Data Set (MDS) assessment revealed R24 had severely impaired cognition. A review of a PASARR Level I Screening form (DCH-3877) signed and dated on 4/19/24 revealed R24 had diagnoses of mental illness and dementia, indicated by marking 'Yes' in sections 1 and 2. The instructions on the form included If any answers to items 1-6 section II is 'Yes, send ONE copy to the local…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has three (3) deficient practice statements (DPS). DPS #1 Based on observation, interview and record review the facility failed to timely identify and assess a facial bruise for one (R36) of four residents reviewed for falls. Findings include: On 12/2/24 at approximately 8:59 AM, R36 was observed lying in bed. The resident had a brownish bruise below their left eye. Behind the resident's bed was a document that noted the resident was a two person assist for bed transfers. When asked about the bruise around their eye, the resident thought they fell but could not specify the date, time, where and how the fall occurred. A review of the resident's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: left femur fracture, malnutrition and COPD (chronic obstructive pulmonary disease). A review of the resident's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status score of 4/15 (severely impaired 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 observation, interview and record review the facility failed to ensure appropriate orders for peripherally inserted central catheter (PICC) dressing changes and monitoring of dressings for two (R387 and R291) of two residents reviewed for PICC lines. Findings include: R387 On 12/2/24 at 10:32 AM, R387 was observed standing at the sink in their room, an intravenous (IV) pump on a pole was observed. R387 was asked if they were receiving antibiotics. R387 explained they were through a PICC line in their right arm. R387 was asked about the dressing over their PICC line. R387 gingerly took their right arm out of their long-sleeved shirt, pulling the shirt away from the dressing. The dressing appeared to be mostly hanging loose, only attached at the top part, the rest of the clear dressing was not adhered to R387's arm. Review of the clinical record revealed R387 was admitted into the facility on [DATE] with diagnoses that included: cutaneous abscess of right foot, cellulitis of right lower limb and long term…

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 follow-up for guardianship for one resident (R49) of one resident reviewed for guardianship. Findings include: On 12/4/24 at 11:51 AM, a review of R49's clinical revealed a competency evaluation dated 10/18/24 signed by two physicians indicated R49 was not competent to make complex medical decisions, provide informed consent, or participate in decisions regarding their financial affairs. A progress note dated 10/17/24 entered into the record by Social Work Director 'O' was reviewed and read, .(R49's son) made aware that resident was seen for capacity evaluation and deemed incapable of making medical and financial decisions at this time. (R49's son) understands that a guardian will need to be appointed and states he will go to the court on 10/21 and file for emergency guardianship appointment. SW (Social Work) will cont (continue) to follow up and assist son as needed. On 12/4/24 at 12:19 PM, Social Work Director 'O' was asked to provide any documentation or evidence they had followed up with R49's son for guardianship. No…

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 monthly drug regimen reviews conducted by the consultant pharmacist were reviewed by the medication provider for recommendations to act on for one (R3) out of five residents reviewed for unnecessary medications. Findings include: A review of R3's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: chronic respiratory failure, chronic kidney disease and type II diabetes. A review of R3's drug regimen reviews revealed the Consultant Pharmacist reviewed R3's medication on 7/8/24 and noted irregularities and/or recommendations. A review of R3's clinical record revealed no report that indicated what the identified irregularities or recommendations were. On 12/4/24 at approximately 3:00 PM an interview and record review were conducted with Director of Nursing/Administrator in Training (AIT) A. AIT A reported that all responses to the consulting pharmacist should be located in the resident'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 #MI00148355 Based on observation, interview and record review the facility failed to timely provide follow-up dental services to one (R25) out of two residents reviewed for dental services. Findings include: A complaint was filed with the State Agency (SA) that alleged R25 was not receiving timely dental services. On 12/3/24 at approximately 2:05 PM, R25 was observed sitting in their room. They were alert and able to answer all questions asked. R25 reported that they had been at the hospital for about two weeks and just returned to the facility. When asked about care in the facility, including, dental services, R25 reported they had not seen a dentist in a long time and would like to see one. R25 opened their mouth and noted that they were missing teeth on their lower/bottom area and wear dentures on their top and were eager to get bottom dentures if possible. A review of R25's clinical record was conducted on 12/3/24 at approximately 2:15 PM. The review revealed the resident was…

