Imperial, A Villa Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that call lights were within reach for four residents (R71, R83, R86, and R115) of five reviewed for accomodation of resident needs. Findings include: Resident #86 (R86) On 2/24/25 at 8:10 AM, R86's call light was unable to be located in R86's room. R86 was interviewed about the location of their call light and was unsure of its location. On 2/25/25 at 12:41 PM, R86's call light was observed on the floor underneath the bed. Certified nursing assistant (CNA) F entered R86's room and was interviewed and asked where R86's call light was located. CNA F stated, It's right here and proceed to pick it up off of the floor and clipped it to R86's pillow. CNA F was further interviewed and asked where R86's call light should be located. CNA F indicated that [R86's] call light should be clipped to their pillow. A record review of R86's electronic medical record (EMR) revealed that R86 was most recently admitted to the facility on [DATE] with…

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: MI00149953 Based on observation, interview, and record review, the facility failed to ensure room furnishings were maintained for ten of ten resident rooms (416, 417, 418, 419, 420, 423, 425, 430, 436, and 440) on Unit D and one (R47) of one resident reviewed for homelike environment. Findings include: On 02/24/25 at 7:23 AM during the initial screening of residents the following was observed: The end cap for the hand rail at left side room of 418 was missing; In room [ROOM NUMBER], a piece of vertical trim approximately four feet long was missing off the left hand corner of the wall as the room is entered. The trim had been laid on the floor behind the door. In room [ROOM NUMBER] the baseboard heater cover was hanging down to the floor on right side behind bed one; In room [ROOM NUMBER] the cover was off the baseboard heater behind the head of both resident beds the entire length of the wall, the sheetrock at the left side of the window, had crumbled away. The window was open…

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 MI00149869. Based on observation, interview, and record review, the facility failed to provide dignity during care for one resident (R216) of three residents reviewed for dignity. Findings included: On 2/25/25 at 12:03 PM, R216 was observed lying in their bed awaiting staff to assist with getting dressed for the day. R216 stated ,I need to be changed, my brief and bed are wet due to my indwelling catheter (a tube inserted into the bladder) is leaking. R216 appeared tearful and stated that ,I am sitting here wet and I am late for therapy. It's not supposed to be like this. It makes me feel ashamed because I cant help myself. On 2/25/25 the medical record for R216 was reviewed and revealed R216 was admitted to the facility on [DATE] with the diagnoses of cerebral infarction with right sided weakness, depression, anxiety and diabetes mellitus. A review of the most recent minimum data set assessment (MDS) dated [DATE] noted a Brief Interview of Mental Status (BIMS) assessment is a 14…

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 properly assess one resident (R65) out of one reviewed for self administration of medications. Findings include: On 2/25/2025 at 2:02 PM, R65 was observed sitting in bed with two medicine cups in front of them. R65 was observed putting one pill in their mouth and then another. R65 was asked what they had just taken, and they responded, A gas pill and a pain pill. R65 stated the pain pill they had taken was Norco (Narcotic) and that they don't take it often because it makes them sleepy. No staff were noted to be in the room or surrounding the area by the room. R65 stated the staff usually just leave their pills with them because they know that they are going to take them. A review of the medical record revealed that R65 admitted into the facility on 3/21/2023 with the following diagnoses, Cerebral Palsy and Anxiety Disorder. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R65 also required staff assistance with bed mobility…

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: MI00149953 Based on observation, interview and record review, the facility failed to ensure a clean environment for one resident (R211 and R165) of 10 residents reviewed for home-like environment. Findings include: A review of the complaint submitted to the State Agency revealed the following, .The room that [R211] lives in is in poor condition. The heater is exposed and looks like it's falling apart. There is brown residue all over the ground under the bed . R211 On 2/24/25 at 7:30 AM, R211 was observed lying in bed, a tube feeding pole was observed as visibly soiled, with dried tube feed formula observed dried and caked to the floor. R211's bed was observed next to a heat vent that had a damaged base board exposing the coils. Attempts to interview R211 were unsuccessful, due to their cognition. A review of R211's medical record revealed they were admitted into the facility on 9/20/24 with diagnoses that included Cerebral Infarction and Gastronomy Status. Further review revealed they were severely cognitively impaired, and was total dependent 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 Based on observation, interview and record review, the facility failed to ensure the proper setting for a specialty mattress (low air loss) was maintained for one resident (R34) of three reviewed who had a specialty mattress. Findings include: On 02/24/25 at 12:23 PM, 02/25/25 at 8:36 AM and 12:18 PM and on 02/26/25 at 7:55 AM, R34 was observed to be supine in bed and dressed in a hospital style gown. R34 had a power unit for the specialty mattress hooked to the foot of the bed. The weight setting on the power unit was set at 400 pounds. R34 did not appear to weigh 400 pounds. R34 did not respond to queries about positioning or comfort. R34 was not observed to reposition themselves in bed. On 02/26/25 at 11:05 AM, R34 was observed to be supine in bed. The mattress setting on the power unit was observed with Unit Manager, Licensed Practical Nurse (LPN) I. The weight setting was observed to be at 400. LPN I acknowledged the weight setting was likely too high. LPN I consulted with the wound care staff and 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.

