Ambassador, 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 the dignity for one resident (R110) of three residents reviewed for dignity, resulting in verbalized feelings of embarrassment and frustration. Findings included: On 9/25/24 at 11:47 a.m. R110 reported that the physician placed an order at least two months ago to be seen by a podiatrist to get the residents toenails cut and for the dry skin and it has not happened. R110 stated, I want my long thick toenails to be cut on both feet because I don't want anyone to see my toenails like that. Its embarrassing and that is why I got very angry. R110 pointed to their feet and the great toe and the second toe on the left foot were observed with dry scaly skin on top of the toes and between the toes with dark areas and long thick toenails with an unpleasant odor. The right foot also had long, thick, discolored toenails and dry skin between the toes. The fifth toenail on the right foot appeared to have been broken and exposed thick dried skin…

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 the Preadmission Screening (PAS)/ Annual Resident Review (ARR) form for Mental Illness/ Intellectual Disability/ Related Conditions Identification (DCH-3877) document was accurate, complete, and sent to the local state agency for an evaluation for a Level II determination for one (R57) of seven residents reviewed for PASSARs, resulting in the potential for unmet intellectual/ developmental disability care needs. Findings include: R57: According to the Electronic Health Record (EHR), R57 admitted to the facility on [DATE] with diagnoses that included Adjustment Disorder, Bipolar Disorder, Anxiety, and Depression. R57 was prescribed two antipsychotic medications; Cymbalta (an anti-depressant) 30 milligrams (mg) twice a day and Olanzapine (an anti-psychotic) 2.5 mg twice a day (used to treat schizophrenia). On 8/24/24 a care plan was initiated for 'use of psychiatric medications'. A review of the only DCH-3877 form in the resident's EHR was dated…

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 podiatry services and treatment were provided in a timely manner for one resident (R110) of one resident reviewed for foot care, resulting in the growth of long toenails, build-up of flaky skin on resident's feet, and delay in needed treatment. Findings include: On 9/25/24 at 11:47 a.m. R110 was observed resting in bed. During the resident interview, the resident complained of needing to be seen by the podiatrist due to long thick toenails. R110 pointed to both feet and said, The physician placed an order for a podiatrist appointment at least two months ago to get the toenails cut and for the dry skin and it has not happened. I don't know if they put my name on the list or not, but I have been mentioning it for about two months. R110's great toe and the second toe on the left foot had dry scaly skin on top of the toes and between the toes with dark areas and long thick toenails. The right foot also had long, thick, discolored…

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 medically related social services for one resident (R70) of two residents reviewed resulting in the delay of obtaining a legal guardian to initiate discharge planning in a timely manner and the resident expressing frustration. Findings include: On 9/27/24 at 10:00 AM, R70 was observed sitting on the side of the bed. R70 was queried about any concerns regarding the care by the facility, R70 responded, I want to be discharged , I don't want to be here. Review of R70's electronic health record (EHR) revealed admission into the facility on 3/12/20 with a pertinent diagnosis of vascular dementia (brain damage caused by multiple strokes). According to the Minimum Data Set (MDS) dated [DATE], R70 scored 8 out of 15 on Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Further review revealed resident did not have a guardian. Review of Report of Physician or Mental Health Professional dated and signed by 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.

In a confidential resident group interview on 8/16/23 at 11:29 AM, 10 of 10 residents reported the lunch and dinner meals was not palatable. Several residents stated that they feel that have to order out to get a decent meal. 10 of 10 residents reported that the portion sized of the meal is small, comparing the portion to kid sized meals. 9 of 10 residents reported that the pork is too tough to cut or chew. 10 of 10 residents reported that the food is not warm and have observed the staff leaving the meal cart doors open and conversating instead of passing trays. In an interview on 08/17/23 at 10:24 AM, Dietary Manager (DM) reported that the residents have had some food committee meetings to discuss food concerns but has cancelled the past few monthly meetings. DM reported that he is aware of food concerns and had been speaking to a few select residents monthly regarding food concerns and possible resolutions. Based on observation and interview, the facility failed to ensure palatable food temperatures and food texture, resulting in poor satisfactory of meals by residents, affecting…

