Chesaning Nursing and Rehabilitation Center

Based on observation, interview and record review, the facility failed to identify targeted behaviors, medication classifications, and the duration of therapy on the informed consents for 3 residents (R5, R6, R22) of 5 sampled residents. Findings include: Resident #5:Record review of Resident #5's Minimum Data Set (MDS) date 11/30/2025 revealed an elderly resident who was his own responsible party. Review of section I: active medical diagnosis included: debility, heart failure, diabetes, anxiety, depression, bipolar and post-traumatic stress disorder. Section N: Medications identified that the resident received antipsychotic, antidepressant, and anticonvulsant medications. Record review of Resident #5's 'Medication Administration Record' (MAR) for December 2025 revealed medications administered of aripiprazole (Abilify) antipsychotic medication 2mg tablet by mouth in the evening for mood stabilizer. Escitalopram (Lexapro) antidepressant medication 10mg tablet by mouth one time a day for depression. In an interview and record review on 12/11/2025 at 9:07 AM with Social Worker (SW) H…

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 2585037.Based on observation, interview and record review, the facility failed to ensure a clean, safe, and homelike environment involving the Therapy room and 5 residents' rooms (Rooms 2, 3, 4, 14, and 19) of 20 rooms in total, resulting in the protentional for injury (therapy equipment stored in the therapy area, increases risk of tripping and falling), resident and family complaint's regarding the environment, anger, dissatisfaction and depression.Findings Include: Self-tour of facility on 8/19/2025 at 9:30AM noted Strong urine odors in the back hall noted coming from room [ROOM NUMBER]. Noted 2 male residents to reside in room, Resident #106 the bed by the window was noted with urinal on nightstand with yellow urine noted with no top on it, half full, next to white Styrofoam drinking glass with a straw. Observations on 8/19/2025 throughout the day of the survey, the urinal was noted to be left on the nightstand not emptied and next to the Styrofoam drinking glass.…

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: 2590687, 2577760, and 2581464. Based on observation, interview and record review, the facility failed to prevent a decline in the quality of life for one resident (Resident #101) of 6 residents reviewed, resulting in Resident #101 having a change in demeanor of a decrease in activity with an increase in depression of tearfulness. Findings include: Record review of Resident #101's Minimum Data Set (MDS) dated [DATE] quarterly assessment revealed an elderly male resident with medical diagnoses of: Heart failure, Diabetes, anxiety, depression and respiratory failure. Record review of Resident #101's physician orders for the month of August 2025 revealed medications of Abilify (antipsychotic), Lexapro (antidepressant), daily for mood and mental stability. Observation and interview were conducted on 8/19/2025 at 9:55AM with Resident #101 seated up in Wheelchair in the dining room, drinking coffee with other residents. He is interacting with staff members and enjoying himself.…

