Medilodge of St. Clair

Based on observation, interview, and record review, the facility failed to properly store medications for one resident (R6) of one reviewed for medication storage, ensure expired medications were discarded when opened, and inhalers were labeled with a resident identifier and/or an opened date in one of four medication carts. Findings include: R6 On 12/08/2025 at 7:32 AM, during a tour of the Dementia unit, R6 was observed in bed asleep. A medication cup containing two pills was observed on the resident's nightstand. On 12/08/2025 at 7:39 AM, an unidentified nurse was asked to observe the medications at R6's bedside and explained they had not begun to pass medications on the day shift and further explained they are not aware of how long those medications had been on the nightstand. A review of R6's medical record revealed they were admitted into the facility on 8/27/25 with diagnoses of Alcohol Dependence with Alcohol-Induced Persisting Dementia, Metabolic Encephalopathy, and Major Depressive Disorder. Further review revealed the resident was moderately cognitively impaired 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 observation, interview, and record review, the facility failed to ensure hand hygiene and medical device cleaning was completed during medication pass for one resident (R89) of four residents observed during observed. Findings include: On 12/10/2025 8:23 AM, Licensed Practical Nurse (LPN) I was observed during a medication pass for R89. LPN I was observed to remove five oral medications, a glucometer, a lancet, glucose (blood sugar) test strip and an alcohol pad from the medication cart. LPN I reported they wanted to recheck R89's blood sugar. The medications were dispensed into a small plastic cup. LPN I brought the items into the resident's room and donned gloves. The medication cup was handed to R89 by LPN I. The lancet was used to prick a finger on the left hand of R89 to get the blood sample for the meter onto the glucose test strip. LPN I doffed their gloves and returned to the medication cart. The glucometer was returned to the medication cart. LPN I prepared an insulin injection for R89 using an insulin pen. A needle was applied to the pen and the amount dialed onto…

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: 2584046.Based on interview and record review, the facility failed to administer physician order medication in a timely manner for two (R900, R901) of two residents reviewed for medication administration. Findings include:R900A review of the Electronic Medical Record (EMR) revealed R900 was admitted to the facility on [DATE] with the following pertinent diagnoses: Right non-union intertrochanteric hip fracture after a fall, hypertension, hyperlipidemia (high cholesterol), legally blind, and anemia. Further review of the EMR revealed the resident was cognitively intact.On 9/4/25, a review of the August 2025 Medication Administration Record (MAR) revealed medications were administered later than one hour outside the window of one hour before and one hour after the designated scheduled time. The record revealed on the day shift (7:00 AM-3:30 PM) over a 10-day period (August 1 thru 10, 2025), R900's morning medication, which were due at 8:00 AM, was administered after 9:00 AM six 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 This citation pertains to Intake MI00149376. Based on interview and record review, the facility failed to follow professional standards of practice for blood pressure medication hold parameters for one resident (R300) of three residents reviewed for medication administration. Findings include: A review of R300's admission facesheet revealed they were admitted to the facility on [DATE] with a diagnosis of Peripheral Vascular Disease (PVD). Further review of the medical record revealed R300 had a moderately impaired cognition. A review of R300's physician orders revealed the following active orders dated 11/6/24: 1. Metoprolol Succinate ER oral tablet Extended Release 24-hour 25 mg (milligram) Give 1 tablet by mouth one time a day related to essential primary hypertension (high blood pressure) and, 2. Losartan Potassium Oral tablet 100mg give 1 tablet by mouth one time a day related to essential primary hypertension. There were no orders to check the blood pressure prior to administering the blood pressure…

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 a pest-free environment, resulting in flies in the facility and resident complaints. This deficient practice had the potential to affect all residents in the facility. Findings include: On 10/1/24 at 2:45 PM, there were several flies observed in the 100 hallway. On 10/1/24 at 2:50 PM, the window in room [ROOM NUMBER] was observed to be open. The exterior screen frame was observed to be bent, leaving an approximately 1 inch gap. The screen was not tight-fitting, to prevent pest entry into the room. On 10/1/24 at 3:00 PM, Maintenance Supervisor V confirmed the bent screen, and stated he would take care of it right away. Maintenance Supervisor V stated that he was unaware of any current fly issue in the facility. Review of a Quality Assistance Form dated 4/4/24 noted: Details: RM [ROOM NUMBER]-2 .screen has gap and not fitting frame of window. Would like to open window when weather permits .Plan of Action: .unable to bend frame…