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 the physical facility, maintain plumbing in good repair, and maintain equipment, resulting in the potential for contamination of the physical facility and food product, affecting all residents who consume food from the kitchen. Finding include: On 8/16/23 at 11:04 AM, the floor underneath the dish machine drain board was observed to have dissolved floor tile grout. Two tiles were observed to be loose at this time. Additionally, the waste disposal flex cuff, in the dish washing area, was observed to be leaking slightly. According to the 2017 FDA Food Code Section 6-201.11 Floors, Walls, and Ceilings. Except as specified under § 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE. On 8/16/23 at 11:15 AM, the two-compartment sink drain line was observed to be leaking on to the floor. Additionally in the back…

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 resident rooms in good repair, maintain clean ventilation, and maintain backflow protection, resulting in a non-homelike facility and potential for contamination of the domestic water supply, affecting all residents in the facility. Findings include: During an environmental inspection on 8/16/23 between 12:16 PM and 2:03 PM, the following observations were made: -Two ceiling tiles, in the hall near room [ROOM NUMBER], were observed to be stained with water damage. -The shower room, near room [ROOM NUMBER], was observed to have gum or [NAME] adhesive on the floor; the ceiling in the shower enclosure was observed to have bubbling paint. -The ventilation screen, in boiler room [ROOM NUMBER], was observed to have fallen out of the vent frame, allowing for potential pests to enter the premise. -The PTAC (packaged terminal air unit) filter, located in room [ROOM NUMBER], was observed to be caked with dust. -The walls, located in 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: MI00133207 Based on observation, interview, and record review, the facility failed to ensure a clean, comfortable, and homelike environment for 34 residents (including Resident #40 and 115) on the third floor, reviewed for physical environment. The facility also failed to maintain a clean comfortable home like environment in the dining room on the third floor that had the likelihood to impact all residents who were using the dining room for their meals and other activities. Findings include: During an observation on 8/15/23 at 10:53 AM, room [ROOM NUMBER] had no window curtains, two beds with matching comforters, rough unfinished dry wall by bathroom, soiled(dark mater splashed) wall behind toilet, discolored broken grout around toilet, toilet paper holder very loose with broken dry wall. During an observation on 8/15/23 at 11:04 AM, room [ROOM NUMBER] had two beds and the bed located closest to the door did not have the privacy curtain in place and the track was broken 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 the bed hold policy was provided to three (Resident #27, #125, and #207) of three residents reviewed for hospital transfer, resulting in the potential for resident's and/or representatives to be uninformed of the facility's bed hold policy. Findings include: Resident #125 Review of the medical record reflected that Resident #125 (R125) was readmitted to facility 8/7/23 with diagnoses including acute encephalitis, muscle weakness, and adult failure to thrive. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/3/23 reflected that R125 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 14 (cognitively intact). Review of the Discharge MDS dated [DATE] reflected that R125 had an unplanned discharge to an acute care hospital and that his return to the facility was anticipated. In an observation and interview on 8/15/23 at 2:24 PM, R125 was observed lying in bed, on back, 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 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident # 91 (R91) was a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included traumatic subdural hemorrhage due to a motor vehicle accident, diabetes, and bi-polar disorder. R91 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 08/15/23 at 2:40pm, R91 was observed resting in bed, upon approach R91 initiated a conversation using American Sign Language (ASL) this surveyor is knowledgeable of alphabet and some basic ASL commonly used words. R91 reported he had no hearing ability, and did not use a hearing aid, when queried how he communicated with staff he reported by writing and pointed to his tablet and using gestures. Review of R91's Minimum Data Set (MDS)'s with the assessment reference dates of 1/29/23, 05/01/23 and 08/01/23 section B question 0200 were consistently coded as 1 meaning R91 had minimal hearing loss. The 1/29/23 MDS further reflected R91…

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.

