The Orchards at Northwest

Based on observation, interview and record review, the facility failed to ensure a medication cart was secured in accordance with professional standards for one medication cart of six medication carts reviewed for medication storage and safety.Findings include: On 03/08/2026 at 08:38 AM, during a tour of the third floor, a medication cart on hall Three- East was observed with a tubular lock key system extended outward (unlocked). The drawers to the cart were opened and closed to ensure findings. Three unidentified residents were observed sitting in wheelchairs close to the medication cart. One unidentified resident was observed walking up and down the Three-East hallway. No staff were observed in the Three-East hallway. The medication cart was stationed not accessible to view of the nursing desk.On 03/08/2026 at 08:40 AM, Nurse Q was observed walking back towards the Three-East Hall. Nurse Q was asked about the unlocked medication cart. Nurse Q stated that nurses are expected to lock their medication carts when not in view of their cart.On 03/10/2026 at 10:54 AM, the Director of…

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

Based on observation, interview, and record review, the facility failed to: 1. Clean surfaces in the kitchen that were visibly soiled; 2. Maintain easily cleanable floors in various areas of the kitchen; 3. Ensure properly working garbage disposal and sink faucet; 4. Ensure chemical solution (quaternary) was an effective sanitizer; 5. Ensure pans were clean and air dried before stacking. This deficient practice would affect any resident that consumed food from the kitchen. Findings include: On 1/6/25 at 10:38 AM, during the initial tour of the kitchen with Dietary Manager (DM) N the following was observed: - caked up dust covered a white opaque circular disk above the handwashing sink - the trash can lid near the handwashing sink appeared dirty and uncleaned. - several floor tiles in the dish tank machine were chipped or missing rendering a floor surface not easily cleanable. - a splattering of grits was on the backsplash of the drain board on the clean side of the commercial dishmachine On 1/6/25 at 12:00 PM, during a return visit to the kitchen, the splattering of grits remained…

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 implement an effective Quality Assurance and Performance Improvement (QAPI) program. Findings include: On 1/8/25 at 3:12 PM, the Nursing Home Administrator (NHA) was interviewed about the facility's QAPI program and process and identified customer service and adherence to the resident smoking policy as areas of concern and opportunities for improvement. The NHA said they were trying to get staff to speak with residents in a professional manner and that resident needs were being met. The NHA indicated that residents were keeping smoking paraphernalia on their persons and were going out to smoke when they got ready and there was no supervision. The NHA was unable to provide objective data gathered regarding these areas of concern. Therefore there was no analysis performed to identify trends and measure the effectiveness of the performance improvement plan. The NHA said the best practice would have been after the problem was identified to count the actual defective items and analyze the data monthly for improvement. 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, interview and record review, the facility failed to continuously implement and operationalize a comprehensive infection control program, encompassing outcome and process surveillance, accurate data collection/documentation/analysis, resulting in a lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis and the potential for the spread of microorganisms, illness and other harmful pathogens among other residents that reside in the facility. Findings include: On 1/8/25 at 9:29 AM, a review of the facility's infection control program was conducted with the Director of Nursing (DON) who has performed as the facility's designated infection control leader since August 2024. Review of the infection control books provided by the facility revealed no documentation of an infection control program from August 10, 2024, through September 30, 2024. The DON confirmed prior to her running the infection control program, it was overseen by the Infection Preventionist (IP) who resigned in early August of 2024. The DON said, I hired…

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

Based on interview, and record review the facility failed to maintain a continuous Antibiotic Stewardship Program that included monitoring antibiotic usage and following protocols for antibiotic use resulting in the potential for unnecessary medications and antibiotic resistance. Findings include: On 1/8/25 at 9:29 AM, a review of the facility's infection control program was conducted with the Director of Nursing (DON) who has performed as the facility's designated infection control leader since August 2024. Review of the infection control books provided by the facility revealed no documentation of an infection control program from August 10, 2024, through September 30, 2024. The DON confirmed prior to her running the infection control program, it was overseen by the Infection Preventionist (IP) who resigned in early August of 2024. The DON said, I hired another IP in September, but it did not work out. The DON was asked how they were able to identify residents on antibiotics during the months of August and September 2024. The DON said that they talked about residents on antibiotics…

