WellBridge of Clarkston

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00141722, MI00142873, MI00140148, MI00140897 Based on observation, interview, and record review, the facility failed to ensure activity of daily living care including personal hygiene, bathing/showers, facial hair care, and dressing for eight residents, (R#'s 385, 391, 2, 39, 54, 238, 49, and 71) of 12 residents reviewed for activity of daily living (ADL) care, resulting in verbalized complaints, frustration, and embarrassment from poor personal hygiene. Findings include: A complaint was made with the State Agency that alleged residents were not receiving ADL care. R385 A review of the medical record and face sheet revealed that R385 was a former resident of the facility and they were originally admitted on [DATE]. R385's admitting diagnoses included Parkinson's, neuropathy, depressive disorder, anxiety disorder and muscle weakness. R385 was discharged home with their family with 24-hour care on 4/23/24. Based on the most recent Minimum Data Set (MDS) assessment, R385 had a…

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

Based on observation, interview and record review, the facility failed to ensure a medication error rate less than five percent when six medication errors out of 27 opportunities for error were observed for three (R44, R43 and R68) out of five residents reviewed during the medication administration observation, resulting in a 22.22% error rate. Findings include: Review of a facility policy titled, Medication Administration dated 1/2021 read in part, .Medications are administered as prescribed in accordance with manufacturers' specifications . Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record (MAR). Compare the medication and dosage schedule on the resident's MAR with the medication label. If the label and MAR are different, . the prescriber's orders are checked for the correct dosage schedule . On 6/4/24 at 8:01 AM, Licensed Practical Nurse (LPN) C was observed as part of the medication pass task. LPN C was observed to place a needle on a NovoLog FlexPen, turn the dial to 14 and inject the Insulin into…

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 # MI00143489. Based on interview and record review, the facility failed to verify an employee (Staff 'M') who was employed at the facility as a Registered Nurse (RN) had the required education, experience and valid nursing license to provide nursing services. This deficient practice had the ability to affect multiple residents that resided in the facility. Findings include: A complaint was filed with the State Agency (SA) that alleged the facility allowed a staff member to work 12 shifts before it was found they did not have a valid RN license. Review of documentation provided by the facility which was identical to the documentation provided from Attorney General (AG) office included an initial complaint filed by the [NAME] President of Clinical Services (Staff 'L') which documented Staff 'L' had been checking licenses of staff and identified some discrepancies with Staff 'M's license and registry information. The interview statement provided to the Office of the Oakland County…

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 #MI00141722 Based on observation, interview, and record review, the facility failed to ensure treatment in a dignified manner for three residents (R#'s 54, 72, and 235) of four residents reviewed for dignity, resulting in the potential for feelings of embarrassment. Findings include: A complaint was received by the State Agency that alleged residents were not being treated in a dignified manner. A review of a facility provided policy titled, Quality of Life-Accommodation of Needs was reviewed and read, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity, and well-being . R54 On 6/3/24 at 9:56 AM, R54 was observed in their bed. At that time, they were asked about various aspects of their stay in the facility and said some staff, Are not respectful. R54 said staff argue and are rude to one another. R54 continued to say the facility was their home but, staff make them feel like, you are in their facility, not home. R72 On 6/3/24 at 1:24 PM, a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a Resident's personal preferences for care was honored for one (R53) of one resident reviewed for self-determination/choices. Findings include: On 6/3/24 at 9:31 AM, R53 was observed lying in bed. R53 was asked about care at the facility. R53 explained they were scheduled to get showers on Tuesday and Friday afternoons. They had asked to have them in the mornings, but had been told they could not be moved to mornings because the day shift nurse aids were too busy. Review of the clinical record revealed R53 was admitted into the facility on 6/22/22 and readmitted [DATE] with diagnoses that included: chronic obstructive pulmonary disease, heart failure and paraplegia. According to the Minimum Data Set (MDS) assessment dated [DATE], R53 was cognitively intact and required the assistance of staff for activities of daily living (ADL's). On 6/4/24 at 11:01 AM, R53 was observed lying in bed. R53 was asked about their indwelling urinary…

