Burcham Hills Retirement Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the accuracy of one discharge Minimum Data Set (MDS) assessment for one resident (resident #103) of three reviewed for discharge. Findings include: According to the clinical record, R103 was admitted to the facility on [DATE]. Nursing progress notes dated [DATE] reflected R103 was found unresponsive and transferred to the hospital. Review of the discharge MDS dated [DATE], question A2105 was coded that R103 went home. On [DATE] at 12:03 PM, MDS Coordinators D and E were interviewed. MDS Coordinator E reported that MDS Nurse F was not working today but responsible for all discharge MDS's . MDS Coordinator D reported she was certain R103 was sent to the hospital and later died and was not discharged home. MDS Coordinator D reported question A2105 should have been coded as a 4 which was acute care hospital.

Based on observation, interview and record review, the facility failed to provide showers/baths for one (Resident 50) of two residents reviewed for activities of daily living. Findings include: A review of the clinical record revealed R50 was admitted into the facility on 4/14/25, with diagnoses that included: depression, seizure disorder, fracture and required one person assistance for bathing. On 5/14/25 at 8:36 AM, R50 was observed sitting up at the edge of her bed. Her hair was observed to be greasy and unkempt. R50 reported that she had only received one shower since being admitted to the facility. R50 reported that she required assistance with showers and that her hair feels greasy (which she did not like). A review of R50's Task record for showers/Baths revealed no documentation indicating that the resident had received any showers since her admission. The only documented responses in the Task record were not applicable. On 5/15/25 at 10:51 AM, during an interview with Director of Nursing (DON), she reported that showers should be offered twice per week, when she first…

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 wound treatments were in place as ordered for one resident (Resident 60) and failed to administer medication as ordered for one resident (Resident 305) of 21 residents reviewed for quality of care. Findings include: Resident #R305 A review of the clinical record revealed R305 was admitted into the facility on 4/4/25, with diagnoses that included: Type 2 Diabetes Mellitus with diabetic neuropathy, major depressive disorder and anxiety disorder. On 5/13/25 at 1:17PM, R305 was observed sitting in her manual wheelchair in her room. R305 reported that the facility had not been consistently administering her weekly diabetes medication, Mounjaro. R305 reported concern related to potential diabetes related complications due to not receiving her Mounjaro regularly. A review of physician's orders for R305 revealed: 4/5/25 Mounjaro Subcutaneous Solution 5mg/0.5ML, inject subcutaneously (under the skin) one time a day, every Saturday for DM…

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 medications were safely stored and administered for one (R7) of one reviewed. Findings include: Review of the medical record reflected R7 admitted to the facility on [DATE], with diagnoses that included hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke). The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/7/25, reflected R7 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 05/14/25 at 9:22 AM, R7 was observed seated in a wheelchair, in their room. A medication cup containing six pills was observed on the stand, under their TV. On 05/14/25 at 9:24 AM, Registered Nurse (RN) R was at the medication cart, in the hallway, and reported the pills in R7's room were from that morning. RN R stated R7 had an order not to hover over him while 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.

Based on interview and record review, the facility failed to ensure the Infection Preventionist completed specialized training in infection prevention and control. Findings include: On 5/14/25 at 2:47 PM, Registered Nurse (RN) DD reported that she was the facilities Infection Preventionist. RN DD stated that she could not locate her training certificate for her Infection Preventionist role. On 5/15/25 at 12:32 PM, RN DD reported that she had recently began retaking the course, however, was not completed with the training. On 05/15/25 at 1:21 PM, Director of Nursing (DON) B reported that the facility was unable to locate the certificate of completion for RN DD and the program was not overseen by any other employee.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number MI00151168. Based on observation, interview, and record review, the facility failed to treat one resident (Resident #3) with dignity and respect out of three residents reviewed. Findings include: Review of the medical record revealed R3 was admitted to the facility on [DATE] with diagnoses that included: traumatic subdural hemorrhage with loss of consciousness and muscle weakness. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/27/25 revealed R3 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and required substantial/maximal assistance with lower body dressing. On 3/17/25 at 9:28 AM, during a telephone interview with Family member D they reported that on 2/28/25 RN A sent R3 to an outside appointment without any pants, hat or coat on. When Family member D met R3 at his appointment his lap was covered with only a sheet and on the bottom of his torso he was only wearing a brief. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00149664. Based on interview and record review, the facility failed to 1) assess and monitor respiratory status for one (Resident #3); and 2) administer respiratory medications as ordered for one (Resident #6) of six reviewed. Findings include: Resident #3 (R3): Review of the medical record reflected R3 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia and dependence on supplemental oxygen. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R3 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R3 died in the facility on [DATE]. A Physician's Order, with a start date of [DATE], reflected R3 was to receive oxygen, titrated at a rate of two to five liters per minute, to maintain blood oxygen saturation levels between 88 and 92 percent…

