The Manor of Farmington Hills

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #2573641 and #1249526Based on interview and record review, the facility failed to ensure timely admission orders and assessments were completed for two residents (R#'s 902 and 905), of three residents reviewed for admissions, resulting in complaints of missed medications. Findings include: R902 On 8/5/25 a concern submitted to the State Agency for reviewed alleged R905 was not provided their medications and was not properly assessed when the day they were admitted to the facility. On 8/5/25 the medical record for R902 was reviewed and reveled the following: R902 was initially admitted to the facility on [DATE], discharged on 6/14/25 and had diagnoses including Type 2 Diabetes and Congestive heart failure. A review of R902’s census data revealed R902 was admitted to the facility on [DATE] and discharged home on 6/14/25. A review of R902’s Hospital After Visit Summary (Discharge Orders) were reviewed and revealed the following medication administration orders: BD Pen Needle Nano…

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 #1249414Based on observation, interview and record review, the facility failed to ensure a call system was operational for one resident (R901) of three residents reviewed for call systems. Findings include:On 8/5/25 a concern submitted to the State Agency was reviewed which alleged R901's call light (a system used to notify staff of the need for assistance) was not being answered. On 8/5/25 the medical record for R901 was reviewed and reveled the following: R901 was initially admitted to the facility on [DATE] and least readmitted on [DATE] and had diagnoses including Dysphagia, End stage renal disease and Congestive heart failure. A review of R901's MDS (minimum data set) with an ARD (assessment reference date) of 6/18/25 revealed R901 needed assistance from facility staff with most of their activities of daily living. R901's BIMS score (brief interview of mental status) was 15 indicating intact cognition. On 8/5/25 at approximately 11:24 a.m., R901 was observed in their room,…

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 MI00153376 Based on observation, interview and record review the facility failed to protect Protected Health Information (PHI) for all residents residing on the 300 Hall on May 24, 2025, resulting in the potential for unauthorized disclosure without consent of resident protected health information. Findings include: On 5/28/25, an anonymous complaint was filed with the State Agency alleging residents' health information was not kept private as a staff member identified as Licensed Practical Nurse (LPN) D had their daughter present on 5/24/25 while preparing medications, administering medications, and taking care of residents. On 6/18/25, a record review of the facility's schedule and room assignment from 5/24/25 was reviewed. Per the Nursing Home Administrator (NHA) the 300 Unit is a short stay rehabilitation unit and LPN D was assigned to Cart 5 which assigned them to rooms 301-318. The 300 Unit resident census from 5/24/25 was compared to the 300 Unit census from 6/18/25 and no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake# MI00150024 Based on observation, interview and record review the facility failed to ensure a resident was turned properly per their needs to prevent accidents and ensure they were fully assessed following the accident for one (R702) of three residents reviewed for falls/accidents. Findings include: A complaint was filed with the State Agency (SA) that alleged the staff was turning R702 and they hit their head against the wall. On 3/4/25 at approximately 10:03 AM, R702 was observed lying in bed. The resident was alert and able to answer questions asked. When asked about the incident that occurred on or about 1/28/25, R702 reported that one Certified Nursing Assistant (CNA) pushed them against the wall when they were changing them and they hit their head. R702 further reported that the CNA pushed again and they hit their head a second time. The resident noted that they did not believe the CNA intended to hurt them, it was just that they should have used a second person to help.…

