Father Murray, A Villa Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure mouth care was provided for one resident (R137) of four dependent residents reviewed for oral hygiene. Findings include: A review of the Electronic Medical Record (EMR) revealed R137 was most recently admitted on [DATE]. The EMR revealed R137 had a pertinent diagnoses of Developmental Disorder of Speech and Language, Cerebral Infarction (Stroke) affecting non-dominant side, Dysphagia (Swallowing Difficulty) and a Percutaneous Endoscopic Gastric (PEG tube) insertion for nutritional support. The EMR revealed R137 is non-verbal and on nutritional support via a tube-feeding only. R137 is not to have anything by mouth. The EMR further revealed that R137 was unable to complete the Basic Inventory for Mental Status and was also dependent for all Activities of Daily Living. On 4/7/25 at 10:13 AM, R137 was observed in bed on their back with the legs drawn up to a 90 degrees angle to body. An observation of R137's mouth revealed thick 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 ensure resident medications were not left at the bedside for one resident (R5) of one resident and failed to store/date medication in one of two medication carts reviewed for medication storage. Findings include: R5 On 4/7/25 at 10:46 AM, R5 was observed lying in their bed. A medication cup of seven pills were observed sitting on the resident's bedside table. At this time, the unit manager of the memory care unit, Unit Manager F was asked to enter the resident's room and explain why the medications had been left at the bedside. Unit Manager F explained that the medications should not have been left at the bedside and would talk to the administering nurse. A review of R5's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Dementia, Delusional Disorders, and Muscle Weakness. Further review revealed the resident was cognitively intact, and required minimal assistance for activities of daily…

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 store oxygen mask and tubing in a sanitary manner for one (R98) of four residents reviewed for supplemental oxygen use. Findings include: A review of the facility record revealed R98 was admitted to the facility on [DATE] with diagnoses including Respiratory Failure and Seizure Disorder. On 04/07/25 at 2:48 PM, R98's oxygen mask and tubing was observed laying on the concentrator not covered or bagged. On 04/08/25 at 8:55 AM, R98 was observed laying in bed wearing a nasal cannula. The oxygen mask/tubing and a second nasal cannula/tubing were observed laying in the open top drawer of the nightstand on top of other items uncovered and not bagged. On 04/09/25 at 10:48 AM, the facility Director of Nursing (DON) was interviewed and made aware of the observations of the oxygen mask/tubing and nasal cannula/tubing being stored uncovered and not bagged. The DON reported the expectation is that they should be bagged when not in use. A review of 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 interview and record review, the facility failed to immunize per acceptable and/or declination for influenza immunizations for one resident (R81) of five sampled residents reviewed for immunizations. Findings Include: A review of R81's medical record revealed they were admitted into the facility on 2/1/24. During a review Infection Control program, the influenza acceptance/declination for R81 was requested and revealed a consent to receive the influenza immunization dated for 10/4/24. Reviewed was a second document dated for 10/10/24 declining the influenza vaccine. A review of the resident's medical record revealed the resident received the influenza immunization on 10/14/24 (four days after declining it). On 4/8/25 at 4:19 PM, the Director of Nursing (DON) was asked about her expectation regarding immunizations being provided per consent, she explained her expectation is that immunizations are provided per acceptance/declination. A review of the facility's Influenza Vaccination Guideline did not reveal information regarding a resident receiving a vaccine after signing 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 interview and record review, the facility failed to document the education regarding benefits and offering of immunizations (COVID vaccine), and immunize per acceptable and/or declination for three residents (R7, R13, and R63) of five sampled residents reviewed for immunizations. Findings Include: During a review of the Infection Control program, acceptance/declinations of the COVID vaccine were requested for R7, R13, and R63. R7 A review of R7's medical record revealed they were admitted into the facility on 7/16/16. A review of R7's COVID declination was signed by the resident during the survey on 4/8/25 however, the resident has a guardian responsible for making medical decisions on their behalf. R13 A review of R13's medical record revealed they were admitted into the facility on [DATE]. A review of their medical record revealed the resident refused the vaccine however, the resident completed a COVID acceptance consent. R63 A review of R63's medical record revealed they were admitted into 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 is related to Intake MI100147010. Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment in one bathroom for two (R907) of two residents assigned to the same room. Findings include: On 9/26/24 at 10:56 AM, in an observation of the bathroom shared between rooms [ROOM NUMBERS] the following was observed: -The faucet handles are broken, the cold handle was missing, and the hot water handle was hanging so that the water could not be turned off. -The warm temperatured water was dripping heavily. -The soap dispenser is not working. -There was no toilet paper available in the room and the toilet paper holder rusty. -The toilet seat was loose and slides easily side to side. -There was feces in the toilet and the bowl was not clean. -The tank lid hung over the flush handle making it difficult to access. -There is no trash can in the bathroom or in room [ROOM NUMBER]. On 09/26/24 at 09:10 AM, an interview with R907 was attempted.…

