Villa at Pine Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from neglect, for one Resident (R10) of two residents reviewed for abuse, resulting in R10 being transferred from their wheelchair with a damaged Hoyer lift sling, hitting their head and causing pain, with the potential to affect 15 additional facility residents who used Hoyer lifts for transfers. Findings include: On 8/19/25 at 11:32 a.m., R10 was observed seated in their manual wheelchair, dressed and well-groomed, propelling their wheelchair around their room. Review of R10's nursing progress note, dated 8/19/25 at 3:29 p.m., revealed R10 had a fall out of the Hoyer lift. The note described, (R10) was in the room with two aides with Hoyer. (R10) was getting put to bed and was hooked up to the Hoyer and upon lifting (R10) was not positioned correctly and sling come loose (sic). (R10) hit head on (the) baseboard of bed when being lowered back to a sitting position in wheelchair. Review of R10's Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide timely incontinence care for one (R60) of one resident reviewed for bladder and bowel incontinence. Findings include:On 8/19/25 at 9:58 AM, R60 was observed lying in bed with oxygen running via nasal cannula. When asked about how they felt the care was and whether there was enough staff to meet their care needs, R60 reported concerns with not having enough staff to change their briefs regularly. The resident further reported they wore disposable briefs and they also had a UTI (Urinary Tract Infection) and still has burning (common pain from a UTI) because they felt like the UTI was because they weren't getting changed frequently. When asked what they considered as frequent, R60 reported they were trying to get a change every three to four hours, but they often had to wait a long time. When asked when the last time they were changed, R60 reported the last time was at 5:00 AM. The resident also reported it (the delay in being changed) was worse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide snacks for a resident with low body weight for one (R54) of three residents reviewed for nutrition. Findings include: On 8/19/25 at 9:06 AM, R54 was observed lying in her bed. R54 appeared to be small and very thin and bilateral arm and hand contractures were observed. R54 was asked about care at the facility. R54 explained she did not get snacks in the evenings, she did not always like the food being served and she was hungry in the evenings and would like to get snacks. sometimes someone would give her something, but she needed assistance to eat and it was hard to get someone to assist her at snack time.Review of the clinical record revealed R54 was admitted into the facility on [DATE] with diagnoses that included: spastic quadriplegic cerebral palsy, moderate protein-calorie malnutrition and anxiety disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R54 was cognitively intact. The MDS assessment also…

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

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 9/9/24 at 8:50 AM, there were 2 10-pound packages of raw ground beef thawing under running water in the 2 compartment sink. The ground beef logs were in a metal pan, with approximately 1/3 of the meat submerged in water, and the rest of the meat was sticking out of the pan. The temperature of the running water was measured to be 92 degrees Fahrenheit. On 9/9/24 at 9:15 AM, Dietary Manager B was queried about the temperature of the running water when thawing meat, and stated that the water should have been cold. According to the 2017 FDA Food Code section 3-501.13 Thawing, Except as specified in (D) of this section, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be thawed: 1. (A) Under refrigeration that maintains the FOOD temperature at 5°C (41°F) or less; or 2. (B) Completely submerged under running water: 1. (1)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide consistent, meaningful and person-centered activities for one (R32) of one resident reviewed for activities, and five of seven residents who attended the confidential Resident Council interview, resulting in potential for loss of interaction, joy, self-esteem, sense of well-being, creativity, and independence. Findings include: R32 A review of R32's clinical record revealed R32 was a long-term resident of the facility and was admitted to the facility on [DATE]. R32's admitting diagnoses included anxiety disorder, bipolar-disorder, insomnia, osteoarthritis, social phobia and depression. Based on a Minimum Data Set (MDS) assessment dated [DATE], R32 had Brief Interview for Mental Status (BIMS) score of 15/15, indicative of intact cognition. On 9/9/24 at approximately 12:15 PM, R32 was observed in their bed. R32 was queried about their daily routine, if they attended any activities and their quality of life at the facility. R32…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #'s MI00146644 and MI00146449. Based on observation, interview and record review, the facility failed to ensure liquids were provided according to their prescribed therapeutic diet texture for one resident (R57) of four residents reviewed for nutrition. Findings include: On 9/9/24 at approximately 9:03 a.m., R57 was observed in their room, up in their wheelchair attempting to eat their breakfast. R57 was observed to be coughing while eating cereal and drinking their juice. Both the milk and juice appeared to be thin. A review of R57's meal ticket revealed they were supposed to have been provided nectar thick liquids for their meals. On 9/9/24 at approximately 9:07 a.m., Nurse C was informed that R57 was coughing while drinking their juice and eating their cereal. Nurse C was observed going into R57's room and assessing them and indicated that their liquids including the milk and the juice were not thickened and they indicated that R57 should have thickened liquids and was then…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide the total amount of physician ordered enteral (tube) feeding, document consistently and accurately the amount of enteral feeding infused, and ensure timely follow up with the physician for one (R63) of one resident reviewed for enteral feeding. Findings include: R63 was a long-term resident of the facility. R63 was originally admitted to the facility on [DATE]. R63 was recently hospitalized and readmitted back to the facility on 8/31/24. R63's diagnoses included stroke with hemiplegia (paralysis of one side), malnutrition, and dysphagia (difficulty swallowing). R63 received part of their nutrition via Percutaneous Endoscopic Gastrostomy (PEG Tube - A tube surgically placed directly on the stomach to receive nutrition and hydration). Based on the Minimum Data Set (MDS) assessment dated [DATE], R63 had a Brief Interview for Mental Status (BIMS) score of 00, indicative of severe cognitive impairment. R63 had a family member appointed…

