The Laurels of Coldwater

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake 2604669 Based on observation, interview, and record review, the facility failed to ensure one resident (R1) of three reviewed was free from the use of a physical restraint. Findings include:Review of the facility reported incident revealed staff applied a sheet to [R1's] wheelchair (restraint) putting resident at risk for potential harm. Review of the medical record revealed R1 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included alcohol dependence with alcohol induced persisting dementia, pathological fracture of pelvis, wedge compression fracture of vertebra, and anxiety disorder. Review of the Brief Interview for Mental Status (BIMS-a cognitive screening tool) dated 8/22/25 revealed R1 scored 7 out of 15 indicating severe cognitive impairment. R1 sustained multiple falls while in the facility. On 8/29/25 at 9:52 AM, R1 was observed in bed with a staff member providing one on one supervision. In a telephone interview on 8/28/25 at 10:32 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 observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 130 residents, resulting in the increased likelihood for cross contamination and bacterial harborage.Findings include: On 07/23/2025 at 10:05 A.M., A common area environmental tour was conducted with Environmental Services Director (ESD) M. The following issues were noted: A-Hall Nursing Station: Two 12-inch-wide by 12-inch-long vinyl flooring tiles were observed (etched, scored, particulate). The concrete flooring sub-surface was also observed exposed through the worn vinyl tiles. (ESD) M indicated she would contact maintenance for necessary repairs as soon as possible. Restroom: The hand sink faucet assembly was observed loose-to-mount. (ESD) M indicated she would contact maintenance for necessary repairs as soon as possible. Lounge: The courtyard entrance/exit door threshold was observed with an air gap. The gap between the metal threshold plate and door slab measured approximately 0.5 - 1.0-inches-deep by 36-inches-long. The metal door frame…

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, record reviews, and 6 (9, 23, 52, 57, 82, 124) of 26 sampled residents, the facility failed to provide palatable food products effecting 126 residents who consume food, resulting in the increased potential for resident decreased food acceptance and nutritional decline. Findings include:R57: Review of the medical record reflected R57 admitted to the facility on [DATE], with diagnoses that included muscle weakness and moderate protein-calorie malnutrition. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/14/25, reflected 57 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 07/22/2025 at 9:48 AM, R57 was observed in bed, eating a bowl of cereal. R57 reported the facility's food was not good, and they had not had a hot meal or cold glass of milk since admitting to the facility. R82: Review of the medical record reflected R82 admitted to the facility on [DATE] and readmitted…

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 advanced directives were listed correctly on one (R44) of one resident investigated for advanced directives.Findings Include:Resident #44 (R44)Review of the medical record reflected that R44 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Diagnoses of respiratory failure, dementia, lung cancer, chronic obstructive pulmonary disease, anxiety, depression and psychosis. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/30/2025 revealed R44 had a Brief Interview of Mental Status (BIMS) of 13 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R44 is independent for care and needs minimal assistant with set up.On 07/21/2025 at 3:21 PM, R44 had a DNR in her electronic Medical Record (EMR) signed and dated 11/23/24. The face sheet also called the banner did not reveal R44 as a DNR, it had full code for advanced directives. 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 observation, interview and record review the facility failed to ensure appropriate monitoring for two residents (R7, R82) receiving psychotropic medications. Findings include:Review of the medical record reflected R7 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included vascular dementia and hypotension due to drugs. Review of the Physician orders revealed an active order for Seroquel Oral Tablet (an antipsychotic), give 25 milligrams by mouth one time a day for Dementia with mood disturbance. Review of Physician orders revealed an active order which stated to monitor for psychotropic medication side effects, including orthostatic hypotension (sudden drop of blood pressure with position change). Review of the Physician order revealed no order for orthostatic blood pressure readings. Review of the vitals tab on the electronic medical record revealed no orthostatic blood pressures had been documented. In an interview on 7/24/2025 at 10:22 AM, Director of Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure one out of 26 residents (Resident #130) care plan was revised. Findings Included:Per the facility face sheet Resident #130 (R130) was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of Physician's orders revealed an order for, [NAME] boot (boots that are puffed up to prevent heels from coming in touch with the bed surface) to bilateral (both) feet while guest is in bed, every shift for Skin integrity., dated 2/11/2025.Review of R130's care plans revealed a care plan in place for, (R130) at risk for impaired skin integrity/pressure injury R/T (related to): decreased mobility, Dx (diagnoses): Alzheimer's Dementia, Anemia, DM (diabetes), HTN (high blood pressure), Bipolar, Mood d/o (disorder), Impaired cognition, Incontinence bladder and bowel, Psychotropic drug use, and protein calorie malnutrition. The care plan was created on 10/14/2021, initiated on 9/17/23, and revised on 2/11/25, however, the [NAME] boots were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure follow-up on monthly pharmacy medication regimen reviews for one (R82) of five reviewed.Findings include: Review of the medical record reflected R82 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included type 2 diabetes, unspecified protein-calorie malnutrition, schizoaffective disorder, major depressive disorder and anxiety. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/8/25, reflected R82 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R82's monthly pharmacy medication regimen reviews reflected to see the report for any noted irregularities and/or recommendations for 1/31/25. Upon further review of R82's medical record, their pharmacy review report for 1/31/25 was not noted. An email was sent to Nursing Home Administrator (NHA) A on 07/23/2025 at 4:03 PM, to request R82's pharmacy review report for…