Based on observation, interview and record review, the facility failed to document interventions, and prevent the development of a pressure ulcer (damage to skin from prolonged pressure to skin), for one resident (R165), of four residents reviewed for pressure ulcers. Findings include: On 2/24/25 at 7:36 AM, R165 was observed asleep in bed. A positioning wedge was noted on the resident's left side, feet elevated with pillows. A review of R165's medical record revealed they were admitted into the facility 12/18/24 with diagnoses that included Anoxic Brain Damage, Chronic Obstructive Pulmonary Disease, and Dysphagia. Further review revealed that the resident was significantly cognitively impaired, and was totally dependent on staff for activities of daily living. Further review of R165's medical record revealed a Nursing Evaluation dated 12/19/24 documented the resident had a stage 2 pressure sore (Partial-thickness skin loss with exposed dermis) to their left buttock, left heel very dry and cracked, right heel very dry and cracked, and scar on their chest from prior surgery. Further…

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 resident inhalers were dated when open in two of six medication carts. Findings include: On 02/26/25 at 9:10 AM, the Unit C back cart was observed with Licensed Practical Nurse (LPN) J. A Breo Ellipta inhaler was not dated when opened on the inhaler and was without a resident identifier and an Incruse inhaler was not dated when opened and was without a resident identifier. LPN J acknowledged the inhalers did not have an open date. On 02/26/25 at 9:26 AM, the Unit C Front cart was observed with Licensed Practical Nurse (LPN) K. Two Trelegy inhalers were observed to not be dated when opened on the inhaler and were without a resident identifier and one Incruse inhaler did not have a resident identifier on the actual inhaler. LPN K reported an open date was required on the inhaler. A review of the policy titled Medication Storage in the Facility dated April 2018 revealed, .Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good…

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 personal protective equipment (PPE-gown, mask, gloves, etc.) was used for one covid positive resident (R577) out of one reviewed for isolation precautions. Findings include: On 2/26/2025 at 9:47 AM, R577's door was noted to have PPE on the outside, as well as a droplet and contact precaution sign. Nurse Practitioner (NP) D was observed to be in the room talking to R577, no PPE was noted to be on. A review of the medical record revealed R577 admitted into the facility on 2/18/2025 with the following medical diagnoses, Covid-19 and Muscle Weakness. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 13/15 indicating an intact cognition. R577 also required staff assistance with bed mobility and transfers. On 2/26/2024 at 9:48 AM, Licensed Practical Nurse (LPN) B was asked if R577 was positive for COVID-19. LPN B stated to their knowledge R577 was positive for covid and still required precautions. LPN B stated NP D should have put on their PPE prior to entering…