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 R902 Review of a complaint submitted to the State Agency (SA) documented concerns of the facility's failure to provide adequate and appropriate care to prevent a pressure wound for R902. A review of the medical record revealed R902 was readmitted to the facility on [DATE] with diagnoses that included: end stage renal disease and dependence on renal dialysis. On 1/14/25 at 10:55 AM, R902 was observed sitting up in bed eating breakfast. A brief interview was conducted with R902 at that time. At 11:17 AM, an observation of R902's buttocks was conducted with the assistance of Unit Nurse Manager (UNM) A. A pink wound dressing, no date noted was observed on the right side of R902's buttocks. On the left side was an identified open area with maceration. There was no treatment applied to the left buttocks. UNM A confirmed the left side opening and stated treatment should be applied to that area. Shortly after, an observation of the facility's treatment cart was conducted and the wound dressing observed on R902 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: MI00149193. Based on observation, interview and record review the facility failed to accurately obtain and monitor weights for one (R902) of one resident reviewed for weight loss. Findings include: During an interview conducted with the complainant on 1/14/25 at 9:50 AM, the complainant verbalized concerns of weight loss and the facility staff not providing assistance for meals for R902. A review of the medical record revealed R902 was readmitted to the facility on [DATE] with diagnoses that included: end stage renal disease and dependence on renal dialysis. On 1/14/25 at 10:55 AM, R902 was observed sitting up in bed eating eggs with their fingers. A white towel covered the front of their chest area, with eggs observed all over the towel. R902's tray consisted of ham, eggs, toast and oatmeal. There was no staff observed in the room. When asked if staff offered to help them with their meal, R902 stated they had but they declined their offer. A review of a Weight Summary for R902…

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: MI00149193. Based on observation, interview and record review the facility failed to ensure the assessment and monitoring of an Intravenous (IV) catheter and Permacath site, for one (R902) of one resident reviewed for wounds. Findings include: On 1/14/25 at 11:17 AM, a partial skin assessment was completed with the assistance of Unit Nurse Manager (UNM) A. Observed on the right side of R902's chest was a split catheter, colored red and the other blue with a dressing dated 12/31/24. On the left side of R902's chest was an IV port covered with a white gauze at the insertion site, no date was noted. A review of the medical chart revealed no documentation, physician orders or care plan that identified the type of each catheter nor the location. Further review of the medical record revealed no orders or care plans implemented for the monitoring and assessment of the catheter sites. A review of the physician orders contained the following order: Change Transparent dressing to PICC every day shift every 7 day(s) for IV maintance <sic>. Ordered 12/17/24. 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 This citation pertains to intake MI00147820. Based on observation, interview and record review, the facility failed to provide appropriate treatment and interdisciplinary collaboration to prevent further decrease in range of motion for one resident (R902) of two reviewed for range of motion. Findings include: A review of a complaint reported to the State Agency on 11/1/24 included an allegation the facility failed to apply the residents hand brace/splint. Record review revealed R902 was admitted to the facility on [DATE] with a history of stroke, limitations of activities due to disability, right hand contracture, heart failure, diabetes, and respiratory failure. Psychological history includes depression, schizophrenia, and generalized anxiety disorder. Most recent BIMS (Brief Interview for Mental Status) assessed 11/11/24 was 11/15 indicating R902 was moderately cognitively impaired. On 12/2/24 at 9:40 AM, R902 was observed in their room in a wheelchair with their right hand contracted in a fist resting on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00147667. Based on interview and record review the facility failed to ensure Physician orders were transcribed and implemented for bowel movements for one resident (R903) of of two residents reviewed for bowel and bladder. Findings include: On 12/2/24 a complaint submitted to the State Agency was reviewed which alleged the facility was not monitoring and treating a change in condition for R903. On 12/2/24 the medical record for R903 was reviewed and revealed the following: R903 was initially admitted to the facility on [DATE] and had diagnoses including Constipation and Colostomy status. A review of R903's comprehensive plan of care revealed the following: Focus-[R903] is at risk for altered elimination pattern, altered body image, fluid imbalance, skin breakdown and pain: has a colostomy. Date Initiated: 10/28/2019 .Interventions-Observe for diarrhea, constipation, dehydration, pain Q (every) shift and report if indicated. Date Initiated: 04/25/2018 .Ostomy care as ordered…

