Harmony Village of Clawson

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to protect residents personal privacy for two (R1 and R5) of two residents reviewed for privacy. Findings include: On 3/18/25 at 9:44 AM, R1 and R5, roommates, were observed sleeping in their beds. The privacy curtain between the beds was observed to only have the mesh top part attached to the ceiling track, the bottom, solid part, which provides privacy was gone. On 3/18/25 at 10:11 AM, R1 was observed sitting in their wheelchair in the room. R5 was observed sleeping in their bed. R1 was asked about the missing privacy curtain. R1 explained it had been removed to clean it. When asked how long it had not been there, R1 explained it had been off for a while. R1 was asked about privacy when getting dressed or changed. R1 explained staff would close the door to the hall. Review of the clinical record revealed R1 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: heart disease, dementia and anxiety…

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 maintain a clean, comfortable, homelike environment for one (R44) of nine residents reviewed for environment. Findings include: On 3/18/25 at 10:00 AM, R44 was observed lying in bed sleeping. R44 was observed to have closely cut hair of uniform length. On 3/18/25 at 12:03 PM, R44 was again observed lying in bed sleeping. R44 was dressed, had a mechanical lift sling positioned under them. A bottle of shampoo/body wash was observed on the windowsill. The head of the bed was elevated and on the floor, under the head of the bed was a pile of hair, approximately four inches in diameter. Review of the clinical record revealed R44 was admitted into the facility on 5/5/22 and readmitted [DATE] with diagnoses that included: metabolic encephalopathy, vascular dementia and anxiety disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R44 had severely impaired cognition and required the assistance of staff for activities of daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review the facility failed to transcribe medication orders correctly from the hospital resulting in one resident (R10) missing prescribed dosages of antibiotic medication (a medication used to treat infection). Findings include: On 3/18/25 at 10:10 AM, R10 was observed in bed. When R10 was asked how their stay at the facility was, the residents was not coherent. A review of R10's medical record revealed that the Brief Interview for Mental Status score (BIMS) completed on 3/3/25 was a 00, which indicated severe impaired cognition. A further review of the record showed that R10 was admitted to the facility initially on 7/15/2019 with the diagnosis of vascular dementia, history of falling and aphasia. Additional review of R10 record revealed that, they were admitted to the hospital on [DATE] for a fall and pain to the lower extremity and discharged from the hospital on 2/20/25 back to the facility. With in the discharge instruction paperwork R10 was to receive an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Change in Condition level one screening Form DCH (Department of Community Health/3877) was submitted to the local Community Mental Health Services Program (CMHSP) for a level two OBRA (Omnibus Budget Reconciliation Act) evaluation upon a change in the resident's condition for one (R61) of two residents reviewed for Preadmission Screening/Annual Resident Review (PASARR). Findings include: Review of the clinical record revealed R61 was admitted into the facility on 1/7/23 and readmitted on [DATE] with a new diagnosis of schizophrenia. According to the Minimum Data Set (MDS) assessment dated [DATE], R61 scored a 15/15 on the Brief Interview for Mental Status (BIMS) exam which indicated intact cognition. The schizophrenia diagnoses was not included in section I of the MDS assessment. Review of R61's physician orders included an order with a start date of 1/31/25 for Seroquel (an antipsychotic medication) oral tablet 50 MG (Milligrams) - give 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 interview and record review the facility failed to ensure a Preadmission Screening/Annual Resident Review (PASARR) was submitted and completed by the local community mental health agency after the 30 day exemption period for one (R8) of two residents reviewed for PASARR screenings. Findings include: Review of the clinical record revealed R8 was admitted into the facility on 1/3/25 with diagnoses that included: schizoaffective disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R8 had intact cognition and had a psychiatric diagnosis of schizophrenia. Review of the initial 3877 form dated 1/3/25 revealed the screening section for questions 1-3 were marked with an X for Yes for mental illness. The section to explain any Yes read, .Patient qualified for exemption. Diagnosed with schizophrenia. Patient is prescribed Seroquel. The 3878 form completed at the hospital identified on 1/3/25, R8 had a hospital exempted discharge (which meant the hospital anticipated R8 to be in the nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure diagnostic practices met professional standards for one (R61) of two residents reviewed for psychotropic medications when R61 received a new diagnosis of schizophrenia. Findings include: Review of the clinical record revealed R61 was admitted into the facility on 1/7/23 and readmitted on [DATE] with a new diagnosis of schizophrenia. According to the Minimum Data Set (MDS) assessment dated [DATE], R61 scored a 15/15 on the Brief Interview for Mental Status (BIMS) exam which indicated intact cognition. The schizophrenia diagnoses was not included in section I of the MDS assessment. Documentation also identified the resident had received antipsychotic, antianxiety, and antidepressant medication. Review of R61's physician orders included an order with a start date of 1/31/25 for Seroquel (an antipsychotic medication) oral tablet 50 MG (Milligrams) - give 1 tablet by mouth every 12 hours for schizophrenia. Review of the most recent psych provider…

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 implement effective timely interventions for wounds and complete accurate assessments for one resident (R4) of two residents reviewed for Pressure Ulcers. Findings include: On 3/18/25 at approximately 11:40 a.m., R4 was observed in their room, laying in their bed. R4 was queried if they had any concerns regarding their care and they reported they had a bed sore that hurt. R4 was observed to be laying flat on their back in their bed without any off loading wedges or pillows provided to them. On 3/19/25 at approximately 8:50 a.m., R4 was observed in their room, up in their bed. R4 was queried if any staff had applied any zinc barrier ointment on him the previous day or that morning and they reported they had not and that the staff could not find it. R4 was observed laying on the bed without any off loading devices, pillows or wedges. R4 indicated they still had pain due to their bed sore. On 3/18/25 medical record for R4 was reviewed and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure an environment free from accident hazards for two (R28 and R61) of five residents reviewed for accidents. Findings include: R28 On 3/18/25 at 10:00 AM, R28 was observed seated in a wheelchair next to their bed with oxygen actively in use via nasal cannula. The resident reported they were on oxygen continuously for difficulty breathing. At that time, a large container of petroleum jelly was observed on their overbed tray table. On 3/19/25 at 8:36 AM, R28 was observed seated in wheelchair outside room with oxygen actively in use via nasal cannula. The container of petroleum jelly remained on the overbed tray table next to the bed. R61 On 3/18/25 at 9:44 AM, and 3/19/25 at 8:41 AM, observation of R61's room revealed there were multiple bottles stored on top of the window sill, including a bottle of Microban Bathroom Cleaner. On 3/19/25 at 9:32 AM, an interview was conducted with the Regional Director of Operations (RDO 'A') who was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medically-related social services to address mental health needs and patient advocacy/guardianship for one (R61) of three residents reviewed for social services. Findings include: Review of the clinical record revealed R61 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, cognitive communication deficit, other impulse disorders, and unspecified mood disorder and a new diagnosis of schizophrenia. According to the profile information in the electronic medical record, R61's spouse had legal guardianship. However, review of the available guardianship documentation revealed that had expired on [DATE]. According to the Minimum Data Set (MDS) assessment dated [DATE], R61 scored a 15/15 on the Brief Interview for Mental Status (BIMS) exam which indicated intact cognition. Documentation also identified…