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 meet professional standards of care for medication administration for two residents (R71, R107) of nine residents reviewed for medication administration. Findings include: On 10/2/24 at 7:40 AM, during the dining room observation, Registered Nurse (RN) J was observed administering medication from a cup which contained a yellowish fruit puree to R107. When RN J completed the medication administration with R107, the nurse subsequently administered medication from a different medication cup to R71, without first returning to the medication cart, sign off that R107 had received their medications, performed hand hygiene, and separately prepare R71's medications. The facility record revealed R71 was admitted on [DATE] with the following pertinent diagnoses: Cerebral Infarction (Stroke), Atrial Fibrillation, Dysphagia, Aphasia, and Alzheimer's Disease. The facility record revealed R107 was admitted on [DATE] with the following 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, interview, and record review, the facility failed to apply compression stockings as physician ordered for one (R111) of four residents reviewed for care standards. Findings include: Review of the facility record for R111 revealed an admission date of 03/01/24 with diagnoses that included Chronic Obstructive Pulmonary Disease and Localized Edema. R111's Physician Orders included an active status order which stated Compression stockings to be applied to bilateral lower extremities before getting out of bed for the day and removed at bedtime one time per day for pedal edema. On 10/01/24 at 12:23 PM, R111 was observed in the dining room waiting for lunch. The resident's feet/ankles were visible as they were wearing slippers that only covered the toes and outer edge of the feet and the feet appeared to be swollen and more red in color than their skin otherwise. Compression stockings were notobserved to be in place. On 10/01/24 at 03:25 PM, R111 was asked about compression stockings and they stated They don't put them on anymore. Additional review of R111's record…

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 update the status of wound from non-pressure to pressure classification and implement interventions (adequate seating and positioning) for a Stage 4 (full thickness skin loss that extends through the skin into the muscle, bone, tendon or joint) pressure ulcer for one Resident (R64) of three residents reviewed for pressure ulcers. Findings include: On 10/01/24 at 10:17 a.m., R64 was observed in their room seated in a high back manual wheelchair, in a reclined position. Their right leg was internally rotated, with their legs positioned up on elevating footrests. R64 reported they had pain all over, reported as 5/10 with 5 being moderate pain. R64 was seated directly on their buttocks and thighs on a pressure relief cushion in their wheelchair. On 10/01/24 at 10:31 a.m., Certified Nurse Assistant (CNA) S was asked about R64's care, and reported R64 was dependent for all care including feeding. Review of R64's Minimum Data Set (MDS)…

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 two deficient practice statements. Deficient Practice #1. Based on interview and record review, the facility failed to provide recommended restorative therapy for one (R59) of three residents reviewed for restorative therapy services. Findings include: On 10/01/24 at 12:45 p.m., R59 was observed seated in their wheelchair in their room. On 10/01/24 at 12:48 p.m., R59 reported they were not walking with staff, or regularly receiving their restorative therapy exercises. R59 stated, .I don't even get it [restorative therapy] once a week. I ask them in the hallway what they are doing and say range of motion [with other residents]. That bothers me, I need to walk . Review of R59's Restorative Program referral, dated 7/29/24, revealed, Walking: Distance: 3' with 2 WW [two-wheeled walker]. Assistance Required: Min [minimal assistance]. Instruct to increase t [weight] on right [side] .ROM: Extremity: See exercise sheets. Frequency: 5x/ wk. [five times a week] . Review of R59 restorative therapy logs…

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 safely and properly store portable oxygen for one (R27) of four residents reviewed. Findings include: Review of the facility record for R27 revealed an admission date of 10/12/19 with diagnoses that included Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure. R27's current physician orders include O2 two liters continuous with humidification. On 10/01/24 at 10:03 AM, during initial interview R27 was using their oxygen concentrator. A portable oxygen tank was observed in a tank holder attached to the resident's four wheeled walker. A second portable tank was observed in a wheeled cart near the bathroom. R27's roommate was not using oxygen and when asked about the second tank R27 stated That's mine. They keep an extra one sometimes so they don't have to go get it but I'm not sure why its over by [R27's roommate]. On 10/02/24 at 01:09 PM, the extra oxygen tank observed on 10/01/24 remained stored in R24's room near the bathroom. On 10/03/24 at 10:30 AM, the oxygen tank previously observed…