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

Based on observation, interview, and record review the facility failed to ensure one out of six medication carts was locked while unattended. Findings Included:On 07/23/2025 at 11:15 AM, a medication cart on the 100 hall was observed to be left unattended and unlocked. no nurse was observed to be in the area; several residents were in the area wandering around. It was not until 11: 21 AM that License Practical Nurse (LPN) K walked up to med cart. LPN K did not notice the medication cart was unlocked so was then informed that the medication cart was unlocked. LPN K then locked the cart and stated that she went to use the restroom and forgot to lock it. Review of the facility's policy and procedure Medication/Treatment Cart Use dated 8/15/2023, revealed, The medication/treatment cart and its storage bins are kept locked until the specified time of medication/treatment administration, In an interview on 7/24/2025 at 10:51 AM, Director of Nursing DON B stated that leaving the medication cart unlocked was not the facility's standard of practice. DON B said the staff were not to do that,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This is related to MI00148888 Based on observation, interview and record review the facility failed to immediately report abuse allegations for one resident (R203) of two reviewed for abuse, resulting in allegations of abuse that were not reported to the Nursing Home Administrator (NHA) and the State Agency timely and the potential for further allegations of abuse to go unreported. Findings include: A review of intake MI00148888 submitted to the state agency revealed in part: What allegedly occurred: On the evening of 11/26/2024, (LPN G) was attempting to assist resident (R203) in his room on the memory care unit. (CNA K) was present. LPN G entered the room and told (R203) she needed to take care of his bloody nose, he had at the time. (CNA K) states that (LPN G) raised her voice when she informed (R203) and walked towards him. (R203) told (LPN G) Stay away from me! Several times. (R203) then yelled, Get the f*ck out of my room! (CNA K) reports (R203) grabbed (LPN G)s arms. (LPN G) then grabbed (R203)s arms and…

