The Timbers of Cass County

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were assessed for risk of entrapment and informed consent was obtained prior to installation of bedrails for 1 (Resident #78) of 1 resident reviewed for bed rails, resulting in the risk for entrapment and injury.Findings include:Review of Clinical Guidance for the Assessment and Implementation of Bed Rails, www.fda.gov, 2003, revealed .National surveys of patient death occurring in the bed environment demonstrate the risk of entrapment.when the patient becomes entrapped in the bed rail itself. The population at risk for entrapment are patients who are frail or elderly.or those who have.agitation, confusion.hypoxia (low blood oxygen level).use of bed rails should be based on patients' assessed medical needs and should be documented clearly and approved by the interdisciplinary team.any decision regarding bed rail use.should be made with the framework of an individual patient assessment.bed rail use.should be accompanied by…

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 medications were administered per the physician's order for 1(Resident #60) of 1 resident reviewed for significant medication errors, resulting in the potential for adverse effects of the administration of digoxin without checking the resident's pulse and/or administering the medication if below the parameter of <60 beats per minute as outlined in the physician order. Findings include: Review of the [NAME]'s Drug Guide revealed, Digoxin (antiarrhythmic medication)-High Alert Medication: This medication bears a heightened risk of causing significant patient harm when it is used in error .Monitor apical (heartbeat heard at the bottom tip of the heart, located on the left side of the chest, it is a more accurate heart rate measure than peripheral pulses, showing actual heart contractions, with a normal adult rate of 60-100 bpm (beats per minute) pulse for 1 full minute before administering. Withhold dose and notify health care professionals if…

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 MI00149672, MI00150373, MI00150362, MI00150996 Based on interview and record review, the facility failed to employ an Activity Director who possessed the required qualifications resulting in the potential for unmet met psychosocial needs, feelings of boredom, isolation, and a lack of person-centered activities. This citation has the potential to impact any resident who relies on the activities program to support their leisure involvement. Findings include: Review of certification standards of the National Certification Council for Activity Professionals revealed ADC (Activity Director Certified) Certification ensures an individual has the knowledge and skills to lead and direct an activities and life enrichment department. ADC Certification validates the competencies necessary to be an Activity Director including leadership, management, advocacy, care planning and documentation. Review of Participating in Activities You Enjoy as You Age, published by the National Institute on Aging,…

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 MI00149672, MI00150373, MI00150362, MI00150546 Based on observation, interview, and record review, the facility failed to provide individualized activities based on resident preferences, needs, and abilities for 4 of 4 Residents (Resident #100, Resident #101, Resident #102, and Resident#103) reviewed for activities, resulting in a potential for social isolation, decreased connectedness to the resident's environment, and decreased overall well-being. Findings include: Review of Activity Involvement and Quality of Life of People at Different Stages of Dementia in Long Term Care Facilities revealed: Despite resident's cognitive status, their activity involvement was significantly related to better scores on care relationship, positive affect, restless tense behavior, social relations .Conclusion: Activity involvement seems to a small yet important contributor to higher well-being in long-term care residents at all stages of dementia . [NAME] D, de [NAME] J, Willemse B, Twisk J, Pot AM.…

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 MI00150362 & MI00149672. Based on interview, and record review, the facility failed to maintain complete and accurate medical records for 1 resident (Resident #103) of 3 residents reviewed for complete and accurate medical records, resulting in the lack of proper documentation of involvement in activities programs. Findings include: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing.High-quality documentation is necessary to enhance efficient, individualized patient care. Quality documentation has five important characteristics: it is factual, accurate, complete, current, and organized . Accessed from: Kindle Locations 24106-24108). Elsevier Health Sciences. Kindle Edition. Resident #103 Review of a Minimum Data Set (MDS) assessment for Resident #103 with a reference date of 1/28/25, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #103 was cognitively intact. Section F of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement transmission-based precautions for 1 (Resident #104) of 3 residents reviewed for isolation precautions, resulting in the potential for the spread of infection, cross-contamination, and disease transmission for residents residing in the facility. Findings include: Review of CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, published 4/12/24 by the Centers for Disease Control and Prevention revealed: Adherence to infection prevention and control practices is essential to providing safe and high-quality patient care across all settings where healthcare is delivered .core practices include: clean and disinfect .frequently touched surfaces .ensure proper use of personal protective equipment .implement additional precautions (i.e., Transmission-Based Precautions) . Resident #104 Review of an admission Record revealed Resident #104 was admitted to the facility on [DATE] with pertinent…