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 #MI00146644. Based on interview and record review the facility failed to administer pain medication for one resident (R273) of three residents reviewed for pain management. Findings include: On 9/9/24, a concern submitted to the State Agency was reviewed and alleged R273 was not administered pain medication per physicians orders. On 9/10/24 the medical record for R273 was reviewed and revealed the following: R273 was initially admitted to the facility on [DATE] and had diagnoses that included Mild Protein-Calorie malnutrition and Multiple Sclerosis. A review of R273's MDS (minimum data set) with an ARD (assessment reference date) of 8/17/24 revealed R273 needed assistance from facility staff with their activities of daily living. R273 BIMS score (brief interview for mental status) was 13 indicating intact cognition. A review of R273's careplan revealed the following: Focus-I have a terminal illness, and I am at the end of life receiving Hospice services through [name of hospice]…

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 facility failed to consistently assess a resident after dialysis; and maintain accessible communication/collaboration between the dialysis center and the facility for one (R4) of one resident reviewed for dialysis. Findings include: Review of R4's clinical record revealed R4 was a long-term resident of the facility. R4 was admitted to the facility on [DATE]. R4's admitting diagnoses included end stage renal failure and aphasia (inability to speak/comprehend). Based on the Minimum Data Set (MDS) assessment dated [DATE], R4 had a Brief interview for Mental Assessment (BIMS) assessment score of 00/15, indicative of severe cognitive impairment. Review of R4's Electronic Medical Record (EMR) revealed a physician order dated 5/22/24 that read In-house dialysis 4 times/week. Further review of records revealed that R4 had been going out for dialysis on Monday, Tuesday, Thursday, and Friday. Further review of physician orders reveals an order dated 6/13/24 that read, monitor dialysis…

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

Based on interview and record review facility failed to provide sufficient staff to provide adequate care and services for residents on the weekends for three of seven residents who attended the Resident Council interview who wished to remain anonymous, resulting in extended call light response and resident dissatisfaction. This deficient practice had the ability to affect multiple residents that resided in the facility. Findings include: A confidential Resident Council interview was completed on 9/10/24 at 10:30 AM. During the interview one resident who wished to remain anonymous reported that they had to wait longer to get assistance after activating their call light on weekends. Two residents who wished to remain anonymous agreed when the concern was brought up and reported longer wait times during the afternoon and midnight shifts. One resident reported that their toilet broke over a weekend and they did not have anyone to fix it. They had a hard time getting assistance to assist them with their toileting as they did not have enough help. Two residents reported they have one…

