Mission Point Nursing & Physical Rehabilitation Ce

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00147590. Based on interview and record review, the facility failed to provide adequate assessment after an injury for one resident (R105), resulting in missed opportunities to identify the potential latent effects of the injury. Findings include: It was reported to the State Agency that the resident did not receive adequate and appropriate care while in the facility. A review of the clinical record for R105 documented an initial admission date of 2/5/22 and re-admission date of 8/16/24. R105 was transferred to the hospital on [DATE] and did not return to the facility. R105's diagnoses included vascular dementia, atherosclerotic heart disease, hypertension, and diabetes mellitus-type 2. A Minimum Data Set, dated [DATE], documented severe cognitive impairment. On 10/29/24 at 3:50 PM, an interview and review of R105's clinical record was conducted with the Director of Nursing (DON). R105's clinical record documented in part the following: 1. SBAR…

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 MI00146598. Based on observation, interview, and record review, the facility failed to ensure medications for three residents (R113, R115, and R116) located in a treatment cart were not expired. Findings include: It was reported to the State Agency that expired medications were not being discarded. On 10/29/24 at 9:00 AM, the contents of the second-floor treatment cart were observed with Licensed Practical Nurse (LPN) G and revealed the following: - A four-ounce tube of menthol-zinc oxide ointment for R113 expired 9/5/24. - A four-ounce tube of menthol-zinc oxide ointment for R115 expired on 10/27/24. - A four-ounce tube of menthol-zinc oxide ointment for R116 expired on 10/4/24. - A 3.53-ounce tube of diclofenac sodium expired on 3/28/24. LPN G said these medications should have been reordered and the expired medications discarded. On 10/29/24 at 2:45 PM, the Director of Nursing (DON) said the outdated medications should have been discarded. The diclofenac sodium should have been re-ordered. On 10/29/24 at 5:20 PM during the exit conference, 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 MI00143714. Based on observation, interview, and record review, the facility failed to maintain a sanitary kitchen, maintain equipment in good repair, and safely store food. This deficient practice has the potential to affect all residents that consume food from the kitchen. Findings include: An initial tour of kitchen was completed with Dietary Manager (DM) J on 8/6/24 (approximately) between 8:45 AM - 10:00 AM. The initial tour included the storage area in the basement of the facility. During the initial tour the kitchen floor dirty. The floor has brown stains food debris throughout the kitchen. The trash can next to hand wash was overflowing and there were trash that included food debris outside the trash can. The surveyor moved the trash can and noticed more dried food waste and other debris behind the trash can. The surveyor queried DM J about the kitchen cleanliness and floor situation and how often they were cleaning the floors. They reported that they had started three weeks ago at the facility and the floor had not been cleaned since they…

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 MI00143714. Based on observation, interview and record review facility failed to maintain a good general repair of the facility with a safe and functional environment for multiple resident rooms/resident equipments and common areas reviewed for physical environment. This deficient practice has the potential to affect the residents living in those room(s)/using the equipment(s) and all residents who use the common areas/elevators with feelings of frustration and dissatisfaction with their living conditions. Findings include: room [ROOM NUMBER] room [ROOM NUMBER] had three residents. During an observation completed on 8/6/24 at approximately 10:15 AM, the surveyor observed the privacy curtains were not functional between 316-1 and 316-2. 8 of the 17 hooks that suspend the curtain from track on ceiling were broke and the curtain was mostly hanging down. The privacy curtains between beds 316-1 and 316-2 as well as the one between 316-2 and 316-3 were not clean. The latter 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 This citation pertains to intake MI00145765 and MI00146157 Based on observation interview and record review, the facility failed to ensure an environment free from physical abuse for two residents (R12 and R100) of five residents reviewed for abuse/neglect/mistreatment, resulting in R12 being transferred to the hospital and sustaining soft tissue swelling and hematoma involving the right posterior parietal-occipital scalp and R82 being transferred to the hospital and sustaining peri-orbital ecchymosis and a left eye sub conjuntival hemorrhage. Findings include: R12 and R267 On 8/6/24 a facility reported incident (FRI) that was submitted to the Stage Agency was reviewed and revealed R12 was pushed over onto the floor by R267 on 7/12/24. R12 On 8/06/24 at approximately 12:59 p.m., R12 was observed in their wheelchair and was queried regarding their altercation with R267. R12 reported they were sitting in the dinning room and that another male resident was trying to get to another female resident and they were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00145584 Based on observation, interview and record review the facility failed to ensure a thorough investigation into an allegation of misappropriation was completed and contact law enforcement for one resident (R13) of one residents reviewed for misappropriation. Findings include: On 8/6/24 a facility reported investigation (FRI) was reviewed that alleged the following: Incident Summary Resident (R13) states that he had three $50.00 bills, totaling $150.00 in his coat pocket he states he hung jacket up in his closet when he went back to get his coat he states his money was gone. He didn't see anyone in his closet or in his room just the cena (Certified Nursing Assistant Q)who was taking care of his roommate . On 8/8/24 at approximately 2:17 p.m., R13 was observed in their room, up in their wheelchair. R13 was queried regarding the allegation of his money and indicated that he thought the female CNA stole it out of his coat pocket. R13 was queried how much money they had 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 Preadmission Screening (PAS)/Annual Resident (ARR) Mental Illness/ Intellectual Disability/ Related Conditions Identification forms DCH-3877 and/or DCH-3878) documents were reviewed, revised, and sent to the local state agency for review and/or evaluation for intellectual/ developmental disability needs for two residents (R79 and R102) of two residents reviewed for PASSARs, resulting in the potential for unmet intellectual/ developmental disability care needs. Findings include: R102 Record review R102's electronic medical record (EMR) revealed admission into the facility on 8/25/23 with a pertinent diagnosis of major depressive disorder and psychotic disorder with delusions and adjustment disorder. According to the Minimum Data Set (MDS) dated [DATE], R102 had severe impaired cognition and required partial/moderate assistance with most Activities of Daily Living (ADLS). Further review of EMR revealed an annual 3877/78 was completed on 4/18/24…