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: 1. Properly label/date and securely store food product once opened or prepared; 2. Discard expired food items; and 3. ensure cleanliness of food and non-food contact surfaces. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected all residents who consume food/supplement from the kitchen and from nourishment room refrigerators/freezers. Findings include: An initial kitchen/food service tour was conducted on 10/29/24 beginning at 9:35 AM with Dietary Supervisor (DS) Z. The following observations were made: At 9:38 AM in the walk-in cooler: an opened, half empty container of nectar-thickened sweet tea with a manufacturer use by date of 9/9/24 and no label to indicate opened or discard dates; an opened bottle of nectar-thickened cranberry juice that was not labeled with opened or discard dates; and a pitcher of what DS Z reported was maple syrup that was not labeled for contents or opened or discard dates. At 9:45 AM in the reach-in cooler: two opened…

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 honor mealtime preferences for 3 anonymous residents (attending a resident council meeting) and Resident #78, resulting in expressed feelings of discontent and a potential for increased loneliness. Findings include: Resident #78 Review of an admission Record revealed Resident #78, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: vascular dementia (chronic condition in which blood flow to the brain is reduced causing impaired thinking, memory, and behavior), feeding difficulties, and major depressive disorder (serious mental health condition causing persistent low mood and loss of interests). Review of a Minimum Data Set (MDS) assessment for Resident #78, with a reference date of 09/29/24 revealed a Brief Interview for Mental Status (BIMS) score of 5/15 which indicated Resident #78 was severely cognitively impaired. Section GG of the MDS revealed Resident #78 required supervision, verbal cueing and/or touching…

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 provide timely notification of exhaustion of Medicare Part A benefits in 1 (Resident #90) of 4 residents reviewed for beneficiary notification resulting in Resident #90 being unaware of changes in regard to financial liability, and frustration. Findings include: Resident #90 Review of an admission Record revealed Resident # 90 was originally admitted to the facility on [DATE] with pertinent diagnoses which included difficulty in walking. Review of a Minimum Data Set (MDS) assessment for Resident #90, with a reference date of 10/1/24 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #90 was cognitively intact. During an interview on 10/29/24 at 11:41 AM, Resident #90 reported that she had just been informed by the facility that she did not have Medicare coverage, and that she could expect to receive a bill from the facility for an estimated amount of $10,000. Resident #90 reported that this was the first time…

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 develop comprehensive care plans for 2 (Resident #53 and Resident #90) of 20 residents reviewed for care planning resulting in the potential for unmet medical, physical, mental, and psychosocial needs. Findings include: Resident #53 Review of an admission Record revealed Resident #53 was originally admitted to the facility on [DATE] with pertinent diagnoses which included need for assistance with personal care. Review of Resident #53's Orders revealed, Empty left Nephrostomy (artificial opening in the skin to allow urine to drain from the kidney) bag every shift . Review of Resident #53's Care Plan revealed that Resident #53 did not have a care plan developed for his nephrostomy bag. During an interview on 10/31/24 at 12:16, MDS RN M reported that she was the staff member responsible for ensuring care plan orders were in place for residents. MDS RN M confirmed that Resident #53 did not have a care plan in place for his Nephrostomy bag, and this 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 residents received care in accordance with professional standards in 1 (Resident #353) of 3 residents reviewed for quality of care, resulting in Resident #353 having dysuria (pain with urination) for approximately 7 days and the potential for a decline in overall physical, mental and psychosocial well being. Findings include: Resident #353 Review of an admission Record revealed Resident #353 was originally admitted to the facility on [DATE] with pertinent diagnoses which included need for assistance with personal care. Review of Resident #353's Progress Notes dated 10/24/24 and documented by Registered Nurse (RN) Q revealed, .This evening Res (Resident #353) c/o (complaint of) frequent urination, he thinks he has a UTI (urinary tract infection). Concerned placed in (provider notification) book . Review of Resident #353's Progress Notes dated 10/25/24 and documented by Nurse Practitioner (NP) SS revealed, . (Resident #353) is seen…