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 irregularities identified by the consultant pharmacist were available for review to identify what the irregularity was and the physician response to the irregularities for one (R61) of five residents reviewed for monthly medication regimen reviews. Findings include: Review of the clinical record revealed R61 was admitted into the facility on 1/7/23 and readmitted on [DATE] with diagnoses that included: unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, cognitive communication deficit, other impulse disorders, and unspecified mood disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R61 had intact cognition with a Brief Interveiw for Mental Status (BIMS) score was 15, receives an antipsychotic, antianxiety and antidepressant medication and had not had a gradual dose reduction (GDR-although he did). Review of R61's monthly medication regimen reviews (MRR) from April 2024…

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 treatment/medication was secured for two residents (R19 and R37) of two residents reviewed for medication labeling and storage. Findings include: On 3/18/25 at approximately 9:14 a.m., R19 was observed in their room, laying in their bed. a prescribed Dermarite periguard ointment was observed unsecured on a bedside table with R37's name on it along with the pharmacy label. On 3/19/25 at approximately 10:45 a.m., R19 was observed in their room, laying in their bed. R19 was still observed with the Dermarite periguard ointment on the bedside table with R37's name on it along with the pharmacy label. On 3/19/25 at approximately 3:46 p.m., R19 was observed in their room, laying in their bed. R19 was still observed with the Dermarite periguard ointment on the bedside table with R37's name on it along with the pharmacy label. On 3/19/25 at approximately 3:48 p.m., Nurse H was informed of the medication/treatment being unsecured with R37's name on it, in R19's room. Nurse H was observed going into the room and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a Physician ordered laboratory (lab) diagnostic was completed for one residents ( R58) of two residents reviewed for diagnostics. Findings include: On 3/18/25 the medical record for R58 was reviewed and revealed the following: R58 was initially admitted to the facility on [DATE] and had diagnoses including Subdural Hemorrhage and Dementia. A Physician order dated 3/6/25 revealed the following: CBC (complete blood count) with Diff (differential), CMP (comprehensive metabolic panel), HA1C (blood glucose), PSA (Prostate-specific antigen), Lipid panel, Vitamin D level, Keppra levels, Diagnoses: HTN (Hypertension), BPH (benign prostatic hyperplasia), Seizure, HLD (Hyperlipidemia), Generalize Weakness, History of Falling- Please Draw. Further review of the medical record revealed no results from the labs ordered on 3/6/25. On 3/20/25 at approximately 1:08 p.m., Unit Manger Nurse V (UM V) was queried regarding R58's missing lab results. UM V was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate and updated wound care evaluations/treatments were present in the medical record for one resident (R14) of one residents reviewed for accurate medical records resulting in the potential for misidentification/inappropriate wound care treatments. Findings include: On 3/18/25 at approximately 9:05 a.m., R14 was observed in their room, laying in their bed. R14 was queried if they had any concerns regarding their care in the facility and they reported that they had a sore on their leg that was not healing. On 3/18/25 the medical record for R14 was reviewed and revealed the following: R14 was initially admitted to the facility on [DATE] and had diagnoses including Congestive heart failure and Chronic obstructive pulmonary disease. A wound evaluation completed by Medical Provider W (MP W) dated 2/11/25 revealed the following: Wound Orders .Wound #6 Right, Posterior Thigh .Wound Cleansing-Normal Saline-Or Wound cleanser/pH balanced cleanser.…

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: MI00149343. Based on interview and record reviews the facility failed to ensure sufficient staffing was provided for multiple residents that resided on the second floor of the facility, approximately 43 out of a total census of approximately 68 residents, resulting in the potential for unmet care needs. Findings include: Review of a complaint submitted to the State Agency (SA) documented in part . (facility name) has many residents who have mental, physical, cognitive and intellectual impairments. A lot of residents are elderly and on hospice . (facility name) is very understaffed. There are not enough staff members to care for the residents. Many residents have fallen because there aren't enough staff members to assist residents when mobilizing . Residents need to be fed, and some are not fed timely because of staffing issues . There are very heavy residents that cannot be moved due to the lack of staff. This results in residents being left in the bed and urinating on themselves . the facility is short staffed during the midnight shift . On 2/18/25…

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: MI00149372. Based on interview and record review, the facility failed to follow the facility's grievance policy and follow up on concerns from a family member for one (R901) of three residents reviewed for resident rights. Findings include: A review of a complaint submitted to the State Agency (SA) documented in part . On Christmas day, the family gathered and waited with excitement for (R901)'s scheduled arrival of 1 PM . at 2 PM (R901) had yet to arrive. A family member then contacted the nursing home to get an ETA (estimated time of arrival) and was informed that he was not coming . The family member was told that because (R901) required a Geri chair for transport, an unknown nurse would not allow him to leave the facility. There are concerns that (R901) was treated unfairly due to his limited mobility . A review of R901's medical record revealed R901 was admitted to the facility on [DATE] with diagnoses that included: dementia, contractures of the left & right knee and 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(s): MI00146628, MI00146773, MI00146696 Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from verbal abuse and physical abuse by a resident for four (R605, R606, R611, and R609) of 12 residents reviewed for abuse, resulting in R605 being slapped by R606 after R605 called R606 a derogatory name, R605 being pushed by R611 after R605 called R611 a derogatory name, and R609 being hit with a shoe by R610. Findings include: A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) revealed an allegation that R606 slapped R605 on 8/15/24. On 11/12/24 and 11/13/24, an unannounced investigation was conducted onsite at the facility. A review of R605's clinical record revealed R605 was admitted into the facility on 2/24/23, readmitted on [DATE], and discharged on 10/24/24 with diagnoses that included: dementia, traumatic brain injury, bipolar disorder, and post traumatic stress disorder (PTSD). A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to thoroughly investigate an allegation of resident to resident physical abuse for two (R605 and R608) of 12 residents reviewed for abuse. Findings include: A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) revealed R608 alleged R605 hit her in the head on 8/16/24. On 11/12/24 at 10:50 AM, an interview was attempted with R608. R608 was difficult to understand and did not want to talk. A review of R608's clinical record revealed R608 was admitted into the facility on 8/7/13 and readmitted on [DATE] with diagnoses that included: Multiple Sclerosis. A review of R608's Minimum Data Set (MDS) assessment dated [DATE] revealed R608 had intact cognition with no behaviors. A review of R608's progress notes revealed a Nursing Progress Note dated 8/18/24 that read, Resident came to nursing station and told assigned nurse that another resident punched her in the head two days ago . This note was written by Licensed Practical Nurse…

