Regency at Chene

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 (R408) of one resident reviewed for dialysis services had timely and complete physician orders for dialysis, restrictions associated with an arteriovenous (AV) fistula, and clearly defined fluid restriction parameters. This failure created the potential for missed treatment, compromised vascular access and inadequate fluid management. Findings Include: On 5/7/2025 at approximately 11:00 AM, observed R408 had three cups of liquid at her bedside. There was also one liter bottle of juice on the bedside table directly behind R408. On 5/7/2025 at 11:30 AM, a review of R408's clinical medical record was conducted. The electronic medial record (EMR) lacked a physician order for dialysis. No orders were noted to restrict staff from obtaining blood pressures on R408's left arm, which contained an AV fistula used for dialysis. The EMR review indicated unclear directives regarding fluid restrictions for R408, lacking specific…

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 wheelchair footrests were in place during a wheelchair transfer and to assist with seated posture for one resident (R19) of two residents reviewed for positioning resulting in the potential for injury. Findings include: On 5/06/25 at 11:46 AM, R19 was observed sitting in the second-floor dining room participating in an activity. R19 appeared seated in a slouched position in the wheelchair without footrests with her feet dangling in the air. Activities Assistant (AA) R was observed leading the activity. On 5/06/25 at 11:53 AM, AA R was observed pushing R19 down the hallway in a wheelchair. The wheelchair did not have footrests. R19 was observed seated in a slouched position leaning back with her feet dangling in the air. On 5/06/25 at 12:30 PM, R19 was interviewed regarding the lack of footrests on her wheelchair. R19 stated, The girls don't put on the footrests to my chair. They take them off and don't put them back on. On 5/06/25…

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 pressure ulcer care per health care provider order and standards of clinical practice for two Residents (R121 and R143) of four Residents reviewed for wound care, resulting in incorrect wound care, and the potential for wound worsening, infection, and overall deterioration in health status. Findings include: Resident # R121 On 05/06/25 at 9:22 AM, R121 was observed in bed, fully dressed, and watching TV. R121 was observed to have a left above the knee amputation (Above-the-knee amputation (AKA) involves removing the leg from the body by cutting through both the thigh tissue and femoral bone). R121 said they had had recent surgery about a month ago due to an infection. R121 indicated that staff changed their wound dressings daily. A review of R121's electronic medical record revealed an admission to the facility on [DATE] with the diagnoses of Atrial Fibrillation, Heart failure, Chronic Obstructive Pulmonary Disease, Depression,…