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 MI00145143, MI00145149, and MI00145155. Based on interview, and record review the facility failed to ensure timely follow up by social work and psychiatric services and physician notification for suicidal ideations for one (903) of one residents reviewed for mental health disorders. Findings include: R903 A review of the medical record revealed that R903 admitted into the facility on 3/5/24 with the following diagnoses: schizoaffective disorder and bipolar type. A review of the Minimum Data Set assessment (MDS) revealed, a Brief Interview for Mental Status score of 15/15, which indicated R903 with an intact cognition. R903's medical record also noted R903 with a history of multiple suicide attempts. The MDS also revealed a resident mood interview (PHQ depression screen) which revealed, R903 answered they had thoughts of feeling down depressed or hopeless and that they would be better off dead, or of hurting themselves, nearly every day. A consult to psychiatry was ordered on 3/5/24 for schizoaffective disorder and another consult to psychiatry was ordered…

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 MI00144520. Based on observation, interview, and record review, the facility failed to protect one resident's (R703) right to be free from physical abuse by another resident (R704), of three residents reviewed for abuse. Findings include: A complaint submitted to the State Agency (SA) indicated the following, Resident [R703] was attacked by another resident [R704] .Resident has facial bandages from the attack .Attacker has been removed from the facility temporarily .Unknown if anyone was notified .Staff and residents are fearful of the attacking resident. Date of incident involving R703 and R704 was indicated to be 5/13/24. A review of R704's electronic medical record (EMR) revealed a progress noted dated, 5/7/24 10:27 AM, revealed the following, Resident reviewed in risk meeting r/t (regarding) behaviors. Resident displays increased aggression. behaviors. On 1:1 monitoring to maintain all resident's safety. Social work is currently seeking alternative placement that will fit…

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 MI00144520. Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one resident (R703) of three residents reviewed for abuse. Findings include: A complaint submitted to the State Agency (SA) indicated the following, Resident [R703] was attacked by another resident [R704] .Resident has facial bandages from the attack .Attacker has been removed from the facility temporarily .Unknown if anyone was notified .Staff and residents are fearful of the attacking resident. Date of incident involving R703 and R704 was indicated to be 5/13/24. A review of R704's electronic medical revealed that R704 was originally admitted to the facility on [DATE] with diagnoses that included UTI (Urinary tract infection) and Dementia. R704's most recent minimum data set assessment (MDS) dated [DATE] revealed that R704 had a severely impaired cognition. R704…

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 full visual privacy during the care of two residents (R43 and R87), resulting in the exposure of sensitive parts of the residents' bodies to other residents and the potential for embarrassment. Findings include: R87: On 02/27/24 at 4:35 PM, R87 was observed to be in bed covered with a blanket. Certified Nursing Assistant (CNA) R entered the room, pulled back the covers of the resident to reveal the top of their bare thighs and incontinence brief and moved a pillow from one side of the torso to the other. The door was not closed and the privacy curtain was not drawn. The actions of the CNA were visible from the hallway. CNA R was asked about the observation and CNA R acknowledged they should have drawn the curtain or closed the door. R43: On 02/28/24 at 9:39 AM, an observation of wound care was completed with the wound care nurse and two additional staff. The drape between the beds was open beyond the halfway point of the two resident beds. There was a resident laying in the next bed. During care of 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 in part to Intake Numbers MI00140365 and MI00141049. Based on observation, interview, and record review, the facility failed to provide a clean and kempt environment affecting one resident (Resident 144) of six residents reviewed for environment, and three resident bathrooms. Findings include: On 02/27/24 at 10:51 AM, R144 was observed lying in bed in their room. Areas of large brown stains were observed on the wall behind the bed, on the ceiling, on the curtains and on the heater. On 02/28/24 at 10:07 AM, R144 was observed lying bed. Areas of large brown stains were observed on the wall behind the bed, on the ceiling, on the curtains and on the heater. On 02/29/24 at 11:00 AM, R144 was observed lying in bed. Areas of large brown stains were observed on the wall behind the bed, on the ceiling, on the curtains and on the heater. On 02/29/24 at 11:04 AM, a interview was held with Nurse T and was asked their expectation for the cleanliness of the room. Nurse P stated, My expectation is 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.