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 individualized activities based on resident preferences, needs, and abilities for 1 of 2 Residents (Resident #55) reviewed for activities, resulting in a potential for social isolation, decreased connectedness to the resident's environment, and decreased overall well-being. Findings include: Review of Activity Involvement and Quality of Life of People at Different Stages of Dementia in Long Term Care Facilities revealed: Despite resident's cognitive status, their activity involvement was significantly related to better scores on care relationship, positive affect, restless tense behavior, social relations .Conclusion: Activity involvement seems to a small yet important contributor to higher well-being in long-term care residents at all stages of dementia . [NAME] D, de [NAME] J, Willemse B, Twisk J, Pot AM. Aging Ment Health. 2016;20(1):100-9. doi: 10.1080/13607863.2015.1049116. Epub 2015 Jun 2. PMID: 26032736. Resident #55 Review…

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 intake pertains to intake MI00146328. Based on observation, interview, and record review, the facility failed to prevent elopement for 1 (R82) of 6 residents reviewed for elopement, resulting in R82 leaving the facility alone, unbeknownst to staff, for an extended period, and was later found under a bush next to the facility resulting in potential for further successful elopements. Findings include: Review of facility policy, Elopement Prevention and Management Program reviewed 01/2024, revealed, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .Wandering is random or repetitive locomotion that may be goal-directed (appears to be searching for something such as an exit) .Elopement occurs when a resident leaves the premises or a safe area without authorization…

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 timely and consistent weight monitoring for one resident (Resident #76) of 4 residents reviewed for nutritional status resulting in undetected weight loss, nutritional status decline and unmet nutritional needs. Findings include: Resident #76 (R76) Review of the Facesheet and Minimum Data Set (MDS) dated [DATE] revealed R76 admitted to the facility on [DATE] with diagnoses including cerebral infarction with right side hemiplegia and hemiparesis (stroke with right side weakness) and dysphagia (difficulty swallowing). A Brief Interview for Mental Status (BIMS) was not completed due to R76 having severe cognitive impairment. On 10/29/2024 at 2:15 PM, R76 was observed to be lying in bed and looked thin. He was unable to respond to questions. Review of R76's weight record revealed the following weights: 10/20/2024: 121.4 lbs. (pounds) 10/09/2024: 120.6 lbs. 09/13/2024: 126.0 lbs. 08/26/2024: 144.6 lbs. 08/12/2024: 139.4 lbs. The weight…

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 provide documentation of education to the resident/representative on the intended or actual benefit versus potential risk(s) or adverse consequences associated with a psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) for 1 (Resident #35) of 5 residents reviewed for unnecessary medications, resulting in the potential for lack of awareness of medication risks versus benefits. Findings include: Resident #35 Review of an admission Record revealed Resident #35 was a female, with pertinent diagnoses which included: dementia in other diseases classified elsewhere, moderate, with mood disturbance; adjustment disorder with depressed mood; and major depressive disorder, recurrent, unspecified. Review of a Minimum Data Set (MDS) assessment for Resident #35, with a reference date of 8/30/24 revealed a Brief Interview for Mental Status (BIMS) score of 6, out of a total possible score of 15, which indicated Resident #35 was severely cognitively impaired. Review of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents' food preferences at meals were consistently honored for 2 (Residents #27 and #78) of 18 residents reviewed for food concerns resulting in resident/representative complaints of food choices not being honored and the potential for decreased meal enjoyment, feelings of frustration, and the potential for weight loss and nutritional decline. Findings include: Resident #27 Review of an admission Record revealed Resident #27 was a female, with pertinent diagnoses which included: generalized anxiety disorder, long-term (current) use of oral hypoglycemic (low blood sugar) drugs, depression, and type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood). Review of a Minimum Data Set (MDS) assessment for Resident #27, with a reference date of 10/22/24 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #27 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 follow professional standards of infection control with resident's tube feeding equipment for one of one resident (R50) reviewed for infection control resulting in the potential for harborage and cross-contamination of pathogens in a vulnerable population. Findings include: Review of facility policy, Cleaning/Disinfecting Resident-Care Items reviewed 01/2024, revealed, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard . Review of facility policy, Tube Feeding reviewed 01/2024, revealed, To provide nutritionally complete tube or parenteral feedings as ordered by the physician or the nourishment of residents who are unable to eat normally .the nursing department is responsible for all feeding equipment .…