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 #MI00147551. Based on interview and record review, the facility failed to educate non-clinical staff regarding wander guards, alarmed exit doors and staff reliabilities during an elopement, resulting in Resident #102 exiting the facility on 9/5/24 at 1:35 p.m., the likelihood for severe injury, and an increase in anxiety and fear. Findings Include: Review of the Face Sheet, progress notes dated 9/5/24 through 9/10/24, and care plans dated 9/3/24 revealed Resident #102 was 86 years-old, admitted to the facility on [DATE], and required supervision due to wandering with a history of attempts to exit the building. The resident was alert with a BIMS (cognitive assessment tool) of 8 (alert, able to be interviewed), and was assessed to be an elopement risk with a wander device placed on her wrist (on 9/3/24). The residents diagnosis included, difficulty walking with unsteadiness, seizures, history of stroke, Cognitive Communication Deficit, Dementia, Anxiety Disorder, Psychotic…

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 report allegations of abuse/neglect for one Resident (#3) of one resident sampled for abuse reporting of abuse/neglect. Findings Included: Resident #3(R3) Review of the medical record revealed R3 was admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), type 2 diabetes, lung cancer, unstageable sacral pressure ulcer, fibromyalgia (widespread and long term body pain), epilepsy, anemia (low red blood cells), gastro-esophageal reflux disease, hypomagnesemia (low magnesium levels in blood), hyperlipidemia (high fat content in blood), sleep apnea, right foot drop, bipolar disorder, anxiety, nicotine dependence, and history of falls. R3's medical record demonstrated she was discharged from the facility on 07/29/2024 and was re-admitted [DATE] that included new diagnoses of a closed fracture of upper end of the right tibia and a fracture of the upper end and lower end of right fibula. The most recent Minimum…

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 investigate, implement preventive measures, and take correction action for an allegation of abuse/neglect for one resident (#3) of one resident review for abuse/neglect. Findings Included: Resident #3(R3) Review of the medical record revealed R3 was admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), type 2 diabetes, lung cancer, unstageable sacral pressure ulcer, fibromyalgia (widespread and long term body pain), epilepsy, anemia (low red blood cells), gastro-esophageal reflux disease, hypomagnesemia (low magnesium levels in blood), hyperlipidemia (high fat content in blood), sleep apnea, right foot drop, bipolar disorder, anxiety, nicotine dependence, and history of falls. R3's medical record demonstrated she was discharged from the facility on 07/29/2024 and was re-admitted [DATE] that included new diagnoses of a closed fracture of upper end of the right tibia and a fracture of the upper end 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.

This citation pertains to intake: MI00146060. Based on interview and record review the facility failed to ensure that five Certified Nurse Aides (CNA)(D, E, F,G, and H) had the required initial competency evaluation and techniques necessary to care for Residents. Findings Included: Record review of the facility staff personnel records demonstrated Certified Nurse Aide (CAN) D was hired by the facility 06/17/2024. The personnel record of CNA D had not demonstrated a completed competency evaluation upon completion of her orientation. Record review of the facility staff personnel records demonstrated Certified Nurse Aide (CNA) E was hired by the facility 08/24/2023. The personnel record of CNA E had not demonstrated a completed competency evaluation upon completion of her orientation. Record review of the facility staff personnel records demonstrated Certified Nurse Aide (CNA) F was contracted CNA that started at the facility 12/28/2023. The personnel record of CNA F had not demonstrated a completed competency evaluation upon completion of her orientation to the facility. Record 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.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 88 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies. Findings include: On 05/21/24 at 08:50 A.M., An initial tour of the food service was conducted with Director of Food and Beverage G. The following items were noted: The TurboChef oven interior surface was observed soiled with accumulated and encrusted food residue. Director of Food and Beverage G indicated he would have staff thoroughly clean and sanitize the TurboChef oven interior surface as soon as possible. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an…