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 # MI00145991. Based on interview and record review the facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) were provided and completed for four (R169, R27, R42, and R62) of four residents reviewed for beneficiary notification, resulting in complaints of not being informed timely of private pay charges for continued services at the facility, and the inability to file an appeal. Findings include: Review of an allegation reported to the State Agency included concerns that the resident and/or representative was not provided with a timely notice for insurance end dates. On 8/19/24 during the entrance conference, the Administrator reported they were currently in transition with their Business Office Manager (BOM) as the former BOM was no longer employed at the facility and had been gone about a week. They were currently having alternating corporate staff fill-in temporarily. 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 R41 On 8/19/24 at 11:12 AM, the resident was observed laying in bed with supplemental oxygen via nasal cannula from an oxygen concentrator. When asked if they had any concerns with lack of sufficient nursing staff, R41 reported concerns with not having enough at times and having to wait long periods of time before staff will respond to their needs. They further reported it seemed like staffing was worse on the weekends. R42 On 8/19/24 at 11:38 AM, the resident was interviewed at bedside. When asked if they felt there was sufficient staffing to meet their needs, R42 reported they need to hire more people all around and couldn't get their pain pill this morning. They further reported at times they waited for help longer than 30 minutes. R77 On 8/19/24 at 12:50 PM, the resident was observed seated on the side of their bed. They reported they had transferred from another nursing facility about five months ago and their top concern since coming to this facility was there were not enough aides on afternoons 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 This citation has two deficient practice statements (DPS). DPS#1 Based on observation, interview and record review, the facility failed to ensure residents were treated in a dignified manner for one (R34) of one resident reviewed for dignity, and multiple residents observed during dining. Findings include: According to the facility's policy titled, Federal & State - Resident Rights & Facility Responsibilities dated 5/14/2024: .A facility must treat each resident with respect and dignity and care for each resident in a manner in an environment that promotes maintenance or enhancement of his or her quality of life .A resident is entitle to know who is responsible for and who is providing his or her direct care . R34 On 8/19/24 at 12:15 PM, R34 was observed attempting to self-propel in their wheelchair from their room doorway into the hall. The wheelchair brakes were engaged as R34 grunted and attempted to propel themselves forward. Numerous staff were observed to pass by R34 without assisting them to disengage 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 provide reasonable accommodation of resident needs and preferences (including bed length and water in reach) for four (R34, R76, R89, and R170) of eight residents reviewed for accommodation of needs, resulting in residents complaining of being uncomfortable, frustrated over loss of independence with grooming or being able to get out of bed, and residents unable to hydrate with or without staff assistance. Findings include: R170 On 8/19/24 at 11:04 AM, R170 was observed lying in bed with no clothing on their upper body and the top blanket covering over their lower extremities. The resident's feet were extended out of the blankets and hung over the end of the bed to the left side of the footboard. The footboard was observed pushed out and down slightly. When asked if they were comfortable as they currently were, they reported No, no I'm not. When asked if the bed was too short, they reported Yes. When asked if anyone else had asked them…

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 secure resident health information from being displayed in a manner viewable to anyone that passed by the nursing station for five (R119, R120, R121, R122, and R123) of five residents reviewed for privacy. Findings include: On 8/20/24 at 8:24 AM, an observation of the 300 hall nursing station revealed there was a piece of paper taped to the top of the nursing desk facing towards the outside of the desk to the hallway. This paper contained personal resident information which included room numbers, names, current weights and type of scales used to weight R119, R120, R121, R122, and R123. Record reviews included: R119 Review of the clinical record revealed R119 was admitted into the facility on 8/9/24 with diagnoses that included: displaced fracture of olecranon process without intraarticular extension of left ulna, dysphagia, malignant neoplasm of esophagus, and unspecified severe protein-calorie malnutrition. R120 Review of the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a physician order for use of supplemental oxygen was obtained, including monitoring of the resident's respiratory status and maintaining the humidifier secured to the oxygen concentrator for one (R42) of one resident reviewed for respiratory care. Findings include: R42 On 8/19/24 at 11:38 AM, R42 was observed laying in bed. The resident reported they had been at the facility since May 2024 when they transferred from another nursing home that was closing. R42 reported they were receiving supplemental oxygen via nasal cannula from an oxygen concentrator with humidified air. The rate of the oxygen flow was set to 4 liters. R42 was asked if they had recently started on oxygen and reported they used their oxygen continuously and had since admission. The container secured to the oxygen concentrator which held water for humidification was empty. R42 was asked who ensured the water was maintained and they reported they had to keep reminding…