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 adequate foot care for one resident (R100) out of eleven residents reviewed for Activities of Daily Living (ADLS). Findings include: On 5/06/25 at 10:51 AM, R100 was interviewed about care in the facility and stated, They don't do enough, my nails are long. R100s feet were observed with thick long toenails and dry flaky skin. On 5/08/25 at 10:20 AM, R100's feet were observed with Registered Nurse (RN) K. RN K described R100's feet as having long thick toenails and flaky skin on feet and that R100 should see the podiatrist. RN K asked R100 if he would like podiatry services and R100 agreed. Record review of R100's Electronic Medical Record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses that included Epilepsy, Hemiplegia and Hemiparesis (weakness) following Cerebral Infarction (stroke) affecting Right Dominant Side. Review of the Minimum Data Set (MDS) dated [DATE] for R100 revealed a Brief interview 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 apply splints and provide Range of Motion (ROM) exercises for one resident (R100) out of four residents reviewed for limited ROM. Findings include: On 5/06/25 at 10:52 AM, R100 was observed in bed with his right elbow and right hand bent not wearing a brace or splint. On 5/07/25 at 10:13 AM, R100's splints were found in his dresser top drawer. When asked about the braces R100 stated, They don't put the splints on me they have too much to do. I would allow it, but they aren't doing it. On 5/08/25 at 10:27 AM, Certified Nursing Assistant (CNA) X was interviewed and said they were not applying R100's splints or performing a ROM program with him. On 5/08/25 at 10:28 AM, Registered Nurse (RN) K was interviewed and said the facility did not have a restorative nurse or aides and the CNAs were responsible for applying splints and performing exercises. RN K said she was new to the position. On 5/08/25 at 10:33 AM, Restorative Nurse Y was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one resident (R54) of 29 residents was free from accident hazards as a results of the resident's call light not being within reach and potentially hazardous products left at the resident's bedside, resulting in a potential for an accident to occur. Findings include. On 5/6/25 at 12:28 P.M., (R54) was observed in bed with the call light entangled in the linen. On the bedside table was a container of hydrogen peroxide and a container of Comet household cleaner. On 5/7/25 at approximately 2:30 P.M. during an observation R54's call light was on the floor, out of reach and the resident was unaware of the location of the call light. R54's bed was positioned at the highest height as the resident asked for an aide and/or nurse. R54 repeated the request stating, I feel sick. Nurse Aide HH responded, summoning assistance from nurse DD voicing symptoms and concerns of the resident. At 3:27 P.M. after providing care to R54 nurse aide HH was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure respiratory equipment was maintained in a sanitary manner for one resident (R28) of three residents reviewed with oxygen, resulting in the potential for compromised air exchange. Findings include: On 5/6/25 at 11:30 A.M. during an observation R28 was observed with oxygen infusing at 3.5 Liters per minute via Nasal Cannula. Attached to the oxygen tubing which was dated 5/5/25 was an oxygen concentrator (a medical devices that provides extra oxygen. An oxygen concentrator uses the air in the atmosphere, filters it and gives you air that is 90%-95% oxygen). On 5/7/25 at approximately 12:00 P.M. record review revealed R28 was signed into hospice on 3/7/25 and the comprehensive plan of care, and the hospice consent were faxed to the facility on 5/6/25. Review of the provided contract and delegated responsibilities of each entity did not identify who was responsible for the maintenance of the oxygen received by R28. On 5/7/25 at 12:30…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the security of the electronic medical record (EMR) of one resident (R306) out of 29 residents reviewed. Findings Include: On 5/7/2025 at 9:30 AM, a medication cart on unit 300 was observed left unattended with the EMR screen open and displaying R306's PHI. The cart faced the hallway, which was actively used by staff and residents, exposing confidential details to unauthorized individuals. On 5/7/2025 at 9:40 AM, Licensed Practical Nurse (LPN) C exited R306 room and, upon interview, confirmed they left the art unsecured with PHI visible. LPN C acknowledged this was not in compliance with facility protocol. 05/07/25 9:53 AM, the unit manager (LPN) B was interviewed and said the computer should have been locked, and no medications should be left unattended on the cart. 05/07/25 10:52 AM, the Director of Nursing (DON) was interviewed and confirmed staff are expected to follow facility policy regarding medication cart security,…

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 (R10) of three residents reviewed for routine dental services, resulting in unmet oral health needs. Findings include: On 5/6/2025 at 11:31 AM, R10 was observed in his room resident demonstrated he did not have teeth. When R10 was asked about his oral health he was not able to provide an answer. On 5/6/2025 at 11:36 AM, Guardian I was interviewed and stated, R10 needs to see the dentist to get dentures. Record review of R10's Electronic Medical Record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses that included Acute Cerebral vascular insufficiency (obstruction of blood flow to the brain) and dysphagia. Review of the Minimum Data Set (MDS) dated [DATE] for R10 revealed a Brief interview for Mental Status (BIMS) of 0/15 which indicated severe cognitive impairment and did not have the oral/dental status completed. Review of the Physician Orders dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the proper assistive device was provided to enhance and promote independence in eating for one resident (R126) of 30 residents observed during dining on the second floor, resulting in a potential for a decline in eating skills and abilities. Findings include: On 5/6/25 at approximately 10:00 A.M. R126 was interviewed concerning the breakfast meal. R126 was observed with two white towels rolled and positioned in each hand. R126 stated his meals were served in the restorative Dining Program. On days when R126 went to therapy, meals were left in the room and the resident fed himself. On 5/6/25 at 1:01 P.M., and 5/7/25 at 12:50 P.M., during a lunch meal observation R126 was observed being fed (1:1) by a nurse aide. R126's food was served on a regular China plate with the beverage served from a sippy cup. The tray card served with the meal on 5/6/25 stated: mechanical soft regular diet adaptive equipment: Scoop plate. On 5/8/25 at 9:00…