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 observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 88 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality. Finding include: On 05/21/24 at 02:55 P.M., An environmental tour of the facility Laundry Service was conducted with Director of Building and Grounds I. The following items were noted: Chemical Room: The entrance door laminate surface was observed (etched, scored, particulate), adjacent to the doorknob lock set assembly. The damaged laminate surface measured approximately 6-inches-wide by 8-inches-long. The exhaust ventilation grill was observed soiled with accumulated and encrusted dust and dirt deposits. On 05/22/24 at 09:55 A.M., A common area environmental tour was conducted with Director of Building and Grounds I and Housekeeping Supervisor J. The following items were noted: 1st Floor: B-Hall: Shower Room: 2 of 2 return-air-exhaust ventilation…

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 services that met the acceptable standards of clinical practice for peripherally inserted central catheter (PICC) line dressings in 1 of 1 sampled resident (Resident #543) reviewed for PICC lines, from a total sample of 18 resident, resulting in the increased likelihood for infection. Findings include: According to Clinical Nursing Skills & Techniques, 6th edition, ([NAME], A., [NAME], P. 2006. page 937), A transparent dressing should be changed with annual site rotation and immediately if integrity of the dressing is compromised. Gauze dressings should be changed routinely every 48 hours and immediately if integrity is compromised. Gauze used underneath a transparent dressing is considered a gauze dressing and should be changed every 48 hours. According to the publication American Nurse Today, dated May 2014, volume 9, number 5, under PICC line dressing changes: Change a transparent dressing every 7 days, if the dressing is no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident received an assessment for meal consumption assistance and received sufficient food intake, in one of four residents reviewed for nutrition and hydration (Resident #24), resulting in significant weight loss. Findings include: Resident #24 Review of the medical record revealed Resident #24 (R24) was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, muscle weakness, myasthenia gravis, schizoaffective disorder-bipolar type, anxiety disorder, major depressive disorder, displaced bimalleolar fracture of left lower leg; closed fracture with routine healing, dislocation of left ankle joint, and orthostatic hypotension. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R24 was cognitively intact with a Brief Interview for Mental Status of 12, did not have a pressure ulcer, and was at risk for pressure ulcer development. Review of R24's Care Plan revealed R24 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 This citation pertains to intakes: MI00142495, MI00142637 Based on observation, interview and record review, the facility failed to ensure sufficient levels of nursing staff to meet resident needs and supervision for two residents (Resident #70 and #547), resulting in repeat falls including injury, and the potential for unmet care needs and facility residents to not attain or maintain the highest practicable physical, mental, and psychosocial well-being. Finding include: Review of the Facility assessment, dated 8/1/23, reflected average census 83. Review of the assessment included data based on census of 93(5/21/23 census of 88), of which 86 required assistance of one or two staff for bathing, 86 required assistance of one or two staff for dressing, 72 required assistance of one or two staff for transferring, 82 required assistance of one or two staff for toilet use, and 82 required assistance of one or two staff for eating. The assessment also revealed 6 residents were dependent on staff for bathing, 3 were…

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 the attending physician documented in the medical record that identified medication review irregularities were reviewed, the action taken, and/or the rationale for no changes to the medications for one (Resident #30) of five reviewed. Findings include: Resident #30 (R30) Review of the medical record revealed R30 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, schizophrenia, and major depressive disorder. The Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 2/12/24 revealed R30 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Physician's Order dated 4/13/23 revealed an order for risperidone (antipsychotic medication) 8 milligrams (mg) by mouth at bedtime for schizophrenia. Review of the Recommendations to the Prescriber from the Pharmacist revealed the following: 8/27/23: The pharmacist recommended decreasing…

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 adequate monitoring with the use of an antipsychotic medication for one (Resident #30) of five reviewed. Findings include: Review of the medical record revealed R30 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, schizophrenia, and major depressive disorder. The Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 2/12/24 revealed R30 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Physician's Order dated 4/13/23 revealed an order for risperidone (antipsychotic medication) 8 milligrams (mg) by mouth at bedtime for schizophrenia. Review of the Physician's Order dated 8/27/20 revealed an order to check lipid panel every 6 months. Review of the Recommendations to the Prescriber from the Pharmacist dated 3/18/24 revealed Antipsychotic medications may induce hyperlipidemia. Please consider obtaining a Fasting Lipid…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% when two medication errors were observed from a total of 25 opportunities for one resident (Resident #40) of five reviewed for medication administration, resulting in a medication error rate of 8%. Findings include: Review of the medical record revealed Resident #40 (R40) was admitted to the facility on [DATE]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/26/24 revealed R40 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 05/23/24 at 8:42 AM, Licensed Practical Nurse (LPN) L was observed preparing and administering medications to Resident #40 (R40). LPN L administered bisacodyl (laxative medication) 5 milligrams (5 mg), did not administer a probiotic, and did not administer loperamide. Review of the Physician's Order dated 4/12/24 revealed an order for a probiotic daily for gastrointestinal…

