Corewell Health Rehab & Nursing Center-Commons Far

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Complaint #2575124.Based on observation, interview, and record review, the facility failed to effectively monitor residents' skin, identify new skin impairments in a timely manner, thoroughly assess and determine the root cause of new skin impairments, and implement treatment in a timely manner for two (R802 and R803) of three residents reviewed for wounds. Findings include:R802On 8/14/25 at 12:05 PM, R802 was observed lying in bed. R802 had a dressing dated 8/13/25 applied to the top part of her left lower leg. The skin surrounding the dressing was observed with dark, purple discoloration. When queried about what happened to her leg, R802 stated, Nothing exciting. R802 appeared confused with further questioning. On 8/14/25 at 2:06 PM, R802 was observed lying in bed on her back. When queried about when treatment is completed on her leg, R802 reported the wound nurse said she would do it at 2:30 PM. R803 said, Be ready for some screaming! and reported it was painful when the bandage 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: MI00151714, MI00150739 Based on observation and interview, the facility failed to maintain a safe, clean and comfortable environment, resulting in the potential to affect the entire resident population. Findings include: The State Agency received a complaint of an allegation the facility failed to maintain a comfortable clean, homelike environment On 4/2/25 at 8:42 AM, The Second-floor hallway was observed with scattered white colored straw wrappers, crumbs, and debris. The floors in rooms 255, 252, 253, and 250 were observed with straw wrappers, moderate amounts of debris, and scattered crumbs of food. Dried red food matter was noted on the wall in front of room [ROOM NUMBER]. Partition curtains in rooms [ROOM NUMBER] were all observed soiled and unkempt. On 4/2/25 at 9:25 AM, A cabinet in the residential dining room of Dayroom [ROOM NUMBER] was observed with a white clear bag containing red colored clothing and a red purse. RN A opened the bag which contained a red [NAME]…

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 ensure resident food items brought in from the outside were labeled and dated resulting in the potential of foodborne illness and had the potential to affect all residents who store and consume food from the 2107 Dayroom community residential refrigerator. Findings include: On 4/2/25 at 9:10 AM, The refrigerator in Dayroom [ROOM NUMBER] was opened and the following items were observed no resident identifier or dates: A brown paper bag from (fast food restaurant), a black three compartment container with a clear lid containing cornbread, and a small clear container containing what appeared to be a white dressing located in the door section. The left bottom crisper revealed a white Styrofoam cup/lid containing a brown colored liquid. The freezer was observed storing a container of vanilla ice cream and a Styrofoam cup/lid with an unidentified frozen substance. Review of the facility policy titled Food Brought in by Others for Residents dated 3/2018…

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(s): MI00151450. Based on interview and record review, the facility failed to conduct accurate and thorough sepsis screening for one (R902) of one resident reviewed for a change in condition. Findings include: A review of R902's clinical record revealed admission to the facility on 1/30/25 and R902 was discharged to the hospital on 3/10/25. Diagnoses included: metastatic cancer (prostate and bone), chronic obstructive pulmonary disease (COPD), and chronic respiratory failure. A review of R902's Minimum Data Set (MDS) assessment dated [DATE] revealed R902 had moderately impaired cognition. A review of the Progress Notes for R902 revealed they tested positive for influenza A on 3/1/25. A review of the Physician's Orders revealed R902 was placed on droplet precautions (isolation precautions used to prevent the spread of respiratory illnesses transmitted via droplets) from 3/5/25 through 3/12/25. The physician's orders indicated R902 was prescribed Tamiflu (an antiviral…