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 residents were screened for eligibility to receive Pneumococcal vaccinations and receive vaccination if eligible for 3 (Resident #18, #35 and #48 ) of 5 residents reviewed for vaccinations, resulting in the potential of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia. Findings include: Resident #18 Review of an admission Record revealed Resident #18 was originally admitted to the facility on [DATE] with pertinent diagnoses which included weakness. Review of Resident #18's MCIR (Michigan Care Improvement Registry) revealed that Resident #18 had last received a Pneumococcal (Prevnar13 ) vaccine on 12/13/2018. Review of Resident #18's Consent for Vaccinations form dated 10/2/23 indicated that Resident #18's legal guardian had consented for Resident #18 to receive the Pneumococcal vaccine. During an interview on 10/31/24 at 9:30 AM, Director of Nursing (DON) B confirmed that Resident #18 had last received a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure COVID-19 immunization were offered to 2 (Resident #18 and #48) out of 5 residents, reviewed for COVID-19 immunizations, resulting in the higher likelihood of infection and complications from COVID-19. Findings include: Resident #18 Review of an admission Record revealed Resident #18 was originally admitted to the facility on [DATE] with pertinent diagnoses which included weakness. Review of Resident #18's MCIR (Michigan Care Improvement Registry) revealed that Resident #18 had last received a Covid-19 immnization on 10/25/22. During an interview on 10/31/24 at 9:30 AM, Director of Nursing (DON) B reported that the facility was not screening and offering Covid-19 immunizations to residents that were eligible at admission or annually. DON B reported that he had been trying to coordinate a Covid-19 immunization clinic since June 2024, but he had gotten busy with other things and was not able to screen and offer Covid-19 immunizations to residents…

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 clean and sanitary room and equipment conditions for 2 (Resident #27 and #55) of 20 sampled residents reviewed for sanitary conditions resulting in: 1.) a stained and soiled privacy curtain and dusty blinds for Resident #27, and 2.) a visibly soiled wheelchair for Resident #55. Findings include: Resident #27 Review of an admission Record revealed Resident #27 was a female, with pertinent diagnoses which included: secondary pulmonary arterial hypertension (high blood pressure that affects the arteries in the lungs), and type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood). Review of a Minimum Data Set (MDS) assessment for Resident #27, with a reference date of 10/22/24 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #27 was cognitively intact. During an observation and interview on 10/29/24 at 11:36 AM,…

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 MI00143214 Based on interview and record review, the facility failed to report timely and accurately to the State Agency a required reportable incident of resident to resident abuse in 2 (Resident #104 and Resident #105) of 3 residents reviewed for reportable incidents resulting in the potential for additional reportable incidents go unreported and/or cause a delay in the investigative process. Findings include: Resident #104 Review of a Face sheet revealed Resident #104 had pertinent diagnoses which included: Alzheimer's disease and vascular dementia with behavioral disturbances. Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 3/9/24 revealed a Brief Interview for Mental Status (BIMS) score of 4/15 which indicated Resident #104 was severely cognitively impaired. Review of Progress Notes for Resident #104 dated 2/28/24 at 7:51 PM., revealed .an incident occurred between Resident #104 and Resident #105 while sitting at the nurse's station, residents were separated, family (daughter) notified Review of Incident…

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 safe transport of a resident in a wheelchair with foot pedals was in place in 1 (Resident #106) of 1 resident reviewed for accidents resulting in the potential for injury to the resident. Findings include: Review of an Face sheet revealed Resident #106 had pertinent diagnoses which included: Visual loss, both eyes, muscle weakness, and legal blindness, as defined in USA. Review of a Minimum Data Set (MDS) assessment for Resident #106, with a reference date of 6/2/24 revealed a Brief Interview for Mental Status (BIMS) score of 8/15 which indicated Resident #106 was moderately cognitively impaired. On 6/18/24 at 10:15 AM., Resident #106 was observed being pushed in his wheelchair in the 100 hall and the hallway to the activities room by Activities Aide (AA) I. Resident #106 did not have footrests in place on his wheelchair. Resident #106 was wearing slippers, and his feet were crossed at the ankles and elevated off the floor. AA I was heard saying to Resident #106 Do you have your feet up? Resident #106…