Based on interview and record review the facility failed to notify the Ombudsman of hospital transfer for one resident, (R201) of one resident reviewed for discharge/transfer. Findings include: A record review revealed that a notification was not sent to the Ombudsman of R201's transfer to the hospital. On 2/29/24 at 2:22 PM, the Nursing Home Administrator (NHA) emailed, I am not able to provide you with the requested document [notification to Ombudsman] as I do not have access to my former social worker director's email who was emailing the discharges/transfers. On 02/29/2024, the policy for Transfers and Discharges was requested. It was not provided.

Based on interview and record review, the facility failed to complete PASARR II (Preadmission Screening and Resident Review II) in a timely manner for two (R73 and R101) of three residents reviewed. Findings include: On 2/28/2024 a record review revealed that R73 did not have a current PASARR II that was due January, 2024. Relevant diagnoses for R73 include: Generalized Anxiety Disorder, Schizophrenia, and Bi-Polar Disorder. On 2/28/2024 a record review revealed that R101 did not have a current PASARR II, that was due August, 2023. Relevant diagnoses for R101 include: Generalized Anxiety Disorder and Bi-Polar Disorder On 2/28/2024, Social Workers (SW E and SW F), were interviewed regarding how PASARR II's are kept track of. SW E related that he is responsible for PASARR II updates and that there is a tickler file on an Excel sheet that is used to keep track of PASARR I and II due dates. SW E acknowledged that PASARR II's were not completed. SW F agreed with that process. On 2/29/24, Social Workers (SW G (Corporate Social Worker) , SW E and SW F), were interviewed for further…

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 MI00140365. Based on observation, interview and record review the facility failed to ensure that a resident was repositioned timely and appropriately for one resident (R87) of three residents reviewed with wound care needs, resulting in the increased potential for delayed wound healing and wound deterioration. Findings include: Resident #87 (R87): On 02/27/24 at 10:05 AM, 10:49 AM, 11:11 AM, 12:06 PM, 12:31 PM, R87 was observed to be out of bed and seated in a wheelchair in the north dining room. R87 was seated with their buttocks forward from the back of the chair so that the spine curved slightly when R87's shoulders touched the back of the chair. R87 was observed to grip the arms of the wheelchair and rock forward at the shoulders three to five times in succession intermittently while seated in the wheelchair. R87 did not appear to be able to lift their body from the chair or move away from the seat of the wheelchair. At 12:31 PM R87 was pulled up straighter and more…

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 Numbers: MI00140260, MI00140264, and MI00142715. Based on observation, interview, and record review, the facility failed to provide timely incontinence care for one resident (R175) out of 11 residents reviewed for Activities of Daily Living (ADL). Findings Include: Resident #175 (R175): On 2/28/24 at 8:57 AM, R175 reported that they have to wait a long time to have their brief changed. R175 stated, It's worse on midnights. R175 explained, that one time they pressed the call light at 1:00 am and didn't get help until almost 9:00 am. R175 further explained, that they have impaired skin on their backside and that a wet brief makes their skin burn. On 2/28/24 at 1:16 PM, R175 was observed lying in bed. The bed sheet was observed to have a large wet circle around R175. The wet circle reached the middle of R175 back to the lower part of R175's legs. R175 was asked how long they had been lying this way. R175 explained they had pressed the call light for assistance, and no one had come…

