Medilodge of Campus Area

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to MI00146912 and MI00150426 Based on observation, interview and record review, the facility failed to preserve the dignity of 3 of 4 residents (Resident #2, #318, #32) reviewed for dignity and 4 of 5 residents for residents that attended the confidential group meeting. Findings include: Resident #2 (R2) Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE], revealed Resident # 2 (R2) was admitted to the facility on [DATE] with a readmission date of 1/04/25 with diagnoses that include congestive heart failure, chronic obstructive pulmonary disease. R2 scored 15 out of 15 (cognitively intact) on the Brief Interview Status (BIMS). On 02/25/25 at 09:58 AM during an interview with R2 it was reported that staff complain chronically about their work load and are continuously talking and complaining about Resident 32 (R32) and how frequently R32 pushes the call light for help. R2 elaborated that staff were observed frequently texting or talking on their personal cell…

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 grievances were promptly documented, investigated, tracked and resolved for 5 of 5 residents that participated in the Resident Council (RC) meeting and Resident #2. Findings include: Review of the Resident Council (RC) minutes dated 9/17/24 reflected concerns with staff not wearing name tags, delayed call light response times, noise levels. RC Minutes dated 10/22/24 reflected the Nursing Home Administrator on record (NHA) A attended the meeting and reported inservices were done with staff in relation to concerns brought forth from the 9/17/24 meeting. Residents reported noise level at night continued to be a problem. RC minutes dated 11/26/24 reflected concern related to staff being on their phones in common areas and at the nurses station. RC minutes dated 12/27/24 reflected the concern with staff being on their personal phones continues, call light response time was an issue and staff being loud at night/noise level was a concern. RC…

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

Based on interview and record review, the facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) were provided to two (R323 and R325) of three residents reviewed for beneficiary notification, resulting in the potential for residents and/or representatives to be uninformed of the potential private pay charges of continued services at the facility and inability to file an appeal. Findings include: On 3/3/25 at 12:10 PM, Self-identified Nursing Home Administrator (NHA) B was asked to provide beneficiary notification information including NOMNC and/or SNF-ABN for three residents. A review of the documents provided revealed R323 was missing a SNF-ABN and the NOMNC for R325 was missing the second page, which is where the resident/resident representative would sign, acknowledging receipt and understanding. On 3/3/25 at 3:17 PM, during an interview with social services director (SSD) N, when asked when a resident should receive a SNF-ABN she reported that she gives one for every NOMNC issued. When asked…

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: MI00150426 Based on observation, interview, and record review the facility failed to accurately record and make a prompt effort to resolve grievances for one resident (#318) of one resident reviewed for grievances. Findings Included: Resident #318 (R318) Review of the medical record revealed R318 was admitted to the facility 02/13/2025 with diagnoses that included atherosclerotic heart disease (build-up of fats, cholesterol and other substances in the artery walls), bilateral peripheral vertigo (dizziness caused by problem in inner ear), hyperlipidemia (high fat content in blood), hypertension, anemia (low red blood cells), and Barrett's esophagus (damage to the lower part of the esophagus). The most recent Minimum Data Set (MDS), with an Assessment Reference date (ARD) of 02/18/2025, revealed R318 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 02/25/2025 at 10:09 a.m. R318 was observed sitting on the side of his bed. R318 explained that he had concerns that he had not received…

