Medilodge of East Lansing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2597662.Based on observation, interview and record review, the facility failed to ensure medications were administered per physician's orders for one (R1) of three reviewed.Findings include: Review of the medical record reflected R1 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included chronic respiratory failure with hypoxia, asthma, tracheostomy status (surgical hole made through the front of the neck, into the windpipe/trachea, for placement of a tracheostomy tube for breathing) and spastic quadriplegic cerebral palsy. The Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/31/25, reflected R1 did not speak, was rarely/never understood and rarely/never understands.On 8/26/25 at 8:05 AM, R1 was observed seated in a wheelchair, in their room. A tracheostomy was observed, secured with tracheostomy ties. R1's hospital Discharge summary, dated [DATE], reflected discharge diagnoses that included tracheostomy dependence,…

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 2597662.Based on observation, interview and record review, the facility failed to provide respiratory care according to physician's orders for one (R1) of three reviewed.Findings include:Review of the medical record reflected R1 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included chronic respiratory failure with hypoxia, asthma, tracheostomy status (surgical hole made through the front of the neck, into the windpipe/trachea, for placement of a tracheostomy tube for breathing) and spastic quadriplegic cerebral palsy. The Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/31/25, reflected R1 did not speak, was rarely/never understood and rarely/never understands.On 8/26/25 at 10:51 AM, R1 was observed seated in a wheelchair, in their room. A tracheostomy was observed, secured with tracheostomy ties. A cough assist machine was observed on a table in R1's room. In an interview on 8/26/25 at 11:01 AM, Respiratory Therapist…

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 MI00151358, MI00150638 and MI00151852. Based on observation, interview, and record review the facility failed to provide Activities of Daily Living (ADL's), including bathing/showering for four dependent resident (R103, R104, R106, and R110) reviewed of ADL care, resulting in increased worsening of pressure wounds and likelihood of feelings of worthlessness, disrespect and the potential for infection. Findings include: Review of three complaints received by the State Agency alleged the facility failed to assist and/or provide residents with ADL care including showering, oral care and grooming. Resident #106(R106) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R106 was a [AGE] year-old male admitted to the facility on [DATE], with re-admission 3/13/25 related to wound infection with other diagnoses that included traumatic brain dysfunction, cerebral vascular accident, acute respiratory failure with anoxic brain damage with tracheostomy, contracture of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes: MI00151418, MI00151694, MI00151358, MI00150699, MI00150638, MI00151442, and MI00151852. Based on observation, interview and record review, the facility failed to ensure sufficient levels of nursing staff to meet resident needs and supervision for seven residents (Resident R102, R103, R104, R105, R106, R110 and R111) and per resident council with 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: During an interview on 4/8/25 at 10:55 a.m., admission Staff N reported facility census was 69 and Director of Nursing B and Nursing Home Administrator A were not currently in the facility. Review of seven complaints received by the State Agency alleged the facility failed to maintain sufficient staff levels to meet resident needs including prevent worsening of pressure ulcers and prevent avoidable fall with injury. Review of the Centers for Medicare and Medicaid…

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 refers to intake MI00151694 and MI00150699. Based on interview and record review, the facility failed to provide adequate supervision for resident with known high risk for falls and implement care planned interventions to prevent fall injuries for 1 residents (R102) out of 3 residents reviewed for falls, resulting in R102 fall with injury requiring emergency room treatment and hospital admission. Findings included: Resident #102(R102) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R102 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included left hip fracture post fall at home, current post care for left hip surgical revision post fall with fracture and infection requiring intravenous antibiotics via central line catheter, peripheral vascular disease, hypertension (high blood pressure), diabetes mellitus, and anemia. The MDS reflected R102 had a BIM (assessment tool) score of 12 which indicated his ability to make daily decisions 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 intake number MI00149947 Based on observation, interview, and record review the facility failed to ensure for one out of seven residents (Resident #7) a comprehensive care plan, including revisions, were in place for prevention and promotion of pressure ulcer healing. Findings Included: Per Resident #7's (R7) electronic medical record (EMR) R7 was admitted to the facility on [DATE]. Diagnoses included right and left knee contractures. In an observation, and attempt to interview, on 2/27/2025 at 9:46 AM, R7 was observed in bed. R7 was observed to have contractures to both arms, both hands and fingers, neck, and was not able to communicate. R7's feet/heels were observed to be lying on the mattress with nothing in between R7's feet/heels and the mattress in order to offload the pressure from the mattress. Offloading boots (boots with air in them that prevents heels from touching the bed mattress and relieves pressure of the heels) were noted to be on the floor in front of R7's closet. 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 This citation pertains to intake number MI00149947. Based on observation, interview, and record review the facility failed to provide for one out of three residents (Resident #7) care and services to prevent and promote healing of pressure ulcers resulting in worsening wounds. Findings Included: Per Resident #7's (R7) electronic medical record (EMR) R7 was admitted to the facility on [DATE]. Diagnoses included right and left knee contractures. In an observation, and attempt to interview, on 2/27/2025 at 9:46 AM, R7 was observed in bed. R7 was observed to have contractures to both arms, both hands and fingers, neck, and was not able to communicate. R7's feet/heels were observed to be lying on the mattress with nothing in between R7's feet/heels and the mattress in order to offload the pressure from the mattress. Offloading boots (boots with air in them that prevents heels from touching the bed mattress and relieves pressure of the heels) were noted to be on the floor in front of R7's closet. An approximately 5 x…

