Heritage Manor Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a supra-pubic (s/p, a tube inserted through the abdomen directly into the bladder to drain urine) indwelling urinary catheter care plan for one (R9) of two residents reviewed for urinary catheter.Findings include:On 3/4/26 at 9:35 AM R9 was observed seated on their bed in t-shirt and sweatpants. A urinary catheter tubing was observed pulling tightly downward from under R9's T-shirt. The catheter was attached to a collection bag resting on the floor. There was approximately 1 liter of urine in the collection bag. R9 was asked about the catheter and said, It's bothering me. R9 lifted up their T-shirt and lowered the waistband of their sweatpants to show the s/p catheter's insertion site. There was an anchoring device on the catheter, but it was not adhered to R9's body. The insertion site had no dressing over it and was open to air. A small shallow ulcer was observed around the stoma (surgically created hole the tubing…

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 assist a wheelchair dependent resident (R35), reliant on the use of the elevator to smoke, of one resident reviewed for smoking resulting in missed opportunities for smoking.Findings include: On 3/3/2026 at approximately 1:00 PM, R35 was observed in their wheelchair at the 2nd floor elevator. R35 said they were waiting to go outside and smoke. On 3/3/2026 at approximately 1:20 PM, R35 was observed at the 1st floor elevator. When asked if they went outside to smoke, R35 stated, no, I missed it. On 3/3/2026 at approximately 1:45 PM, R35 said that they miss their smoke breaks often because there is only one elevator out of two elevators in the building that work. R35 further said that it can take up to 30 minutes to get on the elevator because so many residents and staff are waiting to use it. In addition, R35 stated, It is very upsetting to miss my smoke breaks. If you miss it, it's a non-negotiable - they close the door and won't let you…

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 appropriate indwelling urinary catheter care for one (R9) of two residents reviewed for urinary catheter care resulting in discomfort and irritation at R9's supra-pubic catheter (s/p, a tube inserted through the abdomen directly into the bladder to drain urine) insertion site along with the potential for infection and catheter dislodgement.Findings include:On 3/4/26 at 9:35 AM R9 was observed seated on their bed in t-shirt and sweatpants. A urinary catheter tubing was observed pulling tightly downward from under R9's T-shirt. The catheter was attached to a collection bag resting on the floor. There was approximately 1 liter of urine in the collection bag. R9 was asked about the catheter and said, It's bothering me. R9 lifted up their T-shirt and lowered the waistband of their sweatpants to show the s/p catheter's insertion site. There was an anchoring device on the catheter, but it was not adhered to R9's body. The insertion site…

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 prepare vegetables to the proper food consistency for four residents receiving pureed textured meals in the facility. Findings include: On 3/3/26 at 11:04 AM, during observations of the kitchen lunch service with Head [NAME] S and Dietary Manager (DM) Q, the steam table was set with pans of food ready to be served to facility residents. Due to a lack of space on the steam table, the pan of prepared pureed green beans, also ready to be served to the residents, was sitting in a pan of water on the hot stove. While taking food temperatures, the pureed green beans appeared lumpy. DM Q and the two State Surveyors present obtained and tasted a sample of the green beans. The consensus from the tasting was that the green beans contained lumps. DM Q said the green beans needed to be smoother. Head [NAME] S informed the staff on the tray line to put the meal tickets for the residents on pureed diets aside because the pureed green beans were being smooth out in the blender. On 3/4/26 at 12:34 PM, when Registered…

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 1220384, 1220412, and 2569363.Based on interview and record review the facility failed to ensure that one resident (R406) of five residents reviewed was free from abuse and exploitation of personal funds resulting in certified nursing assistant (CNA) A using a R406's debit card to make purchases totaling $1,900.Findings include:According to a facility reported incident, CNA A used R406's debit card to make a personal purchase.On 7/30/25 at 2:05 PM, R406 was interviewed regarding the incident. R406 acknowledged the incident and said that the facility had recovered some of the money taken from their debit card.On 7/31/25 at 11:00 AM, the Nursing Home Administrator (NHA) was interviewed regarding the incident and reported CNA A had taken R406's money and had made payments toward the $1,900 debit balance, reducing the amount owed to $570.42. The NHA said the facility provides education regarding abuse and expects staff to follow facility policies.Record reviewed noted that R406 was admitted…