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 respiratory care consistent with professional standards of practice for two (R61, R93) of two residents receiving nebulizer treatments. Findings include: R61 On 10/1/24 at 9:02 AM, R61 was observed with a nebulizer treatment in progress. R61 was adjusting the positioning of the device. A nurse was not present. On 10/1/24 at 9:30 AM, R61 was observed to have completed their nebulizer treatment. A nurse was not present. Review the facility record revealed R61 was readmitted to the facility on [DATE] after hospitalization for exacerbation of Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea, and Dyspnea. A Brief Interview for Mental Status revealed a score of 11/15 indicating Mild Cognitive Impairment. On 10/3/2024 at 9:24 AM, a query of R61 revealed the nurse usually sets up their nebulizer treatment and starts it, then usually leaves the room. R61 revealed most nurses do that. R61 revealed when the treatment is…

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, and facility failed to provide medically related social services for two Residents (R23 and R73) of eight residents reviewed for medically-related social services. Findings include: R23 On 10/02/24 at 3:03 p.m., R23 reported they had asked multiple staff to be discharged from hospice services, as they wanted to have therapy assess them to see if they could improve their transfers to possibly be discharged home. R23 reported they felt frustrated, as they had been on hospice a couple of years and had never been on therapy. R23 was aware they had a guardian but had been unable to reach them about their wishes and also felt frustrated with having a guardian. R23 reported they had also shared their wishes with facility staff and the hospice nurse and had not heard back. On 10/02/24 at approximately 3:30 p.m., the Director of Nursing (DON) was asked about R23's reported wishes to come off hospice care and related concerns. The DON reported they had been made aware 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 interview and record review, the facility failed to put a 14 day stop date on an PRN (as needed) antianxiety medication for one resident (R60) out of two reviewed for unnecessary medications. Findings Include: A review of the medical record revealed that R60 admitted into the facility on 1/30/2024 with the following medical diagnoses, End Stage Renal Disease and Atrial Fibrillation. A review of the Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 14/15 indicating an intact cognition. R60 also required staff assistance with transfers and bed mobility. A review of the physician orders revealed the following order. Ativan Oral Tablet 0.5 MG (milligrams) (Lorazepam). Directions: Give one tablet by mouth every 4 hours as needed for restlessness or anxiety. Status: Active. Start Date: 8/28/2024. No end date was noted on the order. On 10/3/2024 at 10:36 AM, an interview was conducted with Social Worker (SW) B. SW B stated R60 is on hospice, and they put PRN orders in often and don't communicate it sometimes. SW B stated they are working on it 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 observation, interview, and record review, the facility failed to ensure one unattended medication cart (the C-wing cart) of three carts reviewed was locked during medication administration. Findings included: On 10/02/24 at 9:00 a.m., Registered Nurse (RN) R was observed preparing R49's medications to be passed from the C-wing cart. R49 agreed to Surveyor observing them take their medications. Once RN R placed R49's medications in a pill cup, they walked into R49's room, and left the medication cart unlocked, leaving the cart unsupervised and accessible to residents and staff. RN R began administering medications to R49, in the second bed in the room, and was not aware they left the medication cart unlocked, as they did not stop and lock the cart, and their back was to the cart. Surveyor was observing R49's medication administration when they saw R49's roommate wheel into the hallway and place their wheelchair on the left side of the medication cart. Surveyor next observed a maintenance staff member place their wheeled maintenance supply cart in front of the medication…

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 complete and accurate medical records for two residents (R5 and R60) out of two reviewed for medical records. Findings include: R5 A review of the medical record revealed that R5 admitted into the facility on [DATE] with the following medical diagnoses, Recurrent Dislocation, Left Shoulder and Pain in Left Shoulder. A review of the Minimum Data Set assessment (MDS) revealed a Brief Interview for Mental Status score (BIMS) of 12/15 indicating an impaired cognition. R5 also required staff assistance with transfers and bed mobility. Further review of the physician's orders revealed the following active orders, Sling and Swathe to left upper extremity at all times. May remove for skin checks and showers. Status: Active. Ordered:2/9/2023. Apply arm sling to left upper extremity when out of bed, adjust snug to chest. Check for circulation after each application. Only Apply when resident is out of bed. Status: Active. Ordered: 9/17/2024.…

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

Based on observation, interview, and record review the facility failed to follow infection prevention and control guidelines for glove use for one (R92) of one resident reviewed for infecton control. Findings include: On 10/2/24 at 7:40 AM, RN J was observed providing a subcutaneous injection to R92 without wearing gloves during a community breakfast. On 10/3/24 at 10:30 AM, the Infection Control and Prevention Practitioner (ICP) I was queried regarding the need for gloves during any injection. ICP I revealed gloves are required for IM injections, not necessarily for subcutaneous (insulin) injections. On 10/3/24 @ 11:30 AM, the Director of Nursing (DON) was queried regarding giving injections without gloves. The DON revealed that giving a subcutaneous injection (insulin) without gloves was OK. A review of the Infection Prevention and Control Program Policy, dated, Reviewed/Revised: 10/25/2022, under the subtitle Standard Precautions, revealed Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies. The Center…