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 accurately complete a Minimum Data Set (MDS) assessment for one resident (#6) of 16 residents reviewed for accurate assessments. Findings Included: Resident #6 (R6) Review of the medical record revealed R6 was admitted to the facility 10/17/2019 with diagnoses that included chronic obstructive pulmonary disease (COPD), atrial fibrillation, peripheral vascular disease (PVD), atherosclerotic heart disease (build-up of fats, cholesterol and other substances in the artery walls), chronic respiratory failure, depression, anxiety, urinary incontinence, lack of coordination, nausea, dysuria (discomfort, pain, or burning when urinating), muscle spasm, metabolic encephalopathy (impaired brain function), thrombocytopenia (low number of platelets), low back pain, generalized edema (excess fluid buildup in the body's tissues), chronic pain, psychotic disorder (mental disorder characterized by a disconnection form reality), developmental disorder of speech and language, obesity, hypertension, absence of left leg above the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the local state mental health authority of Pre-admission Screening (PAS)/Annual Resident Review (ARR) (PASARR) changes for one (Resident #33) of two reviewed for PASARR. Findings include: Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE], reflected Resident 33 (R33) was admitted to the facility with diagnoses that included end stage renal disease, developmental disorder of scholastic skills, and bipolar disorder. Review of R33's clinical record reflected R33 scored 12 out of 14 (cognitively intact) on the Brief Interview Mental Status (BIMS). Review of R33's level one screening/3877 dated 12/28/23 reflected R33 had a mental illness and was learning disabled, the level II screen dated 12/29/23 reflected that R 33 was on a 30 day exemption and expected to be discharged from the facility within 30 days. The next 3877 was dated 9/12/24 and reflected R33 had a diagnosis of bipolar disorder, developmental disorder of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement comprehensive care plans for one resident (#32) of 16 reviewed. Findings Included: Resident #32 (R32) Review of the medical record revealed R32 was admitted to the facility 04/18/2019 with diagnoses that included multiple sclerosis, paraplegia (paralysis that occurs in the lower half of the body), neuromuscular dysfunction of bladder, type 2 diabetes, obesity, diabetic neuropathy (nerve damage caused by diabetes), cardiomegaly (enlarge heart), muscle spasm, anemia (low red blood cells), hyperlipidemia (high fat content in blood), chronic obstructive pulmonary disease (COPD), chronic pain, altered mental status, metabolic encephalopathy (impaired brain function), insomnia, edema, anxiety, major depression, migraine, and gastro-esophageal reflux. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 0f 10/12/2024, revealed R32 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively…

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 include one resident (R#29) in care plan development of 16 residents reviewed for participation in care planning. Findings include: Resident #29 (R29) Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected Resident 29 (R29) was admitted to the facility on [DATE] with diagnoses that included mild cognitive impairment, schizophrenia and seizure disorder. R29 scored 10 out of 15 (mild cognitive impairment) on the Brief Interview for Mental Status (BIMS). On 02/25/25 at 09:04 AM, R29 was observed sitting in her room and was observed to have sad facial expressions. When queried about her mood R 29 reported she did not like living at the facility and wanted to be discharged back to the community. R29 elaborated that she was admitted to the facility last spring or summer and was discharged to an adult foster care in August 2024 with in home services from the community. R29 reported during her initial stay she…

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: MI00150426 Based on observation, interview, and record review the facility failed to follow physician orders for three residents (R11-brace application, R41-prosthetic fitting appointment, and R318-medication administration time) of sixteen residents reviewed for quality of care. Findings Included: Resident #41 (R41) Review of the medical record revealed R41 was admitted to the facility 10/27/2021 with diagnoses included chronic obstructive pulmonary disease (COPD), peripheral vascular disease (PVD), alcoholic liver disease, emphysema (chronic lung disease that permanently damages the lungs making his difficulty to breath), anemia (low red blood cells), alcoholic fatty liver, polyneuropathy (a peripheral nerve disorder that causes multiple nerves throughout the body to malfunction simultaneously), hypertension, hypotension, hyperlipidemia (high fat content), acquired absence of right leg above the knee, acquired absence of left leg above the knee, muscle spasm, chronic pain,…

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 diabetic foot care to one (R47) of one reviewed for foot care, resulting in long toenails and discomfort. Findings include: Review of the clinical record revealed R47 was admitted into the facility on [DATE] with diagnoses that included: Type 2 Diabetes Mellitus and need for assistance with personal care, reduced mobility. Review of R47's physician orders revealed the following order entered on 12/12/24, May be seen by Ophthalmology, Podiatry, Audiologist, Psychiatrist, Psychologist, Optometrist, dentist, and wound care as needed or warranted. Review of R47's progress notes revealed no notes regarding podiatry services. According to the Minimum Data Set (MDS) assessment dated [DATE], R47 had scored 15/15 on the Brief Interview for Mental Status exam (which indicated intact cognition), required partial/moderate assistance with personal hygiene. On 2/25/2025 at 3:52 PM, R47 was observed lying in his bed with his family member (family…