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 relevant Hospice documentation was accessible for two residents (R28, R67) of nine hospice residents from a total of twenty-nine sampled residents, resulting in a lack of coordination of comprehensive services and care provided to the residents. Findings included: Resident # R28 (R28) On 5/7/25 at 11:57 AM nurse P was asked for the location of the Hospice Notebook for R 28. Nurse P indicated all the resident's visits should be in a binder located at the nurse's station. Nurse P searched the residents Hospice Notebook and acknowledged the visits were present, but no other hospice documentation was there. Nurse P indicated she would contact Unit Manager K. who could assist further. On 5/7/25 at 12:11 PM a review of the Hospice Notebook identified for R28 revealed there was no comprehensive assessment, consent for Hospice benefits, or Hospice comprehensive plan of care. On 5/7/25 at 12:20 PM Unit Manager (UM) K was unaware of where 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 administer the Pneumococcal and Influenza vaccines to one resident (R10) of five residents reviewed for infection control resulting in the likelihood for increased risk for acquiring, transmitting and experiencing complications from the pneumonia and the flu. Findings Include: On 5/12/25 at 10:20 AM, the Infection Control Program was reviewed with the Infection Control Registered Nurse (RN) A. RN A was provided a list of residents to be reviewed for vaccinations. RN A provided documentation that R10 did sign to receive the Pneumococcal and Influenza vaccinations on 8/8/2024. There was no documentation that R10 had received either the Pneumococcal or Influenza vaccinations. RN A said she was unable to find the documentation that the vaccination was administered in the vaccination book or in the electronic medical record (EMR). 05/13/25 10:15 AM, the Director of Nursing (DON) was interviewed and acknowledged that there was no documentation that R10 had…

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 MI00150096. Based on observation, interview and record review the facility failed to follow the standard of practice for medication administration for one (R101 of four residents reviewed for medication administration. Findings include: The State Agency received a complaint that R101 did not receive medications on 2/6/25 during the evening medication pass. On 3/25/25 at 10:00 AM R101 was observed in their room, seated in bed watching TV. R101 was interviewed regarding the complaint of missing medications. R101 was observed to open up a notebook and said, Yes, on February 6th I didn't get any of my medications that night. I was worried because I was supposed to get insulin and a blood pressure pill at that time. I didn't say anything to the nurse. The next morning the day shift nurse took my blood pressure and checked my blood sugar. Everything was OK, but it still bothers me that I didn't get my medications that night. R101 did not know who the nurse was on the afternoon/night…

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 MI00150096. Based on observation, interview, and record review, the facility failed to have complete and accurate medical records for one (R101) of four residents reviewed for medication administration resulting in the medication administration record (MAR) left blank and the inability to determine what nurse was assigned to the resident according to the MAR. Findings include: The State Agency received a complaint that R101 did not receive medications on 2/6/25 during the evening medication pass. On 3/25/25 at 10:00 AM R101 was observed in their room, seated in bed watching TV. R101 was interviewed regarding the complaint of missing medications. The resident opened up a notebook and said, Yes, on February 6th I didn't get any of my medications that night. I didn't say anything to the nurse. R101 did not know who the nurse was on the afternoon/night shift of 2/6/25. According to the resident's Electronic Health Records (EHR), R101 admitted to the facility on [DATE] 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 This citation pertains to intake MI149002. Based on observation, interview, and record review the facility failed to ensure appropriate PEG (percutaneous endoscopic gastrostomy (thin flexible tube inserted through the skin of the abdomen into the stomach to deliver nutrition and hydration) tube care was provided including enteral/tube feedings (liquid nutrition delivered through a PEG tube) and water administration for one (R901) of three residents reviewed for PEG tube care, resulting in R901's not receiving the prescribed amount of enteral/tube feeding or water and peg tube care not being provided in accordance to the physician's orders. Findings include: On 1/6/25 at approximately 10:20 AM, R901 was observed lying in bed with tube feeding infusing through a PEG tube using an infusion pump to regulate the rate and amount. The tube feeding bag was unlabeled, undated, and there was no time to indicate when the tube feeding was hung. There was approximately 500 milliliters (ml) remaining in the tube feeding bag.…