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 MI00153787 Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 107 residents who consume food products, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 06/25/25 at 11:52 A.M., A comprehensive tour of the food service was conducted with Dietary Manager A. The following items were noted: The 3-compartment sink sanitizer basin chemical concentration was tested and observed to be more than 500 parts-per-million (PPM) quaternary ammonia. Dietary Manager A indicated she would contact the contractual vendor for necessary adjustments to the chemical dispensing assembly as soon as possible. The 2022 FDA Model Food Code section 4-501.114 states: A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under §7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use…

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 MI00153787 Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 107 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality. Findings include: On 06/25/25 at 12:10 P.M., 6 of 9 first floor Main Dining Room Portable Terminal Air Conditioning (PTAC) unit filters were observed heavily soiled with accumulated and encrusted dust/dirt deposits. The interior and exterior (PTAC) cabinet surfaces were also observed soiled with accumulated and encrusted dust/dirt deposits. Maintenance Director C indicated he would have staff thoroughly clean the filters and cabinet surfaces as soon as possible. On 06/25/25 at 12:15 P.M., The first floor Main Dining Room flooring surface was observed soiled with accumulated and encrusted dust/dirt/food residue deposits. On 06/25/25 at 12:20 P.M, An interview was conducted with Director of Housekeeping and Laundry Services E regarding current staffing levels. Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00153011. Based on interview and record review the facility failed to document complete transfer and discharge information for one (R510) of two residents reviewed for the transfer/discharge process resulting in the potential for the receiving health care provider to be unaware of all the resident's healthcare needs. Findings include: The State agency received a complaint that R510 was improperly transferred. According to R510's Electronic Health Record the resident admitted to the facility on [DATE] with multiple diagnoses that included paraplegia and surgical repair of fractured right femur. A progress note dated 3/19/25 at 6:41 PM indicated R510 returned from the hospital and was then transferred to another long-term facility. There was no additional documentation. There was no transfer form to the hospital. There was no discharge plan, summary note or progress notes to indicate instructions had been given to either the receiving hospital or long-term care facility 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.

This citation pertains to intake MI00148648. Based on observation, interview, and record review the facility failed to establish a record of receipt, disposition, or reconciliation of controlled drugs (a drug that the government regulates for possession and use, i.e. narcotics) in the facility's back-up box (secured storage unit of controlled drugs), resulting in the facility being unable to account for the receipt of, disposition of, or discrepancies of controlled drugs in the facility's back-up box with the potential for drug diversion and controlled drugs being unavailable to administer to residents as prescribed. Findings include: On 12/19/24 at 12:52 PM observation of the facility's narcotic back-up box with the Director of Nursing (DON) revealed there was no plastic lock on the narcotic drawer. The lack of a lock indicated that the narcotic drawer had been opened after pharmacy had delivered a fully restocked narcotic supply. There was no documentation to indicate when pharmacy last delivered the back-up-box or when narcotics had been removed. A sheet of paper with multiple…

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 and address Medication Regimen Review (MRR) recommendations timely for two residents (R35 and R54) of five residents reviewed for medication regimen review, resulting in the continuance of unnecessary medications and a lack of communication of recommended medication changes between pharmacist and physician. Findings include: R35 On 12/20/24 at 12:00 P.M. review of monthly Pharmacy recommendations in the electronic Medical Record for R35, documented the following: Date: 9/9/24 Pharmacist Drug Regimen Review Please take the following action, described below See report. Recommend: please consider reducing this: Resident is on sliding scale insulin (Adelog) AMDA guideline does not suggest using sliding scale insulin because of its retrospective way Of treating hypoglycemic and the lack of evidence to support its efficiency in physiological needs of the body More according to the American Geriatric Society updated Beers Criteria, there is also to this…

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 one resident (R9) was free from significant medication errors out of six residents reviewed for medication administration when only two doses of an antibiotic eye solution (Erythromycin Ophthalmic solution) was administered to the resident of the 56 doses prescribed, resulting in potential for prolonged signs and symptoms of a right eye infection. Findings include: On 12/17/24 at 12:07 PM R9 was observed lying in bed with tube feeding infusing through a feeding tube. The resident's right eye was sunken in and the lids were closed (the eyeball was not visible). A small amount of dried yellow crust was present on both the upper and lower lid. R9 was unable to be interviewed due to severe cognitive impairment. At 1:20 PM, R9's family member was interviewed and reported the resident had a right eye infection last month that was treated with antibiotic eye drops. R9's family member said the right eye infection had improved because…