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: MI00150426 Based on observation, interview, and record review the facility failed to provide medication in a timely manner for one resident (R318) out of four residents reviewed for pharmacy services. Findings Included: Resident #318 (R318) Review of the medical record revealed R318 was admitted to the facility 02/13/2025 with diagnoses that included atherosclerotic heart disease (build-up of fats, cholesterol and other substances in the artery walls), bilateral peripheral vertigo (dizziness caused by problem in inner ear), hyperlipidemia (high fat content in blood), hypertension, anemia (low red blood cells), and Barrett's esophagus (damage to the lower part of the esophagus). The most recent Minimum Data Set (MDS), with an Assessment Reference date (ARD) of 02/18/2025, revealed R318 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 02/25/2025 at 10:14 a.m. R318 was observed sitting on the side of his bed. R318 explained that he had not received his valium until several days…

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 the rationale for no changes to the medication review for one (Resident #4) of five reviewed. Findings include: Resident #4 (R4) Review of the medical record revealed R4 was admitted to the facility on [DATE] with diagnoses that included vascular dementia. Review of R4's Physician's Orders revealed a current orders for Atorvastatin Calcium 20 milligrams (mg). Review of the Medication Regimen Review dated 5/7/2024 revealed this resident is on hospice. please consider the long term benefit of the atorvastatin 20 mg therapy and discontinue at this time. The Physician/Prescriber response was marked as disagree and signed on 5/21/24. There was no documented rationale in R4s medical record as to why the recommendation was not implemented. only a hand written note at the bottom of the document which stated keep on statin. In an interview on 3/03/25 at 2:14 PM, Director of Nursing (DON) B stated…

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 Resident #50 (R50) Review of the medical record revealed R50 admitted to the facility on [DATE] with diagnoses that included acute kidney failure. Review of the Physician's Order dated 2/11/25 revealed an as needed order for Tylenol Oral Tablet 325 MG (Acetaminophen). Give 2 tablet by mouth every 8 hours as needed for Elevated Temperature;Pain. Review of the Physician's Order dated 2/11/25 revealed an as needed order for Norco Oral Tablet 7.5-325 MG (Hydrocodone-Acetaminophen). Give 1 tablet by mouth every 4 hours as needed for pain. Review of these orders revealed no parameters for the maximum dose permitted for acetaminophen, and if given as ordered, would exceed the maximum dose of acetaminophen allowed. In an interview on 03/03/25 at 2:16 PM, Director of Nursing (DON) C agreed the ordered doses exceeded the prescribed parameter of 3000 mg. Based on observation, interview, and record review the facility failed to ensure that two residents (#6), #50) of five reviewed were free from unnecessary medications.…

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 their medication error rate was below 5% when two medication errors were observed from a total of 27 opportunities for one resident (R61) of three reviewed, resulting in a medication error rate of 7.41%. Findings include: On 2/27/25 at 7:55 AM, registered nurse (RN) S was observed preparing and administering Spiriva inhaler (medication used to treat lung disease) 2.5 mcg and Advair discus (steroid inhaler used for lung disease) 250/50 mcg. Resident was handed and self-administered the Advair and immediately after was handed and self-administered the Spiriva. Upon exiting the room, RN S was asked if they would normally give any instructions related to the inhalers, they reported that they would normally have instructed the resident to wait 2 minutes in between each inhaler and that she had forgotten. On 2/27/25 at 4:48 PM, director of nursing (DON) C was asked what their expectation would be for specific instructions related to administration of both Spiriva and Advair inhalers. DON C reported 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 Resident 55 (R55) review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected R55 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) . On 02/25/25 at 08:36 AM, while entering R55's room alongside Social Service Director (SSD) N, R55 was observed in bed, there was a medication cup observed on R55's nightstand. The medication cup was observed to have 5 pills in the cup. R55 reported we woke her up at which time SSD N left the room. R#55 reported she was not woken up for breakfast or to take her medications. When queried if her medication were usually left at the bedside R55 reported yes sometimes. On 02/27/25 at 12:06 PM, during an interview with Assistant Director of Nursing (ADON) T reported there were no current residents in facility that were approved for self administration of medication. The observation that occurred on 2/25/25 at 8:36 am was shared ADON T who reported the expectation was that Nurses were to administer medications and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to address dental need for one resident (resident #2) of 3 reviewed for dental services. Findings include: Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE], revealed Resident # 2 (R2) was admitted to the facility on [DATE] with a readmission date of 1/04/25 with diagnoses that include congestive heart failure, chronic obstructive pulmonary disease and morbid obesity. R2 scored 15 out of 15 (cognitively intact) on the Brief Interview Status (BIMS). On 02/25/25 at 10:11 AM during an interview, R2 was observed to have multiple teeth missing and the teeth that were present were observed to be discolored. R2 stated he had mouth pain and saw a dentist at the facility and extractions and dentures were discussed. R2 stated he wanted to have a 2nd opinion from his dentist in a neighboring town. R2 reported he discussed this with Social Services Director (SSD) N and was instructed R2 or his niece to make the appointment…