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 MI00144627. Based on observation, interview, and record review, the facility failed to serve food at the preferred temperature for one resident (R703) of two residents review for food palatability, resulting in dissatisfaction during meals. Findings include: A review of resident council meeting minutes for the months of March through May 2024 revealed the following, 3/22/24: Residents .stated the food that comes to the floor is cold when they receive it. (Food) cart sits for awhile trays not passed in a timely manner. 4/19/24: Residents stated food from dietary carts, the trays are lukewarm, food not hot . On 5/30/24 at 12:10 PM, R703 was interviewed and asked about food palatability at the facility. R703 indicated the food was frequently cold and stated, I don't eat it. R703 expressed dissatisfaction with the temperature of the food served to them and stated, My kids bring me food. On 5/30/24 at 12:20 PM, an observation was made of multiple staff passing out food trays to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intakes MI00142645 and MI00142751. Based on interview, and record review the facility failed to ensure adequate supervision for wandering behavior was provided for one (R701) of two residents reviewed for supervision, resulting in non consensual resident to resident sexual contact. Findings include: On 2/14/24 at 9:30 AM an incident and accident report (I/A) involving R700 and R701 dated 2/8/24 at 4:30 PM documented the following, Alleged sexual activity between male and female. Resident's were immediately separated, male resident was moved to a separate unit and was placed on a 1:1 (supervision) for safety pending investigation. Both residents denied any wrong doing and feel safe . Review of R700's electronic medical record (EMR) revealed that R700 was originally admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and Dementia. R700's most recent Minimum Data Set Assessment (MDS) dated [DATE] revealed that R700 had a severely impaired cognition. 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 On 12/11/23 at 9:35 AM, during the initial resident review: room [ROOM NUMBER] had wallpaper peeling under the toilet tissue dispenser and the silver tint of the mirror was worn off at the bottom, in room [ROOM NUMBER] the silver tint of the mirror was worn at the bottom and the hand rail end cap was missing at the left side of room [ROOM NUMBER] and the right side of the activity office. On 12/11/23 at 10:48 AM, room [ROOM NUMBER] had five are of tan splash/drips on the entry door, the soap dispenser was off the wall in the bathroom and the liquid soap refill had been left on the sink counter. On 12/11/23 at 4:01 PM, in room [ROOM NUMBER] a golf ball size hole was observed toward to base of the bathroom door, a black sticky build up was on the floor at the foot of bed one, multiple scrapes on the wall opposite bed two and behind the head of bed two and the cove base was missing on the wall behind head of the beds. On 12/12/23 at 8:37 AM, in room [ROOM NUMBER] the cover to baseboard heater under the window 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 observation, interview, and record review, the facility failed to provide facial grooming for three residents (R1, R95, and R115) out of five reviewed for Activities of Daily Living (ADL's). Findings Include: R1 On 12/13/2023 at 8:57 AM, R1 was observed in the dining room. R1 was noted to have extensive chin hair to their lip and chin. A review of the medical record revealed that R1 admitted into the facility on 3/2/2015 with the following diagnoses, Dementia and Anxiety Disorder. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 2/15 indicating an impaired cognition. R1 also required extensive one person assist with bed mobility and transfers. R95 On 12/13/2023 at 9:06 AM, R95 was observed in the dining room. R95 was noted to have extensive chin hair. A review of the medical record revealed that R95 admitted into the facility on 5/26/2020 with the following diagnoses, Dementia and Muscle Weakness. A review of the Minimum Data Set assessment revealed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a call light was in reach for one resident (R105) of three residents monitored for call light placement, resulting in the potential for unmet care needs and the need to ask their roommate to put on their call light when help was needed. Findings include: On 12/11/23 at 10:50 AM, R105 was observed to be in bed dressed in a hospital style gown. R105 was asked about their care and reported they did not like the food. R105 was asked about their call light and reported they did not have it and did not know where it was. The call cord and pressure pad were observed to hang over the lower bed frame at the head of the bed on the left side. The cord led back to the wall receptacle. The call light was visible on approach to the bed from the door. On 12/12/23 at 8:28 AM, R105 was observed to be in bed dressed in a hospital style gown. The head of the bed was up around 45 to 60 degrees and R105 leaned over toward the left side of the bed. 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.

Based on observation, interview and record review, the facility failed to ensure resident rights and preferences were being honored for one sampled resident (R85) of one resident reviewed for self-determination. Findings include: On 12/11/23 at 1:29 PM, R85 was observed lying in bed, and asked about their stay in the facility. R85 explained that they were hoping to discharge soon, but explained that they were frustrated with having to get back in bed after dialysis. R85 explained that they would prefer to sit up in a chair, and prop their legs up however, they were advised that the chair that they had been using for dialysis, needed to be used by another resident therefore, they were told they had to get back into bed. R85 explained that this also occurred last Friday. R85 appeared frustrated, and explained that as a result of not having a chair to sit in, they had to remain in bed until 6:00am the following morning when they went to dialysis again. A review of R85's medical record revealed that they were admitted into the facility on 6/7/23 with diagnoses that included Respiratory…

