Omni Continuing Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain general cleanliness and repair of the premises as well as proper storage of clean and sanitary supplies. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents. Findings Include:On 06/23/2026 at 7:53 PM observed a janitor sink with a chemical pre-dispensing system in place and the cold water faucet on in the [NAME] Hall janitor closet. This set up puts undue back pressure on the faucet's Hose Bib vacuum breaker, which can compromise the integrity of the mechanism.On 06/23/2026 at 8:02 PM observed chipped paint on the toilet base and along the interior surface of the bowl in the [NAME] Hall shower room. [NAME] discoloration was visible on the interior of the bowl in areas where paint was missing. Caulking was missing around the base and showed brown discoloration in some areas.On 06/23/2026 at 8:03 PM observed an approximate one by one foot section 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 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 in a timely manner for two residents (R32 and R54) of seven residents reviewed for PASSARs, resulting in the potential for unmet intellectual/ developmental disability care needs. Findings include: R32 Record review of R32's electronic medical records (EMR) revealed admission into the facility on [DATE] with a pertinent diagnosis of undifferentiated schizophrenia (mental illness). Further review of Brief Interview for Mental Status (BIMs) dated 3/12/25 revealed R32 scored 0 out of 15 (severe cognitive impairment). Record review of R32's PASSAR-ARR (Annual Record Review) revealed completion on 11/21/24 at 2:47 PM. A Level II…

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 Physician order for administering medications through a Percutaneous tube (Peg Tube), a flexible tube surgically inserted directly into the stomach through the skin of the abdomen to deliver nutrition, hydration, and medication, for one resident (R87) of twenty eight residents reviewed for medication administration, resulting in residents not receiving the full amount of their prescribed medications and water, and the potential for PEG tube malfunction due to clogging. Findings include: On 7/1/2025 at 8:26 a.m. during medication administration, Licensed Practical Nurse (LPN) H was observed at the medication cart preparing eight cups of R87's medications individually. LPN H was observed to pour water from a large cup into each cup of individually crushed medication cup without measuring the amount of water poured in each. LPN H was asked how much water would be given with each medication? LPN H said I just use ten milliliters of water with each medication. The Surveyor then observed LPN H attempt to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure respiratory care equipment was stored in a sanitary manner for one resident (R8) out of four residents reviewed for storage of respiratory equipment, resulting in the potential for a decline in of respiratory health. Findings include: On 6/30/25 at 10:48 A.M., R8 was observed in the resident's room. On the resident's bedside tables a CPAP machine (a continuous positive airway pressure device used for treating sleep apnea disorders), face mask and assorted tubing were observed among the resident's personal care items. The resident's face mask was uncovered positioned on the table among the assorted, used/unused tubing, one gallon container of open, undated sterile water and plastic covers. R8's visitor who interjected during the observation stated, They leave that mask and oxygen tubing like that, its not clean. R8 stated, I am supposed to use it twice a day, but they take it off and just throw it there. Throughout the interview 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 routine dental services were provided to one resident (R16) of one resident reviewed for routine dental services, resulting in unmet oral health needs and discomfort. Findings include: On 6/30/25 at 12:00 p.m. R16 was observed in the room, sitting at the bedside. R16 presented as alert and oriented to person, place, situation, and makes all needs known verbally. During the resident interview, R16 had a complaint about mouth discomfort due to teeth pain and needed to see a dentist. R16 asked staff to see the dentist and has waited for quite some time now. R16 was edentulous apart from a few back teeth. The resident opened the mouth, and the back teeth were discolored. The gums appeared swollen and red. R16 stated, There's certain things I like to eat but can't, so I eat soft things like Jello and mash potatoes. I am tired of it. R16 said the dentist removed most of the top teeth months ago but has not come back to remove the rest for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain physical facilities, install backflow prevention, date mark food, and properly cool potentially hazardous foods, resulting in the potential for increased risk of food borne illness, affecting all residents that consume food from the kitchen. Findings include: On 7/10/24 at 9:57 AM, the floor tile grout, located in the dish washing area and the cookline, was observed to be dissolving and worn, resulting in gaps for water accumulation. Additionally, the hose under the dish machine drain board was observed to not be provided with a backflow protection device (a device commonly used in plumbing to prevent contaminated water from backflowing into the potable water system). At this time, Registered Dietician E queried staff who stated the hose is used for cleaning the floor. According to the 2017 FDA Food Code Section 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair. According to the 2017 FDA Food Code Section…