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 #MI00141722, and MI00142873. Based on interview and record review facility failed to follow-up and resolve a grievance promptly for one (385) of two Residents reviewed for grievances resulting in feelings of frustration. Findings include: R385 A record review revealed R385 was a former resident of the facility and they were originally admitted on [DATE]. R385's admitting diagnoses included Parkinson's, neuropathy, depressive disorder, anxiety disorder and muscle weakness. R385 was discharged home with their family with 24-hour care. Based on the most recent Minimum Data Set (MDS) assessment, R385 had a Brief Interview for Mental Status of 15/15, indicative of intact cognition. A complaint received by the State Agency revealed that R385 did not receive their showers/baths for several days despite the requests from the Resident and the family members. The compliant read in part, (R385 - Pronoun omitted) had gone couple of weeks without being showered the concerns have already been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake(s): MI00140148 Based on interview and record review the facility failed to timely and accurately transcribe Physician orders for admission medications for one resident (R387) of one residents reviewed for admissions. Findings include: On 6/3/24 a concern submitted to the State Agency was reviewed which indicated R387 was not provided their medications in a timely manner including their anticoagulant and antirejection medications used for their lung transplant. On 06/04/24 the medical record for R387 was reviewed and revealed the following: R387 was initially admitted to the facility on [DATE] and had diagnoses including Lung transplant status, and idiopathic pulmonary fibrosis. A review of R387's MDS (minimum data set) with an ARD (assessment reference date) of 9/25/24 indicated that R387 required assistance from facility staff with most of their activities of daily living. A Nursing progress note dated 9/21/23 revealed the following: Resident arrived from [local hospital] via…

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 splint was applied per Physicians order for one resident (R26) of two residents reviewed for range of motion. Findings include: On 6/03/24 at approximately 9:20 a.m., R26 was observed in their room, up in their bed. R26 was observed to not have use of their right arm. No splinting device was observed applied to it. A resting hand splint was observed on their dresser. R26 was queried if any staff help offer to apply the splint and they shook their head no and indicated that staff do not offer to put it on. On 6/4/24 at approximately 8:42 a.m., R26 was observed on their room, laying in their bed. R26 was queried if anyone had offered to apply their resting hand splint on their right arm/hand and they indicated that nobody had the previous night. R26's splint was still observed in the same spot and position as the observation on 6/3/24. On 6/4/24 the medical record for R26 was reviewed and revealed the following: R26 was initially…

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 follow physician orders and ensure accurate documentation of an indwelling urinary catheter for one (R53) of two residents reviewed for urinary catheters. Findings include: On 6/4/24 at 11:01 AM, R53 was observed lying in bed, a urinary catheter bag was observed hanging from the bed. R53 was asked if she had any problems with the urinary catheter. R53 explained the indwelling catheter was supposed to be changed monthly, but it had been one month and four days since it had been changed. R53 then clarified, that it was not just four days overdue, but a month and four days since it had been changed. Review of the clinical record revealed R53 was admitted into the facility on 6/22/22 and readmitted [DATE] with diagnoses that included: chronic obstructive pulmonary disease, heart failure and paraplegia. According to the Minimum Data Set (MDS) assessment dated [DATE], R53 was cognitively intact and required the assistance of staff for activities…

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): MI00140148 Based on interview and record review the facility failed to timely and accurately transcribe and Administer Physician ordered medications including anticoagulant (warfarin) and antirejection medicine (tacrolimus) for one resident (R387) of one residents reviewed for significant medication administration. Findings include: On 6/3/24 a concern submitted to the State Agency was reviewed which indicated R387 was not provided their medications in a timely manner including their anticoagulant and antirejection medications used for their lung transplant. On 06/04/24 the medical record for R387 was reviewed and revealed the following: R387 was initially admitted to the facility on [DATE] and had diagnoses including Lung transplant status, and idiopathic pulmonary fibrosis. A review of R387's MDS (minimum data set) with an ARD (assessment reference date) of 9/25/24 indicated that R387 required assistance from facility staff with most of their activities of daily living. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were appropriately inventoried and stored in one (R53) resident's room. Findings include: On 6/3/24 at 9:31 AM, R53 was observed lying in bed. Four clear storage cubes were observed on R53's over-bed tray table. One of the clear storage cubes was observed to contain several medications including a bottle of Rolaids, eye drops, two inhalers and two bottles of medications that were turned on their sides so the labels could not be read. R53 was asked about the medications. R53 explained the inhalers were their medications, but the other medications were their family members medications. When asked why their family member's medications were kept in their room, R53 explained their family member would come by after work and would take the medications then. Review of the clinical record revealed R53 was admitted into the facility on 6/22/22 and readmitted [DATE] with diagnoses that included: chronic obstructive pulmonary…