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 MI00138942. Based on interview and record review, the facility failed to update the careplan with an intervention following a fall for one resident (R427) out of five reviewed for falls. Findings Include: A review of Intake MI00138942 noted the following, .staff [R427] was taken to the shower room, and staff had left the room. [R427] fell out [their] wheelchair and hit [their] head. [R427] has two abrasions on [their] head and knees. [R427] was on the floor for 20 minutes before staff picked [them] up off the floor. A review of an Incident and Accident (IA) report revealed the following, Date: 8/7/2023 at 18:25 (6:25 PM). Incident Description: Nursing Description: Resident observed sitting on buttocks in front of w/c (Wheelchair) in shower room. Resident Description: Pt. (Patient) stated [they] slid out of [their] wheelchair. Further review of the care plan did not reveal an immediate intervention following the fall. A review of the medical record revealed that R427 admitted into…

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

This citation pertains to Intake MI00139471. Based on interview and record review the facility failed to administer medications in a timely manner for one resident (R426) out of one reviewed for medication administration. Findings include: A review of Intake called inot the State Agency noted the following, Resident was transferred from [Hospital] to [Facility] on Friday night 9-9:30 PM .admitted to facility due to blood infection, and to have IV (Intravenous) antibiotic for ten-day timeframe .Saturday, 9/16 afternoon, resident had not received [their] morning medication. A review of the medical record revealed that R426 admitted into the facility on 9/15/2023 with the following diagnoses, Dysphagia and Sepsis. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R426 also required extensive two person assist with bed mobility and transfers. Further review of the physician orders revealed the following orders: Ertapenem Sodium Injection Solution Reconstituted 1 GM (gram), Use 1 gram intravenously one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete care planned repositioning for three (R28, R30, R35) of three residents reviewed for pressure ulcer prevention/care. Findings include: R28 Review of the facility record for R28 revealed an admission date of 02/08/19 with diagnoses that included Multiple Sclerosis, Quadriplegia and Pressure Ulcer of the Right Buttocks, Unstageable. An additional diagnosis of Sacral/Sacrococcygeal Osteomyelitis is dated 11/28/23. The Minimum Data Set (MDS) assessment dated [DATE] indicated R28 was dependent for activities of daily living including bed mobility. The Brief Interview for Mental Status (BIMS) assessment score of 11/15 indicated Moderate cognitive impairment. On 12/11/23 at 12:00 PM, R28 was observed laying on their back in bed. R28 reported that they were receiving wound care treatment and that they could not recall whether or not they had pressure ulcers at the time that they were admitted to the facility. Additional review of R28's…

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 hand splinting as care planned for three (R8, R30, R123) of six residents reviewed for splinting. Findings include: R30 Review of the facility record for R30 revealed an admission date of 11/09/22 with diagnoses that included End Stage Renal Disease, Cerebral Infarction with Right Hemiplegia and Diabetes Mellitus. The Minimum Data Set (MDS) assessment dated [DATE] indicated R30 was dependent for all activities of daily living. The Brief Interview for Mental Status (BIMS) assessment score of 0/15 indicated Severe cognitive impairment. On 12/11/23 at 10:10 AM, R30 was observed laying in bed. R30 was not verbally responsive and did open their eyes and make eye contact. R30's right hand was observed to be in a tightly clenched fist position. No splinting was observed in the right hand and no splinting devices were observed in the room. On 12/11/23 at 1:30 PM, R30 was observed laying in bed. R30 was minimally responsive to questions…

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 MI00138942. Based on interview and record review, the facility failed to provide adequate supervision during a shower for one resident (R427) out of five reviewed for falls. Findings Include: A review of Intake called inot the State Agency noted the following, .staff [R427] was taken to the shower room, and staff had left the room. [R427] fell out [their] wheelchair and hit [their] head. [R427] has two abrasions on [their] head and knees. [R427] was on the floor for 20 minutes before staff picked [them] up off the floor. A review of an Incident and Accident (IA) report revealed the following, Date: 8/7/2023 at 18:25 (6:25 PM). Incident Description: Nursing Description: Resident observed sitting on buttocks in front of w/c (Wheelchair) in shower room. Resident Description: Pt. (Patient) stated [they] slid out of [their] wheelchair. A review of the medical record revealed that R427 admitted into the facility on [DATE] with the following diagnoses, Cerebral Infarction and Bell's…