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 R12 On 9/11/24 The medical record for R12 was reviewed and revealed the following: R12 was initially admitted to the facility on [DATE] and had diagnoses including Schizoaffective disorder, Bipolar disorder and Anxiety disorder. A Physicians order dated 8/28/24 revealed the following: diazePAM Oral Tablet 2 MG (Diazepam) Give 1 mg by mouth every 8 hours as needed (PRN) for anxiety for 14 Days. A review of the EMAR progress notes (electronic medication administration record) for August and September 2024 revealed the following dates of R12's diazepam administration in which no documented non-pharmacological interventions were attempted prior to administration: 9/11, 9/10 (7:45 PM), 9/10 (10:19 AM), 9/9 (4:59 PM), 9/9 (9:36 AM), 9/8 (8:24 PM), 9/8 (6:12 PM), 9/8 (8:14 AM), 9/7 (12:13 PM), 9/6, 9/3, and 9/2/24. On 9/11/24 at approximately 1:10 p.m., during a follow-up conversation with the DON, the DON was queried regarding the lack of documentation of non-pharmacological interventions being attempted prior to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #'s MI00146644 and MI00146449. Based on observation, interview and record review, the facility failed to ensure enhanced barrier precautions were applied for one residents (R12) of two residents reviewed for Pressure Ulcers . Findings include: On 9/9/24 a concern submitted to the State Agency for review indicated the facility staff were not following infection control procedures. On 9/9/24 at approximately 9:52 a.m., R12 was observed in their room, up in their wheelchair. R12 was queried about having any open pressure ulcers/wounds and they indicated they had multiple open wounds on their heel and leg. At that time, R12's room was observed with no signage that indicated staff should be utilizing enhanced barrier precautions (EBP) when providing care to R12. On 9/10/24 at approximately 1:52 p.m., Nurse C was observed in R12's room providing treatment to their wound without a gown on. On 9/10/24 at approximately 2:03 p.m., Nurse C was queried regarding PPE (personal protective…

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 operationalize an antibiotic stewardship program which consistently ensured appropriate clinical indication for use of antibiotic medications for three (R4,R8 and R63) of five residents reviewed for antibiotic stewardship program, resulting in the potential for increased antibiotic resistance. Findings include: On 9/11/24 at 10:30 AM an overview of the facility's infection control program was discussed with the Director of Nursing (DON) and the facility's Unit Manager(UM). And asked what was their process. The UM stated she makes sure the infection meets Mcgeers (a system that identifies if signs and symptoms meet the criteria of an infection and qualifies for an antibiotic) then placed the infection in the book. If it does not meet criteria, they would reach out to the provider and let them know that the criteria is not met (to discontinue the medication) and then do a line listing and mapping. The UM was then asked if these conversations were documented somewhere and if the provider declined to discontinue the medication…

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 # MI00145010 Based on interview and record review, the facility failed to accurately transcribe admission orders and follow up timely for one (R504) of two Residents reviewed for admission orders, resulting in R504 missing four days of their medications, including their blood thinner, diabetic, blood pressure and Gout medications. Findings include: R504 A record review revealed that R504 was a long-term resident of the facility. They were originally admitted to the facility on [DATE]. R504 had multiple hospitalizations during their stay at the facility. R504 was recently admitted to the hospital on [DATE] and they were readmitted back to the facility on 4/1/24. R504's diagnoses included respiratory failure, seizures, cerebral palsy with quadriparesis (weakness and decreased mobility of all four limbs), failure to thrive, and wound infection. Based on Minimum Data Set (MDS) assessment dated [DATE], R504 had severe cognitive impairment. R504 were dependent on staff assistance for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake# MI00144079 Based on observation, interview and record review the facility failed to complete a full investigation following an allegation of resident-to-resident sexual abuse pertaining to two residents (R701 and R706 ) out of four residents reviewed for abuse. Findings include: A complaint was filed with the State Agency (SA) that alleged R701 was sexually abused by R706 who entered into their room on or about 4/14/24 and stuck their hand under the resident's covers and started to rub their thigh near their private/vaginal area. On 4/24/24 at approximately 8:50 AM, R701 was observed lying in bed. The resident was alert and able to answer questions asked. R701 was queried as to life in the facility, including safety and abuse, R701 noted that they did not always feel safe and had issues with other residents and staff. They stated that a male resident that resided in the room across from them had entered into their room about a week ago. They noted that it was in the later…