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 2590687, 2577760, and 2581464. Based on observation, interview and record review, the facility failed to get a signed informed consent for anti-anxiety medication prior to administering it for one resident (R101), resulting in Resident #101 receiving the medication with no written or verbal consent. Findings include: Record review of Resident #101's Minimum Data Set (MDS) dated [DATE] quarterly assessment revealed an elderly male resident with medical diagnosis of: Heart failure, Diabetes, anxiety, depression and respiratory failure. Record review of Resident #101's physician orders for the month of August 2025 revealed medications of Abilify (antipsychotic), Lexapro (antidepressant), daily for mood and mental stability. Observations and an interview were conducted on 8/19/2025 at 9:55AM with Resident #101, who was seated up in Wheelchair in the dining room, drinking coffee with other residents. He is interacting with staff members and enjoying himself. The 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 Number MI00151360. Based on observation, interview and record review, the facility 1) Failed to ensure accurate orders for a feeding tube and 2) Failed to ensure maintenance of the feeding tube, including water flushes, for 2 residents (Resident #1 and Resident #2) of 2 residents reviewed for feeding tubes. Findings Include: Resident #1: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: History of a stroke, left sided weakness, tongue and throat cancer, feeding tube, chronic pain syndrome, depression, weakness, hypertension and atrial fibrillation. The MDS assessment, dated 02/08/2025, revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed some assistance with all care. On 3/26/2025 at 11:29 AM, during an interview with Nurse B, she said Resident #1 had a feeding tube that he had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to Intake Number MI00151360. Based on observation, interview and record review, the facility failed to follow accepted standards of practice for obtaining a physician's order, assessment and monitoring of a Central Venous Catheter/CVS Mediport IV for one resident (Resident #1) of 1 resident reviewed for IV catheters. Findings Include: Resident #1: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: History of a stroke, left sided weakness, tongue and throat cancer, feeding tube, chronic pain syndrome, depression, weakness, hypertension and atrial fibrillation. Resident #1 was receiving chemotherapy and radiation therapy for the cancer. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed some assistance with all care. On 3/27/2025 at 9:20 AM, Resident #1 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 MI00151360. Based on observation, interview and record review, the facility failed to ensure that 1) Physician's orders for dialysis services; 2) Post- Dialysis assessment and monitoring were completed and 3) Dialysis communication forms were complete and included pre-dialysis and post-dialysis assessment, including location and assessment of the dialysis access site for one resident (Resident #4) of 1 resident reviewed for Dialysis care. Findings Include: Dialysis Resident #4: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident 34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Chronic kidney disease, receives dialysis, Diabetes, obesity, anemia, gout, hypothyroidism. Hypertension and bipolar disorder. The MDS assessment dated [DATE] revealed the resident full cognitive abilities. On 3/27/2025 at 11:42 AM Nurse C was interviewed about Resident #4 receiving dialysis services, she said the resident did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to meet professional standards of care regarding implementation of COVID preventive measures in a timely manner during a COVID outbreak emergency, resulting in 11 residents (Resident's #6, #7, #14, #16, #23, #24,#25, #28, #35, #90) and 10 staff members (Nursing Assistant/CNA O, CNA P, CNA Q, CNA R, CNA S, Nurse, LPN G, Social Worker E, Dietary Aide N, Nurse, CNA H, and Dietary Manger A) testing positive for COVID, resulting in one resident's (Resident #7) hospitalization, resulting in rapid spread of COVID throughout the facility and staff members with the likelihood for the continued spread of COVID, resident and staff illness and the hospitalization of (Resident #7. Findings Include: Review of the facility Pandemic COVID-19, Infection Control New Admission's policy dated 2020 (from the facility Emergency Preparedness program-the only COVID policy in the Emergency book found), stated Early prevention of COVID-19 outbreak consists 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 Based on observation, interview and record review, the facility failed to ensure that accurate resident information was completed on the Resident Roster Matrix (802) for five residents (Resident #1, Resident #14, Resident #16, Resident #26, Resident #140) of 12 sampled residents, resulting in COVID-positive residents and the likelihood of unmet care needs. Findings include: Record review of the facility 'MDS/CRC Coordinator' job description copyright 2024 The Compliance Store, LLC. position purpose was to conduct and coordinate the completion of the required Resident Assessment Instrument (RAI) and be responsible for the implementation and ongoing evaluation of each resident's comprehensive plan of care and auditing of medical records for the presence of supporting documentation for all items coded on the MDS. Upon entrance to the facility on [DATE] at 08:30 AM, the surveyors were notified by facility's Social Worker that the facility was having a COVID-positive outbreak and to wear a facial mask. Observations…

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 care plans were updated and revised appropriately with new interventions for four residents (Residents #7, Resident #8, Resident #17, Resident #27) of 12 sampled residents, resulting in revision and interventions necessary for care and services not being care planned with the likelihood for unmet care needs. Findings include: Record review of the facility 'Comprehensive Care Plans' policy, dated 8/2024, revealed it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. (5.) The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Resident #7: In observations and 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 Based on observation, interview and record review, the facility failed to prevent facility-acquired urinary tract infections and follow up on contaminated urine samples for four residents (#7, #8, #9, #31), resulting in the likelihood for urinary tract infections and/or organisms to be unidentified and untreated, bladder injury, pain and decline in overall health status. Findings include: Record review of facility 'Perineal Care' policy copyright 2023, revealed that it is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Record review of the facility 'Minimum Criteria for Initiation of Antibiotics' policy dated 2017 revealed: Suspected Urinary Tract Infection . Note: Foul smelling or cloudy urine is not a valid indication for initiating antibiotics. Asymptomatic bacteriuria should not be treated with antibiotics.…