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 follow professional standards of practice for medication administration for two (R101 and R44 ) of four residents reviewed for medication administration resulting in 1) R101's medications left unattended on the breakfast tray and extended/delayed release medications being crushed without an order and 2) R44's medications being unavailable for administration. Findings include: R101: On 8/6/24 at 9:48 AM, R101 was observed seated upright in his bed eating breakfast independently. A medication cup with 9 whole pills was resting on the breakfast tray next to his plate. R101 was unable to be meaningfully interviewed about the medications due to impaired cognition status. Registered Nurse (RN) G came into the resident's room and was asked about the medications on the resident's breakfast tray. RN G said, Oh he takes them himself, but I need to crush them first. RN G took the medication cup off the table, went to the medication cart and proceeded…

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 weight monitoring occurred for two residents (R27 and R71) deemed to be at nutrition risk out of six residents reviewed for nutrition status, resulting in weight changes to go undetected and potentially compromise nutrition status. Findings include: R27: On 8/6/24 at approximaely1:30 PM R27 was observed in her bed with her eyes opened and music playing on her radio. The resident could not be meaningfully interviewed due to severe cognition impairment. The resident had an IV pole with a tube feeding pump attached. No tube feeding was present on the IV pole. Registered Nurse (RN) C was asked if R27 received tube feedings and replied, Yes, she gets them over night. The feeding goes up at 5:00 PM and is usually completed by 7:00 AM. According to R27's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with history of a stroke, dysphagia (inability to swallow effectively), and dementia. On 3/6/24 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 remove a feeding tube (flexible tube inserted through the abdominal wall to administer liquid nourishment, fluids, and medications) when there was no longer a valid clinical indication for its use in one (R29) of two residents reviewed for feeding tubes resulting in R29 expressing feelings of frustration with the presence of an unused feeding tube along with swelling, redness, and drainage at the insertion site, and leakage through two visible holes/cracks in the tube itself. Findings include: On 8/06/24 at 9:44 AM R29 was observed standing in the doorway of his room with yellow colored drainage on the front of his shirt approximately 4 inches in diameter. Upon interview R29 lifted up his shirt to expose a feeding tube with a saturated dressing around it with yellowish-green and rusty colored drainage. The feeding tube was approximately 1 foot long, hanging loosely without any securement device and tucked down into the resident's pants.…