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

Based on interview and record review the facility failed to offer the 2024-2025 seasonal influenza (flu)vaccine to one resident (R49) of five residents reviewed for influenza vaccines. Findings include: On 12/4/24 at 11:39 AM, a review of R49's immunization records in the electronic medical record were reviewed. The last documented entry for the influenza vaccine was documented 9/10/24 and indicated the 2023-2024 seasonal vaccine was not offered because they admitted to the facility after the influenza season. There was no evidence they had been offered the 2024-2025 vaccine at the beginning of the new flu season. On 12/4/24 at 12:24 PM, an interview as conducted with Infection Control Preventionist 'BB'. They acknowledged it had not been offered or administered and they would follow up on it. A review of a facility provided policy titled, Vaccination of Residents Upon Admission dated 10/2023 was conducted but did not address offering of the influenza vaccine upon the start of the new flu season, between October 1st and March 31st each year.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00143872 Based on observation, interview and record review the facility failed to ensure skin assessments were documented, completed accurately and timely for one resident (R901) of two residents reviewed for changes in condition. Findings include: On 5/28/24 a complaint submitted to the State Agency was reviewed which alleged the facility was not monitoring R901's skin appropriately. On 5/28/24 at approximately 9:51 a.m., R901 was observed in their room, laying in their bed. R901 was queried if they had been sent to the hospital recently and they indicated they had. R901 was queried if they remembered why they were sent to the hospital and they indicated they were sick but were unable to recall the reason. On 5/28/24 the medical record for R901 was reviewed and revealed the following: R901 was Initially admitted on [DATE] and had diagnoses of Metabolic Encephalopathy and Cellullitis of right lower limb (4/12/24) and Sepsis (4/12/24). R901 was last readmitted from the hospital…

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 #: MI00142021, MI00142120, and MI00141180 Based on interview and record review, the facility failed to provide timely medically related social services and follow up to address behavior changes, care planning reviews, and discharge planning for three (R901, 907, and 910) of four residents reviewed for social services. Findings include: R901 A review of the medical record revealed R901 was originally admitted to the facility on [DATE] for skilled nursing and rehabilitation services, after hospitalization for back surgery that resulted from a fall at home. R901 was hospitalized during their stay at the facility and readmitted back to the facility on [DATE]. R901 was living alone in the community prior to the fall and back surgeries. R901's admitting diagnoses included multiple back surgeries (kyphoplasty and fusion of spines at T11-T12, T12-L1, and L1-L2 level), urinary retention, and heart failure. Based on a Minimum Data Set Assessment (MDS) dated [DATE], R901 had Brief Interview…

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 #: MI00142195. Based on observation, interview, and record review the facility failed to initiate a timely investigation for an injury (abrasion on left lower extremity) of unknown origin for one (R908) of two Residents reviewed for abuse with potential for further injuries of unknown origin/abuse. A record review revealed R908's most recent readmission to facility was on 7/14/22. R908's admitting diagnoses included dementia, unspecified psychosis, anxiety disorder, and history of multiple falls. Based on the Minimum Data Set (MDS) assessment dated [DATE], R908 had severe cognitive impairment. R908 needed extensive staff assistance with their mobility in bed, transfers, and Activities of Daily Living (ADLs) such as dressing, bathing etc. An initial observation was completed on 2/5/24, at approximately 10:10 AM. R908 was observed in their bed with their eyes closed. R908 was not dressed, and they were wearing facility provided gown. R908 had a bandage wrapped on their left lower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure six residents (R34, R49, R60, R63, R80 and R94) of six residents reviewed for medications were assessed for the safe self-administration of medication and to have medication kept at the bedside, resulting in the potential for mismanagement of medication and potential for adverse side effects. Findings include: According to the facility's policy titled, Self Administration of Drugs dated 5/2018: .If a resident desires to participate in self-administration, the interdisciplinary team shall assess the competence of the resident to participate, by completing a Self-Administration of Medication Assessment .Based on the interdisciplinary team's review, the decision is made as to whether or not the resident is a candidate for self-administration. This will be recorded on the Self-Administration of Medication Assessment form .In addition, if the resident's BIMS - (mental exam) is less than 13 this will also deem the resident inappropriate…