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

Based on interview, and record review the facility failed to maintain a complete and accurate Antibiotic Stewardship Program, resulting in R9's antibiotic usage for an eye infection not being identified, monitored, or administered as prescribed. This deficient practice has the potential to affect all residents receiving antibiotics in the facility. Findings include: On 12/20/24 at 10:40 AM a review of the facility's Infection Control Program was conducted with the Infection Control Nurse, (IFC) D. IFC D said the facility follows McGeer's criteria (a standardized approach to surveillance and reporting of infections) when prescribing antibiotics to review the (antibiotic) usage for accuracy. Residents prescribed antibiotics are documented on the facility's infection report log for monitoring. The IFC nurse said they become aware of residents who are prescribed antibiotics for infections through communications in the facility's daily meetings, infection reports, and a list obtained from pharmacy. During review of the infection report log for November 2024 with IFC D the line listing…

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 they consistently screened, educated, offered, and administered influenza vaccines for five (R4, R9, R40, R52, and R57) of five residents reviewed for vaccinations/immunizations resulting in R57 consenting to receive the influenza vaccine but not receiving it and the lack of vaccine screening, education, and offering to receive the vaccine for residents R4, R9, R40, and R52. Findings include: On 12/19/24 at approximately 2:00 PM, the five residents (R4, R9, R40, R52, and R57) reviewed for immunizations had no documentation to support they had been screened/assessed, educated on, offered, or administered the influenza vaccine in their Electronic Health Record (EHR). The Infection Control Nurse (IFC) D and the Corporate Clinical Director, Registered Nurse (RN) Q were interviewed at this time. IFC D said the facility used the State of Michigan Influenza Vaccination Assessment and Consent (VAC) form to document and track resident's vaccination…

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 has two deficient practice statements. Deficient Practice #1 Based on observation and interview the facility failed to effectively clean and maintain the physical facility in good repair affecting 25 residents on the third floor, resulting in an unpleasant, non-homelike environment. Findings include: On 12/17/24 at 10:30 a.m. during an observation of the third-floor unit the floor tiles, walls, and base boards were observed to need deep cleaning. Floor tiles were observed cracked, chipped and needed to be replaced. Rooms were noted with cracked, missing floor tiles, broken resident equipment. The unit had a malodorous smell that lingered. Other concerns noted on the unit included: 1. Aluminum tape surrounding the air conditioning units were detached from the unit allowing air, gaping holes and visibility to the outside. 2. Floors in the hallway and resident's rooms had visible collection of dirt, food particles, dust and soiled areas around the base boards and perimeters of the floors. Floors 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.

Based on observation, interview, and record review, the facility failed to follow the standards of practice for medication administration when 1.) an insulin pen was not primed (remove air bubbles from needle and cartridge) prior to administration of insulin to R53, 2.) medications through a PEG (feeding tube that is surgically placed through the abdominal wall directly into the stomach) were not individually crushed and separately flushed through the PEG tube for R9 and 3.) a physician's order for an anti-hypertensive medication was incorrectly transcribed on the Medication Administration Record (MAR) for R9, resulting in the potential for an inaccurate amount of medication to be administered and decreased efficacy of the medications. Findings include: RR53 On 12/19/24 at 8:33 AM, Licensed Practical Nurse (LPN) E was observed preparing to administer 35 units of lantus insulin to R53 at the medication cart. LPN E retrieved a new lantus insulin pen and dialed the insulin pen to 35 units. LPN E proceeded to R53's bedside to administer the insulin. LPN E was queried on the process 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 provide hair care for two residents (R5 and R7) and a shave for one resident (R16) out of a sample of 14 residents reviewed for activities daily living (ADL's), resulting in unmet hygiene needs, loss of dignity and emotional distress. Findings include: On 12/17/24 at 10:20 A.M. during a tour of the third floor, R5 was identified as receiving care from a hospice company. The resident's hair was observed loose, standing straight to the ceiling and matted on the left side of R5's head. Mingled in the resident's hair were white balls and lint from the linen on the bed. R5 was observed on 12/18/27 at 1:50 P.M. and again on 12/19/24 at 12:00 P.M. R5's hair had not been combed and the presence of white lint balls were more pronounced. On 12/18/24 at 6:00 P.M. during an interview with the resident's guardian and brother, both family members mentioned that R5's hair at one time was combed by staff but had been told after inquiring that the Aide no…