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 ensure consistent dialysis communication documentation and assessments were completed for two residents (R94 and R270), and failed to provide meals prior to hemodialysis appointment for one (R269) of three residents reviewed for dialysis. Findings Include: R94 R94 was long-term resident of the facility. R94 was originally admitted to the facility on [DATE]. R94's admitting diagnoses included end stage renal disease, atrial fibrillation, and diabetes. Based on the Minimum Data Set (MDS) assessment dated [DATE], R94 had a Brief Interview for Mental Status (BIMS) score 15/15 indicative of intact cognition. Review of R94's Electronic Medical Record (EMR) revealed that R94 was scheduled for hemodialysis 3 days per week since they were admitted to the facility. Review of R94's care plan dated 4/8/24 that read, For hemodialysis: facility will utilize the dialysis communication form to communicate with the dialysis center. Send the dialysis…

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 properly label, store, and discard expired medications and biologicals in four of seven medication carts reviewed, resulting in the potential for misuse and decreased efficacy of medications. Findings include: A review of a facility provided policy titled, Storage and Expiration Dating of Medications and Biologicals revised 8/2024 was conducted and read, .3. Facility should ensure that food is not to be stored in the refrigerator, freezer, or general storage areas where medications and biologicals are stored .5. Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors .8. Facility should ensure that test reagents, germicides, disinfectants, and other household substances are stored separately from medications .10. Facility should ensure that medications and biologicals that: (1) have 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 ensure menu items listed on meal tickets were provided for seven residents (R#'s 12, 101, 64, 34, 89, 59, and 100) of 28 residents reviewed for dining resulting in the potential for disappointment with meals. Findings include: On 8/19/24 at 1:20 PM, an observation of the lunch meal was conducted in the facility dining room and the following was observed: R12's meal ticket revealed they were to be provided a nutritional juice supplement, it was not observed the nutritional juice was provided to them during the meal service, R101's meal ticket revealed they were to be provided a magic cup supplement, no magic cup was observed to be provided to them during the meal service, R64's meal ticket indicated they were to be provided a double dessert and a nutritional juice supplement, the dessert provided was a single serving and no nutritional juice was observed as provided during the meal service. On 8/19/24 at approximately 1:45 PM, an observation of R34's meal ticket on the tray at their bedside revealed they were…

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

Based on observation, interview and record review, the facility failed to ensure fresh water and assistance with consuming fluids for four residents (R#'s 59, 34, 89, and 100) of four residents reviewed for hydration, resulting in the potential for dehydration. Findings include: On 8/19/24 at 11:05 AM, R59 was observed in bed, asleep. A foam cup full of water, with no ice and felt room temperature to the touch was observed on the bedside table. It was observed the cup was not dated and the top of the straw was contained in it's paper wrapper. On 8/20/24 at 8:20 AM, R34 was observed in their bed. A foam cup full of water with, 8/20 11-7 (Date/midnight shift time) written on the cup was observed. The cup felt room temperature to the touch and the top of the straw was contained in it's paper wrapper. On 8/20/24 at 10:40 AM, R89, R59, and R100's water cups were observed dated 8/20 with 11-7 written on them. The cups all felt warm to the touch and none contained ice. The top of the straw in R59's cup was observed to be contained in it's paper wrapper. On 8/20/24 at 12:45 PM and 2:00 PM,…