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 implement care planned interventions for bed mobility and toileting and develop a care plan to address combative behaviors and hearing deficits for one (R601) of seven residents reviewed for accidents, resulting in a skin tear to the left hand. Findings include: A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) on 8/5/24 revealed an allegation that a man twisted R601's arm on 8/3/24. The alleged perpetrator was noted to be Certified Nursing Assistant (CNA) 'H'. On 11/12/24 at 9:50 AM and 10:55 AM, R601 was observed sleeping. At 10:55 AM, R601's roommate was interviewed and they reported R601 yells a lot. A review of R601's clinical record revealed R601 was admitted into the facility on 6/29/18 and readmitted on [DATE] with diagnoses that included: metabolic encephalopathy, macular degeneration, and dementia. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R601 had severely impaired…

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: MI00146570 Based on observation, interview, and record review, facility failed to provide supervision needed for one (R607) of five residents reviewed for with elopement. This deficient practice resulted in R607 with severe cognitive impairment exiting the facility unbeknownst to facility staff with potential for serious injury from the resident being outside and unsupervised, with access to a five a lane road. R607 Record review revealed R607 was a long-term resident of the facility, originally admitted to the facility on [DATE]. R607's admitting diagnoses included dementia, mood disturbance, anxiety, stroke, muscle weakness, history falls, and malnutrition. Based on the Minimum Data Set (MDS) assessment dated [DATE], R607 had a Brief Interview for Mental Status (BIMS) score of 6/15, indicative of severe cognitive impairment. R607 needed staff assistance with their mobility and Activities of Daily Living (ADLs) such as bathing, dressing, etc. due to their physical and cognitive…

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 MI00145934 Based on observation, interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when failing to report a black eye of unknown source and failed to report information accurately regarding an ankle fracture to the State Agency (SA) for two (R405 and R403) of three residents reviewed for injuries of unknown source. Findings include: Review of a facility policy titled, Abuse, Neglect and Exploitation revised 6/2023 read in part, .Possible indicators of abuse include, but are not limited to: .2. Physical marks such as bruises or patterned appearances such as a handprint, belt or ring mark on a resident's body 3. Physical injury of a resident, of unknown source . Investigations may include but not limited to: .6. Providing complete and thorough documentation of the investigation . R405 On 8/12/24 at 11:21 AM, R405 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: MI00145315. Based on interview and record review the facility failed to ensure the required documentation for the transfer of one (R401) of one resident reviewed for a facility transfer, was noted in the medical record. Findings include: Review of a complaint submitted to the State Agency (SA) documented in part . we chose to move (R401) to a BETTER rehab facility so that she could actually receive care . and BE SAFE . We had to stand with (Facility name) staff at the main desk to ensure that they actually faxed documents over to (another facility name) for the transfer . That took about 2 hours for them to confirm that the documents did actually send. If we hadn't been present daily at (facility name) to monitor (R401) she would have wound back up in the hospital due to lack of care . Review of the medical record revealed R401 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, acute kidney failure, hypertension, atrial…

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: MI00145315. Based on interview and record reviews the facility failed to ensure a medication ordered by the physician was obtained and administered for one (R401) of three residents reviewed for quality of care. Findings include: Review of a complaint submitted to the State Agency (SA) documented concerns of R401's care upon admission to the facility. Review of the medical record revealed R401 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, acute kidney failure, hypertension, atrial fibrillation and severe sepsis. R401 required staff assistance for all Activities of Daily Living (ADLs). The resident was transferred to another facility five days later. Review of the hospital documents provided to the facility upon admission noted an order for Acetylcysteine (Mucomyst 10%) 200 Milligrams (mg) Nebulized Inhalation twice a day. Review of the physician orders implemented at the facility noted on 6/6/24, Acetylcysteine 200…

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(s): MI00145225. Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident resulting in R605, who had a history of aggressive and agitated behavior, pushing one (R606) of six residents reviewed for abuse to the ground and hitting their head, sustaining a laceration, and being transferred to the hospital. Findings include: A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) revealed there was a resident to resident physical abuse incident between R605 and R606 on 6/12/24. On 6/25/24 at 10:10 AM, R606 was observed seated on the side of their bed. They were pleasant, but were unable to participate in an interview. On 6/25/24 at approximately 10:15 AM, R605 was observed walking up and down the hallway on the unit. A review of R606's clinical record revealed the following: A progress note dated 6/12/24 at 6:04 PM, written by Licensed Practical Nurse…

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(s): MI00145225. Based on observation, interview, and record review, the facility failed to report an injury of unknown origin to the Administrator in a timely manner and to the State Agency for one (R608) of six residents reviewed for abuse. Findings include: On 6/25/24 at 10:10 AM, R608 was observed walking quickly up and down the hallway. R608 stopped in the doorway of another resident's room and that resident yelled, Hey! You can't come in here!. R608 had two black eyes and a bruise on their forehead. When addressed, R608 did not respond to questions and continued to walk quickly down the hallway. On 6/25/24 at 10:37 AM, any incident reports with associated investigations for R608 for the month of June 2024 were requested from the Administrator. A review of R608's clinical record revealed R608 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: dementia and violent behavior. A review of a Minimum Data Set (MDS) assessment…

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(s): MI00145225. Based on observation, interview, and record review, the facility failed to thoroughly investigate an injury of unknown origin to rule out abuse for one (R608) of six residents reviewed for abuse. Findings include: On 6/25/24 at 10:10 AM, R608 was observed walking quickly up and down the hallway. R608 stopped in the doorway of another resident's room and that resident yelled, Hey! You can't come in here!. R608 had two black eyes and a bruise on their forehead. When addressed, R608 did not respond to questions and continued to walk quickly down the hallway. On 6/25/24 at 10:37 AM, any incident reports with associated investigations for R608 for the month of June 2024 were requested from the Administrator. A review of R608's clinical record revealed R608 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: dementia and violent behavior. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R608 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.