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 supra-pubic catheter care for one (R37) of two residents reviewed for catheter care, resulting in discomfort at the insertion site, the potential for dislodgment of the catheter, and urinary tract infection. Findings include: On 12/17/24 at 1:02 PM R37 was observed in a wheelchair in the hallway with a catheter tubing pulling straight down from the resident's lower abdomen to a collection bag that was hanging from the back of the wheelchair frame. The catheter tubing was taut and had dark amber urine with some mucus draining into a collection bag with a dignity cover. The resident said he wanted his catheter repositioned because it bothered him. R37 went to his room and lifted his shirt to reveal the a supra-pubic (s/p) catheter insertion site (supra-pubic or s/p catheter is a flexible tube surgically inserted through the lower abdomen directly into the bladder to drain urine). The s/p cath insertion site was slightly…

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 justify the use of a PRN (as needed) antianxiety medication and document the rationale for open ended use for one resident (R54) of five residents reviewed for unnecessary medications. Findings include: Record review of R54's Electronic Health Record (EHR) revealed R54 was admitted into the facility on 7/15/23 with most recent readmission on [DATE] with diagnoses that included cerebral infarction (stroke), major depressive disorder, adjustment disorder with mixed anxiety and depressed mood. According to the quarterly Minimum Data Set (MDS) dated [DATE], R54 had intact cognition. Review of R54's physician orders documented the resident's current medications as follows: -Xanax (alprazolam)- Schedule IV tablet; 0.5 mg (milligrams); amt(amount) ;1 oral. Special instructions take one tablet by mouth twice daily as needed. Start date 10/12/24. End date open ended. There was no 14 days stop date noted to the order. Review of R54's care plan revealed Problem:…

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 proper communication/documentation of Hospice services provided to one Resident (R5) of two reviewed for Hospice services, resulting in a lack of coordination of comprehensive services and care provided to the resident. Findings include: A review of R5's Electronic Medical Record (EMR) revealed an admission date of 7/2/2022, with diagnoses of acute respiratory disease, sarcoidosis, paranoid schizophrenia, anxiety disorder, gout and hypothyroidism. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R5 was rarely understood and was severely impaired in cognitive skills for decision making, was incontinent of bowel and bladder and required one- two person to perform Activities of Daily Living (ADLs). On 12/18/24 at approximately 11:00 A.M. License Practical Nurse (LPN) R was queired concerning the location of the documentation from the hospice company that coordinated care with the facility. LPN R…

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 enhanced barrier precaution were implemented for two residents (R1 and R9) out of twenty four residents reviewed for infection control, resulting in the potential for the transmission of infectious t organisms. Findings include: R1 On 12/19/2024 at 9:25 AM, Certified Nursing Assistant, (CNA) C, was observed to change the brief and provide other care without wearing Personal Protective Equipment (PPE). On 12/19/24 at12:45 PM, observed Registered Nurse (RN) B and Wound Care Coordinator (WCC) A providing care to R1's stage IV sacral coccyx wound without wearing PPE. According to electronic health record (EHR), R1 was initially admitted on [DATE] with diagnosis of sepsis, bacteriuria, stage IV pressure ulcer, and dementia. R1quarterly Minimum Data Set, (MDS) Assessment with a reference date of 11/5/2024 indicate R1had moderately impaired cognition with a BIMS (brief interview for mental status) score of 6/15. 12/19/24 2:24 PM, Registered…

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 residents call lights were properly functioning for one of four units, resulting in a potential for a delay in responding to care needs of the residents that resided on the unit. Findings include: On 12/17/24 at 10:30 A.M. during an observation on the third floor. Residents were observed with assorted bells in their rooms. During the observation the residents were queired concerning the use of the bells. R47 who was alert and oriented indicated he was not sure where the bell was but when he needed a nurse he went to the nursing station. R47's roommate interjected and stated residents on the unit were given the bells because the call lights were not working, and residents were told to use them when they needed help. R35 indicated sometimes the nurses might be down the hall and could not hear the bell. According to R35 sometimes you can ask someone to tell the nurses you need help. On 12/19/24 at 12:05 P.M., Director of Maintenance (DM) K was interviewed concerning the replacement of the call lights 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 review or revise the care plan following falls for two residents (R701 and R704) out of three reviewed for fall care plan interventions. Findings include: R701 A review of the medical record revealed that R701 admitted into the facility on 1/8/2023 with the following diagnoses, Fracture of lower end of Right Tibia and Pressure Ulcer of Left Heel. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 6/15 indicating an impaired cognition. R701 also required assistance with bed mobility and transfers. Further review of Incident and Accident reports for R701 revealed that R701 had falls in the following days: 12/11/2023, 12/30/2023, 1/11/2024, and 4/11/2024. A review of the fall care plan revealed that the interventions had not been updated since 11/8/2023. R704 A review of the medical record revealed that R704 admitted into the facility with the following medical diagnoses, Cerebral Infarction and Epilepsy. A review of the Minimum Data Set assessment revealed a Brief…