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 #MI00144079. Based on observation, interview and record review, the facility failed to develop a comprehensive care plan to address history of drug use for one (R702) of two reviewed for comprehensive care plans. Findings include: Review of a complaint filed with the State Agency alleged R702 overdosed on drugs in the facility on 3/30/2024. On 4/24/24 at 10:25 AM, R702 was observed sitting in a wheelchair in the hallway, conversing with other residents. No signs of alcohol or drug use observed. R702 was cooperative and answered questions appropriately. When queried about recent hospitalization (on 3/30/2024) R702 stated that he had pneumonia and couldn't breathe. When queried about any drug use R702 reported that he had left the facility earlier that day and had smoked weed but denied any further drug use, adding that was only possible if there was something in the weed he had smoked. On 4/24/24 at 1:04 PM the director of nursing (DON) was queried about the events that occurred prior to R702 going out to the hospital on 3/30/24. The DON stated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00144079 and MI00144102. Based on observation, interview and record review, the facility failed to prevent an elopement of one (R704) of residents reviewed for accidents/supervision, resulting in R704 exiting the facility's front door and gone for four and a half hours without staff being aware. Findings include: Review of a complaint filed with the State Agency alleged R704 walked out of the building without staff knowing and was not found for four and a half hours. Review of a Facility Reported Incident (FRI) reported to the State Agency documented R704 exited the facility without the staff's knowledge on 4/19/24. On 4/24/24 at 9:56 AM, R704 was observed walking throughout the hallways pushing a four wheeled walker with a seat. The resident agreed to return to their room for an interview. When asked to recall the events from last Friday (4/19/24) and being outside, R704 pointed to their right arm (the wanderguard bracelet) and stated, I got branded. R704 further reported, I…

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 #MI00144079 and MI00144102. Based on observation, interview and record review, the facility failed to ensure that medically-related social services and follow up to address guardianship, patient advocacy, and care planning reviews for one (R704) of one residents reviewed for social services. Findings include: Review of a complaint filed with the State Agency alleged R704 walked out of the building without staff knowing and was not found for four and a half hours. Review of a Facility Reported Incident (FRI) reported to the State Agency documented R704 exited the facility without the staff's knowledge on 4/19/24. According to the facility's Social Services Manager job description dated 9/2023: .Assess and Evaluate Each Resident's Psychosocial Needs and Develop Goals for Providing the Necessary Service and Take Part in admission Process as Needed .Incorporate the Social Service Goals in the Resident's Plan of Care and Attend Care Planning Conferences .Ensure completion of any…

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 # MI00142974 Based on interview and record review the facility failed to ensure a comprehensive infection control program that consistently identified infections based on symptoms and justified the use of antibiotics, (using McGeer's Criteria for the definition of infections), as well as calculated infection rates, demonstrated on-going tracking, trending, in-services, education, and environmental rounding. resulting in the R902 developing a change of condition resulting in hospitalization related to a Urinary Tract Infection. Findings include: A complaint received by the State Agency revealed that R902 developed Urinary Tract Infection at the facility and they were transferred to the hospital on 2/20/24 after a family member had identified the change in R902's condition and they were admitted to the hospital. On 4/2/24 at approximately 12:30 PM,a verbal request was made to the facility administrator and the Director of Nursing (DON) to meet with the facility's infection…

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 # MI00143570 Based on observation, interview, and record review facility failed to follow-up and resolve a grievance timely for one (R901) of one Resident reviewed for grievances resulting in feelings of frustration. Findings include: A record review revealed R901 was a long-term resident of the facility, originally admitted to the facility on [DATE]. R901's admitting diagnoses included congestive heart failure, metabolic encephalopathy, and breast cancer. A review of the Minimum Data Set (MDS) assessment dated [DATE], R901 had a Brief Interview for Mental Status (BIMS) score of 14/15, indicative of intact cognition. R901 was dependent on staff assistance with their mobility in bed and toileting hygiene. A complaint received by the State Agency dated 3/25/24 revealed that R901 waited for an extended period to get changed when they had requested for staff assistance on a specific date. An initial observation was completed on 4/2/24, at approximately 11:30 AM. R901 was observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake# MI00142589 Based on observation, interview and record review the facility failed to ensure routine scheduled bathing and facial hair removal was provided for two (R702 and R703) out of three residents reviewed for Activities of Daily Living (ADLs). Findings include: A complaint was filed with the State Agency (SA) that alleged residents were not receiving timely grooming services. R702 On 2/20/24 at approximately 11:03 AM, R702 was observed lying in bed wearing a hospital gown. The resident had extremely long facial hair on their chin and around their cheeks. Their hair appeared greasy and unkempt. The resident was alert and asked whether they received scheduled showers and if they needed assistance removing facial hairs. R702 responded that they did not know the last time they had a shower and would like their facial hair to be shaved. On 2/20/24 at approximately 1:10 PM, a second observation of R702 was made. The resident's family member was also in the room. R702's facial…