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 MI00149002. Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices related to enhanced barrier precautions (EBP) for one resident (R901) of three residents reviewed for wound and PEG tube care (percutaneous endoscopic gastrostomy (thin flexible tube inserted through the skin of the abdomen into the stomach), resulting in the potential for the spread of infection. Findings include: On 1/6/25 at 10:30 AM, R901 was observed lying in bed with tube feeding running though a PEG tube by using an infusion pump to regulate the rate of feeding. R901's brief and gown were not covered by a sheet or blanket and were visibly soiled with a brownish liquid. A soiled split 4 x 4 gauze (pre-cut gauze dressing to allow the dressing to lay flat when covering an external catheter insertion site) was observed lying in the residents bed (not adhered to the resident) with dried dark reddish colored drainage on it. At this time Licensed…

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 maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 143 residents who receive meal services (3 nothing by mouth residents, or NPO) out of the facility's total census of 146 residents. Findings include: 1. On 4/17/24 at between 10:15 AM, and 10:42 AM, the following non-food contact surfaces in the kitchen were observed soiled and with visible debris on their surfaces: On the ventilation filters above the fryer. On the top and sides of the fryer. On the sides of the oven next to the fryer. On the grates of the flat top grill. On the six burner oven's stainless steel backsplash. Upon observation the surveyor inquired with Dietary Director, staff A, on if they thought these areas were being cleaned timely and sufficiently to which they replied, these areas are cleaned three times a day after each meal, but it looks like we can improve on it. On 4/17/24 at 11:25 AM, the surveyor requested a copy of the kitchen's cleaning policy…

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 that the garbage storage area was maintained in sanitary condition resulting in an increased potential for the harborage and feeding of pests. Findings include: On 4/18/24 at 10:27 AM, during a tour of the facility with Dietary Manager, staff A, and Cook, staff E, the exterior trash dumpsters were observed with lids in the open position, along with a variety of trash, debris, and used fryer oil surrounding the area. At this time the surveyor inquired with staff A and staff E on the current state of the area to which staff E replied, They just picked it up today, every time they dump it, it looks like this, and they leave the doors open. At this time the surveyor asked staff A if the facility had a waste disposal policy to review to which they stated, yes, I'll get you a copy. On 4/19/24 at 9:27 AM, record review of a policy dated, 4/2015, and titled, Waste Disposal revealed in item number five that, Outside dumpsters will be maintained in a clean manner. Trash will not be overflowing and lids will…

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 ensure the 2nd floor 'wireless' nurse call light system was effectively utilized by staff or had consistently functioning centralized monitor screens on the second floor resulting in the potential for delayed call light response times, and the potential for resident care needs of 47 residents to be unmet. Findings include: On 4/17/24 at 1:36 PM, upon an environmental tour of the facility, resident room [ROOM NUMBER]'s bedside nurse call devices cord was observed frayed and taped over in two sections. At this time the surveyor tested the nurse call device at the bedside and went to the nurse's station to determine its functionality. Upon entering the nurses station, the surveyor heard no audible alarm, however the bedside nurse call device was shown flashing on a computer monitor. On 4/17/24 at 1:37 PM, upon interview with Registered Nurse, staff C, on the lack of an audible alarm being present for the nurse call system they stated, Oh, it works. We just…

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 dignity by not dressing one resident (R16) in personal clothing out of one resident reviewed for dignity, resulting in verbal frustration and impaired mental and psychosocial well-being. Findings include: On 4/16/2024 at 12:26 p.m., R16 was observed in the hallway sitting in a wheelchair fully dressed. R16 reported there was a problem wearing other resident's clothes. R16 stated, These clothes I am wearing are not [NAME] and I want to wear my clothes that I came into the facility with. The clothes R16's was wearing revealed no resident's name. Observed R16' s closet with a coat, three jackets, two sweaters, one blouse with pants and a blanket. R16 was asked how it feels to wear other resident's clothes. R16 head drop with a saddenned face and stated, I don't like it, I don't know who had those clothes on and I don't want to wear them. On 4/18/2024 at 10:02 a.m. R16 reported while dressed in a gown in bed, wanting to be dressed 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 a call light was within reach for one resident (R43) and a wheelchair provided for one resident (R108) of six residents reviewed for accommodation of needs, resulting in unmet care needs. Findings include: R43 On 4/16/2024 at 12:32 p.m., R43 was observed lying in bed with no call light within reach. During an interview, R43 was looking for the call light to get assistance to be repositioned and confirmed being uncomfortable. R43 stated, I can't find it (the call light). On 4/16/2024 at 1240 p.m., Licensed Practical Nurse (LPN) H was interviewed regarding the call light use and purpose. LPN H said, the purpose of a call light is to call for assistance. LPN H confirmed the call light was not within reach for R43. LPN H reported resident needed to be repositioned for comfort and safety. According to the electronic medical records, R43 was admitted into the facility on 8/18/2023 with diagnoses of dysphagia (difficulties in swallowing),…