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) properly store medications in a secure manner in 3 of 3 treatment carts reviewed and (2) ensure that treatment carts remained secure resulting in the potential for residents, visitors, and/or staff to access the medication in the facility with a current census of 104 residents. Findings include: Review of facility policy 5.3 Storage and Expiration Dating of Medications, Biologicals with a revision date of 8/7/23 revealed .3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors . In an observation on 6/18/24 at 10:30 AM., a bottle with a pump top labeled Green Pain Gel was noted on the top of the treatment cart behind the Birch nurse's station. Also noted on top of the treatment cart behind the Birch nurse's station was a basket with tubes and bottles of topical treatment creams and ointments with resident specific information on the labels. 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 ensure proper hand hygiene was performed during medication administration in 3 (Resident #107, Resident #108, Resident #109) of 3 residents reviewed for hand hygiene during medication administration, resulting in the potential for the spread of infection, cross-contamination, and disease transmission for residents who receive medication while residing in the facility. Findings include: Resident #10 & Resident #108 During an observation on 6/20/24 at 9:17AM., Licensed Practical Nurse (LPN) Q prepared oral medications for Resident #108 at the medication cart outside of Resident #108's room. At 9:31 AM LPN Q entered Resident #108's room, used the vital sign machine to check Resident #108's blood pressure, then handed Resident #108 the cup of medications. Resident #108 took medications and requested a pain medication. At 9:36 AM., LPN Q exited Resident #108's room, retrieved a narcotic medication from the medication cart in the hallway, returned to Resident #108's bedside and administered the pain medication 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.

Based on observation, interview, and record review the facility failed to: 1. Ensure general cleaning and general repair of the kitchen; 2. Clean food and non-food contact surfaces to sight and touch; 3. Maintain an environment free from pests; 4. Properly store food product; and 5. Ensure a convenient number of hand sinks in the kitchen. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 93 residents who consume food from the kitchen. Findings include: 1. During the initial tour of the kitchen, at 9:55 AM on 10/9/23, it was observed that the perimeter floor juncture of the walk-in cooler, as well as the area around the wheels of the storage racks, were found with an accumulation of crumb and black spotted debris. An interview with Certified Dietary Manager (CDM) MM found that this area should get deep cleaned once a month. During the initial tour of the kitchen, at 10:22 AM on 10/9/23, observation of the dish machine area found heavy accumulation of grime and standing water under the dirty side of the dish…

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

Based on observation, interview, and record review the facility failed to maintain a medication error rate less than 5% (total error rate of 29.63%) in 3 of 4 sampled residents (Resident #15, Resident #70, and Resident #301) reviewed for medication administration, resulting in the potential for reduced medication efficacy, increased risk of adverse reaction and/or side effects, and administration of wrong medications. Findings include: Resident #15 Review of a Face Sheet revealed Resident #15 had pertinent diagnoses which included sepsis, other schizoaffective disorders-schizoaffective schizophrenia, reduced mobility, and cognitive communication deficient. Review of Physician Orders for Resident #15 revealed . aspirin 81 mg delayed release give 1 tablet PO (by mouth) daily . clozapine 50 mg tablet give 1 tablet PO once a day .colace capsule 100 mg give 1 capsule PO once a day . metoclopramide HCL 5 mg tablet give 1 tablet by mouth before meals . pantoprazole delayed release 40 mg tablet give 1 tablet oral twice a day . During an observation on 10/10/23 at 9:30 AM, Licensed Practical…