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(s): MI00151450. Based on interview and record review, the facility failed to appropriately monitor the respiratory status of one (R902) of one resident reviewed for a change in condition. Findings include: A review of the clinical record revealed R902 was admitted into the facility on 1/30/25 and discharged to the hospital on 3/10/25. Diagnoses included: influenza A, chronic obstructive pulmonary disease (COPD), metastatic cancer of the prostate spread to the bone, obstructive sleep apnea, and chronic respiratory failure. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R902 had moderately impaired cognition and did not require oxygen therapy on admission. A review of the Progress Notes revealed R902 tested positive for influenza A on 3/1/25. A review of the results of a chest X-ray for R902, completed on 3/5/25 revealed, Mild prominent bilateral hilar (wedge shaped middle portion of lungs) markings (may indicate inflammation or congestion). A 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 observation, interview, and record review, the facility failed to maintain the kitchen in a sanitary manner, and failed to ensure potentially hazardous food items were properly cooled. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 10/28/24 between 8:45 AM-9:30 AM, during an initial tour of the kitchen with Director of Dining Services BB, the following items were observed: The handwashing sink located near the entry door to the kitchen, was observed with several gnats flying about. The trash can for the hand sink was observed with no liner, and when the lid was opened, numerous gnats flew out of the can. There were gnats observed in various other areas of the kitchen as well. According to the 2017 FDA Food Code section 6-501.111 Controlling Pests, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: .4. (D) Eliminating harborage conditions. According 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 interview and record review, the facility failed to employ a qualified Social Worker on a full time basis to meet psychosocial, mental and behavioral heath care needs of residents resulting in the potential for unmet needs. Findings include: During the recertification survey conducted from 10/28/24 - 10/30/24, multiple concerns were identified in regard to the facility's social work practices, including mood/behavior management, psychotropic medication, psychosocial assessments, and processes for completion of advance directives and coordination of decision-makers. On 10/29/24 at 8:00 AM, during an interview with the Director of Nursing (DON), when asked if Staff 'D' was the only Social Worker, the DON reported they were. On 10/29/24 at 8:38 AM, an interview was conducted with Staff 'D'. They reported they had worked in their role as a Social Worker since the end of January 2024, but had been with the company since 2023. When asked if there were any other Social Workers Staff 'D' reported they were by themselves. When asked if they were licensed as a Social Worker Staff 'D'…

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 adequate infection control practices during wound care and implement Enhanced Barrier Precautions (EBP) for one (R70) of three residents reviewed for pressure ulcer/injuries, and ensure adequate infection control practices and implementation of Personal Protective Equipment (PPE) for residents on droplet precautions for two (R23 and R333) of two residents observed for transmission-based precautions related to COVID-19, resulting in the increased potential for wound contamination, delayed healing, and spread of infection. Findings include: According to the facility's policy titled, Enhanced Barrier Precautions dated 10/9/2023: Enhanced Barrier Precautions expand the use of PPE (Personal Protective Equipment) beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (Multi Drug…

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 call lights were easily accessible and within reach for three (R7, R8 and R333) of four residents reviewed for call light placement, resulting in the inability to summons help when needed. Findings include: According to the facility's policy titled, Call Light, Answering dated 12/19/2023: .When the resident is in bed or confined to a chair be sure the call lights is within easy reach of the resident . R8 On 10/28/24 at 11:06 AM, R8 was observed laying in bed, pulling at the hospital gown they wore. The room was observed to be warmer in temperature and when asked if they were hot, R8 replied, Uh huh. The call light was observed out of reach, draped across the end of the footboard of the bed. On 10/29/24 at 7:42 AM, R8 was observed laying in bed on their back, asleep. The call light was tucked behind the wall and lower end of the bottom of the mattress completely out of reach near the footboard. Review of the clinical record revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow appropriate protocols to change residents' treatment preferences for code status for three (R32, R52 and R63) of four residents reviewed for advance directives. Findings include: R32 On [DATE] at 10:15 AM, R32 was observed lying in bed. R32 was able to engage in conversation, but appeared slightly confused as R32 reported being hungry while having their breakfast tray in front of them, partially eaten. A review of R32's clinical record revealed R32 was admitted into the facility on [DATE] with diagnoses that included: Alzheimer's Disease. A review of a Minimum Data Set (MDS) assessment revealed R32 had a Brief Interview for Mental Status (BIMS - an evaluation to assist in determining a person's cognitive status) score of six which indicated R32 had severely impaired cognition (A score of 0-7 indicates severely impaired cognition). A review of R32's resident profile in the Electronic Medical Record (EMR) revealed R32's code status…