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 administration error rate of less than five percent, with 13 errors identified out of 35 opportunities, affecting two residents (R73 and R29) of four residents observed for medication administration, resulting in a medication error rate of 37.1%. Findings include: R73: On 8/7/24 at 9:05 AM during observation of medication administration Registered Nurse (RN) C could not use the computer on the medication cart to view the resident's Medication Administration Record (MAR) . RN C used the computer at the nurse's station to access the resident's MAR, wrote R73's medications on a sheet of paper and proceeded to administer medications to the resident by using the paper. The following medication errors were observed: #1) Administered pantoprazole 40 mg (milligram) 1 caplet. Order was for Pantoprazole Sodium 40 mg tablet once a day. Scheduled for 6:00 AM. According to the Medication Administration Record (MAR) the resident received pantoprazole 40 mg at 6:00 AM, the next dose was not due at the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a Physician ordered laboratory (lab) diagnostic was completed for one resident (R48) of one residents reviewed for diagnostics. Findings include: On 8/6/24 the medical record for R48 was reviewed and revealed the following: R48 was initially admitted to the facility on [DATE] and had diagnoses including Paraplegia and Multiple sclerosis. A review of R48's MDS (minimum data set) with an ARD (assessment reference date) of 5/15/24 revealed R48 needed supervision from facility staff with personal hygiene. R48's BIMS (brief interview for mental status) score was 15 indicating intact cognition. A Physician's order dated 3/5/24 revealed the following: order cbc (complete blood count), cmp (comprehensive metabolic panel), tsh (thyroid stimulating hormone), A1C (average blood glucose level), vit D (vitamin D), vit B12 and lipids one time a day every 3 month(s) starting on the 1st for 7 day(s) for Hypertension. Start Date 4-1-24. Further review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to schedule a physician ordered dental appointment for one of one resident (R71) reviewed for dental services resulting in R71 not being seen by a dentist and potential for dental care needs to go unmet. Findings include: On 8/06/24 at 10:54 AM R71 was observed ambulating in the hallway with missing and decayed teeth. R71 was unable to be interviewed due to cognition impairment. According to the Electronic Health Record (EHR) R71 admitted to the facility with Medicaid benefits on 7/11/23 with diagnoses that included schizophrenia and alcohol abuse. The Minimum Data Set (MDS) dated [DATE] identified R71 to have severely impaired cognition with a Brief Interview Mental Status (BIMS) score of 5/15. On 5/22/24 the Physician ordered for the resident to have dentist evaluation for left jaw swelling. There was no documentation to support R71 had seen a dentist. R71 had a valid court-appointed Legal Guardian (LG) with current contact information 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 ensure that personal protective equipment (PPE) was worn while performing wound care for one resident (R104) out of one resident observed during wound care. Findings Include: During an observation of wound care on 8/7/24 at 10:30 AM, Registered Nurse (RN) B entered R104's room to perform wound care for a Stage lll pressure ulcer (wound with full thickness skin loss) on resident's buttock , no PPE was applied by RN B or the staff assisting with treatment. R104's door had signage warning of enhanced barrier precautions. Record review revealed R104 was admitted into the facility on 4/15/24 with a pertinent diagnosis of Pressure Ulcer (bedsore) to right buttock. According to the Minimum Data Set (MDS) dated [DATE], R104 had impaired cognition and was dependent on most Activities of Daily Living (ADLS). Record review of R104's [NAME] (care instructions) dated 8/7/24 it was documented, .Enhanced Barrier Precautions: Gown/Gloves should be worn…

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 MI00141834. Based on observation, interview, and record review, the facility failed to ensure the safe operation of the boiler systems by conducting routine inspections, resulting in inadequate heat to the fourth floor. This deficient practice has the potential to affect all residents, staff, and visitors in the facility who visit the fourth floor. Findings include: On 2/8/24 at 10:00 am in an interview with the Nursing Home Administrator (NHA) revealed the facility maintenance director was off on leave and there were no other maintenance workers employed at the time of survey. The NHA provided the contact information for the corporate maintenance director (CMD) A to be reached via phone. On 2/8/24 at 10:10 am in a phone interview with CMD A revealed there has been recent work on the boiler due to inadequate heat to the fourth floor. On 2/8/24 at 10:15 am during an observation of the environment with the NHA, the boiler was observed to not have any paperwork to specify when the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI140933. Based on observation, interview, and record review the facility failed to provide and maintain effective pest control services to prevent an infestation of rodents, resulting in uncomfortable living conditions with the potential of spreading communicable disease. This deficient practice has the potential to affect all the residents in the facility. On 12/4/23 at 10:30 a.m. upon entry into the facility, there was a strong odor of moth balls. The odor was detected throughout the first floor. On 12/4/23 at 10:47 a.m. the Director of Nursing (DON) was queried about the strong odor of moth balls. The DON said the moth balls were put down to deter mice. The DON acknowledged the facility was having a rodent problem. The DON showed a container of bait that was bought by the facility from an on-line product distributor. The labeling for use restrictions stated, Do not use in homes or other human residences . When used in USDA inspected facilities, this product must be applied 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 This citation pertains to MI00139324. Based on interview and record review, the facility failed to ensure that an allegation of resident-to-resident abuse was reported to the State Agency for one (R105) of five residents reviewed for abuse resulting in the potential for further abuse. Findings include: On 9/20/23 at 11:30 AM an incident report dated 9/17/23 #1239 was reviewed with the Nursing Home Administrator (NHA). The incident included the following: Dietary aide came to third floor and reported incident between two residents. There were two visitors in the cafeteria who reported that R105 pushed another resident after arguing about music that was playing. When the NHA was asked did you report this incident to the State Agency the NHA responded I did not report the incident because I was told it was a verbal altercation only. The NHA agreed any physical altercation between residents should be reported to the State Agency. Record Review of the nursing progress note dated 9/19/23 revealed dietary aide 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 maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting all residents who receive oral food meal services out of the facility's total census of 119 residents. Findings include: 1. On 7/31/23 at 11:13 AM, Cook, staff F, was observed taking temperatures of chicken strips and broccoli florets with a bimetal thermometer. At this time the surveyor inquired with staff F if that was the only type of thermometer they had available to use to which they stated, yes, we have several like this. Review of the U.S. Public Health Service 2017 Food Code, Chapter 4-302.12 Food Temperature Measuring Devices directs that: (B) A TEMPERATURE MEASURING DEVICE with a suitable small-diameter probe that is designed to measure the temperature of thin masses shall be provided and readily accessible to accurately measure the temperature in thin FOODS such as MEAT patties and FISH filets. Pf Further review of the 2013 Food Code Annex 3…