This citation pertains to Intake # MI00144190 Based on observation, interview, and record review, the facility failed to provide ongoing facility sponsored individual activities for one (R604) of one resident reviewed for activities, resulting in the potential for feelings of isolation, depressingly impacting physical, mental, and psychosocial well-being. Findings Include: A complaint was filed with the State Agency that alleged the resident does not have any activities to keep them occupied. Clinical record review revealed that R604 was admitted to this facility on 6/22/23 with a diagnosis of nontraumatic subdural hemorrhage (bleeding in the brain), dementia, receptive-expressive language disorder, and bilateral upper and lower contractures (permanent shortening and tightening of the muscles) which requires full assistance with all activities of daily living. A Brief Interview for Mental Status (BIMS) score assessed on 6/7/24 totaled 0/15 indicating R604 had severe impaired cognition. Further record review from the care plan revealed R604 is nonverbal, enjoys listening to music,…

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 #MI00143854 Based on interview and record review the facility failed to ensure an environment free from sexual abuse for two cognitively impaired residents (R49 and R75) lacking the ability to consent for physical intimacy of six residents reviewed for abuse/neglect/mistreatment. Findings include: On 4/15/24 a facility reported incident (FRI) submitted to the State Agency was reviewed which indicated that on 3/26/24 R75 had wandered into R49's room and was found by staff without any clothes on with R49 in the bed and without any clothes on. Both residents were alleged to be incapacitated with court appointed-legal guardians. R49 On 4/15/24 at approximately 9:23 a.m., R49 was observed in their room, laying in their bed. R49 was queried if they remembered the incident with R75 and they reported they did and that R75 had walked into their room and took their clothes off and got into bed with them. R49 indicated that R75 was trying to touch them everywhere and that R49 had 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.

This citation pertains to intake #MI00143854 Based on interview and record review the facility failed to submit their abuse investigation within the mandatory five business day time-frame for two residents (R49 and R75) of six residents reviewed for abuse. Findings include: On 4/15/24 a facility reported incident (FRI) submitted to the State Agency on 3/26/24 was reviewed which indicated that on 3/26/24, R75 had gone into R49's room and was found by staff without any clothes on with R49 in the bed and without any clothes on. Both residents were alleged to be incapacitated with court appointed-legal guardians. A review of the facility investigation pertaining to the incident between R49 and R75 on 3/26/24 was reviewed and revealed the following: Investigative Summary/Actions Taken: Reportable Event- On March 26th, 2024, Abuse Coordinator was informed by facility staff that resident [R75] had been found with [R49], a male resident, in his room. Both residents were undressed and laying together in his bed, holding one another. [R75]was dressed and removed from the male resident's room…

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 #MI00142062, MI00139621 Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable, and homelike living environment for 18 residents (R1, R8, R10, R19, R24, R26, R28, R31, R38, R47, R60, R87, R96, R98, R204, R252, R256 and R504) and seven of seven anonymous residents who attended the resident council interview. This had the potential to affect all 99 residents who resided in the facility. Findings include: On 2/12/24 at 8:30 AM until 2/14/24 at approximately 10:00 AM, the hall floor leading to the therapy gym was observed with dried white/yellowish crystallized footprints on the right and left side of the hall. It was unknown what substance would have produced the soiled footprints. It was further noted the hallway had a faint urine odor. On 2/12/24 between 9:43 AM and 9:52 AM, an observation of the second floor unit was conducted. The following was observed: Upon exiting the elevator onto the second floor of the facility, a strong odor of urine was detected. R19's room was observed with a dirty unmopped…

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 an ongoing activities program for five (R32, R47, R86, R93, and R98) of five residents reviewed for activities, seven of seven residents who attended the confidential resident council interview, and six additional residents (R50, R94, R75, R57, R84, R1) resulting in behaviors, expression of boredom, and diminished quality of life. This had the potential to affect all 99 residents who resided in the facility. Findings include: On 2/12/24 between 9:51 AM and 11:22 AM, the following observations were made of the 2 North Unit. R47 wandered aimlessly in the hallway of the unit, into the dining room, and at times walked through the dining room and entered the 2 South Unit which was on the other side of the dining room. R47 rambled nonsensically. R47 grabbed plastic cups from the dining room and disposable gloves and put them in her room. R47 was observed folding clothing on their roommate's bed and getting into their roommate's space.…

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 MI00138924, MI00139621, MI00142062, and MI00142469 Based on observation, interview, and record review, the facility failed to ensure there was sufficient nursing staff for the residents on the second floor to address wandering residents, residents who required toileting assistance, and residents with dementia and behaviors for seven (R32, R47, R75, R86, R57, R84, and R1) residents reviewed for staffing , resulting in incontinence, negative resident to resident interactions, residents wandering into potentially unsafe areas, and poor infection control. This had the potential to affect all residents who resided on the second floor. Findings include: R32 On 2/12/24 at 10:39 AM, R32 was observed self propelling in a wheelchair on the hallway of the 2 North Unit. No staff were visible on the unit at that time. R32 stated, Where is everyone? I have to go to the bathroom really badly. Please take me!! When queried if she had been taken to the bathroom yet that morning, R32 reported…

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 #MI00138924, MI00140002, and MI00140828. Based on observation, interview, and record review, the facility failed to provide meals that were palatable and attractive, resulting in resident food complaints and dissatisfaction with the meals provided. Findings include: On 2/12/24 at approximately 8:45 AM, there was a covered pan of cooked zucchini observed on the stove top. When queried, Dietary Manager (DM) U stated that the cooked zucchini was for the lunch meal. On 2/12/24 at 11:30 AM, the same pan of cooked zucchini was observed on the steam table for the lunch meal service. The texture of the zucchini was soft and mushy, and pale in color. On 2/12/24 at 12:30 PM, a lunch test tray was obtained. The cooked zucchini was watery, mushy and bland in taste. In addition, the pureed zucchini was sampled. The texture of the puree was gelatinous, slimy, and was a pale yellowish green color. The pureed zucchini was tasted and was quite bland and flavorless. When plated, the dollop of pureed zucchini spread out onto the plate, and did not hold any shape. It…