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 continuity of care for the role of an Infection Control Preventionist (ICP) and ensure the ICP completed specialized training in infection prevention and control, resulting in the potential for knowledge deficits pertaining to current infection prevention and control standards, outbreaks going undetected because of inadequate infection control surveillance, and a delay in infection control data collection and summary. Findings include: On 1/8/25 at 9:29 AM, a review of the facility's infection control program was with the Director of Nursing (DON) who has performed as the facility's designated infection control leader since August 2024. Review of the infection control books provided by the facility revealed no documentation of an infection control program from August 10, 2024, through September 30, 2024. The DON confirmed prior to her running the infection control program, it was overseen by the Infection Preventionist (IP) who resigned in early August of 2024. The DON was asked when they completed the Nursing Home…

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 screen residents for eligibility to receive the COVID 19 vaccine and/or booster, provide education regarding the COVID 19 vaccine and/or booster, and offer the COVID 19 vaccine and/or booster, resulting in residents not receiving the Covid-19 immunization, and the potential for decreased protection from SARs-CoV-2 virus and serious illness and complications among residents that reside in the facility. Findings include: On 1/8/25 at 9:29 AM, a review of the facility's infection control program was conducted with the Director of Nursing (DON) who has performed as the facility's designated infection control leader since August 2024. Review of the infection control books provided by the facility revealed no documentation of an infection control program related to COVID 19 vaccines and/or boosters. The DON was asked about their COVID 19 vaccines. The DON stated, We do not have any COVID 19 vaccines. No one has received the vaccine. The DON also stated that they previously had an outside company that would come into the facility,…

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 residents with nail care, oral care, shaves, hair care, and body hygiene for five residents (R2, R49, R51, R108, and R112) out of nine residents reviewed for Activities of Daily Living (ADLs), resulting in unmet ADL needs. R2 On 1/6/2025 at 10:38 a.m., R2 was observed lying in bed alert and unable to be interviewed. The surveyor observed R2 with long, dirty, untrimmed fingernails on both hands, with dry scaly skin on bilateral legs and feet. There was white-colored, crusty residue on lips and near both eyes. R2 had matted, unkempt hair. A hospital bracelet dated 12/15/2024 was noted on R2's right arm. On 1/8/2025 at 9:52 a.m., during an interview in R2's room, licensed Practical Nurse (LPN) B rubbed across R2's head and confirmed the resident's hair was not combed and matted on the top and on the back. LPN B was informed of R2's Tuesday's and Friday's afternoon showers days and was asked should the hospital bracelet have been…

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 Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate coordination of emergent or routine care that could cause negative outcomes. This deficient practice had the potential to affect all 120 residents in the facility. Findings include: On 1/08/25 at 12:13 PM review of the nurses' schedule for the months of October, November and December 2024 with staffing coordinator G, revealed there was no Registered Nurse (RN) coverage on the following dates: -[DATE] -[DATE] -[DATE] -[DATE] -[DATE] -[DATE] -[DATE] -[DATE] -[DATE] -[DATE] -[DATE] -[DATE] -[DATE] -[DATE] Staffing coordnitaor G acknowlwdged the facility has not been able to get RN coverage for weekends. O1/08/25 at 2:20PM the Director of Nursing (DON) agreed there hasn't been consistent RN weekend coverage and the expectation is that there is 8-hour RN coverage 7 days per week. Review of the facility policy titled…

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 observations, interviews, and record review the facility failed to effectively clean and maintain the physical plant effecting all residents residing on the second floor and all residents who use the elevator, resulting in an unsafe, poorly functional environment with the potential for cross-contamination and bacterial harborage. Findings include: On 1/8/25 at 8:05 AM the Director of Maintenance (DOM) M was interviewed and said maintenance completed ongoing monthly checklists for environmental and maintenance concerns. On 1/8/25 at 8:20 AM a second-floor environmental tour was conducted with the DOM M. The following items were noted: -The elevator had a soiled exhaust fan. -The second-floor pantry door paint was scuffed. DOM M agreed the door needed to be painted. -The second-floor hallways paint appeared dingy with multiple scratches. DOM M agreed the entire second floor was in need new paint. - Two nails were exposed on the handrail between the soiled and clean linen rooms. DOM M stated I will remove the exposed nails and fix the handrail today. -Resident rooms 227, 228,…