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 insulin administration was performed according to professional nursing standards of practice for one (R332) of one residents reviewed. Findings include: On 10/28/24 at 10:27 AM, R332 was observed sitting up in bed. R332 expressed concern regarding getting their breakfast tray late (which they defined as 9AM or later) and receiving their AM insulin dose hours before. They reported this has been happening since their arrival to the facility. On 10/29/24 at 10:09 AM, R332 reported receiving her breakfast tray that morning around 9:00 AM. Review of the clinical record revealed R332 was admitted into the facility on [DATE] with diagnoses that included: Type 2 Diabetes Mellitus and encounter for orthopedic aftercare following surgical amputation. A review of the administration times (provided by the facility) for R332's morning dose of Humalog insulin revealed the following administration times: 10/26/24 at 6:23 AM, 10/27/24 at 5:32 AM,…

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

Based on observation, interview, and record review, the facility failed to identify, assess, and determine the root cause of bilateral arm bruising for one (R37) of two residents reviewed for skin conditions. Findings include: On 10/28/24 at 12:23 PM, R37 was observed seated in a wheelchair, sleeping, in the dining room of the 3 North unit. R37's left arm was exposed and revealed three small fading circular purple discolorations to the left lower arm under the elbow and a larger discolored area on the top of the left lower arm that resembled a bruise. A review of R37's clinical record revealed R37 was admitted into the facility on 5/22/24 with diagnoses that included: Alzheimer's disease. A review of R37's progress notes revealed no documentation of any recent skin impairments. A review of R37's care plans revealed no care plans related to bruising easily. A review of R37's Physician's Orders revealed R37 was not prescribed any medications that put R37 at higher risk of bleeding and bruising (blood thinners). A review of R37's weekly skin assessments revealed no documentation of any…

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 timely coordinate vision services for one (R6) of one resident reviewed for vision services. Findings include: On 10/28/24 at 10:09 AM, R6 was observed sitting up in bed. R6 reported that their glasses were lost prior to admission to the facility and that they only have reading glasses, which they were observed wearing. R6 reported being without their glasses since July and that the facilities social worker was aware. R6 further stated that they have been getting headaches and eye pain, is unable to read what is on the television, and cannot play bingo. On 10/29/24 at 12:16 PM, social services employee D was queried about their involvement in and knowledge of R6 being without prescription glasses. Social services employee D reported they were recently asked to place R6 on the ancillary services list but not specifically for vision services. Social services employee D reported that vision services providers are in house once per quarter 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 implement preventative pressure ulcer interventions and administer treatment according to physician's orders for one (R70) of three residents reviewed for pressure ulcers. Findings include: On 10/28/24 at 9:46 AM, R70 was observed laying in bed on their back, asleep and their right hand was observed with tremors. The mattress was observed to be a low air loss mattress. Their feet were observed tucked under a brightly colored fleece blanket directly covering their lower extremities (added pressure to the tips of the feet/toes). There were no pressure-relieving boots observed in use, or available for use in the room. The bedside table was observed to have a small Styrofoam disposable tray with several wound care supplies which included: a bandage that was dated 10-27-24 [Nurse G's initials redacted]; a small wood stick still in plastic; a small four ounce cup with gauze and clear liquid; and a small medicine cup with a honey-like substance.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two deficient practice statements (DPS). DPS#1 Based on observation, interview and record review, the facility failed to provide fresh water at bedside, within reach, and offer it throughout the shift for two (R8 and R63) of six residents reviewed for hydration, resulting in the potential for continued dehydration and electrolyte imbalances. Findings include: According to the facility's policy titled, Water Distribution to Residents dated 12/15/2023: .Each resident will have their own styrofoam cup and straw labeled with name and date each day .Each resident's cup will be filled with water each shift and more frequently unless medically contraindicated .Outdated cups will be disposed of each day on midnight shift .It shall be the responsibility of the Director of Nursing, and the Nursing Management team to ensure that clean, fresh water is given to all residents on a 24-hour basis according to the above policy. R8 On 10/28/24 at 11:06 AM, R8 was observed laying in bed, pulling at the hospital…