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 2/12/24 between 8:45 AM-9:15 AM, during an initial tour of the kitchen with Dietary Manager (DM) U, the following items were observed: The paper towel dispenser at the handwashing sink was empty. According to the 2017 FDA Food Code section 6-301.12 Hand Drying Provision, Each handwashing sink or group of adjacent handwashing sinks shall be provided with: (A) Individual, disposable towels;. The filter for the ice machine had a date of installation of 1/6/23. The filter noted replace 6 months after install. In addition, there was an accumulation of dust on the side vents of the ice machine. DM U was queried about the ice machine filter and cleaning, and stated that Maintenance was responsible for both. On 2/12/24 at 10:30 AM, Maintenance Supervisor V was queried about the cleaning of the ice machines and the filter replacements. Maintenance…

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

Based on interview, and record review, the facility failed to ensure the facility was administered in a manner that maintains the safety and care of residents so residents may reach their highest practicable physical, mental, and psychosocial well-being for all 99 residents who reside at the facility, resulting in quality care not being provided to residents, an un-homelike environment, no ongoing program of meaningful activities, inadequate staffing to meet resident's needs, palatable food being not being served, food not served under sanitary conditions, and ineffective infection control and antibiotic stewardship programs. Findings include: On 2/15/24 at 10:34 AM, an interview was conducted with the facility's Administrator regarding systemic failures identified during the survey. The Administrator was asked who was responsible for identifying and addressing systemic failures and indicated the Quality Assurance team and the Administrator were responsible. They were then asked why systemic failures were identified and said it was probably attributed to the building having three…

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 establish an effective Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) plan that identified system issues that resulted in sub-standard quality of care. This deficient practice had the potential to affect all 99 residents in the facility. A review of a facility provided policy titled, Quality Assurance and Performance Improvement revised 10/2022 was conducted and read, Policy: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive data driven Quality Assurance Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life . On 2/15/24 at 10:34 AM, an interview was conducted with the facility's Administrator regarding various systemic failures identified during the survey. The Administrator was asked who was responsible for identifying and identifying systemic failures, developing improvement plans, and reviewing and revising the plans and they said said the Quality Assurance team 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.

This citation has two deficient practices. Deficient Practice #1 Based on interview and record review, the facility failed to have an active plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all of the 99 residents in the facility. Findings include: On 2/13/24 at 12:45 PM, review of the facility's Water Safety Plan dated 4/10/23 noted the following deficiencies: 1. There was no water safety team designated in the water safety plan. The plan noted The Water Safety Team shall consider environmental testing for Legionella to validate that the growth and spread of Legionella is controlled within the building water systems, however no team had been designated. 2. The water safety plan noted, Routinely clean/disinfect or inspect the following system components: Backflow prevention- Annually, Ice Machine- Monthly. Review of the backflow…

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 maintain an effective Antibiotic Stewardship program that included consistent implementation of protocols to ensure that an antibiotic is prescribed for the correct indication, dose, and duration to appropriately treat infection for one resident (R21) of one resident reviewed for antibiotic medications. Findings include: On 2/14/24 at 10:04 AM, a record review of the facility Infection Control Antibiotic Line List from January 2024 revealed R21 was ordered: Bactrim DS Tab 800-160 milligram (mg) 1 tab every 12 hours for a bacterial infection for 7 days start 1/13/24. Record review of the Medical Administration Record (MAR) documented the following: 1/13/24 medication not adminstered, 1/14/24 one of two doses scheduled administered, 1/20/24 one of two doses scheduled admisitered. This documentation revealed the resident did not receive two doses daily for seven days as ordered. Further record review confirmed R21 did not receive the total amount of prescribed antibiotic and there was no documentation to justify the type of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #'s MI00138924, MI00140828 and MI00142062 Based on observation, interview, and record review, the facility failed to ensure treatment in a dignified manner for two residents (R#'s 257 and R29) of eight residents reviewed for dignity. Findings include: A review of a facility provided policy titled Resident Rights revised 8/2021 was reviewed and read, .4. Respect and dignity. The resident has a right to be treated with respect and dignity . R257 On 2/14/24 at 12:08 PM, R257 was observed sitting in their wheelchair in the hallway. R257 was small in stature and appeared to weigh less than 110 pounds. R257 was dressed in an oversized bariatric hospital gown that exposed their chest and was pulled up on their right leg exposing their right upper thigh to their groin area. At that time, they were asked if they wanted to be dressed and said they would like to but didn't have any clothing. With R257's permission, an observation of their closet revealed a red t-shirt and a pair of gray…

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 R19 and R36 Review of a FRI submitted to the State Agency revealed on 1/22/24 alleged R19 hit R36 in the stomach. On 2/12/24 at 10:25 AM, R19 was observed lying in bed. R19 appeared disheveled. When queried about any issues he had with other residents in the facility, R19 pointed in the direction of his roommate and reported he did not like that he turned on the air conditioning. When queried about whether he had been in any fights with any other residents in the facility, R19 denied any fights and stated, Do you mean at the other facility?. On 2/12/24 at 11:36 AM, R36 was observed lying in bed. When queried about any issues he had with other residents in the facility, R36 stated, I was assaulted two times by R19 who was a previous roommate. R36 stated, He (R19) spit on me. He aimed for my face and it landed on my shoulder. Then he punched me in the stomach and rib cage. Another time he punched me in my legs. R36 reported he told the staff about the incidents. Review of R19's clinical record revealed R19 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #'s MI00139287,MI00141773, and MI00141879, MI00142355. Based on interview, and record review, the facility failed to thoroughly investigate allegations and instances of abuse for nine residents (R#'s 93 86, 83, 352, 35, 50, 74, 92, and 552) of 28 residents reviewed for abuse investigations. Findings include: Multiple intakes were received by the State Agency that alleged abuse. A review of a facility provided policy titled, Abuse, Neglect and Exploitation revised 6/2023 was conducted and read, .V. Investigation. A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; .6. Providing complete and thorough documentation of the investigation . R86 and R93 On 2/12/24 at 4:12 PM, an interview was conducted with R93 in their room.…

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 MI00139089, MI00140275, MI00142584 Based on observation, interview, and record review, the facility failed to provide adequate supervision for six (R37, R47, R84, R86, R302, and R505) of 11 residents reviewed for accidents, four of seven residents who wished to remain anonymous who attended the resident council group interview, and one (R1) additional resident, resulting in resident to resident altercations and negative interactions, falls, poor infection control, residents feeling unsafe, invasion of privacy, and wandering into potentially unsafe spaces. Findings include: R47 On 2/12/24 at 9:51 AM, an observation was made of R47 wandering aimlessly in the hallway of the 2 North unit, into the dining room, and at times walked through the dining room and entered the 2 South Unit which was on the other side of the dining room. R47 rambled nonsensically, removed plastic cups from the dining room and disposable gloves and placed them in her room. R47 was observed folding clothing…