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 #MI00141561. Based on observation, interview, and record review the facility failed to ensure freedom from experiencing and overhearing verbal abuse for two residents (R#'s 704 and 706) of three residents reviewed for abuse. Findings include: On 1/3/24 at 10:40 AM, an interview was conducted with R704 and they were asked if any staff members had ever said anything inappropriate to them. R704 said about three weeks ago on the night shift CNA 'A' exited their room after providing care to them and overheard CNA 'A' call them a , fat bch. R704 further said the facility terminated CNA 'A's employment. On 1/3/24 at 10:45 AM, an interview was conducted with R706. They were asked if they heard CNA 'A' make the statement and said they did hear the remark. A review of R704 and R706's most recent Minimum Data Set assessments was conducted and revealed both residents had intact cognition. On 1/3/24 at 11:15 AM, a review of the facility provided investigation folder for the incident between R704 and CNA 'A' was conducted. The folder contained a typed document…

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

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 10/30/23 between 7:25 AM-8:00 AM, during an initial tour of the kitchen, the following items were observed: In the walk-in cooler, there was an opened, undated 1 gallon container of ranch dressing. According to the 2017 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which 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.

This citation has two deficient practice statements. Deficient Practice #1 Based on interview and record review, the facility failed to establish a comprehensive infection control program that identified resident infections, calculated monthly infection rates, tracked and trended infections, utilized laboratory and pharmaceutical data, and ensured departmental surveillance and staff education on infection control. This deficient practice had the potential to affect all residents who resided in the facility. Findings include: Review of a facility policy titled, Infection Prevention and Control Program dated 5/2023 documented: .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 practices .Policy Explanation and Compliance Guidelines .Surveillance .designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to consistently ensure the physicians review, action and rationale of identified medication irregularities documented by the Pharmacy monthly medication reviews were documented and maintained in the resident's medical record for four residents (R17, R25, R36 and R41) of six residents reviewed for unnecessary medications. Findings include: R25 On 10/30/23 the medical record for R25 was reviewed and revealed the following: R25 was initially admitted to the facility on [DATE] and had diagnoses including: Schizophrenia, Multiple Sclerosis and Epilepsy. A review of R25's MDS (minimum data set) with an ARD (assessment reference date) of 8/20/23 revealed R25 needed supervision from facility staff with most of their activities of daily living. R25's BIMS score (brief interview of mental status) was 12 indicating moderately impaired cognition. A review of the monthly medication regimen reviewed for R25 revealed the following dates in which irregularities were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents prescribed psychotropic medication had adequate indication for use of duplicate antidepressants, clinical rationale to support continued use, as well as PRN (as needed) orders, identify and monitor resident specific behaviors and approaches, and document non-pharmacological approaches and behavior details at the time of medication administration for two (R17 and R36) of six residents reviewed for unnecessary medication, resulting in unnecessary use of psychotropic medication, and inability to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence. Findings include: R17 Review of the clinical record revealed R17 was admitted into the facility on 5/31/23 and readmitted on [DATE] with diagnoses which included: adjustment disorder with mixed anxiety and depressed mood, anxiety disorder, mood disorder due to known physiological condition with major depressive-like episode, bipolar disorder…

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 two medication carts were secured while unattended and ensure medications were properly stored and secured, resulting in the potential for unauthorized entry into the carts, misuse, contamination and diversion. This deficient practice had the potential to affect multiple residents in the facility. Findings include: On 10/30/23 at approximately 6:15 AM, a medication cart located on the 200 hall was observed to be open/unlocked and unattended by any Nursing staff. A second treatment cart located on the 300-hall containing various creams and supplies was also noted to be unlocked. An interview was conducted with Nurse X on 10/30/23 at approximately 6:30 AM. Nurse 'X was asked about the facility's policy/protocol for medication/treatment carts. Nurse X noted that they should be locked when unattended. On 10/30/23 at approximately 8:14 AM and on 10/31/23 at approximately 8:50 AM, a COVID 19 reagent bottle was observed on top of the sharp container located in a resident's room. On 10/31/23 at approximately…