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 one (R21) of three residents reviewed for PASSARs, resulting in the potential for unmet intellectual/ developmental disability care needs. Findings include: Review of an admission Level I screen dated 1/29/24 revealed R21 had no mental illness or dementia. R21 did not have a Level I screen after 1/29/24. Review of an admission Record revealed, R21 admitted to the facility on [DATE] with pertinent diagnosis which included bipolar disorder and paranoid personality. Review of a Minimum Data Set (MDS) assessment dated of 2/3/24 revealed R21 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 9 out of 15 and took…

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 revise care plans in a timely manner for two residents (R18 and R121) out of thirty residents reviewed for care planning. Findings include: R18 During an observation on 4/17/24 at 10:25 AM, R18 had bilateral above the knee amputations and two open wounds on the bottom back side of right leg. Record review of electronic medical records revealed admission into the facility on 5/18/23 with pertinent diagnosis of acquired absence of right and left leg above knee. According to the Minimum Data Set, dated [DATE]. R18 had slight impaired cognition and required substantial assistance with Activities of Daily Living (ADLS). Record review of R18's Transition of Care Form dated 6/8/23, documented the following: . Primary Diagnosis: Above the knee amputation of left lower extremity. Record review of R18's active care plans revealed the following: Focus: R18 has Actual impairment to skin integrity r/t (related to) vascular ulcers to left calf, left…

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 appropriate discharge plan to return to the community (home) for one (R79) out of three residents sampled for discharge planning, resulting in a loss of independence, unmet psychosocial needs, and support from family. Findings include: On 4/16/24 at 2:48 p.m. R79 was observed in bed resting. The resident angrily expressed wanting to know discharge plans, I have been her for two months. I'm not getting therapy. I'm not doing anything but laying here. I have everything I need at home. I keep being told I have to wait for the doctor to discharge me, but he hasn't been in here to see me. I want to go home! R79 was alert, oriented to person, place, and situation, and expressed needs and feelings. On 4/17/24 at 12:10 p.m. review of the clinical record documented R79 was initially admitted into the facility on 1/3/24 and readmitted from the hospital on 2/7/24 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type 2 diabetes mellitus,…

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 nail care, scheduled showers, and assist with transfers out of bed for two residents (R13 and R100) out of thirty residents reviewed for Activities of Daily Living (ADLS). Findings Include: R100 During an observation and interview on 4/16/24 at 12:57 PM, R100 was observed lying in bed with long fingernails with debris underneath nails. Resident reported that he would like his nails to be cut and cleaned. Record review of R100's Functional Ability Deficit care plan dated 12/14/23, documented Personal Hygiene- Resident is dependent. Further review of care plans and nursing progress notes revealed no preference for long nails or refusing nail care by resident in the last month. Record review of R100's electronic medical records revealed admission into the facility on 9/3/20 with a pertinent diagnosis of hemiplegia (paralysis of one side of body). According to the Minimum Data Set (MDS) dated [DATE], R18 had intact cognition 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 provide adequate assessment and monitoring of wounds for one resident (R18) out of three residents reviewed for wound care management. Findings Include: During an observation and interview on 4/17/24 at 10:25 AM, R18 two open wounds on the bottom back side of right leg that measured approximately 0.5 cm (Centimeters) long and 0.5 cm wide with a depth of 0.1 cm each. Licensed Practical Nurse (LPN) G reported being made aware of wounds on 4/15/24. Record review of electronic medical records revealed admission into the facility on 5/18/23 with pertinent diagnosis of acquired absence of right and left leg above knee. According to the Minimum Data Set (MDS) dated [DATE]. R18 had slight impaired cognition and required substantial assistance with Activities of Daily Living (ADLS). Record review of Nurses Notes dated 4/7/24 at 12:57 PM documented the following: Note Text: Writer found two open areas to right stump. CNA (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 observation, interview, and record review the facility failed to provide vision services for one resident (R13) of two residents reviewed for assistive devices, resulting in inadequate eyewear for R13. Findings include: During an observation and interview with R13, on 4/16/2024 at 10:40 a.m., the resident was observed wearing a pair of reading glasses and holding the glasses with hand and tape on the right side of the frame (arm), while reading some literature in bed. R13 said the glasses had been broken for about two weeks and everyone knew and saw the glasses was taped up. R13 said the glasses are not prescription glasses and the reading glasses were brought in by brother from the store, because no one at the facility was assisting with getting another pair. The prescription glasses had been lost about two years at the hospital. R13 confirmed the prescription glasses were needed to see when watching television, reading and everything else. The resident further reported several requests made to social…