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 call lights were accessible to four residents (R39, R73, R95 and R111) and an appropriate bed was provided to one resident (R446) of five residents reviewed for accommodation of needs. Findings include: According to the facility's policy titled, Call Light Accessibility and Timely Response dated 8/16/2023: .Staff will ensure the call light is plugged in, functioning, within reach of residents, and secured, as needed . R95: On 10/3/23 at 1:00 PM, R95 was observed laying in bed fanning themselves while complaining about being very hot (the facility's air conditioner currently broken). At that time, the call light was observed wrapped around the wall unit. When asked how they would ask for help if they needed it, R95 reported, I can't find it. (call light). When informed it was hooked around the wall unit, R95 reported, How am I supposed to reach that?. R111: On 10/3/23 at 1:05 PM, R111 was observed laying in bed and when asked how…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to complete routine showers for three Residents (R4, R60 and R98) of four reviewed for activities of daily living (ADLs). Findings include: On 10/3/23 at approximately 10:35 AM, R60 was observed lying in bed. The resident was alert and able to answer all questions asked. When asked about care provided in the facility, R60 reported that often they have to wait for staff to answer call lights and also noted, that they do not always have enough staff to help them up for a shower. R60 explained that their shower days are on Monday and Thursday afternoon shift. R60 stated that yesterday (Monday 10/2/23) they only received a bed bath as their were not enough staff to assist with their shower. R60 reported that they would have preferred a shower. A review of R60's clinical record revealed the were initially admitted to the facility on [DATE] and were readmitted on [DATE] with diagnoses that included: fracture of third vertebra, anxiety, type 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 This citation pertains to intake #MI00139622. Based on observation, interview and record review the facility failed to provide wound care treatments and accurate and/or timely skin assessments as ordered by the physician for three (R34, R43 and R445) of three residents reviewed for quality of care, resulting in the lack of assessment, monitoring, and potential worsening of the condition and delayed healing. Findings include: According to the facility's policy titled, Skin & Wound Policy dated 1/2022: .It is our policy to perform a full body skin assessment .as part of our systematic approach to pressure injury prevention and management. It is also our policy to follow the treatment plans for any wound / skin concerns as ordered by physicians .Treatments will be documented on the Treatment Administration Record .The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include .lack of progression towards healing .Changes in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two deficient practices. Deficient Practice #1 Based on observation, interview and record review the facility failed to ensure the environment was free from environmental hazards including unsecured sharps containers (a hard plastic container that is used to safely dispose of hypodermic needles and other sharp medical instruments, such as Intravenous/IV catheters and disposable scalpels) and free standing oxygen thanks. This deficient practice had the potential to effect effect one resident (R98) and multiple other residents residing in the facility. Findings include: On 10/3/23 at approximately 10:31 a.m., a Sharps container was observed stored on top of a treatment cart, unsecured and free standing on top of the cart. The top was observed to be propped open without any Nursing staff around it. It was noted to contain sharps On 10/3/23 at approximately 12:56 p.m. another Sharps container was observed on top of a Medication cart unsecured and free standing. It was noted to already contain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure medications were properly secured and stored in three medication carts, two medication storage rooms and one resident room (R98) of 5 medication carts and two medication storage rooms reviewed for medication labeling and storage. Findings include: On [DATE] at approximately 1:28 p.m., Nurse O was observed opening a medication cart. A plastic medication cup with a gabapentin pill was observed in the non-controlled section of the medication cart. Nurse O was queried if that was normal process for storing a controlled substance and they indicated it was not. On [DATE] at approximately 2:01 p.m., a medication storage room was observed to be unlocked, unattended by any nursing staff. Nurse M was queried regarding the unlocked medication storage room and they indicated that it should be locked. On [DATE] at approximately 2:08 p.m., an expired daptomycin antibiotic with an expiration date of [DATE] was observed in the medication storage…