During observation of the 1 South medication care on 08/17/2023 at 11:22 a.m. it was observed that the following medications did not have a date when the medication was open placed on the container of th medication: Fluticasone Propionate/Salmeterol discus 500 micrograms (mcg)/50 mcg and Lansoprazole 3 milligrams (mg)/milliliter (ml). In an interview on 08/17/2023 at 11;22 a.m. during 1 South medication care observation, Licensed Practical Nurse (LPN) T explained that all medication is to be dated when opened. She explained that she would discard the medication that was not dated, as listed above, and order new medication. During observation of the 2 South back medication cart on 08/17/2023 at 11:48 a.m. it was observed that the following medications did not have a date when the medication was open placed on the container of the medication: Fluticasone Furoate 100mcg-vilaterol 25mcg/dose inhaler. Based on observation, interview, and record review the facility failed to ensure medication stored in three of five medication carts were dated after opening and discarded at the time 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 1) adhere to infection control practices during medication administration observation; and 2) maintain clean and sanitized environment including resident equipment and common areas, resulting in the potential for cross-contamination, spread of bacteria, and increased risk of infection. Findings include: During an observation on 8/15/23 at 10:53 AM, room [ROOM NUMBER] had no window curtains, two beds with matching comforters, rough unfinished dry wall by bathroom, soiled(dark mater splashed) wall behind toilet, discolored broken grout around toilet, toilet paper holder very loose with broken dry wall. During an observation and interview on 8/15/23 at 11:11 AM, room [ROOM NUMBER] had bathroom wall appeared soiled with dark splash stains behind the toilet. During an observation on 8/15/23 at 2:41 PM, the west(left) wall of the third floor dining room Air Conditioning (AC) units were not on and appeared heavily soiled with dark substance that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00133896. Based on observation, interview, and record review, the facility failed to ensure resident dignity for 2 residents (R#'s, 114 and 115) with a facility census of 154, resulting in the potential for embarrassment and decreased feelings of self worth. Findings include: During an observation on 8/16/23 at 12:50 PM, the first meal tray was delivered to the third floor dining room. During an observation on 8/16/23 at 12:55 PM, Certified Nurse Aid (CNA) GG told another staff member R115 was a, feeder, in front of 20 other residents in the dining room. All 20 residents in the dining room were served meals on trays and ate from trays the entire meal. During an observation on 8/16/23 at 1:08 PM, staff delivered last tray to a resident who was in the dining room at 12:45 p.m. after most all other residents in had finished eating including at the same table. Resident #114 Review of Resident #114's (R114) medical record reflected they were 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.

This citation pertains to intake: MI00133473 Based on record review and interview the facility failed to provide written or spoken notice of a room change for one resident (#359) of one resident reviewed for room change, resulting in the potential for resident anxiety, misinformation of the reason for the room move, and lack of opportunity for resident questions. Findings Included: Resident #359 (R359) Review of the medical record revealed R359 was admitted to the facility 11/10/2022 with diagnoses that included chronic embolism and thrombosis (blood clots), anxiety, depression, adjustment disorder, paraplegia (paralysis of the lower body) , mood disorder, protein calorie malnutrition, alcohol abuse, blindness in right eye, epilepsy (disorder with nerve cell activity is disrupted in brain causing seizures), cerebral infarction (stroke), traumatic brain injury, right sided hemiparesis and hemiplegia (one sided paralysis or weakness) , polyarthritis, and anemia (low red blood cells). Resident was discharged from the facility 03/23/2023. During review of R359's 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.

Based on interview and record review the facility facility to ensure one out of two residents (Resident #5) had an accurate Advanced Directive form, resulting in the potential for resident wishes to not be followed. Findings Included: Review of the facility's Advanced Directive (AD) form titled, Code Status Elective Form revealed the form had options to check if a resident wished to be Full Resuscitation-(Full Code (life saving efforts to be given), or Do Not Resuscitate-(No Code) . (no life saving efforts to be given). A check mark was in the box next to Full Resuscitation-(Full Code), and also the word Full was circled which, per the form, indicated Resident #5 (R5) wished to have all medically appropriate care provided. On the signature line for Resident/Responsible Party the form revealed Verbal Consent dated 12/9/2022, but there was no name of the person who gave verbal consent. The form also revealed that two witness' were to sign the form, however there was only one witness' signature dated 12/9/2022. In an interview on 8/16/2023 at 3:37 PM, Social Worker (SW) E stated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake: MI00138470 Based on interview and record review the facility failed to notify the family member/emergency contact of a change in condition and a required hospital transfer for one resident (#356) of two residents reviewed resulting in the family/emergency contact not being aware of a change in condition and the transfer to the hospital. Findings Included: Resident #356 (R356) Review of the medical record revealed R356 was admitted to the facility 02/10/2023 with diagnoses that included fracture of the left femur, type 2 diabetes, hypothyroidism (low thyroid hormone), hyperlipidemia (high fat in blood), cerebral infarction (stroke), muscle weakness, hearing loss, and dysphagia (difficulty swallowing). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/17/2023, revealed R356 had Brief Interview of Mental Status (BIMS) of 12 (mildly impaired cognition) out of 15. R356 was discharged to the hospital 07/01/2023. In a telephone interview 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.