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 annual Dementia Management and Abuse training were performed for three Certified Nurse Assistant (CNA) H, I and J out of five CNAs reviewed for in-service training resulting in the potential for unmet resident care needs. Findings include: On 1/6/24 at 2:28 PM, review of five CNAs in-service training education content revealed the following: CNA H Date of hire (DOH)- 5/28/2004. Review of a facility provided transcript dated 5/28/24 through 6/28/24 for CNA H, failed to identify abuse and dementia management training. CNA I DOH 5/17/2016. Review of a facility provided transcript dated 5/17/23 through 5/17/24for CNA I, failed to identify abuse and dementia management training. CNA J DOH 6/21/2010. Review of a facility provided transcript dated 6/21/23 through 6/21/24 for CNA J, failed to identify abuse and dementia management training. On 1/08/25 at 8:51 AM Staff Educator K was interviewed and said that she recently started the position in September of 2024 and that there were limited records for staff education. Staff…

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 a call button was within reach for one resident (R178) reviewed for accommodation of needs, resulting in the resident not having a method to request assistance when needed. Findings include: On 1/6/25 at 3:25 PM, R178 was observed awake and lying in bed. R178's bed was positioned against the wall and R178's right arm appeared wedged between the bed and the wall. R178 indicated he was in pain and was unable to free his arm. R178's call light was clipped to his pillow case. R178's indicated he was unable to reach the call light with his left arm. On 1/6/25 at 3:30 PM, Licensed Practical Nurse (LPN) T joined the Surveyor in R178's room and confirmed R178's arm was wedged between the bed and wall and R178 was unable to reach the call light with his other arm. R178 winced in pain as LPN T moved the bed to free his arm. On 1/8/25 at 12:13 PM, the Director of Nursing (DON) said the call light should have been in place where the resident could reach it . On 1/8/25 at 5:30 PM during the exit conference,…

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 an Advance Directive was completed for one resident R14 of nine residents reviewed for advance directives resulting in the potential for inaccurate life sustaining measures or withholding medical treatment. Findings include: On 1/7/2025, record review of the Electronic Medical Record (EMR) revealed R14 was initially admitted into the facility on 6/14/2024 with a diagnoses Candidiasis, Atherosclerotic Heart Disease, Benign Prostatic Hyperplasia Dysphagia and Myocardial Infarction. There was no signed Advanced Directive. According to admission Minimum Data Set (MDS) Quarterly assessment dated [DATE], R14 had Brief Interview for Mental Status (BIMS) of 4/15 impaired cognition. R14 required extensive one-person assistance with activities of daily living (ADLs). On 1/8/2025 at 12:35 PM, Social Worker (SW) L was interviewed regarding R14's Advance Directive and said they had emailed the guardian agency at the time of admission to have them complete 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 notify the physician of a change in condition for one resident (R65) of six residents reviewed for bowel and bladder, resulting in the potential delay o care and treatment. Findings include: On 1/6/2025 at 11:11 a.m., R65's urinal was observed hanging on the foot of the bed with approximately five hundred and fifty milliliters (mls) of red-colored urine. R65 confirmed during an interview it was blood in the urinal that occurred while urinating the previous night before the start of day shift and the nurse was aware. R65 stated, I was scared to death when I saw the blood in my urinal, and no one has done anything about it Yet. According to the electronic health record (EHR), R65 was admitted to the facility on [DATE] with diagnoses of candidal sepsis (a life-threatening condition that occurs when the candida fungus enters the bloodstream .untreated candida infection carries the risk of leading to a systemic infection .), Enterocolitis due…

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 MI00147576. Based on interview and record review, the facility failed to ensure staff reported an injury of unknown source in a timely manner to the abuse coordinator for one resident (R125) out of two residents reviewed for abuse resulting in the untimely investigation of an injury of unknown origin. Findings include: The facility self-reported to the State Agency a resident injury of unknown source. A review of the facility's 5-Day submission dated 10/15/24 documented in part the following: - Investigation Summary: On 10/4/24 R125 complained of bilateral lower extremity pain. An order was entered for a stat x-ray for left knee, tibula, fibula and left foot and ankle. The stat X-ray result revealed no recent fracture or dislocation. The physician was notified of continued pain and swelling to left lower leg and foot. Additional orders given for x-rays for left leg and a venous doppler. The deep vein thrombosis was inconclusive, and R125 was transferred out to the local hospital…