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 one (R10) of two residents reviewed for medication were assessed for the safe self-administration of medication and to have medication kept at bedside. Findings include: On 10/30/23 at approximately 8:14 AM, R10 was observed lying in bed. On the bedside table was a container of eye drops and a scripted container of saline nasal spray. A bottle of COVID-19 reagent was observed on top of the sharp box on the resident's wall. When asked about the medication, R10 reported that he uses the medication daily. On 10/31/23 at approximately 8:44 AM, the same medication was observed on the table. On 10/31/23 at approximately 8:46 AM, an interview and record review were conducted with Nurse K regarding the self-administration of medication. Nurse K reported that residents, including R10, needed an order to self-administer medication. Nurse K looked through R10's clinical record and noted that they could not locate an order. On 10/31/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure healthcare treatment decisions were properly documented for one (R17) of five reviewed for advanced directives/code status. Findings include: A review of R17's clinical record revealed the resident was initially admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses that included: congestive heart failure, type II diabetes and neoplasm of right breast. Review of R17's most recent Minimum Data Set (MDS) indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (cognitively intact cognition). At the top of the resident's electronic face sheet was a Code Status section that read: Full Code, DNR (do-not-resuscitate). An order dated 9/29/23 for a DNR was located in R17's clinical record. On 11/1/23 at approximately 10:54 AM, R17 was observed lying in bed. The resident was alert and able to answer questions asked. When asked their code status wishes, R17 reported that they are DNR. On 11/1/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to consistently notify the resident's legal guardian of refusals of their medications for one (R5) of one resident reviewed for notification of change. Findings include: On 10/30/23 at 7:09 AM, R5 was observed sitting in their wheelchair at the end of the hallway facing the nurse's station. An interview was attempted however could not be conducted due to the resident's cognition level. On 10/30/23 at 9:05 AM, a telephone interview was conducted with R5's legal guardian. When asked if they had any concerns regarding R5's care at the facility the legal guardian began to explain that it came to their attention that R5 was missing some of their medications because R5 has been refusing them. R5 stated the problem is that R5 is not competent to make those decisions due to R5 having the capacity of a child. R5's legal guardian stated in part . I am his legal guardian. I should be notified if he refuses to take his medications . The legal guardian…

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 an effective program to initiate and resolve grievances for one (R67) of three reviewed for dignity/respect. Findings include: On 10/31/23 at approximately 11:30 AM, R67 reported that the facility was not addressing their grievances. The resident reported that they were positive with COVID-19 in the middle of October 2023 and placed on precautions. During that time a Nurse (herein after Nurse R) referred to them as Ms. Covid and it hurt their feelings and they felt they should be addressed by their actual name. R67 further noted that Nurse R never apologized. R67 also noted that they filed a second grievance that noted Nurse R allowed CNA (certified nursing assistant) S to pass their medication(s) that included a narcotic. R67 stated that they felt it was very unprofessional. The facility was asked to provide all grievances/incident-accident (IA) reports since the resident's admission to the facility. Two grievance forms were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a physician's order with medical symptom justification for the use of a physical restraint and specify the times to be used while in bed per plan of care for one (R36) of two residents reviewed for physical restraints. Findings include: According to the facility's policy titled, Bed Rails dated 6/2023: .Full and half bed rails will be safely used only as needed to treat a resident's medical symptoms .Obtain a Physician order that contains statements and determinations regarding medical symptoms and is specific to the circumstances under which bed rails are to be used and time limit for use . On 10/30/23 at 8:20 AM, R36 was observed laying in a bariatric bed with bilateral metal half side rails. When asked about the use of the side rails, R36 reported they used those to help reposition themselves in bed. R36 further reported they preferred to spend most of their time in bed. When asked if the could recall whether the facility 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 Based on observation, interview and record review, the facility failed to ensure appropriate Nursing practices were followed for two residents (R25 and R50) of two residents reviewed for Nursing standards of practice when facility Nursing staff did not timely transcribe a Physician order for R25 and failed to ensure medications were reordered and available for administration for R50. Findings include: R50 On 10/30/23 at approximately 9:01 a.m., R50 was observed in their room, laying in their bed. R50 was queried if they had any concerns and they reported the facility had run out of their Prozac (anti-depressant) and Norco (pain medication) and their Ativan (anti-anxiety). R50 reported they had missed multiple days of their medications. On 10/30/23 the medical record for R50 was reviewed and revealed the following: R50 was initially admitted to the facility on [DATE] and had diagnoses including Generalized anxiety disorder and Major depressive disorder-recurrent. A review of R50's MDS (minimum data set) with an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00140514. Based on interview and record review, the facility to ensure accurate and complete discharge instructions were provided to one resident upon discharge (R80) of one residents reviewed for discharge planning. Findings include: On 10/30/23, review of a concern submitted to the State Agency alleged R80 was not provided with appropriate discharge instructions for follow up medical appointments and was not assisted with discharge planning. On 10/30/23 the medical record for R80 was reviewed and revealed the following: R80 was initially admitted to the facility on [DATE] and discharged on 10/27/23. R80 had diagnoses including Acute kidney failure, Chronic kidney disease (stage 4-severe) and alcohol dependence. A review of R80's MDS (minimum data set) with an ARD (assessment reference date) of 10/15/23 revealed R80 needed assistance from facility staff with most of their activities of daily living. R80's BIMS score (brief interview for mental status) was 15 indicating intact…