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 and interview, the facility failed to maintain equipment in good repair and clean condition, properly store refuse, and maintain physical facility, resulting in contamination of equipment and a non-homelike environment, affecting all residents, staff, and visitors in the facility. Findings include: During an environmental tour on 7/10/24, assisted by Housekeeping Supervisor (HS) F, the following observation were made: 1:11 PM, the Gratiot Hall shower room was observed to have a light out over the sink, resulting in the shower room being dim. 1:31 PM, a box of wound dressing, a box of saline solution, a box of gloves, and a box of abdominal pads were observed to be stored on the floor in the respiratory supply room on the [NAME] Hall. At this time, HS F instructed staff to remove the boxes from the floor. 1:32 PM, the shower bed, located in the [NAME] Hall shower room, was observed to be soiled with discolored water. At this time, HS F stated that showers were done earlier in the day 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 complete an OBRA (Omnibus Budget Reconciliation Act) Level II Evaluation for one (R40) of one residents reviewed for PASARRs (Preadmission Screen and Resident Review), resulting in the potential for unmet mental health services. Findings include: Review of the clinical record revealed R40 was initially admitted into the facility on 8/28/2023 and readmitted on [DATE]. R40's diagnoses included seizures, unspecified convulsions, bipolar disorder, and major depressive disorder. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. The date of R40's most current Level II PASARR was 11/16/2023. On 7/10/2024 at 10:36 AM, a review of R40's most recent Level II PASARR, dated 11/16/2023, was conducted with Social Worker (SW) B. SW B said based on the Level II PASARR from 11/16/2023 a new Level II evaluation was needed by March 15th, 2024. SW B said R40 does not have a current Level II PASARR evaluation. I should have submitted 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 and interview the facility failed to provide timely ADL (Activities of daily living) care to include nail care and shaving, for three residents (R21, R53, and R56) of six residents reviewed for ADL care resulting in dissatisfaction with care. Findings include: On 7/9/24 at 11:40 AM R21 was observed upright in bed, alert and able to participate in an interview. According to record review R21 was admitted [DATE]. According to a Minimum Data Set (MDS) assessment completed 6/26/24, R21 had a Brief Interview for Mental Status (BIMS) of 15/15 indicating intact cognition. R21's nails, on the fingers of both hands, were observed to be long to the point of curving over enough to partially obscure the underside of the nails. R21 was queried about the condition of the nails and said nail clipping had been requested and commented, Two days ago I asked and today someone came and said it will be done. R21 demonstrated that it was hard to pick items up off the bedside table due to the length of the nails…

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 number MI000144806. Based on interview and record review the facility failed to obtain a Physical Therapy (PT) and Occupational Therapy (OT) evaluation upon admission for one (R345) of one resident reviewed for physical rehab, resulting in delayed Physical and Occupational Therapy treatment. Findings include: Review of an admission Record revealed, R345 readmitted to the facility on [DATE] and discharged [DATE] with pertinent diagnosis which included tracheostomy status and gastrostomy status. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R345 had severely cognitive impairment. Review of Physician orders revealed R345 had orders for physical therapy evaluation- treat as indicated and occupational therapy evaluation- treat as indicated dated 5/24/24. Review of an interdisciplinary therapy screen assessment dated [DATE] revealed, PT/OT evaluation recommended for R345. Review of R68's electronic medical record revealed, R68 did not have a PT or OT evaluation.…

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 the standards of infection control for proper PPE use (mask, gloves, gown) and proper hand hygiene, for one resident (R68) out of three residents reviewed for tracheostomy care, resulting in the increased potential for cross-contamination of diseases which place a vulnerable population at high risk for infections. Findings include: In an observation on 7/9/24 at 11:37 a.m., R68 laid in bed and had a tracheostomy. The suction tubing laid on the floor. R68's door had an Enhanced Barrier sign which read, . Providers and Staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities . Device care or use: tracheostomy . Review of an admission Record revealed, R68 admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included chronic respiratory failure with hypoxia and tracheostomy status. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R68 had 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 proper anchoring/securing of an indwelling urinary catheter for one (R73) of four residents reviewed for urinary catheters, resulting in pain and the potential for infection and skin trauma. Findings include: In an observation on 6/21/23 at 10:35 a.m., Resident #73 (R73) laid in bed and had a urinary cathete. Tea colored urine was observed in the tubing. Review of an admission record revealed, R73 admitted to the facility 11/4/22 and readmitted on [DATE] with pertinent diagnosis which included Obstructive and Reflux Uropathy (the backup of urine into the kidneys) and Benign Prostatic Hyperplasia (prostate pushes against the urethra and the bladder). Review of a Minimum Data Set (MDS) assessment, with a reference date of 5/10/23 revealed R73 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 14 out of 15 and required an indwelling catheter. In an observation on 6/26/23 at 8:58 a.m., Certified Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure complete and accurate documentation was maintained in an Electronic Health Record (EHR) for one resident (R139) of 20 residents reviewed resulting in inaccurate and incomplete medical records with the the potential for inadequate care delivery. Findings include: A review of R139's EHR revealed 16 consecutive progress notes from 11/7/22 through 4/17/23 written by Nurse Practitioner (NP) A with the exact same documentation that included; Hematuria (blood in the urine), continue to flush foley. UA (urinalysis) and cultures (C&S) reviewed, negative, (11/7/22, 11/9/22, 11/14/22, 11/16/22, 11/25/22, 11/28/22, 12/8/22, 12/15/22, 12/19/22, 12/22/22, 1/5/23, 1/23/23, 2/20/23, 3/20/23, 4/5/23, and 4/17/23). Review of R139's progress notes written by the physician and other nursing staff did not reveal any documentation to indicate the resident had hematuria during this time. A Urinalysis result for R139 collected 10/26/22 and reported on 10/27/22 indicated…

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.