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 an intervention from the care plan for one resident (R702) out of three reviewed for fall care plans. Findings include: On 9/25/2024 at 9:52 AM, R702 was observed in their room sitting in their wheelchair. R702 was in the room alone and a fall mat was observed on the floor beside the bed. A review of the medical record revealed tat R702 admitted into the facility on 9/30/2022 with the following medical diagnoses, Dysphagia and Disorder of Brain. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 2/15 indicating an impaired cognition. R702 also required assistance with bed mobility and transfers. Further review of the fall care plan revealed the following intervention, Start Date: 6/10/2024. Approach: Concave Mattress. On 9/25/2024 at 10:25 AM, the Director of Nursing (DON) was shown R702's mattress and was queried if it was a concave mattress. The DON stated R702's mattress was a regular mattress, not a concave one. The DON stated they were unsure why…

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 MI00144280. Based on observation, interview, and record review the facility failed to implement interventions to obtain resident weights for two residents who refused to be weighed (R902 and R903) out of three residents reviewed for nutrition, resulting in significant weight changes to go undetected. Findings include: R902 During an interview on 5/15/24 at 9:40 AM with Concerned Family Member (CFM) A, it was reported that R902 was observed during a recent visit to have lost weight. It was believed the facility was not watching the resident's diet. During an observation on 5/15/24 at 11:22 AM, R902 was observed lying in bed and declined to answer any questions. Record review of R902's electronic medical record (EMR) revealed R902 was admitted into the facility on 6/7/23 with pertinent diagnosis of Alzheimer's disease. According to the Minimum Data Set (MDS) dated [DATE] revealed a brief interview of mental status (BIMS) score of 3/15 and resident required substantial/maximal…

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: MI00140904, MI00141103, MI00141276, MI00143450, MI00141973, and MI00142724 Based on observation, interview and ecord review, the facility failed to provide a functional call system that provides direct communication from the residents via the 2nd floor with no call light station, Resident rooms 215, 307, 312, 2nd floor shower room, 3rd floor shower room, and 4th floor shower rooms. This deficient practice had the potential to affect all residents that utilize the shower rooms and residents in rooms 215, 307 and 312. Findings include: During facility rounds on [DATE] at approximately 3:30 PM, it was observed that there was no call light panel/annunciator panel at the nurse's station to notify the staff members of any resident needs. A nurse on duty was queried about the missing panel and how they received alerts. Staff member reported that they did not realize that the call light box was not in place. Call lights in rooms 215, 307, 312 were not functional. Two residents 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to the intakes: MI00140904, MI00141103, MI00141276, MI00141360, MI00141973, MI00142127, and MI00143303 Based on observation, interview, and record review the facility failed to maintain general repair and cleanliness of the resident rooms, and common areas with potential for avoidable contamination, injuries, and decrease in satisfaction of living affecting all 97 residents. Findings include: An initial observation was completed on 4/22/24 at approximately 10:30 AM. The surveyor was waiting near the elevator entrance. There were residents in wheelchairs and one other resident with no assistive device were coming out of the east elevator (elevator on the left side). The elevator had missing handrails on both sides. Multiple fixtures to secure the handrails were exposed. Two staff members were in the elevator. When the surveyor queried the staff member about the missing handrails the staff member reported that it had been missing for a few months. The lights on the elevator switches 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.

This citation pertains to intakes: MI00143303 and MI00143980 Based on interview and record review the facility failed to assist Resident Council to meet for monthly meetings consistently and failed to promptly follow up and resolve concerns and follow up consistently. Findings include: Multiple complaints received by the State Agency and reviewed during this survey had concerns with long call light wait times, concerns with facility's physical environment etc. A request was made to the facility administrator and director of nursing (DON) via e-mail on 4/23/24 at 11:35 AM to provide the resident council minutes for the facility from November-2023 to current date (April 2024) to review the Resident Council concern trends and facility's follow-up on the group concerns. On 4/23/24, at approximately 2:30 PM, Activities Director I reported the facility Administrator did not have any resident council meeting minutes or follow-up documentation for the requested dates. Activities Director I reported that they were new to the role and they had scheduled a day every month for their future…