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 restorative range of motion (ROM) services and hand splints were applied for two (R17 and R41) out of three residents reviewed for limited ROM/Positioning. Findings include: R17 On 10/30/23 at approximately 11:13 AM, R17 was observed lying in bed. The resident was alert and able to answer questions asked. When asked about care in the facility the resident reported that they came to the facility in May 2023 to obtain physical therapy. When their physical therapy was cut they reported that they asked for restorative therapy and was told the facility does not offer that type of care. R17 stated that they were depressed as they were hoping to get more care so that they could return home. A review of R17's clinical record revealed the resident was initially admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses that included: congestive heart failure, type II diabetes neoplasm of right breast. Review of R17's Minimum…

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 proper management of tube feeding, including labeling on the formula to ensure appropriate administration in accordance with physician orders for one resident (R21) of one resident reviewed for tube feeding, resulting in the potential for inaccurate tube feeding administration. Findings include: On 10/30/23 at 7:14 AM, R21 was observed in their bedroom watching TV with their head of bed elevated. The tube feeding was infusing and the label was observed with a date of 10/29/23 at 3:00 AM with no rate documented and the water bag (auto flush) was dated for 10/28/23 at 9:00 PM. On 10/30/23 at 7:30 AM, Nurse J (the assigned midnight nurse) was interviewed and asked how often is tube feeding tubing changed? Nurse J replied every 24 hours, but I don't know. I am agency nurse so I am not sure of facility rules. Record review revealed that R21 was admitted to the facility on [DATE] with the diagnosis of Dysphagia, Contracture of muscles 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.

Based on observations, interviews, and record reviews the facility failed to consistently coordinate and provide breakfast meals for one resident (R44) of one reviewed for dialysis, resulting in frustration and hunger. Findings include: On 10/30/23 at 7:06 AM, R44 was observed laying on their back in bed watching a show on their laptop. When asked if they had any concerns regarding their care at the facility, R44 began to explain how frustrated they were that the facility would not ensure that they received their breakfast before their chair time at dialysis. R44 explained the dialysis was provided in the facility, however it is always a problem for the kitchen staff to provide them their breakfast before their chair time. R44 stated they go to dialysis on Mondays, Tuesdays, Thursdays, and Fridays. R44 stated they had to leave in a few minutes, and they haven't delivered me a tray. R44 stated how they are hungry on those days because the facility can't get it together. R44 stated there was a meeting with the kitchen staff manager who stated they would switch their breakfast meals to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure appropriate narcotic medication practices including: storage and destruction of narcotics, and administration and disposition discrepancies for controlled substances for one (R36) of two residents reviewed for controlled substances, and one resident who attended the confidential resident council interview, resulting unrelieved pain for residents that reported they weren't getting their controlled pain medication at times, and the potential for unidentified diversion of controlled substances. Findings include: According to the facility's policy titled, Administration Procedures for All Medications dated 8/2020: .After administration, return to cart .and document administration in the MAR (medication administrative record) or TAR (treatment administrative record) and the controlled substance sign out record . According to the facility's policy titled, Controlled Substance Disposal dated 8/2020: .The Director of Nursing, 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.