This citation pertains to Intakes: MI00137118 and MI00135021 Based on interview and record review the facility failed to protect two residents (#357, #358) right to be free from abuse of five residents reviewed resulting in the potential of physical harm to the residents. Findings Included: Resident #357 (R357) Review of the medical record revealed R357 was admitted to the facility 11/11/2021 with diagnoses that included right hip osteoarthritis, left sided hemiplegia (paralysis), hyperlipidemia (high fat in blood), dissociative and conversion disorder (mental health condition causes a person to become disconnected form important aspects of their lives and can mimic neurological conditions), nutritional deficiency, muscle weakness, psychomotor deficit (disturbance in psychological control of movement), and hypertension. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2023, revealed R357 had Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. R357 was discharged from the facility 06/15/2023. Review R357 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.

This citation pertains to intake: MI00135021 Based on interview and record review the facility failed to report allegations of abuse (physical abuse) for two residents (#358, #360) of five residents sampled 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 #358 (R358) Review of the medical record revealed R358 was admitted to the facility 01/31/2023 with diagnoses that included malignant neoplasm (cancer) of the prostate, obstructive and reflux uropathy (disorder of the urinary tract), hyperlipemia (high fat in blood), protein calorie malnutrition, hypokalemia (low potassium) hypomagnesemia (low magnesium), altered mental status, dementia with behavioral disturbance, and muscle weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/03/2023, revealed R358 had Brief Interview of Mental Status (BIMS) of 6 (severely cognitively impaired) out of 15. R358 was discharged from the facility 03/02/2023.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the resident and/or resident's representative a written reason of transfer to a hospital for one (Resident #125) of three residents reviewed for transfer/discharge, resulting in the potential of residents and/or family being un-informed of the reason for transfer. Findings include: Review of the medical record reflected that Resident #125 (R125) was readmitted to facility 8/7/23 with diagnoses including acute encephalitis, muscle weakness, and adult failure to thrive. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/3/23 reflected that R125 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 14 (cognitively intact). Review of the Discharge MDS dated [DATE] reflected that R125 had an unplanned discharge to an acute care hospital and that his return to the facility was anticipated. In an observation and interview on 8/15/23 at 2:24 PM, R125 was observed lying in bed, 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 accurately complete a Minimum Data Set (MDS) assessment for 1 (Resident #91) of 31 reviewed for MDS assessments, resulting in the potential for inaccurate care plans and unmet care needs. Findings include: According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident # 91 (R91) was a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included traumatic subdural hemorrhage due to a motor vehicle accident, diabetes, and bi-polar disorder. R91 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 08/15/23 at 2:40pm, R91 was observed resting in bed, upon approach R91 initiated a conversation using American Sign Language (ASL) this surveyor knowledgeable of alphabet and some basic ASL commonly used words. R91 reported he had no hearing ability, and did not use a hearing aid, when queried how he communicated with staff he reported by writing 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 Preadmission/Annual Resident Review (PAS/ARR) was completed after the 30 day exemption period and failed to notify the State Agency Health Authority for 1 Residents ( #107) and failed complete the 3878 portion of the PAS/ARR for 1 Resident (60) of 4 residents reviewed for PAS/ARR from a total sample of 31, resulting in the potential for unmet mental health treatment and services. Findings include; Resident #107 According to the clinical record Resident 107 (R107) was admitted to the facility on [DATE] with diagnoses that included schizophrenia, bi-polar disorder and substance abuse. On 8/15/23 at approximately 10:00 am, R107 was observed resting in bed difficult to engage in conversation. Review of the PAS/ARR dated 9/20/22 reflected R107 had a diagnosis of schizophrenia and received anti depressant and antipsychotic medications, further review of the 3877 and 3878 reflected R107 was expected to be discharged back into the community within 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.

This citation pertains to intake: MI00136732 Based on interview and record review, the facility failed to provide bath/showers and continence care for one Resident (#208) of 5 Residents reviewed, resulting in missed showers and the potential for inadequate hygiene and feelings of embarrassment. Resident #208 (R208) Review of the medical record revealed R208 was admitted to the facility 05/03/2023 with diagnoses that included hyperlipidemia (high fat in blood), congestive heart failure (CHF), major depression, hypothyroidism (low thyroid hormone), hypertension, morbid obesity, fractur of right femur, atrial fibrillation, gastroesophageal reflux, anemia (low red blood cells), osteoarthritis, and muscle weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/08/2023, revealed R208 had a Brief Interview of Mental Status (BIMS) of 9 (moderately impaired cognition) out of 15. R208's MDS-Section G (Functional Status), with the same ARD, revealed that she required extensive assistance with toileting and was totally dependent for showering/bathing.…