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 two (R32 and R70) of two residents reviewed for pain, were assessed, treated, and interventions implemented timely to prevent unnecessary pain. Findings include: R32 On 10/28/24 at 10:52 AM, R32's door was observed to be closed. R32 was heard yelling and crying loudly and uncontrollably from the hallway. Upon entrance to R32's room, R32 was observed seated in a shower chair with an open seat, wrapped in towels. R32 yelled, It hurts! It hurts! and was yelling to get out of the shower chair. At that time, Certified Nursing Assistant (CNA) 'B' left the room to get Licensed Practical Nurse (LPN) 'C' to assist with transferring R32 into the bed. R32 was interviewed and reported pain where I sit and said she wanted out of the chair. At 11:04 AM, R32 was heard from the hallway behind a closed door yelling out and crying. At approximately 11:07 AM, LPN 'A' entered R32's room where CNA 'B' and LPN 'C' were located. At 11:15 AM, R32 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide medically related social services which effectively monitored, identified, and implemented individualized treatment and behavioral interventions for a resident receiving psychotropic medication for one (R70) of four residents reviewed for social services. Findings include: According to the facility's policy titled, Bio-Psycho-Social Wellness Program dated 11/14/16: .Identify and refer residents displaying difficult behaviors to the Social Worker .The Social Worker will review the resident's chart, focusing on factors in the following order: a. Physiological factors b. Environmental factors c. Psychiatric factors .Revise all approaches as necessary .Review resident's progress: monthly, if behavior is monitored via Point of Care documentation .quarterly, if mood is monitored via the PHQ-9 depression Test .per psychiatric evaluation; or .per supportive therapy session .Once mood/behavior is stable, review resident's mood/behavior within 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 ensure monthly drug regimen reviews conducted by the consultant pharmacist were reviewed by the medical provider for recommendations to act upon for two (R51, R44) of five residents reviewed for unnecessary medications. Findings include: R51 A review of R51's drug regimen reviews revealed the Consultant Pharmacist reviewed R51's medications on 3/8/24 and 4/8/24 and 7/3/24 noted irregularities or recommendations. A review of R51's clinical record revealed no report that indicated what the identified irregularities or recommendations were. On 10/30/24 at 1:12 PM, the Director of Nursing (DON) was asked to provide the documentation of recommendations made by the pharmacist on the above dates for R51. On 10/30/24 at 4:01 PM, the DON reported the pharmacist's recommendations from 3/8/24, 4/8/24, and 7/3/24 were not reviewed by the medical provider and provided the following: A Note to Attending Physician/Prescriber dated 3/8/24 that noted, (R51) receives 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 provide justification for the use of antipsychotic medications with residents with dementia, identify targeted behaviors and symptoms, develop and implement individualized non-pharmacological interventions, and monitor for continued use for one (R37) of five residents reviewed for unnecessary medications. Findings include: R37 On 10/28/24 at approximately 10:05 AM, R37 was observed in bed sleeping. At 11:19 AM, R37 remained sleeping in bed. At 12:23 PM, R37 was observed sleeping in a wheelchair in the dining room of the 3 North Unit. At 2:32 PM, R37 was observed sleeping in a wheelchair in the dining room. On 10/29/24 at approximately 11:50 AM, R37 was observed sleeping in a wheelchair in the dining room. At 2:39 PM, R37 was observed sleeping in the wheelchair in the dining room. A review of R37's clinical record revealed R37 was admitted into the facility on 5/22/24 with diagnoses that included: Alzheimer's Disease, psychotic disorder,…