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 MI00143232. Based on interview and record review, the facility failed to promptly conduct a thorough investigation for allegations of abuse/neglect, including an injury of unknown origin for seven (R910, R911, R915, R916, R917, R918, and R921) of 10 residents reviewed for abuse/neglect. Findings include: R921: The State Agency received a Facility Reported Incident (FRI) on 4/12/24 for an incident that occurred on 4/10/24. The FRI reported that R921, a Hospice patient (receiving palliative care) was observed on the floor by Certified Nursing Assistant (CNA) C on 4/11/24 at 7:50 AM with an injury of unknown source with serious bodily injury. There was no corresponding 5-day investigation report for this incident. The facility's 'Unusual Occurrence Report' dated 4/10/24, (2 days prior to the FRI) indicated R921 was observed in the room unresponsive on the floor with bleeding around the head on 4/10/24 at 8:30 AM. The type of injury was documented as 'unknown'. R921 did not have…

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: MI00143303 and MI00143980 Based on observation, interview, and record review, the facility failed to follow-up on grievances expressed by two (R912 and R919) of four Residents reviewed for grievances resulting in frustration and ongoing communication concerns. Findings Include: R912 R912 was admitted to the facility on [DATE]. R912's admitted diagnoses included Major depressive disorder, schizoaffective disorder, anxiety disorder and heart failure. Based on assessment dated [DATE], R912 had Brief Interview for Mental Status score of 14/15, indicative of intact cognition. An observation was completed on 4/24/24 at approximately 2:00 PM. During the observation R912 reported that they were missing a bag with their personal belongings that included some important receipts, debit card, and clothes. R912 reported that the bag with their belongings were taken to the laundry. They had spoken with several staff members in the last two weeks and they still have received any follow up…

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 MI00143878. Based on interview and record review, the facility failed to immediately report an injury of unknown origin to the Nursing Home Administrator and/or the State Agency (SA) for one ( R921) of 10 residents reviewed for abuse/neglect. Findings include: The State Agency received a Facility Reported Incident (FRI) on 4/12/24 for an incident that occurred on 4/10/24. The FRI reported that R921, a Hospice patient (receiving palliative care) was observed on the floor by Certified Nursing Assistant (CNA) C on 4/11/24 at 7:50 AM with an injury of unknown source with serious bodily injury. The facility's 'Unusual Occurrence Report' dated 4/10/24, (2 days prior to the FRI) indicated R921 was observed in the room unresponsive on the floor with bleeding around the head on 4/10/24 at 8:30 AM. The type of injury was documented as 'unknown'. R921 did not have vital signs. The Unusual Occurrence Report was signed by the Nursing Home Administrator (NHA)/Abuse Coordinator on 4/15/24. On 4/24/23 at 11:30 AM during an interview the NHA acknowledged that R921…

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 MI00142890. Based on observation, interview, and record review, the facility failed to prevent employee to resident abuse for one resident (R602) of four residents reviewed for abuse, resulting in R602 being hit in the face and sustaining a laceration and hematoma (bruising). Findings include: On 3/6/2024 at 1:30 PM, review of the admission Face Sheet documented R602 was admitted to the facility on [DATE] with diagnoses of dementia, violent behavior, mood disorder, adjustment disorder, anxiety, and depressed mood. According to the Minimum Data Set (MDS) dated [DATE] indicated R602 was severely impaired in cognitive (ability to think) skills for daily decision making and required supervision to perform all activities of daily living (ADL's). On 3/6/2024 at 1:40 PM, R602 was observed seated on the unit, neatly dressed, pleasantly confused, and frequently wandering the hallway. R602 approached Certified Nurse Assistant (CNA) D gesturing and patting his chest smiling. Per 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 has two deficient practice statements. Deficient Practice Statement #1 Based on observation, interview, and record review the facility failed to administer and document wound care treatments consistently for two residents (R1 and R72) out of three residents reviewed for skin care, resulting in the potential for spread of infection and worsening of wounds. Findings include: Resident #1 During an interview on 10/30/23 at 2:40 PM with Licensed Practical Nurse (LPN) B, it was reported that R1's pressure ulcer had healed on right heel a couple months ago. Review of R1's face sheet revealed admission into the facility on 1/13/23 with a primary diagnosis of metabolic encephalopathy (chemical imbalance in blood). According to the Minimum Data Set (MDS) dated [DATE], revealed R1 had intact cognition and supervision during most Activities of Daily Living (ADLS). During an observation on 10/31/23 at 2:22 PM, R1's right heel was bandaged with gauze and was not dated. Upon further inspection R1 had an open area…

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.