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 (gloves), hand hygiene, and point of care testing, for one resident (R79) out of four residents reviewed for medication administration, resulting in the potential for increased cross-contamination of diseases which place a vulnerable population at high risk for infections. Findings include: In an observation on 4/18/24 at 8:14 a.m., Licensed Practical Nurse (LPN) P entered R79's room with blood glucose supplies in hand with gloved hands. LPN P placed the glucometer (used to test blood sugar levels) on R79's bed and not on a barrier. LPN P then poked R79's finger with lancet and collected blood in the glucometer strip. LPN P removed the gloves, disposed the lancet in sharps box, exited the room and did not perform hand hygiene. In an observation on 4/18/24 at 8:17 a.m., LPN P placed the glucometer in the med cart and did not clean it after use. LPN P did not perform hand hygiene…

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 MI00141762. Based on interview and record review, the facility failed to provide accurate resident identifying documents and medical records upon emergent transfer to the hospital for one resident (R601) of three residents reviewed for emergency transfer, resulting in resident identification and medical information not being sent with EMS (Emergency Medical Service) personnel to the hospital and the potential for unmet care needs upon transfer. Findings include: Review of an admission Record revealed, R601 admitted to the facility on [DATE] with pertinent diagnoses which included Atrial Fibrillation (abnormal heart rhythm), Hypertension (high blood pressure), and Type 2 Diabetes. Review of a Minimum Data Set (MDS) assessment, with a reference date of 12/13/23 revealed R601 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15, out of a total possible score of 15. Review of Physicians order revealed, R601 had an order transfer to ER (emergency…

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 staff adhered to transmission-based precautions during meal pass on Unit 300, resulting in the potential for the spread of harmful pathogens among the residents in the building. Findings include: On 10/24/23 at 8:43 AM, the door to an isolation room (Room XX) was opened. Licensed Practical Nurse (LPN) C closed the door and said the resident in Room XX was diagnosed with COVID-19. During an observation on 10/24/23 at 12:43 PM, Certified Nurse Aide (CNA) G entered isolation Room XX to deliver a lunch meal tray without donning person protection equipment (PPE). A sign on the door to Room XX indicated the room was occupied by a resident on contact and droplet precautions. On 10/24/23 at 12:45 PM, a second meal tray was delivered to isolation Room XX by CNA H who donned a face shield, gloves, mask, and gown prior to entering the room. CNA H was observed exiting the isolation room into the hallway with the gown still on. CNA H said she was supposed to take it off in the room but was looking for a bag. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intakes MI00138233 and MI00139515. Based on observation, interview, and record review, the facility failed to ensure prescribed medications were provided in a timely manner for two residents (R134 and R139) out of seven residents reviewed for medication administration, resulting in resident apprehension and the potential for unmet health care needs. Findings include: It was reported to the State Agency that the facility was short staffed and residents were getting their medications late. R134 On 10/24/23 at 8:44 AM the Medication Administration Records (MARs) for Unit 400 were reviewed with LPN C. The MAR for Resident #134 (R134) who resided on Unit 400 was colored red. LPN C said when the MAR was red that signified the medication administration is late. R134 was scheduled to receive four units of Lispro (fast-acting) insulin at 7:00 AM. LPN C said the insulin should have been administered by 7:59 AM at the lastest. On 10/24/23 at 8:50 AM, R134 was observed awake and in bed with his…