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 provide appetizing and temperature appropriate food products to 3 residents (Resident #53, #57, and #16) of 4 residents reviewed for food palatability, resulting in dissatisfaction with meals, and the potential for decreased food acceptance and nutritional decline. Findings include: Resident #53 Review of a Minimum Data Set (MDS) assessment for Resident #53, with a reference date of 8/23/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #53 was cognitively intact. In an interview on 10/9/23 at 10:18 AM, Resident #53 reported the food at the facility was terrible. Resident #53 gave the example that rice served the other day was crunchy, the vegetables were often overcooked and mushy, and the food was not served hot when his meal tray was delivered to his room. In a follow-up interview on 10/11/23 at 10:54 AM, Resident #53 reiterated his concerns about the food. At this time, Resident #53 also reported that for breakfast that day he…

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 provide written notification of the facility bed hold policy upon discharge to an acute care hospital for 2 ( Resident #1, Resident #72) residents reviewed for emergency hospital transfer resulting in the potential for unanticipated expense or the loss of desired room placement in the facility. Findings include: Resident #1 Review of an admission Record revealed Resident #1 was originally admitted to the facility on [DATE] with pertinent diagnoses which included chronic kidney disease and reduced mobility. Further review of admission record revealed that Resident #1 had an activated guardian. Review of Resident #1's Progress Notes dated 10/4/23 and documented by Registered Nurse (RN) M revealed, (Resident #1) seen by (Nurse Practitioner) in regard to poor intake and elevated sodium levels . N/O (New order) received to send res (Resident #1) to the ER for evaluation and treatment. A call placed to 911 and the EMTs (Emergency Medical Transport) arrived…

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 residents received care in accordance with physician orders in 1 of 20 residents (Resident #73) reviewed for standards of care, resulting in the delay in care and the potential for further health complications. Findings include: Review of a Face Sheet revealed Resident #73 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #73 , with a reference date of 9/19/23 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #73 was cognitively intact. In an interview on 10/09/23 at 12:00 PM, Resident #73 reported that his left eye had been irritated for a few weeks now and the facility said that they were working on getting eye drops for him. Resident #73's left eye was observed drooping and blood shot. Review of Resident #73's Provider Note dated 10/2/23 revealed, .eye redness .Past History: .Facial nerve palsy,…

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 assistance with Activities for Daily Living (ADL) care was provided for 1 (Resident #9) of 3 residents reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for Resident #9. Findings include: Review of a Face Sheet revealed Resident #9 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: bilateral below the knee amputation. Review of a Minimum Data Set (MDS) assessment for Resident #9, with a reference date of 6/29/23 revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #9 was cognitively impaired. Review of the Functional Status revealed that Resident # 9 required extensive assistance from staff for dressing and hygiene, and was totally dependent on staff for transferring out of bed. During an observation and interview on 10/09/23 at 02:01 PM Resident #9 was lying in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to adequately monitor and/or track resident's behaviors in 2 (Resident #44 and Resident #52) of 20 residents reviewed for behaviors, resulting in the potential for inadequate individualized care, insufficient behavioral data, and the inability to attain their highest practicable mental and psychosocial well-being. Findings include: Resident #44 Review of a Face Sheet revealed Resident #44 had pertinent diagnoses which included acute respiratory failure with hypoxia and adjustment disorder with mixed anxiety and depressed mood. Review of a Minimum Data Set (MDS) assessment for Resident #44, with a reference date of 9/8/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #44 was cognitively intact. During an interview on 10/9/23 at 1:24 PM, Resident #44 reported that she has been eating chicken noodle soup and juice for lunch and dinner since she had been here. Resident #44 reported she cannot hold…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has 2 DPS Statements. DPS A Based on observation, interview, and record review, the facility failed to 1.) properly maintain infection control practices in a contact isolation room and 2.) adequately clean frequently touched surfaces, resident use equipment, and ensure general cleanliness in the facility for 3 of 25 residents (Resident #56, # 9 and #35) reviewed for infection control, resulting in the potential for the development and transmission of communicable diseases and infections to a vulnerable population. Findings include: Resident #56 Review of a Face Sheet revealed Resident #56 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: recurrent clostridium difficile (C. diff) (severe bacterial infection in the colon that causes diarrhea, can cause damage to the colon and can be fatal). During an observation on 10/09/23 at 12:13 PM Resident #56's door was closed and there were posted signs on the wall next to the door. The postings on the wall indicated…

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