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 offer pneumococcal immunizations per Centers for Disease Control and Prevention (CDC) recommendations for two (Resident #24 and Resident #69) of five reviewed. Findings include: Resident #24 (R24) Review of the medical record revealed R24 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included diabetes and chronic kidney disease stage 3. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/29/24 revealed R24 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the immunization history in R24's medical record revealed they received the Pnemovax 23 on 10/20/15 and refused Prevnar 13. Review of the Immunization Informed Consent revealed on 11/17/22, R24's medical decision maker gave consent for a pneumococcal immunization. According to CDC's PneumoRecs VaxAdvisor, the recommendations for R24 were Give one dose…

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 offer an updated COVID-19 vaccine to one (Resident #69) of five reviewed. Findings include: Review of the medical record revealed Resident #69 (R69) was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, hypertension, and obstructive sleep apnea. The MDS with an ARD of 4/18/24 revealed R69 scored 14 out of 15 (cognitively intact) on the BIMS. Review of the immunization history entered in R69's medical record revealed their last COVID-19 vaccine was received on 1/16/23. There was no documentation that R69 was offered an updated 2023-2024 COVID-19 vaccine. In an interview on 05/24/24 at 8:34 AM, Infection Preventionist (IP) M reported R69 was due for another COVID-19 vaccine. When asked if a consent or declination was received from R69, IP M reported they did not have record of a consent or declination.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake #MI00141710 and MI00142200 Based on observation, interview, and record review, the facility failed to report allegations of abuse to the Nursing Home Administrator (NHA) and State Agency immediately for one (Resident 5) of 3 reviewed, resulting in allegations of abuse that were not timely reported to the Nursing Home Administrator and the potential for further allegations of abuse to not be reported timely. Findings include: According to the clinical record, Resident 5 (R5) was a [AGE] year-old female with a diagnosis of dementia. R5 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status on 01/17/23. On 01/24/24 at 2:00pm, R5 was observed in her room, sitting up in her wheelchair eating a snack. R5 did not answer any questions. Review of the facility reported incident (FRI) dated 12/12/23, reflected Resident 5 (R5) was observed to have bruising on her left upper arm wrapping around inner to outer, (dark purple) 10 x 10 centimeters (cm), left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake #MI00141710 and MI00142200 Based on observation, interview and record review, the facility failed to ensure the protection of residents and thoroughly investigate allegations of abuse for two residents (Resident #5 and #7) of three reviewed for abuse, resulting in the potential for further abuse to occur and allegations of abuse not being thoroughly investigated. Findings include: According to the clinical record, Resident 5 (R5) was a [AGE] year-old female with a diagnosis of dementia. R5 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status on 01/17/23. On 01/24/24 at 2:00pm, R5 was observed in her room, sitting up in her wheelchair eating a snack. R5 did not answer any questions. Review of the facility reported incident (FRI) dated 12/12/23, reflected Resident 5 (R5) was observed to have bruising on her left upper arm wrapping around inner to outer, (dark purple) 10 x 10 centimeters (cm), left lateral breast bruise dark purple in color,…

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 MI00141018. Based on observation, interview and record review, the facility failed to prevent a fall for one (Resident #2) of three reviewed, resulting in Resident #2 sustaining a fall with injury. Findings include: Review of the medical record revealed Resident #2 (R2) was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed R2 had severely impaired cognitive skills for daily decision making. R2 died in the facility on [DATE]. Review of R2's care plans revealed an intervention initiated on [DATE] of [R2] has 1:1 [one on one care/supervision] during waking hours to help with redirection. Another intervention initiated on [DATE] revealed when ambulating with [R2], attempt to redirect her from doorways, objects in the hallway and/or dining room, from peers. She at times may bump into these things with altered spatial awareness. Review of the Fall with Injury Incident Report…