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 #'s MI00131428, MI00131482, MI00131728, MI00134560, MI00135871, and MI00137478. Based on observation, interview and record review, the facility failed to ensure there was sufficient nursing staff to meet resident needs which included R23, R28, R40 and R63, and multiple residents that attended the confidential resident council interview. This deficient practice has the potential to affect all residents that reside in the facility. Findings include: Review of multiple complaints reported to the State Agency included concerns allegations of not having adequate staffing to provide care per resident's plan of care, such as medications, showers/baths, toileting, and incontinence care. On 6/13/23 at 12:04 PM, an interview was conducted with Certified Nursing Assistant (CNA 'M') who reported they had worked at the facility for about five years. When asked about their current assignment, they reported the had been assigned to all of 500 hall and that they had also been given half of the 700 hall, even numbered rooms. When asked if they were able to provide…

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 MI00131873, MI00134560, MI00135871, MI00132686, and MI00137478, Based on observation, interview, and record review, the facility failed to ensure Activity of Daily Living (ADL) care was provided for five residents (R#'s 335, 28, 236, 37, and 76) of seven residents reviewed for ADL care, resulting in verbalized complaints, and feelings of dissatisfaction and discomfort. Findings include: A review of an undated facility provided policy titled, Assisting the Nurse In Examining and Assessing the Resident was conducted and read, .4. Grooming and Dressing .As you provide the resident with personal care needs, you should note: a. The type of bath the resident likes (i.e., tub, shower, etc.); b. Assistance needed with bathing, hair and nail care, dressing and undressing, mouth care; and c. Any changes in the resident' s grooming or dressing habits .6.Ambulation. As you provide the resident with daily care, you should note: a. Assistance needed with ambulating (i.e., cane, wheelchair,…

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 intakes: MI00131873 & MI00132686. This citation has two Deficient Practice Statements (DPS). DPS #1 Based on observation, interview, and record reviews the facility failed to consistently administer Parkinson's medications timely, obtain and retain consultations of appointments completed for the Parkinson's pump and implement a care plan for the care and maintenance of a Parkinson's pump for one (R51) of one resident reviewed for Parkinson's disease care. Findings include: On 6/13/23 at 11:47 AM, R51 was observed in their room. An interview was conducted with the resident at that time. R51 verbalized frustration and the concern of the timely administration of their by mouth Parkinson's medication. R51 pointed to a pump on their abdomen and stated they have a pump and take oral medications for their Parkinson's disease. R51 stated the nurses feel they have an hour before or after the due time of their oral Parkinson's medication and that is not the case for them. R51 stated they need…

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 #MI00132802. Based on observation, interview and record review, the facility failed to ensure residents were treated in a dignified manner for one (R69) of three residents reviewed for dignity, resulting in the loss of autonomy, expressions of frustration, and loss of self-worth. Findings include: According to the facility's policy titled, Quality of Life - Dignity dated August 2011: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .Staff will knock and request permission before entering resident's rooms .Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice . On 6/13/23 from 11:40 AM to 12:04 PM, Certified Nursing Assistant (CNA 'C') was observed entering in and out of multiple resident rooms without knocking, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00131873. Based on observation, interview and record review, the facility failed to accommodate the needs of one (R40) of four residents reviewed for preferences/accommodation of needs. Findings include: On 6/13/23 at 11:00 AM, an interview was conducted with R40 at bedside. R40 was asked about the small circular assist rail to the right side of the bed and reported they had that installed for a few weeks and wanted another one put on the other (left) side but was told it was a state rule and both couldn't be placed. They reported they felt it would be very helpful in repositioning themselves in bed and attempting to gain some strength in their upper extremities. On 6/14/23 at 12:35 PM, R40 was asked about their ability to move both upper extremities and reported although they were not as strong as they wanted, due to arthritis, they were able to move both arms to reach to both the left and right side of the bed. Review of the clinical record revealed R40 was admitted into the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number: MI00133441 and MI00137478. Based on observation, interview, and record review, the facility failed to ensure medications were prepared, administered, and documented according to professional nursing standards of practice for three (R63, R238, and R586) residents reviewed for medications. Findings include: On 6/13/23 at 11:12 AM, R63 came to the hallway and asked why they had not received their morning medications yet. R63 reported they typically received their morning medications by 9:00 AM. R63 explained they were deaf and had a cochlear implant and they were able to read lips. On 6/13/23 at approximately 11:15 AM, R63's Medication Administration Record (MAR) revealed R63's 9:00 AM medications had been signed out as administered by Nurse 'A'. On 6/13/23 at 11:25 AM, Nurse 'A' entered R63's room. R63 asked the nurse why they had not received their medication. Nurse 'A' explained they would be right back because they had to get something. On 6/13/23 at 11:32 AM, Nurse 'A'…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake # MI00131482. Based on observation, interview and record review, the facility failed to provide timely incontinence care for one (R40) of three residents reviewed for bowel and bladder incontinence, resulting in discomfort and potential skin breakdown when they had to wait an extended period of time in a urine soaked brief. Findings include: Review of complaints reported to the State Agency included an allegation that residents were being left wet and/or soiled for extended periods of time. According to the facility's policy titled, Urinary Continence and Incontinence - Assessment and Management dated October 2010: .Management of incontinence will follow relevant clinical guidelines . On 6/13/23 at 11:00 AM, an interview was conducted with R40 at their bedside. At that time, R40 was wearing a hospital gown, had a stack of towels on top of the bed and reported they were hoping to get their brief changed, get dressed and washed-up soon. On 6/13/23 at 12:15 PM, R40 remained in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure consistent weights were obtained per facility policy for one resident (R60) of two residents reviewed for nutrition. Findings include: R60 was recently re-admitted to the facility on [DATE]. R60 was initially admitted to the facility on [DATE]. R60 was recently hospitalized on [DATE] and readmitted back to the facility. R60's admitting diagnoses included sepsis, decubitus ulcer (pressure ulcer) on the sacrum, acute respiratory failure, and history of stroke. Based on the MDS (Minimum Data Set) assessment dated [DATE], R60 was non-verbal and had severe cognitive impairment. R60 was totally dependent on staff assistance with their Activities of Daily Living (ADL). An initial observation was completed on 6/13/23, at approximately, 11:50 AM. R60's room door had signage that revealed they were on transmission-based (contact) precautions. R60 was observed in their bed with their eyes closed. R60 was receiving oxygen via nasal canula.…