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 the proper concentration of chemical sanitizer, failed to ensure handwashing to prevent cross contamination, and failed to ensure hot food items were held at 135 degrees Fahrenheit or higher. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 8/7/23 at 12:25 PM, 2 red sanitizer buckets with wiping cloths located in the main kitchen area, were tested and found to contain no sanitizer. District Manager Q stated they probably needed to be changed. According to the 2017 FDA Food Code, Section 3-304.14 Wiping Cloths, Use Limitation, .(B) Cloths in-use for wiping counters and other equipment surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under § 4-501.114; On 8/7/23 at 12:30 PM, Dietary Staff R was observed preparing food for the lunch meal. With gloved hands, Staff R was observed going into the walk in cooler, and was also observed lifting the lid of the garbage can to throw away…

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 a comfortable, homelike environment for three residents, (R4, R27, R102) of three residents reviewed for a comfortable homelike environment, resulting in verbalized complaints and dissatisfaction with the physical conditions of the building. Findings include: On 8/7/23 at 10:18 AM, R4 was asked about their stay in the facility, and explained that as long as they've been a resident in the facility, they have never seen anyone wash or paint the walls. R4 was asked how long they had been a resident in the facility and explained that it had been approximately eight years. R4 further stated, That's nasty. A review of R4's medical record revealed that they were admitted into the facility on 6/3/2015 with diagnoses of Hepatic Failure, Diabetes, and Chronic Obstructive Pulmonary Disease. A review of R4's Minimum Data Set assessment revealed that the resident was cognitively intact. On 8/7/23 at 10:25 AM, R102 was observed sitting 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.

This citation pertains to Intake M100136063. Based on interviews and record review, the facility failed to protect the resident's (R88) right to be free from verbal abuse by staff. Findings include: Review of the facility record for R88 revealed an admission date of 01/21/22 with diagnoses that included Paraplegia, Wedge Compression Fracture of the Third Thoracic Vertebrae, Myocardial Infarction and Anoxic Brain Damage. The Minimum Data Set (MDS) assessments dated 04/24/23 indicated that R88 required total (dependent) staff assistance for toileting hygiene. The Brief Interview for Mental Status (BIMS) assessment scores of 15/15 indicating intact cognition. Review of an Incident received by the State Agency revealed that R88 alleged that on 04/03/23, while being assisted with toileting hygiene, requested additional assistance from Certified Nurse Assistant (CNA) G who responded You can wipe your own a. R88 reported that when asking for assistance to clean their soiled hands CNA G responded You're a grown man, you can wash your own hands. On 08/07/23 at 10:02 AM, initial interview…

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

Based on observation, interview and record review, the facility failed to document and provide showers per resident schedule for one sampled resident (R41) of two reviewed for showers resulting in, dissatisfaction with hygiene and bathing care. Findings include: On 8/7/23 at 9:27 AM, R41 was observed lying in bed and asked about their stay in the facility. R41 explained that they are scheduled to receive showers three times a week, Mondays, Wednesdays and Saturdays, and had not been receiving their showers on Saturdays for several months. R41 explained that it's frustrating because they have been told the reason for not receiving the showers is due to short staffing. A review of R41's medical record revealed that she was admitted into the facility on 7/30/21 with diagnoses that included Hypertension, Diabetes, and Chronic Obstructive Pulmonary Disease. A review of R41's quarterly Minimum Data Set assessment dated for 6/11/23 revealed that the resident had a Brief Interview for Mental Status score of 14/15 indicating an intact cognition, and required extensive assistance of 2 or more…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that podiatry services were offered to one resident (R92) of one reviewed for ancillary services, resulting in discomfort and dissatisfaction with services. Findings include: On 8/7/23 at 11:43 AM, during an initial tour of the facility R92 was interviewed about their satisfaction with services at the facility. R92 indicated that they needed to see a podiatrist to have their toenails trimmed. R92 stated, They hurt. I've requested to see a podiatrist. An observation of R92's toenails revealed that they extended over the top of the toe and appeared jagged and twisted. On 8/8/23 at 9:00 AM, a review of R92's electronic medical record (EMR) revealed no documentation related to podiatry care or services. Further review revealed no podiatry goal/interventions observed on R92's care plan. R92 was most recently admitted to the facility on [DATE] with diagnoses that included End stage renal disease and fracture of neck. R92's most recent…