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 MI00139554 Based on interview and record review, the facility failed to ensure current Cardiopulmonary Resuscitation (CPR) certification for 6 licensed nursing staff of 6 reviewed, resulting in the potential for all facility residents who are a full code to not being resuscitated during a cardiopulmonary arrest. Findings include: Review of Licensed Practical Nurse (LPN) N's and Registered Nurse (RN) M's CPR certification revealed online completion with indication on card noted to state, The mentioned individual is now Certified in the mentioned Course by demonstrating proficiency by successfully passing the examination in accordance with the Terms and Conditions of (name of course). Review of RN J's CPR certification revealed online completion with small print on back of card unable to be deciphered. Review of RN K's, I's, and L's CPR certification revealed online completion with indication on card noted to state, The above mentioned Student is now certified in the above…

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 MI00 138515 Based on observation, interview, and record review the facility failed to complete investigation of an accident/hazard and prevent interventions of accident/hazardous events for one resident (#1) of three residents reviewed for accidents/hazardous events resulting in the potential of accident/hazardous events that would potential injury to residents. Findings included: Review of the medical record revealed R1 was admitted to the facility 04/17/2023 with diagnoses that included Alzheimer's disease, dementia, type 1 diabetes, celiac disease (an immune reaction to eating gluten), obstructive sleep disease, hypertension, hypothyroidism (low thyroid hormone), hyperlipidemia (high fat content in blood), aortic valve stenosis (narrowing of the valve), bilateral osteoarthritis of knees, vitamin D deficiency, post traumatic stress disease (PTSD), breast cancer, and history of transient ischemic attack (TIA-a brief stroke like symptoms). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/2023 had a Brief…

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 #'s MI00125600 and MI00130528. Based on observation, interview and record review, the facility failed to maintain sufficient staffing for 3 residents (Resident #57, #31, #2 & #4) and 11 of 11 confidential group interview resident from a total sample of 20, resulting in needs not met in a timely manner and the potential to affect all 95 facility residents. Resident #4 (R4) On 3/06/23 at 1:59 PM, R4 was observed sitting up in bed, eyes closed, hands elevated, with family member (FM) H at bedside. FM H stated call light response had been 45 minutes. Resident #2 (R2) On 3/07/23 at 8:29 AM R2 stated staffing was an issue at the facility, R2 stated more people were needed, and that was the problem, the current staff were run ragged. R2 stated it took upwards of 25 minutes to answer call lights and meals were an hour late. Resident #31 (R31) During an interview on 3/06/23 at 1:30 PM R31 stated the facility was short staffed, and it really bugs her. In an interview on 03/06/23 01:53 PM,…

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, record reviews, 2 (#39, #54) of 20 sampled residents, and 11 of 11 from the confidential group meeting, the facility failed to provide palatable food products effecting 89 residents, resulting in the increased likelihood for resident decreased food acceptance and nutritional decline. Findings include: On 03/08/23 at 09:15 A.M., An initial tour of the food service was conducted with Director of Food & Beverage W and Sous Chef X. The following items were noted: On 03/08/23 at 11:32 A.M., An interview was conducted with Sous Chef Y regarding monitoring food product temperatures. Sous Chef Y stated: Food products are tempted four different times. Sous Chef Y also stated: The food is tempted directly out of the oven. Sous Chef Y additionally stated: The food is tempted out of the hot box. Sous Chef Y further stated: The food is tempted when on the floor in the steam table. Sous Chef Y finally stated: The food is tempted after all residents are served. On 03/08/23 at 11:39 A.M., Lunch meal food products were observed leaving the food production kitchen.…

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 MI00130528. Based on observation and interview, the facility failed to ensure the routine implementation and monitoring of isolation precautions utilized by facility staff for the care of Covid positive residents reviewed for infection control practices and failed to properly disinfect insulin pens prior to needle application (R298), resulting in potential cross contamination and spreading of Covid and the potential for medication contamination. During an observation on 03/06/23 at 1:25 PM, a resident' door had signage for contact and droplet precautions including the donning (proper way to put on personal protective equipment (PPE). Included a sign with a large red plus/positive sign on the door. Also observed was a cart outside of that door with gloves, N95 mask and yellow gowns, no goggles or face shields were in that cart. No signage for doffing (removing PPE) was posted. No observation of a trash container in the hall near the cart. Certified Nursing Assistant (CNA) was taking lunch trays into this room for both residents in Styrofoam containers. As…