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 2 of 2 medication carts (Rehab Hall and Long-Term Hall medication carts) were clean and sanitized, free of crushed pills, pieces of loose papers and dust in the drawers, and proper medication storage, resulting in the likelihood of cross contamination, low medications count with increased cost and missed resident medications. Findings Include: Observation of facility medication carts done on 10/14/24 at 10:30 a.m., revealed the following: Medication Cart on the Rehab Hall was found to have the second, and third drawers dirty with crushed meds, dust, and papers on the bottom of the carts. During an interview done on 10/14/24 at 10:30 a.m., Nurse, LPN V stated I don't know who is supposed to clean it, maybe third shift. Observation of facility medication carts done on 10/15/24 at 11:39 a.m., revealed the following: Second and third drawers had crushed pills and dirt/dust and pieces of paper on the bottom. In the narcotics drawer,…

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 1) Failed to maintain food preparation and kitchen equipment in a sanitary and good working condition, and 2) Failed to ensure that partially opened food items had a open and use-by date on them, resulting in an increased likelihood for food borne illness with hospitalization, and cross contamination affecting 35 residents who consumed oral nutrition from the facility kitchen and ice machine of a total census of 35 residents. Findings Include: Review of the Public Health Service 2009 Food Code, adopted by the Michigan Food Law, effective October 1, 2012, Chapter 4-501.14 directs that equipment cleaning frequency is to be throughout the day at frequency necessary to prevent recontamination of equipment and utensils. Review of the facility Date Marking for Food Safety policy (un-dated), stated The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. The marking system shall consist of, the day/date of opening, and the day/date the item must be consumed…

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 1) Ensure resident monthly infection data was analyzed for 7/24 and 8/24 for a census of 35 residents, and 2) Ensure enhanced barrier precautions were used during wound care, resulting in the likelihood for cross contamination, resident, and staff illness, antibiotic usage with possible hospitalization. Findings Include: Infection Control Data Analyzing: Review was done of 7/24 and 8/24 facility monthly data reports. Both reports had documentation of infection rates, and the total numbers of each infections. No documentation of any analysis done regarding the infection rates, employee call-ins, antibiotic usage or immunizations was found. During an interview done on 10/15/24 at 10:20 a.m., the Infection Control Nurse/IC, LPN T and Director of Nursing/DON both confirmed there was no analyzing that had been done from the monthly data collected in the Infection Control program. The IC Nurse T stated, I just do what I am told, no one asked me anything (regarding monthly infection rates and residents or staff) in…

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 monitor and justify the administration of antibiotic medications for four residents (#7, #8, #9, #31), resulting in Resident #7 and Resident #31 to have recurrent urinary tract infections, Resident #8 and Resident #9 to be receive antibiotic without clinical rational and the likelihood of antibiotic resistance due to an inappropriate usage, resistance or the development of opportunistic organisms, and hospitalizations. Findings include: Record review of the facility Infection Prevention and Control Program' policy 10/2022 revealed the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. (6.) Antibiotic Stewardship: (a.) An antibiotic stewardship program will be implemented as part of the overall…

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 assessment, monitoring and timely provision of care, per professional standards of practice for one resident (Resident #7), resulting in a lack of documentation and glucose monitoring with a change of condition with the likelihood for a lack of change of condition and delay in the treatment of low blood glucose level. Findings include: Record review of the facility 'Promoting/Maintaining Resident Dignity' policy dated 8/2024 revealed it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life . § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care…

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

Based on interview and record review, the facility failed to ensure weight monitoring timely for two residents (Resident #17, Resident #27) of 4 residents reviewed, resulting in a lack of weight monitoring/follow-up of abnormal weights, and the likelihood for unidentified nutritional deficiencies and decline in overall health. Findings include: Record review of facility 'Weight Monitoring' policy dated 8/2024 revealed based on the resident's comprehensive assessment, the facility will ensure that all resident's maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. (5.) A weight monitoring schedule will be developed upon admission for all residents: (a.) Weights should be recorded at the time obtained . (b.) Residents with weight loss- monitor as directed by Dietitian/designee. (c.) If clinically indicated- monitor weight daily. (d.) All others- monitor weight monthly. (6.) Weight…