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

Based on observation, interview, and record review, the facility failed to maintain clean equipment, resulting in the potential for an increased risk of foodborne illness, affecting all residents that consume food from the kitchen. Findings include: During an observation in the kitchen on 8/20/24 at 9:38 AM numerous fruit flies were observed near the handwashing sink and dishwasher. The A dining room kitchenette was observed on 8/21/24 at 10:38 AM. The floors were sticky, and brown liquid stains were noted on the countertop. The sink was soiled and had excessive hard water buildup on the faucet. The cupboards near the sink were soiled and sticky. Under the sink the bottom of the cupboard was warped and buckled from water damage. The portable steam table pans were observed with water and food debris in all three pans. The plate warmer was observed with food debris. Food trays were observed stored on a folding chair across from the steam table. Fruit flies were noted near the sink. The B dining room kitchenette was observed on 8/21/24 at 10:52 AM. The portable steam table pans were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a clean and homelike environment in eight out of 24 resident rooms, a resident lounge, and a resident TV/reading area resulting in un-cleanliness of resident living areas. Findings Included: During a tour on 8/20/2024 at 11:30 AM, R31's room was entered. It was noted that the floor next to bed B had three towels on the floor, and a strong foul smelling odor was noted. R31, who resided in bed B, stated that she had accidents (urinary incontinence) on the floor. R31 said housekeeping had already been in and cleaned her room, but did not pick up the towels or clean the floor. R31 stated she has the accidents frequently. On 8/21/2024 at 11:45 AM, R31's room was observed to have multiple flies, more than a dozen, in the room and several over R31's mattress. The mattress was observed to be stained from what R31 stated was urine and lymph fluid (a clear-yellowish fluid that can leak from the skin) drainage, an odor that was strong and not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to report an allegation of abuse (bruise of unknown origin) to the State Agency for one Resident (#106) of two Residents reviewed for abuse. Findings Included: Resident #106 (R106) Review of the medical record revealed R106 was admitted to the facility 05/17/2024 with diagnoses that included cerebral vascular accident (stroke), atrial fibrillation, dysphagia (difficulty swallowing), Hemiplegia (paralysis) of the left side, hypertension, hyperlipidemia (high fat content in blood), depression, seizures, and cognitive communication deficit. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/25/2024, revealed R106's Brief Interview of Mental Status (BIMS) was 00 (severe cognitive impairment) out of 15. During observation and attempted interview on 08/20/2024 at 10:28 a.m. R106 was observed lying in bed. R106 did not verbally respond to verbal questions. During a telephone interview on 08/20/2024 R106's family…

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 investigate, implement preventive measures, and take corrective action for an allegation of abuse (bruise of unknown origin) for one Resident (#106) out of two Residents reviewed for abuse. Findings Included: Resident #106 (R106) Review of the medical record revealed R106 was admitted to the facility 05/17/2024 with diagnoses that included cerebral vascular accident (stroke), atrial fibrillation, dysphagia (difficulty swallowing), Hemiplegia (paralysis) of the left side, hypertension, hyperlipidemia (high fat content in blood), depression, seizures, and cognitive communication deficit. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/25/2024, revealed R106's Brief Interview of Mental Status (BIMS) was 00 (severe cognitive impairment) out of 15. During observation and attempted interview on 08/20/2024 at 10:28 a.m. R106 was observed lying in bed. R106 did not verbally respond to verbal questions. During…

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 develop and implement the care plan, in 1 of 26 residents reviewed for care plans (Resident #24) resulting in unmet needs. Findings include: Resident #24 (R24) Review of the electronic medical record reflected R24 was admitted to the facility on [DATE] with diagnoses that included acquired absence of left leg below the knee, history of falling, acquired absence of right leg below the knee, need for assistance with personal care, and cognitive communication deficit. The Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 7/22/24, reflected that R24 scored a 15 out of 15 on the Brief Interview for Mental Status (cognitively intact). On 08/20/24 at 11:59 AM, R24 was observed in bed. During an interview attempt, R24 reported that he could not hear me. Despite multiple attempts at getting closer to the resident and speaking very loudly, R24 stated that he still could not hear me well enough to answer…

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 revise the Care Plan for two (Resident #68 and #88) of 26 reviewed for Care Plans. Findings include: Resident #68 (R68): Review of the medical record reflected R68 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included dependence on renal dialysis. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/21/24, reflected R68 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 08/22/24 at 11:00 AM, R68 was observed seated in a wheelchair. A clear dressing, dated 8/19/24, was visible near her right chest. R68's Care Plan reflected she received hemodialysis (process to filter blood for people with kidney failure) and had a right internal jugular cuffed catheter (used for hemodialysis access). During an interview on 08/22/24 at 10:08 AM, Certified Nurse Aide (CNA) P reported R68 had a dialysis access site in her chest,…