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 maintain complete and accurate medical records for two (R28 and R52) of four residents whose clinical records were reviewed for advance directives, resulting in the increased potential for delayed and/or omitted involvement of the resident/legal representative in decision making regarding medical directives, and conflicting physician/extender documentation of medical directives. Findings include: According to the facility's policy titled, Advance Care Planning dated [DATE]: .During the intake assessment or rooming procedure, a healthcare team member looks for Advance Directive .When a patient has indicated that they have an Advance Directive, this is noted in the Electronic Health Record .and a copy is requested for the patient's record. DPOAH (Durable Power of Attorney for Health) cannot be followed without a copy being present in the patient's medical record .[Facility name redacted] employees that are not on the care team may sign the OOH (Out of…

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

Based on observation, interview, and record review, the facility failed ensure sanitary practices during food service for two residents (R20 and R55) as well maintain sanitary conditions in the kitchen which has the potential to effect all residents who consume food from the kitchen. Findings include: On 12/3/23 between 8:45 AM-10:00 AM, during an initial tour of the kitchen, the following items were observed with Chef L 1. A tray of bacon was observed in the walk-in refrigerator unsealed without any opened or used by date. 2. A ham was wrapped in plastic wrap with no opened or used by date. 3. Three containers of chicken were observed thawing in refrigerator without a use by date or received date on the container. 4. The reach in refrigerator was observed to contain a bowl of egg salad and a bowl of tuna salad which were both undated. 5. Dried hanging utensils were observed to contain a white substance on them. 6. The hot box, oven and steam machine were all observed to have food debris with dried grease covering the tops of the appliances. 7. Multiple drain flies were observed in…

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

Based on observation, interview, and record review, the facility failed to ensure dignified treatment for four residents (R#'s 2, 32, 39, and 47) of four residents reviewed for dignity. Findings include: A review of a facility provided policy titled, Quality of Life: Dignity dated 7/19/23 was reviewed and read, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality . 12/4/23 from 8:50 AM until 9:30 AM, and from 12:40 PM until 1:15 PM, observations of the breakfast and lunch meals were conducted. R#'s 2, 32, 39, and 37 were observed in the 3 North dining room and were observed to need one-to-one assistance with dining. During the observations, Certified Nurse Aide 'N' and Nurse 'M' were overheard multiple times to refer to residents who needed one-to-one dining assistance as feeders. On 12/4/23 at approximately 3:45 PM, the dining observations and use of the term feeder were shared with the facility's acting Director of Nursing and they indicated that it was not appropriate to use that term.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a clean, comfortable, safe, and home-like environment to ensure that resident room floors, windows, and common area windows were clean and in good repair affecting multiple residents (R4, 54, 70, 78) and Resident Rooms 202, 243, 309 and 353 throughout the facility resulting in an unclean physical environment, resident dissatisfaction, and complaints regarding the lack of cleanliness and drafty windows. Findings include: R4 R4 was recently re-admitted to the facility on [DATE] after a hospitalization. R4 was a long-term resident of the facility and had been at the facility since 7/23/2018. R4's admitting diagnoses included stroke with right hemiplegia (right sided weakness), urinary retention, dysphagia (difficulty or inability to swallow), and heart failure. R4 was receiving nutrition through a PEG (feeding tube - Percutaneous Endoscopic Gastrostomy tube in which a tube is placed into a patient's stomach through the abdominal wall, most commonly…

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 timely implement wound care treatment as ordered by the wound practitioner for one (R49) of three residents reviewed for pressure ulcers. Findings include: On 12/3/23 at 11:51 AM, R49 was observed sitting in their wheelchair at a table in the community room with a book in their hand. A brief interview was conducted with the resident at that time. Review of the medical record revealed R49 was admitted into the facility on [DATE] with diagnoses that included: Parkinson's disease, dementia, and the need for assistance with personal care. Further review of the medical record revealed R49 developed a stage III pressure wound to the coccyx area while residing in the facility. Review of a Nurses Note dated 1/9/23 at 6:41 PM, documented in part . resident stated to that nurse she had an area on her bottom. Nurse assessed the area, then asked writer to look at it. Resident stated she doesn't know when she started feeling as if something was on 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 Quality Assurance and Quality Improvement (QAPI) program failed to identify a repeated issue regarding the facility's prescribing and implementation of unnecessary psychotropic medications (R12 and R60), the QA committee/program failed to identify this issue and implement their QAPI plan to address the repeated psychotropic concerns, potentially affecting the health, safety, and quality of life for all residents who resided in the facility. Findings include: Review of the facility's CASPER report revealed the facility was cited for Unnecessary Psychotropic Medications in 2018, 2021, 2022 and again in 2023. Based on observations, interviews and record reviews R's 12 & 60 were identified to have been prescribed unnecessary psychotropic medications for the 2023 survey. On 12/5/23 at 10:31 AM, a meeting was held with the facility's Administrator to discuss the priority and ongoing issues that the facility's Quality Assurance committee had identified and was working on to improve. The Administrator verbalized various areas…