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

Based on interview and record review the Facility failed to ensure that the regular in-service/training and competency evaluations based on performance review every 12 months for the 8 Certified Nursing Assistants (CNA) (N, Q, T, LL, MM, OO, PP and RR) resulting in the potential for unmet resident care needs. Findings include: On 2/14/24 and 2/15/24 facility was requested to provide the annual competency evaluations for the for the following staff members: 1. CNA N: Date of Hire (DOH) - 04/20/22 2. CNA T: DOH - 10/8/12 3. CNA LL: DOH - 12/10/20 4. CNA MM: DOH - 9/24/20 5. CNA Q: DOH -10/11/04 6. CNA OO: DOH - 11/8/04 7. CNA PP: DOH - 11/5/90 8. CNA RR: DOH - 3/10/21 Facility administration provided the copies of completed training transcripts for 5 of the requested staff that did not meet the 12 hours of annual training requirements for Certified Nursing Assistants. The facility provided documents titled Certified Nurse Aide Competency Check List for CNAs LL, MM, Q, OO, N, PP, and T that were completed between 2/5/24 and 2/8/24. These evaluations were not based on employment date 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.

Based on observation and interview the facility failed to ensure appropriate medication storage for one of three medication rooms and one of six medication carts resulting in the potential for unauthorized access to medication storage areas. Findings include: On 2/13/24 at 10:11 AM, the 1 north medication cart was left unlocked. Unit Manger I walked passed the cart and locked it. Unit Manger I was then interviewed and asked if the cart should be locked. She indicated it should. At that time, an observation of the contents of the cart was conducted and revealed an unopened vial of insulin. At that time, Unit Manager 'I' was asked how the insulin should be stored and said it should have been in the refrigerator. On 2/13/24 at 10:39 AM, the 2nd floor medication room was observed unlocked and Nurse EE was observed to enter the room without having to unlock the door. Nurse EE was interviewed and asked should the medication room be locked and Nurse EE replied, Yes, it should be. On 2/13/24 at 11:00 AM, an interview with the Director of Nursing (DON) was conducted and she was asked how…

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 an effective pest control program, resulting in gnats in R87's room and throughout the facility. Findings include: On 2/12/24 at 9:00 AM, numerous gnats were observed flying around in the main kitchen. There were 2 red, apple shaped plastic containers observed on the shelf behind the coffee machine. When queried, Dietary Manager (DM) U stated they were (non-professional) traps for the gnats. When queried about whether or not a professional pest control company had been out recently to provide services to eradicate the gnats, DM U stated he was unsure of the date they were last there. On 2/12/24 at 11:00 AM Maintenance Director V was queried about their pest control program, and stated he would have to look for any service reports they may have. On 2/12/24 at 1:00 PM, review of the pest control service reports provided, revealed the date of the last pest control service was 8/28/23. When queried at that time if there were any more current visits from the pest control company, Maintenance Supervisor V…

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 upon interview and record review, the facility failed to complete/document the 12-hour annual in-service training requirement for eight of eight Certified Nurse Assistant's (CNA) (CNAs N, Q, T, LL, MM, OO, PP and RR) reviewed for required training resulting in the potential for staff being unaware of best practice guidelines when caring for residents and provision of inadequate resident care. Findings include: On 2/14/24 a request was sent via e-mail for 5 staff members and on 2/15/24 surveyor provided a request in person to the facility Administrator for the staff members (CNAs) to provide the annual 12-hour training completion and transcripts. The facility provided transcripts for only 5 staff members that did not meet the annual 12 hrs. training requirement for all the staff. Facility provided transcript hours for the five staff members did not meet the 12-hour per year training requirement. The completed transcript hours for staff ranged from 0.75 hours to 6.5 hours. An interview was completed with the facility Administrator on 2/15/24, at approximately 9:15 AM.…

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

Based on interview and record review the facility failed to ensure visitation rights for one resident (R601) of one resident reviewed for visitation rights. Findings include: On 4/16/24 at 10:45 AM, a review of R601's closed clinical record was conducted and revealed they were cognitively intact and their own responsible party upon admission to a private room in the facility on 3/27/24 for sub-acute rehabilitation. A review of progress notes was conducted and revealed the following: A nursing note dated 4/7/24 at 10:10 PM, that read, .Resident had a visit from her significant other .Resident significant other was reminded of visiting hours of the facility due to his previous visiting times of coming after midnight and leaving near 4am <sic> .After midnight the nurse reminded the visitor that facility visiting hours resume tomorrow . A nursing note dated 4/9/24 at 11:17 PM, that read, .Resident's boyfriend arrived at facility and was notified that visiting hours were over around 9 p.m. Writer gave him a 10-minute curtsey <sic> visitation and made DON (Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00138924. Based on interview and record review the facility failed to ensure personal funds were readily accessible for one resident (R11), of one resident reviewed for personal funds resulting in the resident expressing anger and frustration of not having control over their personal funds. Findings include: On 2/13/24 at 10:30 AM during resident council, R11 said there is a problem with their funds since being transferred from a sister facility. R11 said since they transferred they had not received their monthly payment. R11 said the Business Office Manager (BOM) and Administrator had been trying to work on it, and stated, it's held up in the other facility. A record review revealed that R11 was admitted to the facility on [DATE] from a sister facility with a diagnosis of cerebral palsy, brief psychotic disorder and muscle weakness. R11 scored 14/15 on the Brief Interview for Mental Status indicating intact cognition. On 2/14/24 at 9:43 AM, R11 was interviewed about 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 an environment free from physical restraints for one resident, (R70) of one resident reviewed for restraints resulting in the likelihood for physical discomfort and psychosocial distress utilizing the reasonable person concept. R70 was originally admitted on [DATE] from another skilled nursing facility for long term care. R70's admitting diagnoses included: protein calorie malnutrition, dementia, contracture of both knees, history of falls and suicidal ideations. Based on the Minimum Data Set (MDS) assessment dated [DATE], R70 had Brief Interview for Mental Status (BIMS) score of 3/15, indicative of severe cognitive impairment. R70 needed 2-person assistance with their mobility/repositioning in bed, 1-person assist with eating, and 2-person assist for transfers to their Geri (recliner with wheels) chair. R70 was able to answer simple yes/no questions with cues. An initial observation was completed on 2/12/24, at approximately 8:30…