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 In an observation on 8/1/23 at 10:00 a.m., a urine smell was noted on the 2nd floor. A cart overflowing with soiled linen and covered with a sheet sat in the hall near dirty linen room. The linen in the cart was not individually bagged. In an observation on 8/2/23 at 9:41 a.m., a cart with soiled linen sat near resident room on the 2nd floor. The cart was uncovered, and the linen was not individually bagged. In an interview on 8/2/23 at 9:44 a.m., Unit Manager (UM) B reported the soiled linen cart stays in the hall and goes from room to room. UM B then reported the cart is usually covered. In an interview on 8/2/23 at 9:49 a.m., Licensed Practical Nurse (LPN) C reported the soiled linen cart goes room to room. LPN C reported the cart is near the room, so the CNAs don't have to carry soiled linen down the hall. LPN C confirmed that the soiled linen put in the cart is not individually bagged. In an interview on 8/2/23 at 9:51 a.m., Certified Nursing Assistant (CNA) D reported soiled linen and briefs should be put…

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

Based on observation, interview, and record review the facility failed to maintain an effective pest control program to ensure that the facility is free of pests resulting in an increased potential for contamination of food, both food and non-food contact surfaces, and foodborne illness potentially affecting staff, visitors and all 119 residents. Findings include: On 7/31/23 at 10:51 AM, two live flies were observed in the first floor's hallway. On 7/31/23 at 11:03 AM, four live flies were observed in the kitchen's dishwashing area. On 7/31/23 at 11:37 AM, three live flies were observed near the kitchen's walk-in coolers. Upon observation the surveyor inquired with Dietary Manager, staff E on the current state of the insects in this area to which they responded, we get a few now and then. On 7/31/23 at 11:39 AM, the surveyor requested the facility's pest control policy to review to which staff E responded, I have it right here. On 7/31/23 at 11:42 AM, record review of the most recent pest control service report dated, 7/13/23 revealed under the heading, pest activity found 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 and interview the facility failed to ensure that garbage storage area was maintained in sanitary condition resulting in an increased potential for the harborage and feeding of pests. Findings include: On 8/2/23 at 10:27 AM, during an environmental tour of the facility with Maintenance Director, Staff H, the exterior trash dumpsters were observed with lids in the open position, one of two dumpsters missing its side sliding doors, one of two dumpsters situated on the grass next to the pavement, along with a variety of trash and debris surrounding the area. At this time the surveyor inquired with staff H on the current state of the area to which they replied, I'm not normally here when they come and pick up, but I know we had to have a new one delivered because there were holes in the bottom of it. Every time they dumped it, trash would fall out of the bottom. I talked to them two or three weeks ago and let them know we needed another one. The surveyor then asked staff H if the area is normally found in this condition to which they stated, usually.