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 hygiene, grooming, and activities of daily living (ADL) needs were met for two of three residents reviewed (Residents #38 and #86). This resulted in the residents not receiving ADL care according to their individual preferences with the potential of feelings of shame or embarrassment and unmet care needs. Findings include: Resident #38 (R38) Review of the electronic medical record indicated that Resident #38 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the right dominant side, aphasia (difficulty speaking or understanding others), and reduced mobility. The [NAME] for Resident #38 revealed that the resident was dependent on one staff for bathing and grooming assistance. On 08/20/24 at 12:39 PM, Resident #38 was in bed watching television. The resident understood questions and was easily conversant. Resident #38 explained that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that two Residents (#24, #102) physician orders were followed and failed to provide an assessment/intervention for bowel constipation for one Resident (#27) out of 26 Residents reviewed for Quality of Care. Findings Included: Resident #27 (R27) Review of the medical record revealed R27 was most recently re-admitted to the facility 08/13/2024 with diagnoses that included bipolar disorder, left knee pain, dysphagia (difficulty swallowing), insomnia, left femur fracture, type 2 diabetes, morbid obesity, low back pain, hypertension, hyperlipidemia (high fat content in blood), gastro-esophageal esophagitis, and schizophrenia. R27's most recent completed Minimum Data set (MDS), with an Assessment Reference Date (ARD) of 07/14/2024, revealed a Brief Interview of Mental Status (BIMS) of 11 (moderate cognitive impairment) out of 15. During observation and interview on 08/20/2024 at 02:15 p.m. R27 was observed sitting up in her wheelchair, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to MI00138939. Based on observation and interview, the facility failed to maintain a clean, homelike environment, resulting in ceiling tiles with water damage and peeling, water damaged wallpaper. Findings include: During an observation on 10/26/23 at 9:25 AM, on the hallway for rooms 125 to 133, water damage was observed on a ceiling tile near the exit door to outside. On 10/26/23 at 10:24 AM, on the hallway for rooms 101-115, water damage was observed on a ceiling tile near the exit door to outside. During an observation on 10/26/23 at 11:08 AM, the secure unit was observed to have water damage on a ceiling tile near room [ROOM NUMBER]. Two ceiling tiles near room [ROOM NUMBER] were observed with water damage around a vent. Wallpaper was noted to be peeling above the exit door to outside, near rooms 482 ad 483. Four ceiling tiles were observed with water damage near rooms [ROOM NUMBERS]. Two ceiling tiles were observed with water damage around a vent, near room [ROOM NUMBER]. 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 MI00138939. Based on observation, interview and record review, the facility failed to report a resident elopement to the State Agency for one (Resident #6) of three reviewed for elopement, resulting in a resident elopement not being reported to the State Agency and the potential for further elopements not being reported. Findings include: Review of the medical record reflected Resident #6 (R6) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included dementia, bipolar disorder and repeated falls. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/16/23, reflected R6 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 10/30/23 at 9:39 AM, R6 was observed asleep, lying on her right side, in bed. During an interview on 10/30/23 at 9:34 AM, Certified Nurse Aide (CNA) F reported R6 slept a lot on day shift and did not wander or exit seek on day shift.…

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 MI00138939. Based on observation, interview and record review, the facility failed to ensure a resident elopement was thoroughly investigated for one (Resident #6) of three reviewed for elopement, resulting in the potential for resident elopements not being thoroughly investigated and the potential for further elopements to occur. Findings include: Review of the medical record reflected Resident #6 (R6) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included dementia, bipolar disorder and repeated falls. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/16/23, reflected R6 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 10/30/23 at 9:39 AM, R6 was observed asleep, lying on her right side, in bed. During an interview on 10/30/23 at 9:34 AM, Certified Nurse Aide (CNA) F reported R6 slept a lot on day shift and did not wander or exit seek on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to MI00138939. Based on observation, interview and record review, the facility failed to prevent an elopement for one (Resident #6) of three reviewed for elopement, resulting in the resident exiting the facility through an alarmed door, without staff knowledge, and being brought back into the facility by an unknown individual. Findings include: Review of the medical record reflected Resident #6 (R6) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included dementia, bipolar disorder and repeated falls. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/16/23, reflected R6 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 10/30/23 at 9:39 AM, R6 was observed asleep, lying on her right side, in bed. During an interview on 10/30/23 at 9:34 AM, Certified Nurse Aide (CNA) F reported R6 slept a lot on day shift and did not wander or exit seek on day…

