West Woods of Bridgman

Based on observation, interview, and record review the facility failed to provide ADL (activities of daily living) care, to include nail care, to a dependent resident in 1 (Resident #36) of 4 residents reviewed for ADL care, resulting in the potential for Resident #36 to experience feelings of embarrassment and diminished self-esteem.Findings include:Resident #36Review of an admission Record revealed Resident #36 was a male, with pertinent diagnoses which included: spastic quadriplegic cerebral palsy (a severe form of cerebral palsy, a movement disorder, that affects movement in all limbs) and unspecified intellectual disabilities.Review of a Minimum Data Set (MDS) assessment for Resident #36, with a reference date of 6/10/25 revealed a Staff Assessment for Mental Status indicating Resident #36 had a problem with both short-term and long-term memory. Further review of said MDS revealed Resident #36 was dependent on staff for Shower/Bathe self (The ability to bathe self, including washing, rinsing, and drying self.), and Personal hygiene (The ability to maintain personal hygiene,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 individualized activities designed to support the psychosocial well-being of 1 of 18 Residents (Resident #1) reviewed for activities, resulting in a potential for feelings of social isolation, loneliness, anxiety and boredom.Findings include: Review of Revolutionizing the Experience of Home by Bringing Well-Being to Life: The [NAME] Alternative Domains of Well-Being, Copyright 2012, Rev. 2020, revealed The [NAME] Alternative defined one domain of wellness as Connectedness- the state of being connected; alive .engaged, involved . without meaningful interactions the individual can become disconnected .develop loneliness, helplessness, and boredom.Resident #1Review of an admission Record revealed Resident #1 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Alzheimer's disease (a progressive disease that primarily affects memory, thinking and behavior), major depressive disorder (persistent sad…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate care and appropriate treatment for 2 residents (Resident #3 and Resident #16) of 18 sampled residents reviewed for quality of care, resulting in the potential for development of new wounds and infection. Findings include: Resident #3: Review of an admission Record revealed Resident #3 was a female with pertinent diagnoses which included diabetes, paralysis affecting right dominant side, difficulty in walking, weakness, joint inflammation, and need for assistance with personal care. Review of current Care Plan for Resident #3, revised on 3/26/24, revealed the focus, .Impaired skin integrity related to: She had a diagnosis that delay wound healing: Stage 3 kidney disease (kidney damage where the kidneys are not functioning optimally); congested heart failure; coronary artery disease; irregular heart rate; high blood pressure, and diabetes.admitted with a diabetic ulcer to her right heel that has closed and remains at risk to resurface - tx (treatment) order in place for protection only. with 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.

Based on observation, staff interview, and record review, the facility failed to provide services to prevent the development of and promote healing of pressure ulcers/injuries for 1 (Resident #8) of 3 residents, resulting in the development of pressure ulcers. Findings include: Resident #8: Review of an admission Record revealed Resident #8 was a male with pertinent diagnoses which included need for assistance with personal care, muscle weakness, stroke, tracheostomy, diabetes, and respiratory failure. Review of current Care Plan for Resident #8, revised on 4/30/25, revealed the focus, . Altered functional mobility and ADL's (activities of daily living) related to: (Resident #8) admitted from skilled rehab to our facility for skilled rehab. Does flinch or wince when moved in bed. with the intervention .SKIN: Heels elevated in bed as tolerated; Inspect heels with care and report to charge nurse as indicated.APM (alternation pressure mattress) to bed, Setting: Static *pressure relieving pad to wheelchair *sage boots (help reduce the risk of bedsores by keeping the heel floated,…