Based on observation and interview the facility failed to ensure that all kitchen equipment is maintained in a safe, and its originally approved operating condition resulting in an increased potential for harm. Findings include: On 7/31/23 at 11:00 AM, the automatic sensing designated handwashing sink's paper towel dispenser was observed not functioning while the surveyor attempted to dry their hands after washing them. At this time upon interview with Dietary Manager, staff E, on the current state of the paper towel dispenser they stated, It hasn't worked for a little while now, I think it's the batteries. We have a stack of paper towels we use right now instead. At this time the surveyor observed a wet stack of paper towels on the three compartment sink's side countertop. On 7/31/23 at 11:02 AM, the surveyor asked staff E if the stack of paper towels were stored on the clean or dirty side of the 3- compartment sink to which replied, Neither, it doesn't work. At this time the surveyor asked staff E to clarify why they meant by saying it doesn't work to which staff E replied, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI138254. Based on interview and record review the facility failed to allow family members to visit without restrictions for one resident (R316) reviewed for visitation rights resulting in the potential for the lack of privacy, feelings of isolation and loneliness. Findings include: On [DATE] at 1:10 p.m. the complainant was contacted and spoken to regarding the allegation family members had visitation restrictions when visiting R316. The complainant was upset while describing family members were told they had to call and make an appointment before coming to visit, and they had to stay in a common area where other residents and staff were. The complainant also said the resident was denied being able to see grandchildren due to restrictions. R316 expired on [DATE]. Per the complainant, there were family members that did not have the chance to see R316 before dying. On [DATE] at 1:16 p.m. review of the medical record documented R316 was admitted into 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 Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for personal sleeping preferences for one (R46) of 26 residents reviewed for care plans, resulting in the potential for unidentified and unmet resident care needs. Findings include: On 7/31/23 at 11:30 A.M. R46 was observed in her room with the door open and the privacy curtain positioned halfway the length of the bed. While standing in the hallway R46 was observed only wearing a brief, sleeping on a mattress without any sheet or bedding. On 8/1/23 at 11:45 A.M. R46 was observed walking to the bathroom in her room nude. The resident's door was left open and residents and staff in the hallway had full view of the resident when the resident walked from her bathroom to the doorway. At 12:30 p.m. during a lunch observation R46 was observed pacing back and forth in her room nude. The resident was observed pacing to her doorway and then abruptly exiting the room walking toward the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to correctly transcribe a physician's order for one (R38) of three residents reviewed for urinary tract infections (UTI), resulting in ineffective treatment of a urinary tract infection. Findings Include: Record review of R38's face sheet revealed admission into the facility on [DATE] and readmission on [DATE] with a pertinent diagnosis of UTI. According to the Minimum Data Set (MDS) dated [DATE], R38 had intact cognition and required limited to extensive assistance with most Activities of Daily Living (ADLs). Record review of Medication Administration Record (MAR) dated July 1, 2023, to July 31, 2023, documented the following order: Nitrofurantoin Macro crystal Oral Capsule (antibiotic) 100 MG (Nitrofurantoin Macro crystal) Give 1 capsule by mouth two times a day every 7 day(s) for UTI for 7 days. Start Date- 7/26/23 at 5:00 PM. Further review revealed R38 received one dose on 7/26/23 at 5:00 PM and had missed eleven doses by 8/1/23. During an interview…

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

Based on interview and record review the facility failed to ensure 12 hours of in-service education was provided for two of five Certified Nurse Assistances (CNA's C and E), resulting in the potential for care performance concerns. Finding include: On 8/2/2023 at 3:10 P.M., review of five CNA's training education revealed the following: 1.CNAC, Date of Hire 6/30,2011, The facility provided a computerized list for the 12 months look back of in-service training time. The total in-service hours completed 7.50 hours. 2. CNA E, Date of Hire 10/13/2014, The facility provided a computerized list for the 12 months look back of in-service training time. The total in-service hours completed 4.25 hours. At approximately 3:45 P.M., during an interview the Administrator stated: The facility has an online training system, our expectation is that all our Certified Nurse Assistances will complete the required 12-hour annual in-services. Review of the facility's policy Titled: Online Training System, revised 4/30/2020, stated in part . Certified Nurse Assistance (CNAs) are required to complete 12…

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 infection control for proper gloves use and hand hygiene and proper storage or personal resident equipment, resulting in the potential for increased cross-contamination of infection. This deficient practice had the potential to affect all residents within the facility. Findings include: In an observation on 7/31/23 at 10:38 a.m., Housekeeper L exited a resident room and wore gloves. Housekeeper L removed her gloves and put on new gloves. Housekeeper L did not perform hand hygiene before application of new gloves. In an observation on 7/31/23 at 10:42 a.m., a basin and urine collection hat sat on the floor in a resident bathroom. In an observation on 7/31/23 at 10:43 a.m., Housekeeper L exited a resident room while wearing gloves and took a mop of the housekeeping cart. Housekeeper L then reentered the resident room. Housekeeper L exited the resident room, removed gloves and did not perform hand hygiene after removing gloves. In an observation and interview on 7/31/23 at 10:45 a.m.,…

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.