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 MI00138483 and MI00139515. Based on interview and record review, the facility failed to ensure medications were accurately documented as administered per physician's orders for R120 and 125 resulting in inaccurate and incomplete medical records. Findings include: It was reported to the State Agency that staff were not following physician's orders for medication administration. A review of the clinical record for Resident #120 (R120) documented an admission to the facility on 5/2/23 with diagnoses that included hypertension, dysphagia, schizophrenia, major depressive disorder, and gastro-esophageal reflux disease. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment. A review of R120's September 2023 and October 2023 Medication Administration Records (MAR) revealed no documented entries for the administration of the following medications: - Atorvastatin 40 mg tablet for hypertension on 9/8/23 - Mirtazapine 7.5 MG tablet for dysphagia on 9/8/23,…

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 MI00129879 and MI00130059. Based on interview and record review, the facility failed to inform the family/resident representative of a change in condition for one resident (R195) of five residents reviewed for change in condition, resulting in the family not knowing the resident had a skin tear. Findings include: Review of an admission Record revealed, Resident #195 (R195) admitted to the facility on [DATE] with pertinent diagnosis which included COVID-19. Review of a Minimum Data Set (MDS) assessment, with a reference date of 6/29/22, revealed R195 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 10 out of 15. Review of a progress note for R195 with a date of 6/26/23/22 at 10:50 a.m. revealed, Late Entry . pt (patient) has old bruise on right arm that opened small skin tear noted wound care was done and cleaned and wrapped with kerlix. will notify wound care to evaluate. The progress note was created on 6/26/22 at 10:56 a.m. Review of a progress note…

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 MI00129879. Based on interview, and record review, the facility failed to identify, assess, and implement timely skin care for one resident (#195) out of three residents reviewed for skin conditions, resulting in delay in treating skin concerns and the potential for other skin care needs to go undetected. Findings include: Review of an admission Record revealed, Resident #195 (R195) admitted to the facility on [DATE] with pertinent diagnosis which included COVID-19. Review of a Minimum Data Set (MDS) assessment, with a reference date of 6/29/22 revealed R195 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 10 out of 15. Review of a progress note for R195 with a date of 6/23/22 at 10:50 a.m. revealed, Late Entry . pt (patient) has old bruise on right arm that opened small skin tear noted wound care was done and cleaned and wrapped with kerlix. will notify wound care to evaluate. Review of a progress note with a date of 6/27/22 at 4:45 a.m. revealed,…

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 MI00131349. Based on interview and record review the facility failed to ensure the physician supervised one of one reviewed for resident's medical care (R196) resulting in the lack of physician involvement for two facility aquired pressure ulcers. Findings include: The State Agency received a complaint that R196 developed pressure ulcers that went untreated while at the facility from 8/3/22 - 8/15/22 when he was quarantined for Covid-19. According to R196's Electronic Health Record (EHR), the resident directly admitted into the facility's Covid unit from another long-term care facility on 8/3/22 because he tested positive for Covid-19. R196 had additional diagnoses that included vascular dementia and cellulitis of his left lower leg, right foot/3rd toe, and right lateral heel. admission orders included prescribed skin treatments for left lower leg, right foot/3rd toe and right lateral heel every day adn prn (as needed). According to a nurse's progress note dated 8/4/22 at 12:15…

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 MI00131349. Based on interview and record review, the facility failed to maintain complete and accurate medical records for two residents (R195 and R196) reviewed for comprehensive and accurate medical records, resulting in an inaccurate reflection of the resident's medical condition and treatments along with the potential for providers to not have an accurate picture of the residents's status and condition. Findings include: Resident #196 (R196) The State Agency received a complaint that R196 developed pressure ulcers that were not treated while at the facility during Covid-19 quarantine from 8/3/22 - 8/15/22. According to R196's Electronic Health Record (EHR), the resident directly admitted into the facility's Covid unit from another long-term care facility on 8/3/22 because he tested positive for Covid-19. R196 had additional diagnoses that included cellulitis of his left lower leg and right foot/3rd toe and right lateral heel. According to a nurse's progress note dated 8/4/22…

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.