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 initiate wound care interventions for one resident (R352) of four residents reviewed for skin management. Findings include: Resident #352 (R352): On 2/27/24 at 9:27 AM, R352 was observed lying in bed with their feet lying flat on the mattress. They were asked about their stay in the facility and explained that they were admitted the week prior, and had not had anyone wrap or take care of the wounds on their legs until yesterday, 2/26/24. A review of R352's medical record revealed that they were admitted into the facility on 2/21/24 with diagnoses that included Peripheral Vascular Disease, Cerebral infarction, Hypertension, and Chronic Obstructive Pulmonary Disease. Further review of the medical record revealed that the resident was alert and oriented x 4 (person, place, time, & situation), and required extensive assistance for Activities of Daily Living. Further review of the medical record revealed that R352 had the following wounds: Wound #1 Right, Anterior Lower Leg, acute Partial Thickness Venous Ulcer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide adequate supervision to prevent a fall for one resident (R109) of four residents reviewed for falls. Findings include: Resident #109 (R109): On 2/29/24 at 11:00 AM, a review of R109's incident and accident reports (I/As) since their admission to the facility were reviewed and revealed the following, Incident Description: 2/1/2024 18:29 (6:30 PM) Nurse Description: Resident was placed in dinning room sitting in their w/c (Wheelchair) getting prepared for dinner, resident's CNA (Certified Nursing Assistant) walked out of the dinning room leaving resident sitting at the table. Another resident stated to writer that resident attempted to stand in front of their w/c and tried to walk and fell onto the floor .Immediate Action Taken: Head to toe assessment .Placed back in wheelchair with two staff assist . On 2/29/24 at 11:12 AM, a review of R109's fall care plan interventions revealed the following, When resident attempts to stand or is observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the care plan included interventions for one resident (R21) with a diagnosis of Post Traumatic Stress Disorder (PTSD), resulting in the potential for staff to trigger episodes of aggression, re-traumatization and unmet care needs. Findings include: Resident #21 (R21): On 02/27/24 at 9:51 AM, R21 was observed to be in bed. R21 awakened upon call of their name and sat up to the side of the bed. R21 appeared groggy. R21 answered queries and promptly returned to sleeping on their back in bed. R21 was not observed to be out of their room on 02/27/24. On 02/28/24 at 7:52 AM, R21 was in bed dressed asleep in bed and did not awaken to a call of their name. R21 was not observed to out of their room on 02/28/24. On 02/29/24 at 9:50 AM, R21 was observed to be in bed. R21 was not observed to be out of their room on 02/29/24. A review of the record for R21 revealed R21 was admitted into the facility on [DATE]. Diagnoses included PTSD, Major…

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, observation and interview the facility failed to ensure that medications were properly tabled and stored in one medication cup and three residents' rooms (R119, R191, and R603) resulting in the potential for diversion of the medication and or misuse. Findings include: On 02/28/24 at 8:10 AM, during a medication pass observation with Licensed Practical Nurse (LPN) S , three round , blue pills were observed in a medication cup in the top drawer of the medication cart. LPN S indicated they were not from them and had left them in the drawer. The pills were identified on www.drugs.com as alprazolam/xanax one milligram with the code 031 on the pill. Resident #119 (R119): On 2/27/24 at 9:27 AM, R119 was observed in bed, the over bed table was observed with a medication cup with three pills inside the cup. There were two round pills and one oval shaped pill. R119 was asked how long the medication had been sitting on the table. R119 stated This morning. On 2/27/24 at 9:30 AM, R119 was observed 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.

This citation pertains to Intake Number MI00140264. Based on observation, interview, and record review the facility failed to honor food preferences for one resident (R160) of two residents reviewed for food preferences resulting in resident verbalized frustration. Findings include: Resident #160 (R160): On 02/27/24 at 9:45 AM, R160 (Resident 160) reported they do not get what was on the meal ticket. The meal ticket read: Standard (indication of the standard meal for all residents and for items desired on tray) Double portions 2 x 1 Hard boiled eggs with whole slices toast, 8 oz milk 1%. The meal ticket also indicated R160's dislikes of: pancakes/waffles, oatmeal. R160 did not received double portions and the following was noted on the tray: two pancakes, two sausage links, no syrup, one four oz apple juice, and no coffee. R160 was asked if they requested replacements, and R160 stated it is useless to ask, it takes an hour to answer call-lights during meal times. Resident further stated, I want a large coffee, hard-boiled egg, and toast uncut in order to make a sandwich, and they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake number MI00128493. Based on observation, interview, and record review, the facility failed to serve food in a palatable manner and at the preferred temperature for two residents (R161 and R355) and seven confidential group residents of twelve reviewed for food palatability, resulting in dissatisfaction during meals. Findings include: On 11/16/22 at 11:39 AM, during an initial tour of the facility R161 was interviewed about food palatability at the facility and stated, The food is always cold. On 11/16/22 at 11:47 AM, a review of R161's medical record and most recent minimum data set assessment dated [DATE] revealed that R161 had an intact cognition. On 11/17/22 at 10:15 AM, seven confidential residents met for a group meeting and were interviewed/asked about food palatability at the facility and indicated that the food typically did not taste good and was usually cold. The group indicated that the food served to them yesterday (11/16/22) was The best we have ever had and stated,…