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 allegations of abuse and injuries of unknown origin were reported to the State Agency in a timely manner for four residents (R2, R22, R37 and R44) of 31 residents reviewed for abuse/neglect/mistreatment. Findings include: R2 and R37 On 2/13/24 a facility reported investigation (FRI) was reviewed that as initially reported to the State Agency on 6/21/23 that indicated an allegation that R2 had a resident altercation with R37 on 6/13/23. On 2/13/24 the medical records for R2 and R37 were reviewed and revealed the following: R2 was initially admitted to the facility on [DATE] and had diagnoses including Paranoid schizophrenia and Restlessness and Agitation. R37 was initially admitted to the facility on [DATE] and had diagnoses including Dementia and Psychotic disorder with delusions. A review of the facility reported investigation pertaining to the altercation between R37 and R2 that was submitted to the State Agency on 6/21/23 and took…

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 #MI00139436 Based on interview and record review the facility failed to document an involuntary discharge, notify the ombudsman and allow the resident to stay at the facility through the appeals process for one (R503) of one residents reviewed for involuntary discharge. Findings include: The unanimous complainant alleged that the resident was given an involuntary discharge without an appeal and forced to leave the facility. It should be noted that an attempt was made to contact the resident named in the complaint however the phone number on file in the electronic record for R503 was not in service. On 2/13/24 at 12:13 PM an interview was conducted with social services advocate D. When asked why R503 was issued an involuntary discharge they stated that the resident could care for themselves, was independent, and ultimately no longer met criteria. Additionally Social Services Advocate D stated that there was an incident with another resident (no additional details were provided regarding this incident) and R503 was no longer happy at the facility,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure a comprehensive plan of care was revised and modified to reflect a resident centered and individualized behavior plan of care for one (R57) of ten residents reviewed for accidents/supervision. Findings include: On 2/12/24 at 10:10 AM, R57 was observed in their room sitting on a chair with the overhead bed table in front of them. The resident was facing down to the floor and did not lift their head to make eye contact with the surveyor. A limited interview was conducted at that time. After the interview the resident began to sing loudly as the surveyor exited the room. On 2/13/24 at 10:58 AM, R57 was observed attempting to drop themselves to the floor in the hallway, yelling profanities as three staff members held them up and attempted to deescalate R57's behavior by offering the resident snacks and putting on music for the resident to listen to. Review of the medical record revealed R57 was admitted to the facility on [DATE],…

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 MI00142029 and MI00142062 Based on observation, interview and record review the facility failed to ensure appropriate Nursing standards were utilized for two residents (R28 and R38) of two residents reviewed for Medication administration. Findings include: R28 On 12/12/24 the medical record for R28 was reviewed and revealed the following: R28 was initially admitted to the facility on [DATE] and had diagnoses including dementia, adult failure to thrive and encounter for palliative care. A Physicians order with a start date of 11/8/23 revealed the following: Ativan Tablet 1 MG (milligram) (LORazepam) Give 1 tablet by mouth two times a day for anxiety-D/C (discontinued) Date 02/12/2024 1933. A second Physicians order dated 11/22/23 revealed the following: Morphine Sulfate Oral Solution 20 MG/5ML (Morphine Sulfate) *Controlled Drug* Give 0.25 ml (milliliters) by mouth every 2 hours as needed for pain/sob (shortness of breath). A review of R28's comprehensive plan of care revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #'s MI00139621 and MI00142062. Based on observation, interview, and record review, the facility failed to ensure activities of daily living (ADLs) showers and baths were provided to one (R18) of five Residents reviewed for ADL care with potential for negative physical, psychosocial outcomes, and loss of dignity for residents who are dependent on staff for assistance. Findings include: R18 was originally admitted to the facility after a hospitalization on 9/20/23. R18's admitting diagnoses included heart failure, lymphedema, morbid obesity, spinal stenosis, chronic respiratory failure, adjustment disorder with depressed mood, and osteoarthritis of bilateral knee. Based on a Minimum Data Set (MDS) assessment dated [DATE], R18 had Brief Interview for Mental Status (BIMS) score of 15/15, indicative of intact cognition. An initial observation was completed on 2/12/24 at approximately 9:40 AM. R18 was observed sitting in their wheelchair next to their bed. R18 had a facility provided…

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 There are two deficient practices. Deficient Practice Statement #1 This citation pertains to intake #'s MI00142170 and MI00142532. Based on interview and record review the facility failed to address a change in condition timely for one resident (R502) of one resident reviewed for a change in condition resulting in a delay of acute care treatment. Findings include: Review of a complaint submitted to the State Agency (SA) allegation of R502's change of condition to not have been timely identified and assessed. The medical record for R502 was reviewed and revealed the following: R502 was initially admitted to the facility on [DATE] with diagnoses that included: anxiety and manic depression. A review of R502's minimum data set (MDS) dated [DATE] revealed R502 had a Brief Interview for Mental Status (BIMS) score of fifteen, indicating R502 had intact cognition. A record review revealed [DATE] a progress note was written by licensed practical nurse (LPN) I that stated Writer reached out to (family member XX) due 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 that resident weights were obtained timely and nutritional interventions by the dietician were implemented timely for two (R70 and R82) of seven residents reviewed for nutrition resulting in the potential for weight loss with decline in nutritional and overall functional status. Findings include: A facility provided document titled Weight Monitoring with a revision date of 1/21 read in part, A comprehensive nutritional assessment will be completed upon admission on residents to identify those at risk for unplanned weight loss/gain or compromised nutritional status. Assessments should include the following information: a. General appearance (e.g., robust, thin, obese, or cachectic) b. Height c. Weight d. Food and fluid intake e. Fluid loss or retention f. Laboratory/Diagnostic Evaluation Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan 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 facility failed to appropriately position the resident while administering the enteral tube feeding (liquid nourishment and water administered directly into the stomach through a PEG [Percutaneous Endoscopic Gastrostomy] tube) for one (R4) of two residents reviewed for tube feeding resulting in the potential of aspiration pneumonia, respiratory distress and rehospitalization. Findings include: R4 was admitted to the facility on [DATE] after hospitalization. R4's admitting diagnoses included post-polio syndrome, colitis (inflammation of the colon), malnutrition, Gastro-esophageal Reflux Disease (GERD), and dysphagia (difficulty swallowing). Based on the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7/15, indicative of significant cognitive impairment. An observation was completed on 2/12/24 at approximately 11:15 AM. During this observation R4 was observed in their bed lying on their back with head of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement a resident centered care plan regarding dialysis care and failed to ensure consistent ongoing communication with the dialysis entity for one (R6) of one resident reviewed for dialysis. Findings include: On 2/13/24 at 8:15 AM, R6 was observed sitting in their wheelchair at the doorway of their room, a limited interview was conducted at that time. Shortly after, R6 was observed from the hallway, sitting on their bed, with their shirt removed and a PICC (Peripherally inserted central catheter) line observed in the chest area. Review of the medical record revealed R6 was initially admitted to the facility on [DATE], with a readmission date of 12/14/23 and diagnoses that included end stage renal disease and dependence of renal dialysis. R6 required staff assistance for all Activities of Daily Living (ADLs). Review of the medical record revealed multiple incomplete and missing communication forms between the dialysis center and 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 irregularities identified by the pharmacist was reviewed by the physician for two (R's 25 & 20) of five residents reviewed for the pharmacist drug regimen review. Findings include: Review of a facility policy titled Medication Regimen Review revised 3/22 documented in part, . The pharmacist shall document . the nature of any identified irregularities . the attending physician has documented a valid clinical rational for rejecting the pharmacist's recommendation . The pharmacist shall communicate any irregularities to the facility . Written communication to the attending physician, the facility's Medical Director, and the Director of Nursing . Written communications from the pharmacist shall become a permanent part of the resident's medical record . R25 On 2/12/24 at 9:48 AM, R25 was observed lying on their back in bed sleeping. The resident continued to sleep and did not awake with verbal stimuli. Review of the medical record…