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

Based on observation, interview and record review, the facility failed to provide tracheostomy emergency care equipment (Ambu bag, trach device and obturator (Key component used during the insertion or change of a tracheostomy tube (trach; inserted into the stoma (opening in the trachea to maintain an open airway and facilitate breathing) at the bedside for 1 (Resident #8) of 1 resident reviewed for respiratory care, resulting in the potential of serious negative outcome if Resident #8 were to need emergent tracheostomy replacement. Findings include: According to Emergency and Basic Equipment for Individuals with Tracheostomy: All clinical staff should be aware of the location of equipment for individuals with tracheostomy. Equipment should be kept at bedside in an easily accessible location for both routine and emergency use. When transferring an individual to a different location within a unit or to an outside unit, emergency equipment should also be available.Clinicians should be prepared in case of emergency as the medical condition of a patient with tracheostomy and/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 Based on observation, interview and record, the facility failed to ensure proper labeling of medications in 1 of 1 medication cart (South medication cart) reviewed for medication storage, resulting in the potential for residents to receive medications with altered potency and decreased efficacy.Findings include:During an observations and interview on 8/19/25 at 2:05 PM and 8/20/25 at 7:05 AM, Registered Nurse (RN) was at working out of the South Medication Cart. RN L reported she did not know everything that was in the drawer. She continued reporting she kept a few of her personal things in the drawer and used the code alert to test wander guard bracelets. Observed the top left drawer on both dates to contain:-cooking timers- glucometers-code alert tester for wander guard bracelets-key ring with multiple keys attached, RN L stated, I have no idea what those keys are for. I've never used them.-2-vape pens that were labeled with a resident's name. RN L stated, Those vaping pens were confiscated from a resident…

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

Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records in 1 of 18 residents (Resident #3) reviewed for accuracy of medical records, resulting in inaccurate treatment records and the potential for providers to not have an accurate picture of resident status and condition.Findings include: Resident #3: Review of an admission Record revealed Resident #3 was a female with pertinent diagnoses which included diabetes, paralysis affecting right dominant side, difficulty in walking, weakness, joint inflammation, and need for assistance with personal care. Review of current Care Plan for Resident #10, revised on 3/26/24, revealed the focus, .Impaired skin integrity related to: She had a diagnosis that delay wound healing: Stage 3 kidney disease (kidney damage where the kidneys are not functioning optimally); congested heart failure; coronary artery disease; irregular heart rate; high blood pressure, and diabetes.admitted with a diabetic ulcer to her right heel that has closed and remains at risk to resurface - tx (treatment)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 MI00152539 Based on interview and record review the facility failed to ensure that a therapy evaluation (a process to determine a resident's need for therapy services) was completed at the time of re-admission to the facility following an inpatient hospital stay for 1 (Resident #2) of 3 residents reviewed for therapy evaluation at the time of re-admission, resulting in the potential for the inability to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an admission Record revealed Resident #2 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: muscle weakness, need for assistance with personal care, and stiffness of the right and left shoulders. Review of a Minimum Data Set (MDS) assessment for Resident #2, with a reference date of 2/3/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #2 was cognitively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 person centered care plan for 2 Residents (#8 & #32) of 16 residents reviewed for person centered care plans. Findings include: Resident #8 Review of an admission Record revealed Resident #8 had pertinent diagnoses which included: need for assistance with personal care and bed confinement status. Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 7/30/24 revealed a Brief Interview for Mental Status (BIMS) score of 99/15 which indicated Resident #8 was unable to participate in the assessment. Observations were made on 8/20/24 at 10:27 AM., 8/21/24 at 8:37 AM., and 8/21/24 at 12:07 AM., where Resident #8 was observed unkempt, and unshaven, with facial hair that varied in length, and growth and did not appear to be indicative of a beard or other shaped facial hair. In an interview on 8/21/24 at 2:13 PM., Certified Nursing Assistant (CNA) K reported Resident #8 required total care for activities 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 MI00146198. Based on interview and record review, the facility failed to update the transfer status of one resident (Resident #268) of 16 residents reviewed for comprehensive care plans resulting in a skin tear. Findings include: Resident #268 (R268) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R268 admitted to the facility on [DATE] with diagnoses of unsteadiness on feet, need for assistance with personal care and difficulty walking. Brief Interview for Mental Status (BIMS) reflected a score of 13 out of 15 which indicated R268 was cognitively intact (13 to 15 cognitively intact). The most recent MDS completed on 7/18/2024 indicated a BIMS couldn't be completed. She passed away under Hospice care on 7/19/2024. Review of the Investigation Summary of the Facility Reported Incident (FRI) revealed On 7-8-2024 (R268) was sent to the hospital and had an inpatient stay and readmitted to the facility on [DATE]. Upon readmission her care plan transfer status was a 1…