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 assistance to ensure ancillary services were arranged for 2 of 4 residents (Residents #141 and 3) reviewed for optical care, and audiology care, resulting in delayed care and treatment and frustration. Findings include: Resident #141 According to the clinical record including the Minimum Data Set (MDS) dated [DATE] , Resident # 141 (R141) was a [AGE] year old female admitted to the facility with diagnosis that included chronic kidney disease, hypertension and unspecified bilateral hearing loss. Further review of the MDS reflected R141 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS), section B of the MDS reflected R141 had moderate hearing loss and no hearing aid. On 08/15/23 at 12:46 PM, R141 was interviewed in her room, R141 noticeably struggled to hear questions, and elaborated that she had a hearing test in June and thought she was getting hearing aids but had not been updated or informed…

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 implement its policy and procedures to assure the accurate dispensing, administering, and documentation of controlled substances for two of five medication carts, resulting in the potential for controlled drug diversion. Findings Included: During observation of the 1 South medication cart on 08/17/2023 at 11:22 a.m. it was observed that the document entitled Controlled Substance Shift Inventory was not signed for 08/17/2023 at 07:00 a.m. by the oncoming nurse. The total number of medications at the end of the shift was also not completed. In an interview on 08/17/2023 at 11:25 a.m. Licensed Practical Nurse (LPN) T explained that she was the oncoming nursing for the 1 South medication cart. She explained that it was the expectation that the outgoing nurse and the oncoming nurse would count the controlled medication at 07:00 a.m. and record the total numbers and sign their signature in the appropriate box, which was located on the document entitled Controlled Substance Shift Inventory. LPN T explained that she…

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

Based on observation, interview, and record review the facility failed to ensure a medication error rate less than five percent when 2 medication errors were observed from a total of 36 opportunities for one resident (R121) of four residents observed during medication administration, resulting in a medication error rate of 5.56 percent (%). Findings include: During an observation on 8/17/23 at 9:35 AM, Licensed Practical Nurse (LPN) N administered R121's medications scheduled for 9:00 AM; LPN N did not administer Januvia (used to treat diabetes) 50 milligrams (mg) or Nifedipine extended release (ER, used to treat high blood pressure) 90 mg. In review of R121's physician orders and August 2023's medication administration record (MAR), there were two active orders for Nifedipine: 120 mg daily and 90 mg daily scheduled to be administered at 9:00 AM. Januvia 50 mg was scheduled to be administered at 9:00 AM. R121's August 2023's MAR revealed LPN N documented Nifedipine 90 mg, Nifedipine 120 mg, and Januvia 50 mg, were administered on 8/17/23 at 9:00 AM. During an interview on 8/17/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide dental services for one of three residents reviewed for dental services (Resident #139), resulting in continued mouth pain and unmet needs. Findings Include: Resident #139 (R139) R139 was observed sitting on her bed on 8/15/23 at 1:00 PM and stated during an interview that she had oral pain, had cavities, and needed a crown. In review of R139's Minimum Data Set (MDS) admission assessment dated [DATE], revealed she was 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); and required extensive assistance for personal hygiene (includes brushing teeth). The same MDS assessment indicated R139 had obvious or likely cavity or broken natural teeth. During an interview on 08/16/23 at 12:55 PM, Social Worker E stated she was not aware R139 needed to see the dentist. During an interview with Social Services Director J 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 interview and record review the facility failed to ensure two out of 31 one resident's (Resident #5 and 75) medical records were complete and accurate resulting in the potential for unmet care needs. Findings Included: Resident #5 (R5): Review of the facility's Advanced Directive (AD) form titled, Code Status Elective Form revealed the form had options to check if a resident wished to be Full Resuscitation-(Full Code (life saving efforts to be given), or Do Not Resuscitate-(No Code) . (no life saving efforts to be given). A check mark was in the box next to Full Resuscitation-(Full Code), and also the word Full was circled which, per the form, indicated Resident #5 (R5) wished to have all medically appropriate care provided. On the signature line for Resident/Responsible Party the form revealed Verbal Consent dated 12/9/2022, but there was no name of the person who gave verbal consent. The form also revealed that two witness' were to sign the form, however there was only one witness' signature dated…

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.