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 14-day end date was applied to an as needed (PRN) psychotropic medication for one resident (R177) of five residents reviewed for unnecessary medication. Findings include: On 12/11/23 at 12:30 PM, R177 was observed sitting on the side of their bed eating lunch. They were asked how they were doing, and answered in slow one-word answers. A review of R177's medical record revealed that the resident was admitted into the facility on 6/9/22 with diagnoses that included Alzheimer's Disease, Cognitive Communication Deficit, and Psychotic Disorder. Further review revealed that the resident was severely cognitively impaired, and was independent for Activities of Daily Living. On 12/12/23 at 12:13 PM, R177 was observed sitting on the side of their bed eating their lunch. Personal Caretaker P was asked about R177's behavior today, and explained that they seemed out of it yesterday but had come around today. A review of R177's physician orders revealed the following which was ordered on 11/24/23: Haldol…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure medications were administered timely and/or stored securely for three residents (R188 and R205) from a total sample of six residents reviewed for medications. Findings include: On 12/12/23 at 8:59 AM, Licensed Practical Nurse (LPN) K was observed during a medication pass for R188. During the preparation multiple white tablets were observed in an unlabeled plastic medication cup in the top drawer of the C unit back medication cart. LPN K indicated they had been left by a prior nurse and may have been Tylenol. The pills were discarded. On entry to the residents's room, two pills were observed in a medication cup on the bedside table of the resident. R188 was asked what the medications were and reported one was a muscle relaxant and they were not sure of the other one. LPN K reported these were not provided to R188 by them. A review of the ordered medications indicated the medications to be Sucralfate, a one gram caplet pinkish in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a nebulizer mask in a sanitary manner, for one resident (R188) of four reviewed for infection control. Findings include: On 12/11/23 at 10:30 AM, R188 was observed in bed asleep and covered in their blanket. R188 did not wake for an interview. During that time a chair was observed with a nebulizer mask and machine laying directly on the seat of the chair. On 12/12/23 at 12:38 PM, R188 was observed asleep in bed and did not wake for the interview. The nebulizer mask and machine were observed to lay directly on the seat of the chair next to R188's bed. On 12/13/23 at 10:00 AM, R188 was observed asleep in bed and did not wake for the interview. The nebulizer mask and machine were observed to lay directly on the seat of the chair next to R188's bed. On 12/13/23 at 11:51 AM, R188 was observed asleep. The Unit Manager, LPN F was asked about the proper storage for R188's nebulizer and explained that it should be behind on the table in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00135691, MI00136564 and MI00134919. Based on observation, interview, and record review the facility failed to ensure personal items were maintained and labeled and the inventory form updated with new item for two residents (R708 and R707) of four reviewed for missing items, resulting in lost items and items not returned from the laundry. Findings include: R708 On 08/28/23 at 12:49 PM, a complainant indicated R708 did not receive all their personal items back upon discharge from the facility. The complaint indicated that all that was initially returned were a baby doll and some papers. It was reported that at one time of discharge R708 had a closet full and over flowing with clothes. Still missing were items like a cream colored suede winter coat, a blanket with family and resident pictures with the resident's name on it, a wooden jewelry box which included, pearl earrings, bracelets and a crucifix on a chain which R708 worn most days and outfits of clothing. The complainant…

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 MI00136727. Based on observation, interview and record review, the facility failed to supervise wandering behaviors increasing the risk for provoked reaction for one sampled resident (R704) by the perpetrator (R705) wandering into the residents room space, from a total sample of four residents reviewed for abuse. Findings include: On 8/28/23 at 9:00 AM, a progress noted was reviewed in R705's electronic medical record (EMR) which documented the following, 3/24/23 11:00 AM, Note Text: [R705] wandered into resident [R704's] room. Writer heard resident yelling from room. As I was getting up to go to resident's room, I heared a big boom. As I walk in to the door I observed [R704] on the floor on top of [R705] as they was laying on their back on the floor. [R704] was on their left side laying on left side with their hands around [R705's] neck. [R704] was observed squeezing [R705's] neck. Writer immediately grabbed [R704's] hands to removed them off of [R705's] neck. [R704] yelling…

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.