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

Based on observation, interview, and record review the facility failed to provide nail care to dependent residents in 1 of 16 residents (Resident #8) reviewed for activities of daily living needs. Findings include: Review of an admission Record revealed Resident #8 had pertinent diagnoses which included: need for assistance with personal care and bed confinement status. Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 7/30/24 revealed a Brief Interview for Mental Status (BIMS) score of 99/15 which indicated Resident #8 was unable to participate in the assessment. Observations were made on 8/20/24 at 10:27 AM., 8/21/24 at 8:37 AM., and 8/21/24 at 12:07 AM., where Resident #8 was observed unkempt, and unshaven, with facial hair that varied in length, and growth and did not appear to be indicative of a beard or other shaped facial hair. During an observation and interview on 8/21/24 at 2:13 PM., Certified Nursing Assistant (CNA) K reported Resident #8 required total care for activities of daily living. CNA K reported Resident #8 required staff 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 MI00146198. Based on observation, interview, and record review the facility failed to implement gait belt use for safety during transfers of 2 of 8 residents (Resident #268, Resident #61) reviewed for transfer status resulting in the potential for injury during transfer. Findings include: Resident #268 (R268) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R268 admitted to the facility on [DATE] with diagnoses of unsteadiness on feet, need for assistance with personal care and difficulty walking. Brief Interview for Mental Status (BIMS) reflected a score of 13 out of 15 which indicated R268 was cognitively intact (13 to 15 cognitively intact). The most recent MDS completed on 7/18/2024 indicated that a BIMS couldn't be completed. She passed away under Hospice care on 7/19/2024. Review of the Investigation Summary of the Facility Reported Incident (FRI) revealed On 7-8-2024 (R268) was sent to the hospital and had an inpatient stay and readmitted 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 Based on observation, interview, and record review, the facility failed to identify PTSD (Post Traumatic Stress Disorder) triggers and implement interventions to mitigate triggers for 1 of 1 residents (Resident # 32) reviewed for trauma informed care, resulting in the potential for previous traumas to be retriggered causing mental distress. Findings include: Review of Trauma-Informed Care in Behavioral Health Services, U.S Department of Health and Human Services, 2014, revealed: Beyond identifying trauma and trauma-related symptoms, the initial objective of TIC(Trauma-Informed Care) is establishing safety .safety has a variety of meanings. Perhaps most importantly, the client has to have some degree of safety from trauma symptoms .trauma reactions can be triggered by sudden loud noises, tension between people, certain smells, or casual touches . Review of an admission Record revealed Resident #32, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: major depressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Quality Assessment and Process Improvement (QAPI) meetings had the Medical Director as a mandatory attendee at least quarterly resulting in the potential for the Medical Director to not be notified of quality deficiencies occurring in the facility. Findings include: Review of the [NAME] Woods of [NAME] Quality Assurance/Process Improvement Meeting sign in sheets dated 1/17/2024 and 2/14/2024 revealed that the Medical Director did not attend. Review of the [NAME] Woods of [NAME] Infection Control Meeting that was used as the sign-in sheet for the Quality Assurance/Process Improvement Meeting dated 3/13/2024 and 4/14/2024 revealed that the Medical Director did not attend. During an interview on 8/22/2024 at 11 AM when discussing the QAPI Program, Nursing Home Administrator (NHA) A acknowledged the Medical Director didn't attend the meetings for 4 consecutive months and failed to attend at least 1 meeting in the quarter. Review of the Quality…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper use of personal protective equipment (PPE) for enhanced barrier precautions in 2 (Resident #1 and Resident #18) of 8 residents reviewed for implementation of enhanced barrier precautions, resulting in the potential for the spread of infection, cross contamination and disease transmission. Findings include: Resident #1 Review of an admission Record revealed Resident #1 had pertinent diagnoses which included: cerebral infarction (stroke), need for assistance with personal care and type 2 diabetes (disease that does not allow the body to regulate blood sugar) mellitus without complications. Review of a Minimum Data Set (MDS) assessment for Resident #1, with a reference date of 8/5/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident # was cognitively intact. Resident #18 Review of an admission Record revealed Resident #18 had pertinent diagnoses which included: cerebral palsy (a neurological (brain) disorder that appears in early childhood and permanently…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: MI00143833 Based on interview and record review the facility failed to ensure residents received care in accordance with professional standards of nursing practice to ensure accurate transcription of medications and monitoring of potentially dangerous medications in 1 of 2 residents (Resident #84) reviewed standards of practice, resulting in an overdose of blood thinner medication and potential bleeding. Findings include: Review of an admission Record revealed Resident #100 was a male with pertinent diagnoses which included atrial fibrillation and high blood pressure. Review of current Care Plan for Resident #100, revised on 1/19/24, revealed the focus, .Potential with acute condition change with cardiopulmonary, metabolic, or infectious complications . (Resident #100) has a history of hypertension and atrial fibrillation . with the intervention .Review hospital discharge to determine baseline upon admission .Review of residents medication regime to identify a possible ADR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 MI00143833 Based on interview and record review, the facility failed to ensure medications were administered at the correct dose per the physician's order for 1 of 2 residents (Resident #100) reviewed for significant medication errors, resulting in the potential for adverse effects of an overdose of an anticoagulant medication. Findings include: Review of Intake dated 4/9/24, revealed, .However, the much greater concern is that this facility did not follow the prescribing instructions provided to them by (Local Hospital) for dosing (Resident #100)'s Warfarin and overdosed him causing him to have to be transported by Ambulance, put through additional examinations and tests, unknown physical damage, by having his blood way too thin. In addition, the facility and medical professionals did not follow standard protocol for Warfarin overdosing and were extremely slow to respond to this overdose when brought to their attention . Review of an admission Record revealed Resident #100 was a…