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 a self-administration assessment was completed for one (R68) of one resident reviewed for medications observed at the bedside. Findings include: Review of the medical record revealed R68 was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease, dementia, and acute cystitis. On 12/3/23 at 9:10 AM, R68 was observed sleeping in bed. Observed on R68's bedside table was a tube of hydrocortisone cream maximum strength and two containers of nystatin powder. Review of the medical record revealed no assessment completed for the resident to self-administer their hydrocortisone and Nystatin medications. On 12/3/23 at 2:50 PM, the Infection Control Nurse (ICN) A (who also covered as the Director Of Nursing - DON- for the survey) was asked to come in R68's room. Once in the room, ICN A observed the hydrocortisone cream and two nystatin containers and removed all of the medications from R68's room. When asked ICN A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident's personal choices were honored for one (R70) resident reviewed for choices. Findings include: On 12/3/23 at 9:24 AM, R70 was observed in bed watching TV. An observation of the room was made and the TV closest to the door was very loud. An interview was conducted with R70 to see if the care being rendered at the facility was that of satisfaction, however R70 stated that due to the loud volume of roommates television he was unable to hear. R70 stated that he can't even think most of the time, and stated that their physical well-being has improved but the mental and emotional part is a struggle. R70 was asked if they ever made a complaint about the volume of roommate's television to anyone, R70 explained that they had to several people but no one has addressed it. Record review revealed that R70 was admitted to the facility on [DATE] with the diagnosis of vascular dementia, muscle wasting atrophy and polyneuropathy, had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure services provided consistently met professional standards of nursing practice for one (R333) of one resident reviewed for nursing services. Findings include: On 12/3/23 at 9:47 AM, R333 was observed sitting in their wheelchair in their room. R333 complained of their eyes being irritated and uncomfortable. R333 stated they told the nurse earlier that they needed their eye drops. R333 stated in part . the nurse gives it (eye drops) whatever time she wants to . A few minutes later the nurse (later identified as Registered Nurse - RN F) entered the room with a breakfast tray for R333's roommate. Before RN F exited the room, RN F was asked if they were the nurse for R333 and RN F replied they were. RN F was then informed of R333's complaints of eye discomfort and irritation and stated, R333's eye drops were scheduled. RN F was asked if the eye drops were scheduled to be given this morning and RN F stated no, the eye drops were not due at…

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 timely and appropriate assistance with Activities of Daily Living (ADL) for one (R4) of one Resident reviewed for ADL care with potential for negative physical, psychosocial outcomes, and potential loss of dignity for residents who are dependent on staff for assistance. Findings include: A facility provided document titled, Quality of Care, dated 6/15/23, read in part, (Facility Name Omitted) will provide or arrange for the provision of necessary care and services to attain or maintain practicable physical, mental, and psychosocial well-being of residents in accordance with the Comprehensive Assessment and Plan of Care subject to the resident's right of Self-Determination. A. Activities of Daily Living 1.By provision of treatment and services, that an individual resident's ability to perform activities of daily living (ADL) does not diminish, except as the unavoidable consequence of the resident's condition. Such ADLs include, but…