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 includes intake MI000150426 Based on observation, interview and record review, the facility failed to provide requested dietary items for three residents (R29, R60 and R319) of ten residents reviewed for food. Findings include: Resident #60 (R60) Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected Resident 60 (R60) was admitted to the facility on [DATE] with diagnoses that included: anxiety and depression. R60 scored 14 out of 15 (indicating intact cognition) on the Brief Interview for Mental Status (BIMS). On 2/25/2025 at 9:50 AM, during an interview with R60, he reported he often has requested double portions of certain foods and he rarely has been provided double portions or what is indicated on his meal ticket. On 3/03/25 at 11:48 AM, R60 was observed sitting up eating lunch, he reported his lunch was correct however his breakfast that morning was incorrect. He reported that he asked for two packets of brown sugar for his oatmeal and only received one (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 This citation includes intake MI000150119 Based on observation, interview and record review, the facility failed to 1) ensure tracking and trending of employee illness; 2) implement timely Transmission-Based Precautions (TBP) for one COVID-19 positive resident (Resident #30) of one reviewed; and 3) ensure appropriate cleaning and storage of a CPAP (continuous positive airway pressure) mask for one (Resident #319). Findings include: During review of the facility's Infection Prevention and Control Program on 02/27/25 at 2:01 PM, Assistant Director of Nursing (ADON) T reported there was a sheet for the charge nurse to write down the reason for employee call-ins, and the Scheduler kept the employee call-in forms. If they were seeing trends in call-ins, the data was entered into the infection watch system, with tracking that included which hall staff worked on and who they had cared for. If staff tested positive for COVID-19 or when noticing multiple staff calling in for the same thing, the data was entered into the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain consent and/or declination for influenza and pneumococcal immunizations for one (Resident #18) of five reviewed for immunizations. Findings include: Review of the medical record reflected Resident #18 (R18) admitted to the facility on [DATE], with diagnoses that included heart failure, chronic obstructive pulmonary disease (COPD) and end stage renal disease with dependence on renal dialysis. According to the medical record, R18 had a medical Power of Attorney in place. Review of the medical record reflected R18 had not received any immunizations in the facility. There were no immunization consents or declinations in the medical record. In an interview on 02/27/25 at 2:01 PM, Assistant Director of Nursing (ADON) T reported influenza immunizations were offered yearly, and the facility began attempts to obtain consents and/or declinations around August. The facility provided a Progress Note dated 12/11/24, which reflected multiple messages had been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer COVID-19 booster immunizations to three (Resident #6, #18 and #32) of five reviewed for immunizations. Findings include: Resident #6 (R6) Review of the medical record reflected R6 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included congestive heart failure and chronic obstructive pulmonary disease. According to the medical record, R6 had a Guardian in place. According to the medical record, R6 had last received a COVID-19 immunization on 12/2/23. The medical record did not reflect documentation that any further booster immunizations had been offered. Resident #18 (R18) Review of the medical record reflected R18 admitted to the facility on [DATE], with diagnoses that included heart failure, chronic obstructive pulmonary disease (COPD) and end stage renal disease with dependence on renal dialysis. According to the medical record, R18 had a medical Power of Attorney in place. Review of the medical record reflected…