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 MI00140174 and MI00140241. Based on observation, interview and record review, the facility failed to ensure food was palatable and served at an appetizing temperature, resulting in the potential for decreased food acceptance and nutritional decline for all residents that received food from the facility's kitchen. Findings include: On 10/26/23 at 9:59 AM, Resident #8 (R8) was queried on the taste and temperature of the food. R8 used a thumbs down gesture and asked if that was close enough. The facility's grievance log reflected R8 had a concern pertaining to cold food on 10/5/23. On 10/10/23 one resident had concerns pertaining to cold food and the taste of the food. An additional resident concern for 10/10/23 pertained to food temperature. A test tray from the main dining room was provided at the conclusion of resident room tray preparation, on 10/31/23 at 12:58 PM. The meal was provided on a tray, with a plate cover and plate warmer. Lids were on the beverage cup and jello bowl. The meal consisted of two chicken tenders, tater tots, a roll, vegetables…

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 MI00137838 and MI00135892. Based on observation, interview, and record review, the facility failed to revise the care plan in 5 of 25 residents reviewed for care plans (Resident #53, #57, #88, #140 & #144), resulting in unmet needs. Findings include: Resident #140 (R140) Discharge summary dated [DATE] at 12:00 AM indicated R140 had a history of depression, anxiety, and chronic back pain. R140 was admitted to the facility after hospitalization for a septic left hip joint and a spinal fusion, and finished a course of intravenous (IV) antibiotics. Social Services progress note indicated R140's Brief Interview for Mental Status (BIMS), a short cognitive screener was 15 (cognitively intact). Physician Progress Note dated [DATE] at 12:00 AM indicated R140 complained of popping in her right shoulder and pain with movement. R140's [DATE] Radiology Report revealed x-ray of the right shoulder indicated she had moderate degenerative joint disease (DJD) of the right shoulder. R140's Pain…

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 quality care and treatment services to 4 of 25 reviewed in sample (Resident #7, #19, #32, & #58), resulting in constipation (Resident #32), the potential for delayed wound healing (Resident #7 & 58), and low blood sugars (Resident #19). Resident #58 (R#58) During an observation and interview on 7/10/23 at 11:29 AM, R58 stated she had a sore on the back of her left thigh that was painful and would bleed at times; R58 had an open area that was approximately 4 centimeters in length and 3 cm in width and surface depth. R58's Minimum Data Set (MDS) with assessment reference date of 11/16/22 indicated she was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short performance based cognitive screener of 15 (13-15 Cognitively intact). The same MDS assessment revealed R58 did not reject care during the look-back period. Progress note dated 6/01/23 at 12:00 AM revealed R58 . still complains of raw areas…

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 completion of advance directive information for one (Resident #6) of one resident reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time) resulting in the potential for a resident's preferences for medical care to not be followed by the facility. Findings include: Review of the medical record revealed that Resident #6 (R6) was admitted to facility [DATE] with diagnoses including major depressive disorder, bipolar disorder, and anxiety disorder. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed that R6 had moderate difficulty hearing, was understood by others, and was usually able to understand others. Section C of the same MDS revealed that R6 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 10 (moderately impaired cognition). Review of R6's medical record completed with the following…

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

Based on observation, interview and record review the facility failed to report allegations of abuse for two residents (#117, #139) of 15 residents in the survey sample for abuse resulting in allegations of abuse not being reported to the State Agency and the potential for further allegations of abuse to go unreported and not thoroughly investigated. Findings Included: Resident #117 (R117) Review of the medical record revealed R117 was admitted to the facility 02/13/2023 with diagnoses that included multiple sclerosis, depression, protein-calorie deficiency, suicidal behavior, toxic encephalopathy (brain dysfunction caused by toxins), and dysphagia (difficulty swallowing). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/2023, revealed R117 had a Brief Interview for Mental Status (BIMS) of 12 (mildly impaired cognition) out of 15. Resident #139 (R139) Review of the medical record revealed R139 was admitted to the facility 01/23/2023 with diagnoses that included atrial fibrillation, chronic obstructive pulmonary disease (COPD), peptic ulcer…