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 accurate administration and indication for use of an antibiotic medication for one resident (R21) of five residents reviewed for unnecessary medication resulting in the potential for adverse side effects and antibiotic resistance. Findings include: A Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed R21 was admitted the facility on 7/15/23 with diagnoses of non-traumatic brain dysfunction, hypertension, dementia, and a seizure disorder. Their Brief Interview for Mental Status (BIMS) totaled 7, indicating severe impaired cognition. On 2/14/24 at 10:04 AM, a record review revealed R21 was ordered: Bactrim DS Tab 800-160 milligram (mg) (antibiotic medication) 1 tab every 12 hours for bacterial infection for 7 days starting on 1/13/24. Record review of the Medical Administration Record (MAR) documented the following: 1/13 medication not administered, 1/14 one of two doses scheduled administered, 1/20 one of two doses scheduled…

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 a medication error rate of less than five percent. Six medication errors were observed from a total of 29 opportunities for four out of five residents (R38, R69, R82, R62) resulting in an error rate of 20.69%. Findings include: R38 On 2/13/24 at 8:56 AM, Licensed Practical Nurse (LPN) AA was observed preparing the morning medications for administration to R38. LPN AA retrieved one vial of Lantus from R38's medication compartment, and it was identified there was no open date for the insulin. LPN AA contacted a physician by phone. LPN AA stated that the physician instructed to use another resident's Lantus for R38's dose until the order was refilled. LPN AA said they didn't think they could do this and attempted to locate another vial of Lantus within the medication cart and stock room. Upon return, LPN AA indicated there was no Lantus. Medication administration observation continued for R38's morning administration. LPN AA indicated ordered Flonase (allergy relief nasal spray) and GenTeal ophthalmic…

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 timely laboratory services as ordered by the physician for one (R18) of one resident reviewed for laboratory services. Findings include: R18 was originally admitted to the facility after hospitalization on 9/20/23. R18's admitting diagnoses included heart failure, lymphedema, morbid obesity, spinal stenosis, chronic respiratory failure, adjustment disorder with depressed mood, and osteoarthritis of bilateral knee. Based on the Minimum Data Set (MDS) assessment dated [DATE], R18 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicative of an intact cognition. An initial observation was completed on 2/12/24 at approximately 9:40 AM. R18 was observed sitting in their wheelchair next to their bed. During this observation an interview with R18 was completed. During the interview R18 reported that they were not getting the care they needed at the facility. When queried further on their concerns R18 reported that 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 interview and record review, the facility failed to implement their policy and ensure accurate education, tracking and administration of the pneumococcal vaccine for one (R38) of five residents reviewed for the pneumococcal vaccination. Findings include: On 2/14/24, A review of the clinical record revealed R38 was admitted to the facility in September 2023, and most recently re-admitted [DATE] with diagnoses that included: diabetes, hypertension, alcoholism, and right leg amputation. Minimum Data Set (MDS) dated [DATE] 4 revealed a Brief Interview for Mental Status (BIMS) of 15/15, indicating intact cognition. R38's Vaccination status was reviewed in the medical record and documentation indicated R38 did not receive the pneumonia vaccine. A record review of vaccination consent for R38 was provided by Registered Nurse DD, the facilities infection control lead. The consent for R38 revealed R38 consented to receive the pneumococcal vaccine on 9/25/23. Further review of the consent showed handwritten…

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(s): MI00138696. Based on interview and record review, the facility failed to provide basic life support (BLS), including cardiopulmonary resuscitation (CPR - a life saving procedure used during cardiac arrest when the heart stops beating), in a manner that met professional standards of practice for one (R801) of three residents reviewed for CPR. Findings include: Review of a complaint submitted to the State Agency on [DATE] revealed allegations that when police officers arrived at the facility on [DATE], CPR was in progress by facility staff. The back board was not placed under R801 properly, the oxygen connected to the bag valve mask was not turned on, and the automated external defibrillator (AED - a medical device that analyzes the heart's rhythm to determine if an electrical shock is needed. If it is needed, the device is used to help the heart re-establish an effective rhythm). An onsite, unannounced investigation was conducted at the facility from [DATE] through…

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 #: MI001138621, MI00138744 Based on observations, interviews, and record review, the facility failed to ensure activities of daily living (ADLs) showers and baths were provided to one (R803) of two Residents reviewed for ADL care with potential for negative physical and psychosocial outcomes, and potential loss of dignity for residents who are dependent on staff for assistance. Findings include: R803 was admitted to the facility on [DATE]. R803's admitting diagnoses included osteoarthritis, severe obesity, depression, and chronic obstructive pulmonary disease (COPD). R803 had Brief Interview for Mental Status (BIMS) of 15/15, indicative of intact cognition. R803 needed staff assistance with their activities of daily living (ADL). An initial observation was completed on 8/16/23 at 10:05 AM. R803 was observed in their bed. During this observation an interview was completed. R803 reported they needed staff assistance with their ADLs and showers. R803 reported that they 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.