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 MI00143189 Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by staff for 1 (Resident #3) of 4 reviewed for abuse, resulting in the potential for a decline in physical, mental, and psychosocial well-being Findings include: Review of the medical record revealed that Resident #3 (R3) was initially admitted to facility 10/25/22 with diagnoses including Huntington's Disease, dementia with behavioral disturbance, unspecified psychosis, muscle weakness, and difficulty in walking. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/1/24 reflected that R3 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 7 (severe cognitive impairment). Review of R3's ADL (Activities of Daily Living) Care Plan reflected that R3 was independent with transfer, ambulation, bed mobility, dressing, personal hygiene, and toileting. Review of a Facility Reported Incident (FRI) dated 2/19/24 revealed, .On 2/8/24, [Certified Nurse Aide…

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 MI00143189 Based on observation, interview, and record review, the facility failed to timely identify, investigate, and report a staff to resident allegation of abuse to the abuse coordinator (the Nursing Home Administrator), and failed to timely report the allegation to the State Agency for 1 (Resident #3) of 4 residents reviewed for abuse, resulting in delayed identification, investigation, and reporting and the potential for further allegations of abuse to go unreported. Findings include: Review of the medical record revealed that Resident #3 (R3) was initially admitted to facility 10/25/22 with diagnoses including Huntington's Disease, dementia with behavioral disturbance, unspecified psychosis, muscle weakness, and difficulty in walking. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/1/24 reflected that R3 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 7 (severe cognitive impairment). Review of R3's ADL (Activities of Daily Living) Care Plan reflected that R3 was independent…

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 MI00143099 Based on observation, interview, and record review, the facility failed to provide assistance with activities of daily living (ADLs) for 1 (Resident #2) of 3 residents reviewed for ADLs, resulting in unmet care needs and the potential for a decline in emotional and physical health. Findings include: Review of the medical record revealed that Resident #2 (R2) readmitted to facility 4/25/23 with diagnoses including acquired absence of right leg above knee and left leg above knee, congestive heart failure, lack of coordination, muscle spasms, conversion disorder with seizures, mild cognitive impairment, and schizoaffective disorder. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/14/24 revealed a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact). Section E of the same MDS revealed that R2 did not exhibit rejection of care. In an observation and interview on 4/30/24 at 10:19 AM, R2 was observed sitting in her…

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 prevent a significant medication error for one resident (#463) of four residents reviewed resulting in the potential for decreased efficacy of anticonvulsant medication resulting in the potential of seizure activity. Findings Included: Resident #463 (R463) Review of the medical record revealed R463 was admitted to the facility 11/30/2023 with diagnoses that included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), sever protein-calorie malnutrition, cerebral infarction (stroke), type 2 diabetes, hyperlipidemia (high fat in blood), atrial fibrillation, epilepsy (nerve activity in brain disturbed), gout (build-up of uric acid in bone joints), hypothyroidism (low thyroid hormone), anemia (low red blood cells), kidney failure, chronic pain, tracheostomy, dysphagia (difficulty swallowing), and hypertension. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/06/2023, demonstrated that a Brief Interview of Mental Status (BIMS) could not be assessed. 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.

Based on observation, interview, and record review the facility failed to follow infection control guidelines for glucometer cleaning and handling of medication for four residents (#15, #17, #38, #463) of four residents during medication administration observation resulting in the potential to spread infection and blood borne pathogens. Findings Included: Resident #15 (R15) Review of the medical record revealed R15 was admitted to the facility 7/09/2022 with diagnoses that included type 2 diabetes, heart failure, hyperkalemia (high potassium), dementia, metabolic encephalopathy (brain disease), gastro-esophageal reflux, dysphagia (difficulty swallowing), personality disorder, psychotic disorder, cerebral infarction (stroke), mood disorder, and depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/01/2023, demonstrated a Brief Interview of Mental Status (BIMS) of 6 (severe cognitive impairment) out of 15. Resident #17 (R17) Review of the medical record revealed R17 was admitted to the facility 12/08/2022 with diagnoses that included chronic…

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 accurately complete Minimum Data Set (MDS) assessments for three (Resident #25, #41, #53) of 15 reviewed, resulting in inaccurate assessments and the potential for unmet care needs. Findings include: Resident #25 (R25) Review of the medical record revealed R25 admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included retention of urine. The MDS with an Assessment Reference Date (ARD) of 11/9/23 revealed R25 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had an indwelling urinary catheter. According to the medical record, R25 was transferred to the hospital on [DATE] and returned on 11/7/23. The Physician's Orders revealed R25's indwelling urinary catheter was discontinued on 10/30/23. On 12/11/23 at 10:33 AM, R25 was observed sitting on the edge of his bed. R25 did not have an indwelling catheter in place. Registered Nurse (RN) O entered…