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

Based on observations, interview, and record review the facility failed to maintain safe and sanitary conditions in the kitchen for all residents who receive food prepared or stored in the kitchen resulting in the potential for biological contamination and the potential for the development of food borne illnesses. Findings include: Review of a submitted complaint intake from a State Agency dated 06/06/23 revealed Residents are not being fed enough food. Expired food is being served. Multiple times where there has been no meat or other protein source served with meals. Facility runs out of dairy products. During the initial kitchen tour on 06/26/23 at 09:52 AM., noted an open bottle of Worcestershire sauce located on the top shelf of the middle rack in the dry storage with an open date of 01/24/22. Noted dirt, dust, and debris on the floor of the dry storage area. Subsequent observations on initial kitchen tour included . In a refrigerator next to the dietary manager office noted hard boiled eggs, ham lunch meat, and American cheese without an open date . vanilla yogurt with an open…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 #MI00137460 Based on interviews and record review the facility failed to follow posted menus for two residents (Resident #3 and #45), resulting in the potential for decline in nutritional intake and a potential for weight loss. Findings include: Resident #3 Review of an admission Record revealed Resident #3, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Multiple Sclerosis Review of a Minimum Data Set (MDS) assessment for Resident #3, with a reference date of 05/23/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #3 was cognitively intact. During an interview on 06/26/23 at 1:16 PM., Resident #3 reported the food is terrible. Resident #3 reported the meat is dry and the potatoes are hard. Resident #3 reported there are no menus delivered to the rooms anymore. Resident #3 reported have no idea what is for lunch before I get to the dining room and it is placed in front of me. I require…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 MI00130808 Based on observation, interview and record review the facility failed to ensure proper infection control measures were implemented for cleaning and disinfecting resident shared equipment, properly storing a nebulizer mask for Resident #59, and ensuring Resident #44's bedside fall mat had a cleanable surface area resulting in the increased potential for the development and transmission of communicable diseases and infection in a vulnerable population. Findings include: Review of a facility Policy with a date of 3/2020 revealed: Policy: It is the policy of this facility to implement the Infection Prevention and Control Program utilizing a systematic, coordinated and continuous approach guided by OSHA regulations, and pertinent state, federal and local regulations pertaining to infection control In an observation on 06/26/23 at 11:02 AM., room [ROOM NUMBER]'s bedside tables were soiled with dried crusted food, stuck on spillage, and multiple soiled cup ring marks. In an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00130808 & MI00130380 Based on observation, and interview, the facility failed to maintain a sanitary, home-like environment, resulting in the potential for pest harborage conditions and a non-home-like environment. Findings include: In an observation on 6/26/23 at 10:25 AM., noted in room [ROOM NUMBER], the window to the outside had clear packaging tape around the frame and opening areas which was soiled, and had stuck on dead insect carcasses. The entire window had clear packaging tape around it, which appeared to be in place as a weather strip/barrier to the outside. In an observation on 6/26/23 at 10:35 AM., noted in room [ROOM NUMBER] the window to the outside had black duct tape around the frame and opening areas which was soiled, and had stuck on dead insect carcasses. The entire window had black duct tape around it, which appeared to be in place as a weather strip/barrier to the outside. In an observation on 6/26/23 at 10:53 AM., noted in room [ROOM NUMBER] the window…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain dignity for one resident (R17) of 18 residents reviewed for dignity, resulting in the likelihood of feelings of embarrassment and humiliation based on the reasonable person concept. Findings include: According to the Minimum Data Set (MDS) 6/12/2023, R17 had a BIMS (Brief Interview Mental Status) of 99 indicating that he was not capable of making decisions on his own. Required total dependence of two-plus persons physical assistance to transfer. Resident was always incontinent of bowel and bladder dependent on staff for ADL care. His diagnoses included cerebral palsy (a condition marked by impaired muscle coordination/spastic paralysis and/or other disabilities typically caused by damage to the brain before or at birth, aphasia (disorder that affects how you communicate), seizure disorder/epilepsy, anxiety, and depression. During an observation and interview on 6/26/2023 at 11:08 AM, Certified Nursing Assistant (CNA) Z pulled R17 backwards in 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.