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 R98 On 10/5/23 The medical record for R98 was reviewed and revealed the following: R98 was initially admitted to the facility on [DATE] and had diagnoses including Depression, Insomnia and Congestive heart failure. A review of R98's MDS (minimum data set) with an ARD (assessment reference date) of 7/7/23 revealed R98 needed extensive assistance with most of their activities of daily living. R98's BIMS sore (brief interview for mental status) was 13 indicating intact cognition. A Physician's order dated 9/25/23 with a start date of 9/30/23 revealed the following: Prazosin HCl Oral Capsule 2 MG (Prazosin HCl) Give 2 mg by mouth at bedtime for PTSD (Post traumatic stress disorder)/Nightmares A review of R98's October 2023 Medication Administration Record (MAR) revealed R98 had not been administered their Prazosin in October. On 10/5/23 at approximately 1:51 p.m., during a conversation with Nurse Manager L (NM L), NM L was queried why R98 had not been provided their Prazosin that had the start date of 9/30/23 with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure appropriate communication devices and services were in place for one resident (R497) of one resident reviewed for communication, resulting in the potential for unmet care needs. Findings include: On 10/03/23 at 09:48 AM, R497 was observed in bed lying on their back with several blanket sheets under them, daughter was present. On 10/03/23 at 09:48 AM, an observation of R497's room revealed no communication boards, pencil or paper. On 10/03/23 at 10:53 AM, R497 was attempted to be interviewed, however R497 does not speak English. There were no boards or means of communication to communicate to the resident. On 10/03/23 at 10:57 AM, R497's daughter attempted to translate however, it was still a challenge as to English not being primary language. Record review revealed the R497 was admitted to the facility on [DATE] with the medical diagnoses of need for assistance with personal care, heart failure and muscle weakness. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure appropriate catheter care was provided and Physician orders were obtained for an indwelling catheter for one resident (R5) of three residents reviewed for Catheters. Findings include: On 10/3/23 at approximately 11:32 a.m., R5 was observed in their room, laying in their bed. No catheter observed on R5. R5 was queried if they had a catheter and they reported that it had fallen out the previous night and nobody had put a new one in. R5 was observed with medical tape on their left leg that they said the Nurses never took off when the catheter fell out. On 10/4/23 at approximately 10:45 a.m., R5 was observed in their room, laying in their bed. R5 was observed to have an indwelling catheter in place, draining yellow urine into a drainage bag. R5 was queried when the Nursing staff had placed the catheter and they reported that it was during the night on the previous day. R5 was observed to not have any anchor or securement device securing…