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 develop a comprehensive care plan for a tracheostomy (a surgical opening in the neck to provide an airway to the lungs) for one resident (R175) reviewed for tracheostomy care. Findings include: On 1/6/25 at 1:00 PM, R175 was observed awake, lying in bed with a tracheostomy (trach) tube secured around his neck. Review of R175's clinical record documented an admission date of 12/16/24. R175's diagnoses included acute respiratory failure with hypoxia, laryngeal cancer, esophageal cancer, and tracheostomy status. On 1/8/25 at 12:10 PM, the Director of Nursing (DON) reviewed R175's care plans and confirmed that a comprehensive care plan for tracheostomy care had not been developed for R175. The DON said R175 should have a care plan that addressed tracheostomy care which would include how to care for it and what to look for. On 1/8/25 at 5:30 PM during the exit conference, the Nursing Home Administrator and Director of Nursing did not offer additional documentation or information when asked.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to remove broken and hazardous objects from one resident (R85) room to ensure safety of three residents reviewed for accident hazards, resulting in the potential for injuries. Findings include: On 1/6/2025 approximately at 9:57 a.m., R85 was observed lying in bed alert and able to be interviewed. Observed a long sharp metal screw protruding at the top of a detached closet door propped and leaning toward R85' s bed which was proximal to the closet. Observed a detached bed bumper with multiple protruding screws against the wall behind the resident's bed. R85 said during an interview that the closet door had been broken since admission [DATE]). R85 stated, I don't want that door with that screw in it to fall and hit me in my head. I am right here when it falls. It couldn't miss me. According to the electronic health record (EHR), R85 was admitted to the facility on [DATE] with diagnoses of anoxic brain damage, epilepsy, paroxysmal atrial…

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 one resident (R20) deemed to be at nutrition risk out of six residents reviewed for nutrition status, resulting in the potential for compromise in nutrition status to go undetected. On1/6/25 at approximately 10:00 AM R20 was observed in bed. The resident could not be meaningfully interviewed due to severe cognitive impairment. The resident had an intravenous (IV) pole with a tube feeding pump attached. No tube feeding was present on the IV pole. According to R20's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included fecal impaction, cerebral palsy acute and chronic respiratory failure, and anoxic brain damage. According to the Minimum Data Set (MDS) dated [DATE] R20 was classified as comatose and totally dependent on staff for all activities of daily living. R20 had a feeding tube (flexible tube…

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 (1) have emergency tracheostomy (a surgical opening in the neck to provide an airway to the lungs) supplies readily available for one resident (R175) and (2) failed to consistently follow the physician's medical orders for tracheostomy care (R74) out of three residents reviewed for tracheostomy care. Findings include: R175 On 1/6/25 at 1:00 PM, R175 was observed awake and lying in bed. R175 was observed with a tracheostomy (trach) tube secured around his neck. An emergency trach bag/box was not visible in R175's room. On 1/6/24 at 1:04 PM, Licensed Practical Nurse (LPN) W was queried if R175 had emergency trach equipment. LPN W and LPN X entered R175's room. Both LPN W and LPN X searched R175's room and were unable to locate emergency trach equipment. LPN X said the equipment was usually tacked on the board. LPN X pointed to a empty bulletin board at the head of R175's bed. LPN X said it was an issue that the trach emergency equipment was not in R175's room and that they need to correct that now. Review 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 medical supplies for one resident (R10) reviewed for tracheostomy (a surgical opening in the neck to provide an airway to the lungs) care were not expired. On [DATE] at 1:20 PM, R10 was observed in bed eating lunch. Licensed Practical Nurse (LPN) X entered the room with the State Surveyor to check for tracheostomy (trach) supplies. LPN X stated that R10 did not have a trach but R10 had a stoma. On [DATE] at 12:30 PM, R10 provided permission for a nurse and the Surveyor to look through the supplies in his room. On [DATE] at 12:34 PM, the contents of a multi-drawer storage cabinet located in R10's room were observed with the Director of Nursing (DON) and revealed the following: - One box of (Brand XX) HME expired [DATE]. (HME is a heat and moisture exchanger designed to replicate the functions of the nose and upper airways to improve respiratory function following laryngectomy.) The box contained approximately 30 devices. - Three…