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 a comprehensive plan of care for two residents (#18, #25) of 15 residents reviewed for planning of care resulting in the potential for unmet care needs or the potential for inadequate/inappropriate resident care. Findings Included: Resident #18 (R18) Review of the medical record revealed R18 was most recently admitted to the facility 10/26/2022 with diagnoses that included Huntington's Disease (nerve cells break down over time), chronic obstructive pulmonary disease (COPD), anemia (low red blood cells), adult failure to thrive, protein malnutrition, asthma, dementia, hypothyroidism (low thyroid hormone), hypertension, polyneuropathy (damage to multiple peripheral nerves), insomnia, hyperkalemia (high potassium), dysphagia (difficulty swallowing), depression, anxiety, hyperlipidemia (high fats in blood), gastro-esophageal flux, and osteoarthritis (arthritis in end of bones form wear). The most recent Minimum Data Set (MDS), with 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.

Based on observation, interview, and record review the facility failed to provide ensure appropriate treatment and services for contracture management for one resident (#18) of two residents reviewed resulting in the potential for the development and worsening of contractures and pain. Findings Included: Resident #18 (R18) Review of the medical record revealed R18 was most recently admitted to the facility 10/26/2022 with diagnoses that included Huntington's Disease (nerve cells break down over time), chronic obstructive pulmonary disease (COPD), anemia (low red blood cells), adult failure to thrive, protein malnutrition, asthma, dementia, hypothyroidism (low thyroid hormone), hypertension, polyneuropathy (damage to multiple peripheral nerves), insomnia, hyperkalemia (high potassium), dysphagia (difficulty swallowing), depression, anxiety, hyperlipidemia (high fats in blood), gastro-esophageal flux, and osteoarthritis (arthritis in end of bones form wear). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/17/2023, demonstrated a Brief Interview of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement physician's orders and urology recommendations to attempt to restore continence for one (Resident #25) of one reviewed, resulting in the potential for continence status to not be restored to the extent possible. Findings include: Review of the medical record revealed Resident #25 (R25) revealed R25 admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included end stage renal disease, dependence on dialysis, and retention of urine. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/9/23 revealed R25 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the urology consult note dated 10/12/23 revealed instructions were to return in about one month (around 11/12/23) for a follow up trial of void versus discuss suprapubic catheter. The note also revealed to start Flomax (medication for urinary retention). Of note,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician documented review of pharmacy recommendations/follow up occurred for 1 resident (Resident #6) of 5 residents reviewed resulting in the potential for medication side effects and/or unnecessary medications for residents. Findings include: Resident #6 (R6) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R6 admitted to the facility on [DATE] and had diagnoses of congestive heart failure, depression, anxiety, and chronic pain. Brief Interview for Mental Status (BIMS) score was a 15 which indicated her cognition was intact (13-15 cognitively intact). Review of R6's Pharmacy Medication Review Progress Notes in the EMR dated 8/3/2023 revealed, Chart reviewed- 1 recommendation to MD, 1 to nursing. Review of R6's monthly pharmacy review dated 8/3/2023 note to attending physician/prescriber revealed the following recommendations: lipid panel, LFTS (Liver Function Tests), A1C (measures average blood sugar levels over…

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 medication rate was less than 5% when eleven mediation errors were observed from a total of 35 opportunities for one resident (#463) of four residents reviewed for medication administration resulting in a medication error rate of 31.43% and resulting potential for adverse reactions, and/or side effects, and/or decrease drug efficacy. Findings Included: Resident #463 (R463) Review of the medical record revealed R463 was admitted to the facility 11/30/2023 with diagnoses that included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), sever protein-calorie malnutrition, cerebral infarction (stroke), type 2 diabetes, hyperlipidemia (high fat in blood), atrial fibrillation, epilepsy (nerve activity in brain disturbed), gout (build up of uric acid in bone joints), hypothyroidism (low thyroid hormone), anemia (low red blood cells), kidney failure, chronic pain, tracheostomy, dysphagia (difficulty swallowing), and hypertension. The most recent Minimum Data Set (MDS), with 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.