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 MI000148211. Based on interview and record review the facility failed to ensure infection control surveillance was monitored, mapped and documented monthly to maintain a safe and sanitary environment for all 62 residents who resided at the facility. Findings Included: On 12/17/2024 via email to Administrator A a request was sent to provide the facility's August through December 2024 Infection Control line listing with the color coded maps of each unit. Upon receiving the requested infection control documents on 12/17/2024, it was revealed that only August, September, and October 2024 line listings (residents listed that have an infection, what the organism is, and the antibiotic if applicable) were received. Also the only map that was received was for the month of September 2024. In an interview on 12/17/2024 at 2:15 PM, Administrator A was asked to provide the line listing and mapping for November 2024 infection control surveillance. Administrator A stated that no nurse had been performing the duties of the infection control program since November…

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 number MI00148475. Based on interview and record review the facility failed to ensure one of four residents (Resident 2) had a person-centered baseline care plan developed, and implemented with appropriate interventions and revisions as needed. Finding Included: Review of Resident #2's (R2) face sheet it was revealed R2 was admitted to the facility on [DATE] for a 10 day respite with expected discharge on [DATE]. R2 no longer resided at the facility at the time of the onsite survey. Review of R2's admission fall risk assessment dated [DATE], revealed as question to be answered Yes or No if R2 had displayed any of the following behaviors: was a high risk for falls. R2 was easily distracted, had periods of altered perception or or awareness of surroundings,episode of disorganized speech, restlessness, lethargy, mental function varies throughout the course of the day, wanders, abusive and resists care. The question was answered Yes. The assessment revealed R2 had Clinical Condition…

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 accurate completion of Minimum Data Set (MDS) assessments for three (Resident #36, #59, and #68) of 17 reviewed. Findings include: Resident #36 (R36) Review of the medical record revealed R36 admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus. The MDS with an Assessment Reference Date of 7/21/24 revealed R36 received insulin injections seven days out of the seven day look back period. Review of R36's medical record revealed they did not receive insulin during the look back period. In a telephone interview on 10/28/24 at 2:15 PM, Regional Director of Assessment Coordination F agreed R36 did not receive insulin during the look back period and reported the MDS was coded incorrectly. Resident #59 (R59) Review of the medical record reflected R59 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included chronic respiratory failure, cerebrovascular disease and gastrostomy…

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 comprehensive care plans for 3 (Resident #4, 22 and 28) of 17 reviewed, resulting in the potential for unmet care needs. Findings include: Resident #22 Review of an admission Record revealed Resident #22 (R22) admitted to the facility on [DATE] with diagnoses which included major depressive disorder and moderate protein calorie malnutrition. On 10/27/24 at 11:48 AM, R22 was observed in bed, sleeping. R22's lunch was on his bedside table and appeared untouched. R22's plate consisted of a small scoop of ground pork, a scoop of mashed potatoes and gravy, and a scoop of diced squash. R22 appeared to be underweight. Review of a Physician Order dated 10/27/23 revealed a diet order stating Diet: regular diet, mechanical soft texture, thin liquids/double entree . Review of a Dietary Progress Note dated 6/19/2024 revealed R22 was struggling with weight loss and had an ordered diet of mechanical soft (ground) texture, thin liquids/double…

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 timely collection of an ordered urinalysis (urine test) for one (Resident #60) of two reviewed. Findings include: Review of the medical record reflected Resident #60 (R60) admitted to the facility on [DATE], with diagnoses that included diabetes and chronic kidney disease. The quarterly Minimum Data Set, (MDS), with an Assessment Reference Date (ARD) of 9/20/24, reflected R60 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 10/27/24 at 11:39 AM, R60 was observed seated in a recliner, in her room. She stated the prior Monday (10/21/24), she reported cloudy urine and burning with urination. R60 reported she had blood drawn on 10/25/24 but had not had a urine sample collected. A Nurse Practitioner Progress Note for 10/23/24 reflected R60 was seen for painful urination, right flank (lower back) pain and reports of milky urine. The note reflected a urinalysis…