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 and privacy, by not repairing broken window blinds for one resident (R35) of one resident sampled for visual privacy resulting in feelings of disrespect and the potential of exposure during care. Findings Include: On 1/06/25 at 11:56 AM, R35 was observed in bed on their back. R35 was covered with a sheet and was not wearing a gown. An interview was conducted with R35 regarding their stay in the facility. R35 stated that they don't have many complaints but would like window blinds to be fixed because it had been broken for a while and was covered with a soiled sheet. R35 said that although they like being next to the window, they did not like that someone could see them from the outside, especially at night. R35 stated, They (staff) won't tell someone to fix it .It looks bad and I'm tired of looking at that dirty sheet. The sheet was observed hanging on the lower portion of the window blinds and was stained. The blinds had several…

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 MI00141452. Based on observation, interview, and record review the facility failed to implement proper hand hygiene and glove use during wound care for one resident (R606) and failed to provide the proper receptable for the disposal of Personal Protective Equipment (PPE) for one resident (R608) out of 10 residents reviewed for infection control, resulting in the potential for increased cross-contamination of diseases which place a vulnerable population at high risk for infections. Findings include: R606 In an observation on 3/21/24 at 10:36 a.m. R606 had a dressing on the right foot. R606 reported having an infection in the right foot. Review of Physician orders revealed R606 had orders for wound care of right toes/foot every day shift every two days which was last revised on 3/21/24. In an observation on 3/21/24 at 11:48 a.m., Wound Nurse (WN) C prepared to perform wound care on R606's right foot. WN C placed R606's foot a towel on the bed. Wound supplies laid on R606's bedside table without a barrier. WN C applied gloves and did not perform hand…

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 inake MI00141101. Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for two residents (R402 and R410) of four residents reviewed for accommodation of needs, resulting in unmet care needs and the potential for further unmet care needs. Findings include: R402 On 11/28/2023 at 9:45 a.m., R402's call light was observed behind the head of the bed on the floor and out of reach. During an interview R402 said, I can use the call light for help only if I could reach it. Where is it (while looking around for the call light). I needed some help earlier with my breakfast, but I didn't see the call light. On 11/28/2023 at approximately 10:00 a.m., during observation and interview in R402's room (room [ROOM NUMBER]), Certified Nursing Assistance (CNA) C confirmed R402 can use the call light for assistance and the call light should be in reach but was not. CNA C said that she had not been in R402's room to provide care, but only to pass 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 MI00140791 Based on interview and record review, the facility failed to provide adequate supervision for one resident (R404) out of three residents reviewed for elopement which resulted in R404 exiting a store unsupervised while on a facility outing without staff knowledge and the potential for injury. Findings include: Record review of R404's face sheet revealed admitted to facility on 11/09/2022 diagnoses included intracerebral hemorrhage, encephalopathy, chronic kidney disease stage 3, anxiety disorder, and dysphagia. Review of the Minimum Data Set (MDS) dated [DATE] for R404 revealed a Brief interview for Mental Status BIMS of 9/15 moderate cognitive impairment and resident used wheelchair for mobility. In an interview on 11/28/2023 at 10:45 AM with R404 revealed R404 went on a shopping outing with the activities group and other residents to Retail Store YY on 10/20/2023. R404 reported he left the building by himself and self-propelled to the Retail Store XX store down and…

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

Based on interview and record review, the facility failed to ensure that two of five Certified Nurse Aides (CNA L and CNA M), whose in-service training files were reviewed, had the required annual dementia training within the required time period, resulting in the potential for unmet education needs, unmet resident care needs, and the potential for residents assigned to CNAs who have a diagnosis of dementia to not receive adequate care. Findings include: On 10/17/23 at 11:00 AM, CNA in-service training logs were reviewed with the Director of Nursing (DON) for the following CNAs: CNA L: Date Of Hire 5/28/04 CNA M: Date Of Hire 4/13/21 During the review there was no documentation that CNA L and CNA M had recieved Dementia training. In an interview on 10/17/23 at 3:58 PM, the Director of Nursing (DON) explained in-services should be set up periodically and records of training should be readily available. By the end of the annual survey, the DON was unable to provide documentation that CNA L and M completed annual dementia training during their required time period.