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 2 deficient practice statements. Deficient practice statement #1. Based on observation, interview, and record review the facility failed to ensure an adaptive communication device/communication board was present and within reach for one resident (R173) of three residents reviewed for accommodation of needs, resulting in the potential for impaired communication, lack of ability to communicate care needs, and dissatisfaction with services. Findings include: On 11/16/22 at 9:30 AM, during an initial tour of the facility R173 was attempted to be interviewed in their room regarding care at the facility. R173 was unable to respond to any questions. On 11/16/22 at 9:34 AM, An unidentified staff member entered the room and stated, The resident is non-verbal. The unidentified staff member then left the room. No adaptive communication device/communication board was observed to be present and/or within reach of the resident. On 11/17/22 at 2:34 PM, R173's care plan in their electronic medical record (EMR)…

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 follow up on the preadmission screening/annual resident review (PASARR) form 3877 for one resident (R148) out of two reviewed for PASSAR requirements, resulting in the potential for unmet mental health needs. Findings Include: A review of the medical record revealed that R148 was admitted into the facility on 1/15/2021 with the following diagnoses, Anxiety, Schizophrenia, and Major Depressive Disorder. A review of the Minimum Data Set Assessment (MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 13/15 indicating intact cognition. R148 also required extensive two-person assistance with bed mobility and transfers. Further review of the medical record revealed a positive Level 1 screening for the reasons as stated, Schizophrenia, Seroquel (antipsychotic medication), and Risperdal (antipsychotic medication). The PASSAR was dated for June 2021. Additional review revealed another positive Level 1 screening for the reasons stated,…

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 care plan the use of an antipsychotic medication for one resident (R43) of five residents reviewed for mood/behavior/ psychiatric care, resulting in the lack of intervention for psychiatric health. Findings include: On 11/18/22 at 11:15 AM, R43's electronic medical record was reviewed and revealed the following, R43 was originally admitted to the facility on [DATE] with diagnoses that included Schizophrenia unspecified and Unspecified fracture of shaft of right tibia (shinbone). R43's minimum data set assessment (MDS) dated [DATE] was reviewed and indicated that R43 had an intact cognition. On 11/18/22 at 11:19 AM, R43's medication orders were reviewed and revealed that R43 was prescribed, Olanzapine (Zyprexa) 10mg (milligrams)/Give 1 tablet by mouth at bedtime. Order date: 11/4/22. On 11/18/22 at 11:23 AM, a review of, Wikipedia revealed that, Olanzapine is an atypical antipsychotic primarily used to treat schizophrenia . On 11/18/22 a review of R43'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 MI00131657 and MI00132326. Based on obervation, interview, and record review the facility failed to revise and implement goals on the care plan to address falls, communication, transfers and/or application of devices, for five sampled residents (R68, R136, R173, R455, and R604), reviewed for comprehensive care plans. Findings include: A review of the intake noted, It was alleged the resident fell multiple times and sustained injuries. It was alleged that the facility failed to notify the resident's responsible party of the resident's falls/change in condition. A review of R604's electronic medical record noted, R604 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Hypertension, Respiratory failure with Hypoxia, and Muscle Weakness. A review of R604's Minimum Data Set (MDS) assessment noted, R604's cognition as moderately impaired and activities of daily living as total dependence of two staff physical assist. R604 discharged from the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains in part to MI00132326. Based upon observation, interview and record review the facility failed to provide timely incontinence care or provide a resident with showers at a frequency consistent with the resident's care plan and preference for two sampled residents (R1, R85) of ten reviewed for Activities of Daily Living (ADL) care resulting in resident dissatisfaction with care, discomfort and the potential for skin irritation and breakdown. Findings include: R85 On 11/16/22 at 1:40 PM, R85 was queried about how care needs are met by the facility and reported that staff come, shut the call light off, say they will come back but don't or staff just turn the call light off and leave. R85 reported that they usually put the light on to be changed or for ice water. R85 then reported they had been laying in bed wet from incontinence for the the last 30-40 minutes and a staff person had come in then but left without changing them and had not returned. R85 then activated their call light again. R85…