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 legally incompetent resident was provided a representative that had legal authority to act in the best interest/make informed medical decisions in a timely manner for one resident (R4) of one residents reviewed for medically related social services. Findings include: On 10/4/23 at approximately 11:25 a.m. R4 was observed in their room, laying in their bed. R4 was queried if they had anyone that helped make their medical decisions and handle their personal business and they indicated that their daughter helped them. On 10/3/23 the medical record for R4 was reviewed and revealed the following. R4 was initially admitted on [DATE] and had diagnoses including Dementia and Heart failure. A review of R4's MDS (minimum data set) with an ARD (assessment reference date) of 8/17/23 revealed R4 needed extensive assistance from facility staff with most of their activities of daily living. R4's BIMS score (brief interview for mental status) was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake number(s): MI00133087. Based on interview and record review, the facility failed to ensure controlled substances were received, administered, reconciled appropriately, and discrepancies in counts investigated for one (R815) of four residents reviewed for medications, resulting in R815 receiving too much opioid pain medication and the potential for drug diversion. Findings include: A complaint was submitted to the State Agency that alleged the facility did not administer R815's patch appropriately. According to the complainant, On 11/9/22, the nurse but <sic> a 25 & 12 mg (milligram) patch on (R815) and on 11/11/22 the nurse put a 50 mg patch but never removed the 37 mg patch. As of Saturday 11/12/22, (R815) was disoriented confused and very sleepy lethargic and shaking cuz <sic> of the overdose of the patch. They then realized their error and removed all three patches on 11/12/22 . An unannounced, onsite investigation was conducted from 9/19/23 through 9/21/23. Review of R815'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 number(s): MI00138623 and MI00138901. Based on observation, interview, and record review, the facility failed to notify the residents' representatives of a hospital transfer and black eye for two (R804 and R805) of two residents reviewed for notification of changes. Findings include: R804 Review of a complaint submitted to the State Agency revealed an allegation that the facility transferred R804 to the hospital without notifying the responsible party. According to the complaint, the responsible party was not notified of the transfer until 36 hours later. On 9/21/23 at 2:00 PM, R804 was observed lying in bed. When interviewed, R804 was able to answer yes or no questions only. Review of R804's clinical record revealed R804 was admitted into the facility on [DATE] and readmitted on [DATE] after a hospital transfer that occurred on 8/17/23. R804's diagnoses included: hemiplegia (paralysis of one side of the body), aphasia (difficulty speaking), and dysphagia (difficulty swallowing).…

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): MI00136323 & MI00132921. Based on interviews and record reviews the facility failed to implement their grievance policy for two (R's 817 & 813) of three residents reviewed for grievances. Findings include: R817 Review of a complaint submitted to the State Agency (AS) documented concerns of the facility to have failed to follow up with care concerns submitted to the facility. Review of the medical record revealed R817 was admitted to the facility on [DATE] with diagnoses that included: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia, spinal stenosis, atrial fibrillation, hypertension, and overactive bladder. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11 (which indicated moderately impaired cognition) and required staff assistance with all Activities of Daily Living (ADLs). Review of emails submitted to the facility's Previous Social Worker (PSW) I from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake number(s): MI00139106 and MI00138623 Based on observation, interview, and record review, the facility failed to report allegations of abuse, mistreatment and a black eye of unknown origin to the State Agency for two (R801 and R805) of six residents reviewed for abuse. Findings include: Review of a facility policy titled, Abuse, revised on 4/13/23, revealed, in part, the following: .The facility will ensure that all allegations involving abuse, neglect .mistreatment, injuries of unknown source .are reported immediately to the Administrator and: Reported to the State Survey Agency immediately but not later than two hours after the allegation is made if the allegation involves abuse . R801 Review of a complaint submitted to the State Agency alleged R801 was abused by a staff member at the facility, that someone put her phone in her drawer where she could not get to it, and that someone turned off the call light and threw it under the bed and said they were busy. An unannounced,…

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): MI00139106 and MI00138623 Based on observation, interview, and record review, the facility failed to investigate allegations of abuse and mistreatment and thoroughly investigate a black eye of unknown origin for two (R801 and R805) of six residents reviewed for abuse. Findings include: Review of a facility policy titled, Abuse, revised on 4/13/23, revealed, in part, the following: .Once reported, the facility conducts a timely, thorough, and objective investigation of any allegation of abuse. It is the facility's policy to investigate all allegations involving Abuse, Neglect .Mistreatment, including any Injuries of Unknown Source .The investigation process includes: .Determining the purpose of the investigation and issue(s) to be investigated with focus on whether or not he allegation has occurred, the extent, and cause .Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge…