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 ensure that one resident's (Resident #22) behavior's were documented and monitored, resulting in the likelihood for increased resident behaviors with no documentation of interventions done or effectiveness, lack of follow-up regarding care plan's, and medication reviews not being accurate. Findings Include: Resident #22: Review of the Face Sheet, care plans and nursing notes dated 10/11/24 though 10/14/24, revealed Resident #22 was 57 years-old, not able to make his own healthcare decisions, and required staff assistance with Activities of Daily Living/ADL. Review of the residents diagnosis included, epilepsy, intellectual disabilities, schizophrenia, adjustment disorder, major depression, Dementia, and delusional disorders. Review of the residents Behavioral care plan (un-dated), stated (Resident #22) has a behavior problem (repeatedly) yelling out, being sexually inappropriate to staff and purposely throwing myself out of bed for attention. He has attention seeking behaviors and often impulsive. Monitor behavior episodes…

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 obtain consents for antipsychotic medication usage for one resident (Resident #8), resulting in Resident #8 being administered antipsychotic medications without appropriate consent and risk-versus-benefit analysis or medications explained to the resident/responsible party and the increased likelihood for serious side effects and adverse reactions. Findings include: Record review of the facility 'Use of Psychotropic Medication' policy dated 8/2024 revealed residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. (1.) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotic's, antidepressants, anti-anxiety, and hypnotics. (5.)…

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 MI00145893. Based on observation, interview and record review, the facility failed to ensure a clean and safe environment for 11 residents' rooms, 2 main hallways, and 1 residential sitting area, resulting in the likelihood for resident injury (bug and spider bites and hand splinters), anger and frustration from family members and residents, cross contamination with illnesses with increased use of antibiotics. Findings Include: During a walk-through of the facility done on 9/12/24 starting at 10:00 a.m., accompanied by the Administrator, the following concerns were observed: -room [ROOM NUMBER]: Extreme odor of urine near bed 2; resident in bed at the time. -room [ROOM NUMBER]: Several used tissues were observed on the floor near bed 1, the walls had numerous areas of chipping paint and black scuff marks from wheelchairs. -room [ROOM NUMBER]: The bedside curtain between bed 1 and bed 2 had several stains on it. -room [ROOM NUMBER]: The bedside curtain had several areas 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 MI00145893. Based on interview and record review, the facility failed to ensure that one resident (Resident #103), had the required Activities of Daily Living (ADL) care (showers) of 6 residents reviewed for ADL's, resulting in an increased likelihood for offensive odors, skin issues, and decreased self-esteem with isolation. Findings Include: Resident #103: Review of the Face Sheet, Care Plans dated 6/22, and shower sheets (dated 7/3/24, 7/16/24 and 7/23/24), revealed Resident #103 was 69 years-old, admitted to the facility on [DATE] and re-admitted on [DATE], was cognitively impaired and unable to make healthcare decisions, and required staff assistance with all ADL's. The residents diagnosis included, stroke with severe cognitive impairment, seizures, anxiety disorder, Alzheimer's Disease, mood disturbance, and diabetes. Review of the facility ADL care plan (6/22) stated assist with ADL's. During an interview done on 9/16/24 at 11:18 a.m., the Director of Nursing…

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 MI00135195 and MI00138197. Based on observation, interview, and record review, the facility failed to follow professional standards of nursing practice for medication administration vital sign assessments for 6 residents (Resident #2, Resident #10, Resident #26, Resident #21, Resident #14, and Resident #3) reviewed for provision of nursing services, resulting in medications administered late, medications administered outside of physician-ordered parameters, medication errors without management follow through, incomplete laboratory testing, and the potential for less than therapeutic effects of medications, decreased effectiveness of medications, and the potential for a delay in treatment and the worsening of medical conditions. Findings: Resident #2 (R2): Review of an admission Record revealed R2 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: hypotension (low blood pressure). Review of a Minimum Data Set…