Based on observations, interviews, and record reviews the facility failed to maintain a medication error rate of less than five percent when two medication errors were observed from a total of 25 opportunities observed during medication administration, resulting in a medication error rate of 8%. Findings include: On 10/31/23 at 8:25 AM, Registered Nurse (RN) M was observed preparing the morning medication administration for R22. RN M' was observed to have crushed the Carbamazepine 400 mg (milligram) ER (extended release) tablet and opened and crushed the contents of eight capsules of the Depakote Sprinkles 125 mg Delayed Release (DR) capsules. RN M was observed to have combined all of the crushed morning medications for R22 (which included the Carbamazepine ER & Depakote DR medications) and added vanilla pudding to the medication cup and was observed to have administered it to the resident at 8:34 AM. Review of the Carbamazepine ER manufacturer insert, documented in part . capsules may be swallowed whole or may be opened and all the beads sprinkled on a teaspoon of soft food such as…

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

Based on observation, interview, & record reviews the facility failed to ensure seizure medications were administered per the manufacturer instructions and physician orders for one (R22) of four residents reviewed for the medication administration observation, resulting in two significant medication errors. Findings include: On 10/31/23 at 8:25 AM, Registered Nurse (RN) M was observed preparing the morning medication administration for R22. RN M' was observed to have crushed the Carbamazepine 400 mg (milligram) ER (extended release) tablet and opened and crushed the contents of eight capsules of the Depakote Sprinkles 125 mg Delayed Release (DR) capsules. RN M was observed to have combined all of the crushed morning medications for R22 (which included the Carbamazepine ER & Depakote DR medications) and added vanilla pudding to the medication cup and was observed to have administered it to the resident at 8:34 AM. Review of the medical record revealed R22 had a diagnosis of . Epilepsy and epileptic syndromes with complex partial seizures . Review of the physician orders revealed R22…

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 infection control practices were followed by staff during a COVID-19 outbreak. This deficient practice had the potential affect all 79 residents that resided at the facility. Findings include: Upon entry into the building on 8/16/23 at 8:30 AM it was reported by the Administrator that there were several residents throughout the building that had tested positive for COVID-19. The Administrator provided a list of 23 residents that had tested positive for COVID-19. The list noted residents with COVID-19 resided on the 100, 200 and 300 halls. On 8/16/23 at approximately 12:00 PM, observations were made on the 200 halls. At that time, five rooms on the hall that had residents noted on the COVID-19 list, had precaution signs on the doors that read, Contact Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit.…

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#MI00138688 Based on observation, interview and record review the facility failed to inform a resident that their sleep/anxiety medication was discontinued, resulting in the resident not receiving medication for three days for one (R703) out of two residents reviewed for medication administration/quality of care. Findings include: A complaint was filed with the State Agency (SA) that alleged the facility had DC (discontinued) R703's medication they had been on for several months and did not provide the resident with notice. On 8/16/23 at approximately 2:00 PM, R703 was observed lying in bed. The resident was alert and able to answer all questions asked. The resident reported that they were admitted to the facility in April of 2022. They noted that they were their own responsible person and thus in charge of making all their own decisions. They continued to report that they received support from psychologists/psychiatrists as well as services from physicians. When queried as to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00136230 A complaint was received by the State Agency that alleged the resident sustained a fall. Based on observation, interview, and record review, the facility failed to ensure wheelchair brakes were in working order for one resident (R704) of two residents reviewed for accidents, resulting in a fall with sustainment of a hematoma to the forehead. Findings include: On 8/17/23 at 9:00 AM, R704 was observed in bed asleep. At that time, R704's wheelchair was observed to the right side of the bed. It was observed the wheelchair had an automatic breaking mechanism that when functioning properly applied the brakes when no weight was in the seat of the chair, and the brake disengaged when weight was applied to the seat in order to prevent the chair from rolling during a transfer into the chair. At that time, R704's automatic brake on the wheelchair was tested and it was discovered the left wheel was locked, however; the right wheel still had free travel causing the chair to swivel…

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.