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 continuous supplemental oxygen as prescribed by the physician (R8) and ensure that a physician order was in place for supplemental oxygen provided to (R59) for two of three residents reviewed for respiratory care. Findings include: R8 On 6/13/23 at 10:52 AM, an observation was made of R8's room. An Oxygen concentrator was observed on and running at 2L (liters), the tubing was observed wrapped together in front of the concentrator. R8 was not in their room. At 11:04 AM, R8 was observed in the common area propelling themselves around in their wheelchair. A portable oxygen cylinder was observed on the back of the wheelchair but was not on nor was the nasal cannula tubing attached to the resident. The tubing was wrapped inside of a plastic bag attached to their wheelchair. There was no oxygen being provided to R8. At this time an interview was attempted. R8 repetitively complained about pain in their right arm. 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.

Based on observation, interview, and record review the facility failed to ensure medications had the appropriate indication for use for one (R59) of five residents reviewed for the medication regimen review. Findings include: Review of the physician order and June 2023 Medication Administration Record (MAR) documented the following order, . Gabapentin Capsule 300 MG (milligram), Give 1 capsule by mouth three times a day for ANTICONVULSANTS . Review of the medical diagnoses revealed no diagnosis of a seizure disorder or convulsant disorder. On 6/15/23 at 9:28 AM, the Director of Nursing (DON) was interviewed and asked why R59's Gabapentin indication for use was documented as an Anticonvulsant when R59 did not have a medical diagnosis of convulsions or a seizure disorder, the DON then started looking into their computer system and through R59's medical record. The DON then stated in part . Why did they put that? That's not the correct diagnosis for that. She has nerve pain and that is what she takes it for . Review of the monthly pharmacist reviews dated 8/24/22, 9/6/22, 10/3/22,…

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 #MI00133441. Based on observation, interview, and record review, the facility failed to lock the medication cabinet for one (R63) resident. Findings include: On 6/13/23 at 11:40 AM, Nurse 'A' left R63's room and left the medication cabinet in the room unlocked and they keys in the key hole. Nurse 'A' left the room and went to another unit to the medication room. When Nurse 'A' went to open the medication room, they realized they did not have their keys. Upon return to R63's room, Nurse 'B' was standing outside the room and handed Nurse 'A' their keys. Nurse 'A' reported she should have locked the cabinet and took the keys with her. Review of a facility policy titled, .During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to timely provide laboratory services to two (R' 59 & 21) of two resident reviewed for laboratory services. Findings include: On 6/13/23 at 11:31 AM, R59 was observed lying on their back in bed. Upon interview, R59 stated they had pain in their stomach and . feels like my bladder is falling out of me . R59 explained that the nurses took their urine yesterday (6/12/23) however something happened to the urine and the resident stated they would have to provide the nurses with another sample. When asked what happened to their urine, R59 stated they were unsure on what happened. R59 stated they are supposed to have their labs drawn today and hopefully they can find out what is going on with them. Review of the medical record revealed R59 was admitted to the facility on [DATE] with diagnoses that included: chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia and chronic kidney disease. A Minimum Data Set (MDS)…

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.