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 follow physician orders for two residents (R166 and R454) out of two reviewed for quality of care, resulting in the potential for unmet care needs and worsening health conditions. Findings Include: Resident 166 On 11/16/202 at 9:40 AM, an interview was conducted with R166 regarding their stay in the facility. R166 stated that they were working to discharge and had been doing things to make the transition easier, such as learning how to take care of themselves and doing their own exercises. A review of the medical record revealed that R166 admitted into the facility on 9/2/2021 with the following diagnoses, Long Term Current Use of Insulin, Hemiplegia, and Type Two Diabetes Mellitus. A review of the Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status score of 15/15 indicating intact cognition. R166 also required one-person extensive assist with bed mobility and transfer. Further review of the medical record revealed the following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview and record review, the facility failed to apply and document the application of a physician ordered splint for two (R140 and R54) residents reviewed for range of motion (ROM) resulting in the potential for a decline in range of motion and progression of contracture. Findings include: Review of the facility record for R104 revealed an admission date of 7/29/19 with diagnoses that included CVA (cerebral vascular accident) with left hemiplegia (weakness), viral hepatitis and depression. R104's minimum data set (MDS) assessment indicated resident required total/maximum assistance with all care. On 11/16/22 at 2:40 PM, R104 demonstrated left hand range of motion (ROM) limitation and limited ability to manually open the hand using the right hand. R104 denies ever having a splint for the hand and reports receiving no therapy following their stroke. R104's nails on the left hand are noted to be long. When queried regarding the nail length R104 reported a preference for having the nails…

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 check serum blood glucose and administer insulin per order and professional standards of practice for one resident (R355) of three reviewed during the medication administration task, resulting in the potential for unnecessary administration of insulin, dysglycemia (blood sugars too low or too high), and/or adverse side effects: On 11/18/22 at 9:34 AM, Licensed Practical Nurse (LPN) F was observed passing medications on the high 200 hall (even numbered rooms). LPN F indicated she needed to obtain R355's blood sugar and administer the resident their scheduled morning medications. On 11/18/22 at 9:44 AM, LPN F entered R355's room. R355 was observed to be lying in bed and appeared very thin. When queried, R355 indicated they has just finished eating breakfast. R355 also indicated their blood sugar had not been checked yet this morning. The last noted blood sugar level entered into R355's chart read, 11/17/2022 [at] 20:12 (8:12 PM) - 152.0 mg…

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 ciation has two deficient practices. Deficient Practice #1. Based on observation, interview, and record review the facility failed to ensure medication were secured in a locked medication cart and ensure medication in the Nurse carts on the 2 North unit were properly labeled. Findings included: On 11/18/22 at 11:39 AM, a observation was made of the 2 North back Nurse medication cart. The cart was observed to have two inhalers with a label on the outside bag and not the inhaler device. The Nurse was asked the facility's procedure for labeling and reported they were not sure because they were from a agency. Deficient Practice #2. Based on observation, interview, and record review, the facility failed to label and store medications per standard of care for the dementia unit, resulting in the potential for medication administration errors. Finding Include: On 11/18/2022 at 11:43 AM, the 2 Nort front cart was observed for medication storage with Nurse S. Upon opening the top drawer, there was one Humalog (Insulin pen), as well a Flonase (Nose Spray) with no open date and expiration…

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 offer/provide routine dental services for one resident (R139) of one reviewed for dental services, resulting in the potential for untreated and unmet dental needs or desires. Findings include: On 11/17/22 at 9:22 AM, R139 was observed lying in bed. During an interview regarding the care they receive at the facility, the resident was observed to be missing most of their teeth. When queried regarding the last time they were seen by a dentist, R139 indicated they did not know. R139 stated, I want some teeth! (Indicating they wish they had dentures). Upon asking the facility for any/all of R139's dental visits and documentation of such, the facility provided only a consultation for a modified barium swallow study and nothing further. R139's medical record was reviewed and revealed no dental visits, dental consults, nor documentation of such. R139's personal belonging inventory sheets were also reviewed and did not reveal any indication that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two deficient practices. Deficient Practice #1. Based on observation, interview and record review the facility failed to ensure a resident room was maintained at a preferred and comfortable temperature for two residents (R85, R183) at a comfortable temperature resulting in resident discomfort and a temperature greater than 81 degrees Fahrenheit (F). Findings include: R85 On 11/16/22 at 1:40 PM, was observed to be in bed dressed in a hospital style gown. R85 was queried about how care needs are met by the facility and reported they usually put the light on to be changed or for ice water. R85 then reported they had been laying in bed wet from incontinence. R85 then reported it was very hot in their room and had difficulty sleeping due to the resident in bed one and the temperature. The room felt physically warmer than the air in the hallway. The roommate had a specialty air bed and oxygen concentrator which potentially add warm air to the room during normal operation. R85 indicated they had told…

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.