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 interventions to promote pressure ulcer healing and prevent the worsening of pressure ulcers for one resident (R4) of three residents reviewed for pressure ulcers, resulting in the potential for delayed wound healing and/or the worsening of wounds. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R4 was a [AGE] year old female admitted to the facility on [DATE] and most recent readmission [DATE], with diagnoses that included dementia, schizophrenia, cardiac disease, hypertension (high blood pressure), kidney disease, stage 4 pressure ulcer, anxiety and depression. The MDS reflected R4 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required supervision or touch assistance with bed mobility, transfers and partial/moderate assist with dressing, bathing and toileting. During an observation and interview 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 Based on observation, interview, and record review the facility failed to obtain a physician order for oxygen for one resident (R4) out of four residents reviewed for respiratory care. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R4 was a [AGE] year old female admitted to the facility on [DATE] and most recent readmission [DATE], with diagnoses that included respiratory failure, dementia, schizophrenia, cardiac disease, hypertension (high blood pressure), kidney disease, stage 4 pressure ulcer, anxiety and depression. The MDS reflected R4 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required supervision or touch assistance with bed mobility, transfers and partial/moderate assist with dressing, bathing and toileting. During an observation and interview on 10/27/24 at 10:01 AM, R4 was sitting upright in bed, dressed in a hospital gown and appeared able to answer questions without…

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 MI00145607 Based on interviews and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff for one (R3) of 3 residents reviewed for abuse. Findings include: Review of the medical record revealed that R3 had an original admission date of 2/20/24 and a last admission date of 6/20/24. R3 was last discharged for hospital care on 7/20/24 and was not in the facility during survey. R3 had the following pertinent diagnoses: Cerebral infarction, unspecified (a condition that occurs when blood flow to the brain is blocked or reduced), Major Depressive Disorder, and Anxiety Disorder. Reveiw of the Minimum Data Set (MDS) with an assessment reference date of 2/26/24 documents a Brief Interview for Mental Status (BIMS) score of 6/15 (severe cognitive impairment). The MDS revealed R3 was able to make self understood and was able to understand others with clear comprehension. Review of a Facility Reported Incident (FRI) disclosed documentation on 6/21/24 of a staff Registered Nurse, (RN) C to resident (R3) abuse. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00145078. Based on interview and record review, the facility failed to ensure the physician was notified of a change in treatment orders when one resident (Resident #3) did not transfer to the emergency room (ER) for bleeding, as ordered. Findings include: Review of the medical record reflected Resident #3 (R3) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included respiratory failure, tracheostomy status and morbid (severe) obesity due to excess calories. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/8/24, reflected R3 scored 15 out of 15 (cognitively intact) on the Brief Interview Status (BIMS-a cognitive screening tool). According to the medical record, R3 was his own responsible party. R3 was transferred to the hospital on 6/9/24 and did not reside in the facility at the time of the survey. According to R3's medical record, his most recent weight was 768.4 pounds on 5/18/24. A Situation, Background,…

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 MI00145078. Based on interview and record review, the facility failed to routinely assess and monitor a change in condition for one (Resident #3). Findings include: Review of the medical record reflected Resident #3 (R3) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included respiratory failure, tracheostomy status and morbid (severe) obesity due to excess calories. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/8/24, reflected R3 scored 15 out of 15 (cognitively intact) on the Brief Interview Status (BIMS-a cognitive screening tool). According to the medical record, R3 was his own responsible party. R3 was transferred to the hospital on 6/9/24 and did not reside in the facility at the time of the survey. According to R3's medical record, his most recent weight was 768.4 pounds on 5/18/24. A Situation, Background, Assessment, Recommendation (SBAR) document, dated 6/8/24 at 9:20 AM reflected the nurse suspected R3…

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 MI00144740 and MI00145260. Based on interview and record review, the facility failed to ensure appropriate orders to treat pressure ulcers for one (Resident #2) of four reviewed. Findings include: Review of the medical record reflected Resident #2 (R2) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included cardiac arrest, respiratory arrest and anoxic brain damage. R2 did not reside in the facility at the time of the survey. R2's medical record reflected a facility-acquired pressure ulcer to the sacrum that was unstageable (full-thickness skin and tissue loss where the extent of tissue damage in the ulcer cannot be confirmed due to the wound bed being obscured by slough (non-viable tissue that can present as yellow, tan, gray, green or brown) or eschar (dead or devitalized tissue that can present as black, brown, tan or scab-like)). On 6/4/24, R2's sacral pressure ulcer measured 0.47 centimeters (cm) in length by 0.8 cm in width, with a wound bed…