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 cite pertains to intake MI00137696 and intake MI00139186 Based on interview and record review, the facility failed to document, accommodate, and provide routine showers to two(R802 and R807) of two residents reviewed for showers, resulting in skin irritation and the resident's feeling as if they had poor hygiene. Findings include: R807 Record review revealed that R807 was admitted on [DATE] and readmitted on [DATE] with the diagnosis of Hemiplegia and hemiparesis following cerebral infraction, Parkinson's disease and overactive bladder. Record review of the Minimum data set (MDS) revealed that R807 had a brief interview for mental status(BIMs) of 12, (indicating moderately impaired cognition) and needed moderate assistance with his activities of daily living(ADL's). On 9/20/2023 at 5:00PM, the Director of Nursing(DON) and the Administrator were interviewed regarding R807 showers received during their stay at the facility. The documentation that was received contained several holes (missing documentation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00132921 and MI00132451. Based on interviews and record reviews the facility failed to implement adequate fall interventions for one (R817) a resident with a history of falls, resulting in a fall. Findings include: Review of a complaint submitted to the State Agency (SA) documented a concern with the facility failing to implement interventions to prevent the resident's fall. Review of the medical record revealed R817 was admitted to the facility on [DATE] with diagnoses that included: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia, spinal stenosis, atrial fibrillation, hypertension, and overactive bladder. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11 (which indicated moderately impaired cognition) and required staff assistance with all Activities of Daily Living (ADLs). Review of a progress note dated 12/14/21 at 7:27 PM, documented in part . During…

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 cite pertains to intake(s) MI00137696 and MI00138070. Based on observation, interview and record review, the facility failed to maintain adequate catheter care for one residents(R806) of one sampled for catheter care, resulting in the potential for urinary tract infections (UTI) and discomfort. Findings include: Review of an intake submitted to the State Agency (SA) documented concerns of Foley Catheter care not taking place. Record review revealed that R806 was admitted to facility on 06/21/23 with the diagnoses of Spinal Stenosis lumbar region, Low back pain and Urinary Tract infection. Record review of the Minimum Data Set (MDS) assessment revealed that R806 had a Brief interview for mental status (BIMs) score of 13, indicting an intact cognition and needed moderate assistance with activities of daily living(ADLs). The MDS also indicated that there was a indwelling foley Catheter in place. A clinical record review of R806 medical orders and care plans revealed that there were no orders or care plans put in place for R806's catheter. On 9/20/2023 at 5PM, the Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake number(s): MI00139106. Based on interview and record review, the facility failed to ensure respiratory care was provided according to standards of practice and the plan of care for one (R801) of two residents reviewed for respiratory care, resulting in R801 experiencing respiratory distress and a transfer to the hospital. Findings include: Review of a complaint submitted to the State Agency revealed an allegation that on 7/23/23, R801 was asking for their oxygen and saying they could not breathe. R801 was observed without their oxygen applied and they were transported to the hospital due to low oxygen. Review of R801's clinical record revealed R801 was admitted into the facility on 6/29/23, readmitted on [DATE], and discharged to the hospital on 7/23/23 with diagnoses that included:congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had moderately impaired cognition, required…

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: MI00137355. Based on interviews and record reviews the facility failed to ensure labs were completed as ordered by the physician for one (R809) of seven residents reviewed for pressure ulcer care. Findings include: Review of the medical record revealed R809 was admitted to the facility on [DATE] with diagnoses that included: dementia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, aphasia, and type 2 diabetes mellitus. A Minimum Data Set (MDS) assessment dated [DATE], documented Severely impaired cognitive skills for daily decision making and required staff assistance for all Activities of Daily Living (ADLs). Review of a Wound Rounds Note dated 4/25/23 at 1:57 PM, documented in part . has unstageable area at the sacrum as well as on the left buttock . has a very foul smell. The wound has been covered by an eschar . Assessment And Plan . Unstageable ulcer to the sacrum. Patient does have a very foul smell. We need to check for ESR…

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.