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

Based on observation, interview, and record review, the facility failed to routinely complete thorough pressure ulcer assessments and documentation consistent with professional standards of practice for one resident (Resident #7) of 2 reviewed for pressure ulcer care, resulting in the potential for deterioration in wound and health status. Findings include: Review of the medical record revealed that Resident #7 (R7) was readmitted to facility on 7/18/22 with diagnoses including varicose veins of right lower extremity with ulcer of calf, varicose veins of right lower extremity with ulcer other part of foot, chronic peripheral venous insufficiency, type 2 diabetes mellitus, and lymphedema. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/5/23 revealed that R7 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 13 (cognitively intact). Section M of the same MDS indicated that R7 had one unstageable pressure injury that was present upon admission, one venous and arterial ulcer, and a diabetic foot ulcer. In an observation…

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 record review, the facility failed to ensure two Licensed Practical Nurses (LPN E and H), and one Registered Nurse (RN G) had specific competencies and skills necessary to meet resident needs, and failed to ensure two Certified Nurse Aides (CNA F, Q) had their required annual competency evaluation in skills and techniques necessary to care for residents, resulting in the potential for nursing staff to lack the necessary qualifications and training to adequately care for the needs of the residents with a facility census of 124. Findings include: Registered Nurse (RN) G, with an indicated date of hire of 1/25/23, personnel file reviewed and was not noted to include any competencies/skills check-off review. Certified Nurse Aide (CNA) F, with an indicated date of hire of 1/25/23, personnel file reviewed and was not noted to include any competencies/skill check-off review. Licensed Practical Nurse (LPN) H, with an indicated date of hire of 11/24/20, personnel file reviewed and was not noted to include any competencies/skill check-off review. LPN E, with an…

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

Based on observation, interview, and record review the facility failed to provide treatment and services for mental or psychosocial concerns for one resident (#57) with suicidal ideations of four residents reviewed resulting in the potential for adverse outcomes of a resident with suicidal ideations. Findings Included: Resident #57 (R57) Review of the medical record revealed R57 was admitted to the facility 01/20/2020 with diagnoses that included pain right shoulder, benign prostatic hyperplasia (enlarge prostate), dorsalgia (back pain) , trans ischemic attack, cerebral infarction (stroke), anxiety, type 2 diabetes, morbid obesity, atherosclerotic heart disease, hyperlipidemia (high fat content in blood), sleep apnea, atrial fibrillation, hypertension, gastro-esophageal reflux, and major depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/29/2023, revealed R57 had a Brief Interview for Mental Status (BIMS) of 13 (cognitively intact) out of 15. Section D00300 (mood-depression total severity score) of the MDS, with the same ARD, 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.

Based on observation, interview, and record review, the facility failed to; (1. label open multi-dose tuberculin vial with open date in 1 of 2 medication rooms; (2. ensure multi-dose insulin pens were dated upon opening in 1 of 3 medication carts and; (3. label open multi-dose prescription eye drops with open date in 1 of 3 medication carts reviewed for labeling, dating and expiration of medications. This deficient practice resulted in the potential for administration of expired medications and decreased therapeutic effects of administered medications, the potential for cross contamination, and medication errors in a current facility census of 124. Findings include: Medication vials should always be discarded whenever sterility is compromised or questionable. In addition, the United States Pharmacopeia (USP) General Chapter 797 [16] recommends the following for multi-dose vials of sterile pharmaceuticals: ?If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter…

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 obtain meet criteria to treat a urinary tract infection, in one of one resident reviewed for diagnosis of urinary tract infection (Resident #90), resulting in the potential for inappropriate antibiotic and treatment. Findings include: Resident #90 (R90) R90's Minimum Data Set (MDS) assessment with assessment reference dated of 6/23/23, revealed she admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 14 (13-15 Cognitively Intact). The same MDS revealed R90 had the diagnoses of end stage renal failure that required hemodialysis, anemia, heart failure, stroke, diabetes mellitus, anxiety and depression. Progress Note dated 7/07/23 at 7:42 AM revealed R90 had complained of nausea and received Zofran (antiemetic, prevent nausea and vomiting) before she went offsite for dialysis; the dialysis nurse notified the facility that they sent R90 to the hospital for 10/10 (pain…

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.