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 assure timely transportation to and from dialysis for one resident (R92) of one residents reviewed for dialysis. Findings include: On 8/7/23 at 11:43 AM, during an initial tour of the facility R92 was interviewed about services at the facility and indicated that they frequently waited an hour or more to be picked up from their dialysis appointments. R92 stated, It's across the parking lot. R92 expressed feelings of frustration over having to wait that long and indicated that the hour or more wait time occurred on a weekly basis. On 8/7/23 at 12:15 AM, verification was made that R92's dialysis provider was located within walking distance from the facility across the parking lot approximately three hundred yards away from the facility. On 8/8/23 at 9:00 AM, a review of R92's electronic medical record (EMR) revealed that R92 was scheduled to attend dialysis appointments on Monday, Wednesday, and Friday mornings. Further review of R92's EMR revealed that…

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 expired medications were removed from one of three medications rooms and ensure resident medications were not left at the bedside for one resident (R68), resulting in the potential for decreased effectiveness of medication, lost doses of medication or medication not taken. Findings include: On 08/08/23 at 1:05 PM, the Desk One Medication room was checked with Licensed Practical Nurse N. Expired bottles of the OTC (over the counter) medication Melatonin were observed as noted: Expired 4/23, 22 bottles; Expired 2/23, three bottles; Expired 6/23, three bottles. A Magnesium OTC was also observed: Expired 4/23, one bottle. On 08/08/23 at 4:25 PM, the Unit Manager for the desk one medication room reported they had been made aware of the expired over the counter Melatonin and reported they had not been using the dosage and were moving the stock from central supply to the Desk One medication room. On 08/09/23 at 8:35 AM, the medication room observation was reviewed with the Director of Nursing (DON). The DON…

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 upon observation, interview and record review, the facility failed to serve food in a palatable manner and at the preferred temperature for three (R52, R92, R211) of ten residents reviewed for food concerns. Findings include: R52 Review of the facility record for R52 revealed an admission date of 03/29/23 with diagnoses that included Acute Kidney Failure, Sepsis and Stage Four Sacral Pressure Ulcer. The Minimum Data Set (MDS) assessment dated [DATE] indicated R52 primarily requires maximum assistance with self care tasks. The Brief Interview for Mental Status (BIMS) score of 13/15 indicated intact cognition. On 08/07/23 at 10:12 AM, R52 reported the food is poor and stated the hot food is usually cold and the meat is always too dry. It feels like they serve mashed potatoes every day. On 08/08/23 at 10:59 AM, R52 stated They gave me mashed potatoes again yesterday. When asked about their breakfast that morning R52 stated I only ate the cereal, I can't eat the eggs. Its usually powdered scrambled eggs that…

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 that bedtime snacks were offered/provided to one resident (R40) of seven residents reviewed for bedtime snacks. Findings include: On 8/8/23 at 9:31 AM, resident council meeting notes were reviewed for the months of March 2023 to August 2023 and revealed the following regarding bedtime snacks, June 1, 2023, snacks not given; July 6, 2023, snacks not passed. On 8/8/23 at 10:35 AM, R40 was interviewed about being offered and provided bedtime snacks. R40 stated, I'm not aware when bedtime snacks are brought to the unit. I am not offered a bedtime snack. I would like a bedtime snack. On 8/8/23 at 11:02 AM, a thirty day review (7/8/23-8/8/23) was completed of R40's bedtime snack record in their electronic medical record (EMR) and revealed that R40 was offered bedtime snacks on 7/10, 7/25, 7/30, 8/1, and 8/7. No other documentation was present in R40's EMR to indicate whether R40 received or was offered a bedtime snack on the other days of the 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.

Based on observation, interview and record review, the facility failed to ensure infection control practices were followed during resident provided care for three residents (R42, R76, R23) of three residents reviewed for infection control practices. Findings include: On 08/08/23 at 3:23 PM, a wound observation for R42 was completed with Licensed Practical Nurse (LPN) K. R42 was on enhanced contact isolation (gown and glove use during care) precautions. LPN K donned personal protective equipment (PPE), hand hygiene was completed and gloves were donned. The soiled dressing to the right buttock was removed, gloves removed and hand hygiene was done. New gloves were donned and the buttock wound was then cleansed and a new dressing applied. LPN K reached into their pocket under their isolation gown and removed a pen. No hand hygiene was completed. A date and time were then written on the dressing. This was repeated for the ankle wound. LPN K determined a larger dressing was needed for the ankle wound and therefore doffed the PPE, completed hand hygiene and returned with a new dressing 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.