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 assess, monitor, and care for a resident receiving enteral tube feedings for one resident (Resident #6) reviewed for enteral tube feedings, resulting in the potential for aspiration pneumonia and an overall deterioration of health status. Findings: Resident #6 (R6): Review of an admission Record revealed R6 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia, diabetes, heart disease, and gastro-esophageal reflux. Review of R6's Care Plan revealed, (R6) needs the HOB (head of bed) elevated a minimum of 30 degrees during tube feeding and for 1 hour after. Date Initiated: 05/04/2022 . During an observation on 10/12/23 at 08:33 AM, R6 was in bed on her back with her tube feeding running. The head of R6's bed was at 22 degrees. During an observation on 10/12/23 at 11:54 AM, Certified Nursing Assistant (CNA) V and CNA U were providing incontinence care to R6. The head 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 1) Failed to implement an effective and current system of surveillance of staff illnesses to identify possible communicable diseases and infections to prevent the spread of an illness/outbreak, 2) Failed to perform incontinence care using infection control practices, and 3) Failed to ensure that staff were educated on and wore the appropriate recommended Personal Protective Equipment (PPE) while providing care for residents. This deficient practice placed all residents residing in the facility at risk for the potential for the development and spread of disease and infection and the potential for an outbreak to go undetected. Findings: Employee Surveillance: Review of the Employee Infection Surveillance log revealed the following boxes to complete for each employee illness: Employee Name, Department, Facility Area Last Worked, Date of Call-in, Symptoms, When did symptoms start, Symptoms for how long, Seen by MD/NP/PA, Expected to return to work,…

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 1) Failed to implement, and operationalize an antibiotic stewardship program and 2) Failed to ensure accurate monitoring and documentation of an antibiotic for three residents (Resident #13, Resident #19, Resident #30) reviewed for antibiotic use, resulting in the potential for inappropriate antibiotic utilization and the potential for antibiotic resistance. Findings: Resident #13 (R13): Review of an admission Record revealed R13 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: osteomyelitis (bone infection) in the sacral wound, dementia, and adult failure to thrive. R13 was a full code (all resuscitation procedures to be provided to keep the person alive in the case of a medical emergency). Review of R13's Physician Progress Notes dated 9/29/23 revealed, .UA (urinalysis) is ordered. Patient is asymptomatic, just as precaution. Review of R13's Nurses Progress Note dated 9/29/23 revealed,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to treat one resident (Resident #14) with dignity during care resulting in the potential for diminished feelings of self-worth. Findings include: Resident #14 (R14): Review of an admission Record revealed R14 was a [AGE] year old female, last admitted to the facility on [DATE], with pertinent diagnosis of morbid obesity, dementia, and anxiety disorder. R14 was completely dependent on staff for all hygiene needs. During an observation on 10/11/23 at 1:52 PM, Certified Nurse Aide (CNA) V provided peri care to R14 following urination and a bowel movement. While R14 laid on her right side, CNA V attempted to pull the brief out from under R14 and noted the under pad was soaked with urine. CNA V advised R14 that a new under pad was needed and left the room to obtain the new linen. R14 laid uncovered from the chest down while CNA V was out of the room. CNA V returned to the room with a new under pad and continued to clean R14. CNA V looked for and could not locate…

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 1) Failed to ensure that residents received complete and comprehensive wound assessments and 2) Failed to ensure the effectiveness of treatments and interventions based on wound assessments for one resident (Resident #13), reviewed for quality of care, resulting in the lack of assessment, monitoring, documentation, and the potential for the worsening of a wound and a delay in treatment. Findings: Resident #13 (R13): Review of an admission Record revealed R13 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: osteomyelitis (bone infection) in the sacral wound, dementia, and adult failure to thrive. R13 was a full code (all resuscitation procedures to be provided to keep the person alive in the case of a medical emergency). Review of a Minimum Data Set (MDS) assessment for R13, with a reference date of 7/29/23 revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible…

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 accurately document administration of controlled substances for three residents (Resident #13, Resident #22, and Resident #11) resulting in the potential for overdose and/or ineffective management of pain, and the potential for drug diversion of controlled substances. Findings: Resident #13 (R13): Review of an admission Record revealed R13 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: heart disease, dementia, and adult failure to thrive. Review of R13's Physician Order dated 8/23/23 revealed, Norco Oral Tablet 5-325 MG (milligram) (Hydrocodone-Acetaminophen) Give 1 tablet by mouth two times a day for pain (to be administered at 8:00 AM and 8:00 PM) and Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain. Review of R13's Pharmacy Controlled Substance Proof-of-Use Record revealed the following: *On 10/9/23 1 tab of Norco 5/325…

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.