This citation has two Deficient Practice Statements (DPS). DPS #1. Based on observation, interview, and record review the facility failed to calibrate (test using a control solution to ensure accuracy) for 3 of 5 glucometers (medical device used to measure blood sugar) in the facility resulting in the potential for inaccurate blood glucose readings. Findings include: On 10/17/23 at 12:15 PM during observation of blood sugar monitoring with the use of an [EvenCare G2] glucometer Licensed Practical Nurse (LPN) A was asked about calibration of the glucometer. LPN A said that midnight shift performs the calibration and documents it on a 'log'. There was no glucometer calibration log on the 1st floor medication cart, the nurse's station, or the medication room. During inspection of the 1st floor medication cart there were no 'testing solutions' observed. On 10/17/23 at approximately 12:30 PM with LPN D observation of the the 2nd floor's East Medication cart revealed a [EvenCare G2] glucometer in the medication cart without any testing solution for calibration. Upon inquiry LPN D said,…

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 serve standardized portions for menu items and ensure palatable temperatures of food and coffee for six residents (R24 , R49 , R59, R70, R86, and R94) and for eight of eight residents who attended the confidential group meeting, resulting in complaints of small portions, cold food/coffee, and tasteless meals. Findings include: On 10/16/23 at 12:40 PM review of the planned, posted menu indicated residents were to receive BBQ chicken, Roasted Potatoes, Steamed Broccoli, and Fruit Cobbler. Observation of the resident's lunch trays revealed some residents were observed with boneless chicken breast that were less than the three-ounce portion identified on the kitchen production menus. The sliced apple pie that was used as a substitute for the fruit cobbler was sliced very thin (approximately 1/8inch). The roasted potatoes were discolored, dark, and unattractive. Residents were randomly queried concerning the food and indicated overall dissatisfaction with the meals and taste of the food served, some 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 This citation pertains to intake MI00139366. Based on interview, and record review the facility failed to prevent physical restraint use in one resident (R62) out of 10 residents reviewed for abuse resulting in the potential for physical and psychosocial harm. Findings include: Record review of R62's face sheet revealed admitted to facility on 5/4/2022 diagnoses included diffuse traumatic brain injury, anoxic brain damage, and dementia. Review of the Minimum Data Set (MDS) dated [DATE] for R102 revealed severely impaired cognition and R62 required dependent assistance for mobility. Record Review of the nursing health status note dated 10/8/2022 revealed During walking rounds at approx. 6:20pm writer observed resident in Geri-Chair with pieces of his brief in his mouth. Writer was able to remove the pieces from resident's mouth, writer then removed the remaining portion of the brief off the resident for safety. Writer informed the CNA (Certified Nursing Assistant) assigned to the resident what happened, and not…

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 MI00139366. Based on interview and record review, the facility failed to report allegations of abuse for one resident (R62) of ten total residents reviewed for abuse, resulting in allegations of abuse that were not reported to the State Agency timely and the potential for further allegations of abuse to go unreported, and not thoroughly investigated. Findings include: Record review of R62's face sheet revealed admitted to facility on 5/4/2022 diagnoses included diffuse traumatic brain injury, anoxic brain damage, dementia. Review of the Minimum Data Set (MDS) dated [DATE] for R102 revealed severely impaired cognition and required dependent assistance for mobility. Record Review of the nursing health status note dated 10/8/2022 revealed During walking rounds at approx. 6:20pm writer observed resident in Geri-Chair with pieces of his brief in his mouth. Writer was able to remove the pieces from resident's mouth, writer then removed the remaining portion of the brief off 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 MI00135592. Based on interview and record review the facility failed to provide an arm rest on a resident's wheelchair for one resident (R119) out of nine residents reviewed for accidents, resulting in R119 falling from wheelchair and obtaining large hematoma (when an injury causes blood to pool and collect under skin). Findings include: An interview on 10/16/23 at 9:30 AM with concerned family member (CFM) I, it was reported that R119 was sent to dialysis with only one armrest on wheelchair and resident fell and had to be taken to the hospital. Review of R119's face sheet revealed admission into the facility on 4/4/23 with a diagnoses of end stage renal disease and a history of falling. According to the Minimum Data Set MDS dated [DATE], R119 had impaired cognition and required extensive assist with Activities of Daily Living (ADLS). Further review documented under Balancing During Transitions and Walking, Section E. Surface to surface transfer .- Not steady- only able 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.