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 MI00143527 Based on observation, interview, and record review, the facility failed to prevent the development of a medical device related pressure ulcer for 1 (Resident #1) of 3 residents reviewed for pressure ulcers resulting in the development of a facility acquired deep tissue injury (DTI-intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister) with the potential for delayed wound healing and/or worsening pressure ulcer. Findings include: Review of the medical record revealed that Resident #1 (R1) was readmitted to the facility 3/27/24 with diagnoses including acute respiratory failure, protein-calorie malnutrition, tracheostomy status, cognitive communication deficit, and retention of urine. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/2/24 revealed that R1 was rarely/never understood with a staff assessment…

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 complete a Level II Screening for Mental Illness/Intellectual/Developmental Disability/Related Condition Exemption Criteria Certification or refer to Community Mental Health for an OBRA Level II evaluation for one (Resident #60) of one reviewed for Preadmission Screening/Annual Resident Review (PASARR), resulting in the potential for lack of appropriate mental health treatment and services. Findings include: Review of the medical record reflected Resident #60 (R60) admitted to the facility on [DATE], with diagnoses that included post-traumatic stress disorder, anxiety disorder, depression, altered mental status and unspecified dementia. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/30/23, reflected R60 scored one out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), did not walk and required extensive to total assistance of one to two or more…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement nutrition interventions for one (Resident #54) of three reviewed, resulting in the potential for further weight loss. Findings include: Review of the medical record revealed Resident #54 (R54) admitted to the facility on [DATE] with diagnoses that included major depressive disorder, vascular dementia, mood disorder, and dysphagia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/13/23 revealed R54 scored 8 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and needed set up help for eating. Review of the weight history revealed on 6/7/23, R54 weighed 127 pounds and on 9/4/23, R54 weighed 107.8 pounds. R54 sustained a 15.11% weight loss in three months. Review of R54's [NAME] (care guide) revealed interventions that included one to one assistance with meals and drinks with straws. On 09/25/23 at 09:00 AM, R54 was observed in bed with the head…

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 honor pharmacy recommendations upon readmission from the hospital for three (Resident #16, #20 and #36) of five reviewed for pharmacy medication regimen reviews, resulting in the potential for unnecessary medications, medication interactions and adverse reactions. Findings include: Resident #36 (R36): Review of the medical record reflected R36 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included quadriplegia, delusional disorders, generalized anxiety disorder and major depressive disorder. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/28/23, reflected R36 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), did not walk and required total assistance of one to two or more people for activities of daily living. On 09/27/23 at 1:20 PM, R36 was observed lying in bed, with the head of the bed elevated. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to justify the continued PRN (as needed) use and/or provide a duration of use of a psychotropic medication for two (Resident #16 and Resident #36) of five reviewed, resulting in the potential for unnecessary medications and adverse reactions. Findings include: Resident #16(R16) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R16 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), respiratory failure with use of ventilator, heart failure, diabetes, kidney failure, anxiety, psychotic disorder, and depression. The MDS reflected R16 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required two person physical assist with bed mobility, transfers, toileting, and one person physical assist with locomotion on unit, dressing, hygiene, and bathing. Continued review of R16 MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one resident (Resident #25) was prepared for a CT scan out of one reviewed, resulting in delayed services and frustration and anger. Findings include: Review of the medical record revealed R25 admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/15/23 revealed R25 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 09/25/23 at 10:01 AM, R25 was observed in bed after being transported back to the facility via stretcher. R25 reported she was very angry and frustrated because she was supposed to have a CT scan performed that morning, but it was cancelled because the facility did not pre-medicate her due to her allergy to the contrast. R25 reported this was the second time her CT scan was cancelled for this reason. R25 reported she is not sure if the facility knew she needed pre-medication for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to perform acceptable infection control standard while performing suprapubic catheter care for one resident (#36) of one resident reviewed for suprapubic catheter care resulting in the potential to spread infection to other staff and residents. Findings Included: Resident #36 (R36) Review of the medical record revealed R36 was admitted [DATE] with diagnoses that included quadriplegia (paralysis of all 4 limbs), chronic respiratory failure, autonomic dysreflexia (overreaction of involuntary nervous system to stimulation) , neuromuscular dysfunction of bladder, severe protein-calorie malnutrition, tracheostomy, colostomy, hyperlipemia (high fat in blood), hypokalemia (low potassium), constipation, diarrhea, delusion disorder, venous insufficiency, sleep apnea, muscle spasm, nicotine dependency, anxiety, dysphagia (difficulty swallowing), insomnia, depression, gastro-esophageal reflux, chronic pain, and anemia (low red blood cells). The most…

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.