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 a left hand splint was applied for one resident (R20) of one resident reviewed for positioning/mobility. Findings include: On 12/03/23 at approximately 10:02 a.m., R20 was observed in their room, laying in their bed. R20 was observed to have a contracture of their left hand. No splint/brace was observed to be applied. R20 was queried if the staff had recently put any splints on their hand and they reported that they sometimes do, but it has been a while and the staff probably forgot. On 12/4/23 at approximately 8:47 a.m., R20 was observed in their room, laying in their bed. R20's left hand was not observed to contain any brace/splints. R20 was queried if anyone had recently applied their splint and they reported nobody had put it on. R20 was queried if they knew where the brace was and they reported they did not. On 12/4/23 at approximately 10:53 a.m., R20 was observed in their wheelchair, in the common area and did not have any…

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 appropriate resident supervision was provided for two residents (R52 and R71) of four residents reviewed for accidents. Findings include: R52 On 12/3/23 at approximately 10:08 a.m., R52 was observed in their room, laying in their bed. R52 was queried if they had any concerns with their care in the facility and they reported that R71 wanders into their room almost daily and takes their things and touches all their stuff and they have to yell out for help so the staff can remove them. R71 On 12/03/23 at approximately 9:40 a.m., R71 was observed in their room, laying in their bed. R71 was observed to have their bed next to the wall with a fall mat on the other side with a wander guard on their ankle. On 12/4/23 at approximately 10:54 a.m., R71 was observed in their room, dressed and sitting on regular chair in the middle of room. Multiple other rooms on R71's hall were noted to have their doors open. On 12/4/23 at approximately 11:59…

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 identify and/or report medications prescribed/administered in excessive doses and durations for one (R12) resident reviewed of five residents reviewed for unnecessary medications resulting in the potential for prolonged use of medications. Findings include: On 12/3/23 at 8:45 AM, R12 in room lying in bed an interview was attempted but due to R12 cognition it was not effectively conducted. A record review revealed that R12 was admitted to the facility on [DATE] with the medical diagnosis of vascular dementia, muscle weakness, anxiety disorders with a Brief Interview for Mental Status (BIMs) score of 3 (indicating a severely impaired cognition) dated for 11/17/23. A further review of the record, revealed that R12 was ordered Clonazepam 0.5 milligrams(mg) 1 tab by mouth 3 times a day for anxiety on 9/13/21, and was prescribed Clonazepam 0.5 mg 1 tab by mouth every 6 hours as needed (PRN) on 9/22/23 with an end date of 12/21/23. There was a request made…

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 as needed psychotropic medication orders were written with a stop date, resident centered target behaviors were identified, and non-pharmaceutical interventions were implemented prior to the use of as needed psychotropic medications for two residents (R#'s 60 and 12) of five residents reviewed for unnecessary medications. Findings include: A request for a policy for behavior monitoring and as needed use of psychotropic medications was made, however; the facility only provided an untitled, undated piece of paper with three typed lines that read, PRN (as needed) Antipsychotics are written for 14 days and evaluated by Psych. Discontinued if non-use <sic> If being used a new order is written by Psych for 14 days. On 12/4/23 at approximately 1:15 PM, R60 was observed seated at their bedside preparing to eat lunch. R60 appeared calm, quiet, and carried on casual, appropriate conversation. On 12/4/23 at 2:09 PM, a review of R60's clinical…

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 the ordered altered diet to one resident (R63) during medication administration resulting in the potential for aspiration. Findings include: On 12/3/2023 at 08:51 AM, Registered Nurse G was observed for medication administration task. During medication preparation for R63, this surveyor observed granulated powered MiraLAX (medication used to treat occasional constipation) mixed with water dispensed from a carafe on the medication cart into a clear plastic cup with a white plastic straw. On 12/3/2023 at approximately 09:00 AM, this surveyor observed RN G administer R63 prepared MiraLAX from a clear plastic cup with a white plastic straw. R63 demonstrated difficulty swallowing as evidenced by a frequent wet audible cough. R63 also demonstrated periodic facial movements imitating chewing in-between coughing. It was observed while R63 was coughing, RN G gently rubbed the back and right shoulder of R63 and verbalized, Just take your time, it is OK. Record review on 12/4/2023 of the Active Order Summary…

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.