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 develop or implement the care plan, in 2 of 20 residents reviewed for care plans (Resident #4 & #494) resulting in unmet needs. Findings include: Resident #4 (R4) On 3/06/23 at 1:59 PM, R4 was observed sitting up in bed, eyes closed, hands elevated, with family member (FM) H at bedside. Pictures of right- and left-hand splints with directions for splints were posted on R4's wall; with directions to provide passive (performed by caregiver) range of motion (ROM, exercises to prevent joint deformity) prior to application. R4 was not observed wearing splints on her hands. FM H stated the staff did not don R4's splints per care plan and when asked staff was told the splints did not fit her. R4's Minimum Data Set (MDS) assessment dated [DATE] indicated she was admitted to the facility on [DATE], her cognitive skills for daily decision making were severely impaired (never, rarely made decisions). R4 was totally dependent in activity of daily…

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 revise care plans for one (Resident # 39) of 20 residents reviewed, resulting in the potential for unmet care needs. Findings include: Resident # 39 (R39) admitted to facility 1/20/2023 with diagnoses including chronic diastolic heart failure, chronic kidney disease stage 2, and acute posthemorrhagic anemia. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/6/2023 revealed that R39 had a Brief Interview for Mental Status (BIMS) score = 14 (cognitively intact). Section G of MDS revealed that R39 required two-person extensive assist with bed mobility, transfers, and toilet use and was independent with eating after set up. In an observation and interview on 3/06/23 at 12:58 PM, R39 was observed lying in bed, on back, with head of bed at an approximate 30-degree angle. R39 stated that she had received therapy upon facility admission, but that therapy was stopped as she was not able to gain strength. R39 denied limitations to joints and was noted to lift and bend both arms and legs. R39…

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 MI00130528. Based on observation, interview and record review, the facility failed to provide necessary care and services to ensure that a resident's range of motion in their hands and splint care was provided per care plan in one of two reviewed for restorative nursing care (Resident #4), resulting in risk of worsened contractures, skin breakdown and pain. Resident #4 (R4) On 3/06/23 at 1:59 PM, R4 was observed sitting up in bed, eyes closed, hands elevated, with family member (FM) H at bedside. Pictures of right- and left-hand splints with directions for splints were posted on R4's wall; with directions to provide passive (performed by caregiver) range of motion (ROM, exercises to prevent joint deformity) prior to application. R4 was not observed wearing splints on her hands. FM H stated the staff did not don R4's splints per care plan and when asked staff was told the splints did not fit her. R4's Minimum Data Set (MDS) assessment dated [DATE] indicated she was admitted to 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 a medication error rate of less than five percent when two medication errors were observed from a total of thirty-three opportunities for one resident (Resident # 298) of eight reviewed for medication administration, resulting in a medication error rate of 6.06% and the potential for reduced efficacy of medications and increased risk of adverse reactions/side effects. Findings include: On 3/07/23 at 8:00 AM, Licensed Practical Nurse (LPN) C was observed to prepare multiple medications for Resident #298 (R298) including two insulin pens for administration. LPN C entered R298's room with oral medications, Basaglar Kwikpen, Novolin 70/30 Flexpen, and disposable plastic cup containing glucometer, test strip, multiple unopened alcohol swabs, and two unopened disposable insulin pen needles. LPN C was then observed to wash hands, place gloves, remove caps from both insulin pens, and place disposable insulin needles directly onto each pen without first cleansing the rubber hub at top of the insulin pens with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to dispose of expired medications in one of four medication carts and two of four medication rooms reviewed, resulting in the potential for decreased medication efficacy and adverse side effects in a current facility census of 95 residents. Findings include: On 3/07/23 at 2:43 PM, [NAME] Medication Room located on the third floor of the facility was reviewed in the presence of Licensed Practical Nurse/Unit Manager (LPN/UM) E. During the review, it was noted that the medication refrigerator within the medication room contained a Tuberculin Purified Protein Derivative box with a handwritten date of O (opened): 12/16/22 with an opened, undated Tuberculin vial noted within box. LPN/UM E confirmed the opened date indicated on the box, stated that she would consider the vial to be expired, and that the medication would be disposed of. Within a medication cupboard, in the same medication room, a Geri-Lanta Antacid bottle was noted with an expiration date 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.