Based on interview and record review, the facility failed to notify a Responsible Party of a change in care/condition for 1 of 18 residents (Resident #71) reviewed for notification of change, resulting in the Responsible Party not participating in medical decisions regarding care and treatment. Findings included: Resident #71: Review of an admission Record revealed Resident #71 was a male with pertinent diagnoses which included Korsakoff syndrome (memory disorder results from vitamin B1 deficiency, damages nerve cells, part of the brain involved with memory), traumatic head injury, Wernicke's encephalopathy (life threatening illness which affects the peripheral and central nervous system), adult failure to thrive, depression, and history of falls. Review of a Minimum Data Set (MDS) assessment for Resident #71, with a reference date of 5/3/23 revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated Resident #7 was moderately cognitively impaired. Review of current Care Plan for Resident #71, revised on 5/2/2023, revealed the focus, .Altered functional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement resident comprehensive care plans for 1 residents of 18 (Resident #8) reviewed for care planning resulting in a lack of service for residents to maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual V1.17, Chapter 4, revealed, .the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident #8: Review of an admission Record revealed Resident #8 was a female with pertinent diagnoses which included stroke, dementia, need for assistance with personal care, muscle weakness, legal blindness, repeated falls, difficulty in walking, anxiety, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 1) follow professional standards of nursing practice for physician notification of a change in condition, 2) complete assessments when an injury occurs, 3)notify of incident to nursing staff and kitchen personnel and 4) administer treatment with an order for 1 of 18 residents (Resident #42) reviewed for accidents, resulting in the potential for further injury and the affected resident not maintaining or achieving their highest practical physical well-being. Findings include: Review of the Fundamentals of Nursing revealed, Patient care requires effective communication among members of the health care team. The medical record is an important means of communication because it is a confidential, permanent, legal documentation of information relevant to a patient's health care. The record is a continuing account of a patient's health care status and is available to all members of the health care team. [NAME], [NAME] A.; [NAME], [NAME] Griffin;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #42: Review of an admission Record revealed Resident #42 was a male with pertinent diagnoses which included ataxic gait (unsteady, staggering gait, poor balance, widened base of support), diabetes, muscle weakness, need for assistance with personal care, kidney disease, dysphagia (impairment in the production of speech resulting from brain disease or damage), and cognitive communication deficit, and unsteadiness on feet. Review of a Minimum Data Set (MDS) assessment for Resident #42, with a reference date of 5/1/23 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated Resident #42 was moderately cognitively impaired. Review of current Care Plan for Resident #42, revised on 2/21/23, revealed the focus, .(Resident #42) has altered functional mobility and ADLs related to blindness, age-related debility. He cannot see but is aware of his surroundings, needs guidance to ambulate to bathroom . with the intervention of .ABLE TO LEAVE ON TOILET: No stand by assist (revision…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmacy recommended laboratory diagnostic services were followed and completed for one resident (R17) reviewed for laboratory services, resulting in the potential of delayed treatment and impaired coordination of care. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R17 was unable to complete a BIMS (Brief Interview Mental Status) to determine his cognition. Section E - Behavior indicated R17 did not experience hallucinations or delusions and did not reject cares including bloodwork. His diagnoses included cerebral palsy (a condition marked by impaired muscle coordination (spastic paralysis) and/or other disabilities, typically caused by damage to the brain before or at birth), aphasia (disorder that affects how you communicate), seizure disorder/epilepsy, anxiety, and depression. Review of R17's Order Summary 12/27/2022 reported the resident was ordered Valporic Acid Solution (an anti-seizure medication, including…

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