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

Based on observation, interview, and record review, the facility failed to ensure meals were served in a timely manner and in accordance with the scheduled mealtimes for the residents (including R39), resulting in late meals and resident dissatisfaction. Findings include: Review of an undated facility policy Meal Times noted: Tray line/Room trays/Dining room: Lunch 12:30 pm. All times are within +/- 10 minutes. On 8/19/24 at 1:05 pm, the first lunch cart left the kitchen to be delivered to the resident rooms. On 8/19/24 at 1:55 pm, the last lunch cart left the kitchen to be delivered to the resident rooms. On 8/19/24 at 2:00 pm, Certified Dietary Manager O was queried about the late lunch meal delivery and stated that they had a call-in for the morning shift, and that it put them behind for the rest of the day. A confidential Resident group meeting was conducted with five residents on 8/20/24 at approximately 11:30 AM. During the meeting, all five residents reported that they were not served meals timely on many occasions. When asked what time they ate their breakfast, Anonymous…

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 utilize appropriate infection control standards and practices including adherence to implementation of and donning proper Personal Protective Equipment (PPE) specific to Enhanced Barrier Precautions (EBP) (R172), proper hand hygiene, and unsafe disposing of human waste (R15), resulting in the potential for spread of infection that could potentially affect all residents in the facility. On 8/21/24 at 7:46 AM, Licensed Practical Nurse (LPN X) was observed during medication administration not performing hand hygiene. LPN X donned gloves to administer eye drops, and when the residents telephone fell to the ground, LPN X picked the phone up off the floor, hands remained gloved, placed the phone back to the resident, and attempted to administer eye drops without changing gloves and performing hand hygiene. When prompted, LPN X acknowledged hand hygiene should have been performed and gloves changed. Resident 15 Clinical record review revealed R15…

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 and interview the facility failed to ensure all corridor areas used by residents were provided with safe and secure hand rails. This deficient practice has the potential to affect all residents who are independently ambulatory with, or without an assistive device. Findings include: Observations conducted during survey between 8/19/24 - 8/20/24 at 3:00 PM revealed concerns regarding the facility's handrails. These concerns included multiple sections of the handrails and hard plastic corner caps/molding were observed to have broken, jagged, missing pieces which exposed the sharp plastic and/or metal underneath throughout the 100 and 200 hallways. Additionally, the handrail near the exit hallway closest to the kitchen was observed pulled away and down from the wall slightly. On On 8/20/24 at 3:06 PM, an interview and observation of the 100 and 200 hallways was done with the Maintenance Director (Staff 'S'). When asked if the conducted any audits of the facility's handrails, Staff 'S' reported they didn't do anything like a monthly audit, but checked once every blue…

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 address grievances for one resident (R31), of one resident reviewed for grievances, resulting in unresolved concerns. Findings include: On 8/19/24 at 10:13 AM, an interview was conducted with R31 in their room and they said, I need some antibiotics. When queried about the need for antibiotics R31 said the facility was not regularly supplying them with new, sterile, intermittent straight urinary catheters. They further explained they had been re-using catheters and believed they developed a urinary tract infection (UTI). They were asked if they made the facility aware of their concerns with a possible UTI and re-using catheters and they said they had. They were then asked if they filled out any type of complaint/grievance form and said they did not. On 8/19/24 at 11:49 AM, a review of a progress note dated 8/14/2024 at 12:50 PM entered into the record by Nurse 'J' read, .While in care conference Resident c/o (complains of pain) pain in groin area and upon urinating also stating having a discharge from his penial <sic> area…

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 #MI00145754 Based on observation, interview, and record review, the facility failed to provide necessary care and services consistent with the residents needs and choices. Findings include: A review of a complaint reported to the State Agency included an allegation the facility staff failed to provide adequate and appropriate care based on the patient's needs. Clinical record review revealed R47 was admitted to the facility on [DATE] for hypertension, heart disease, peripheral vascular disease, diabetes, and multiple myeloma. R47 underwent debridement of nonviable tissue and a partial calcanectomy (removal of heel bone) of the left foot. A Vacuum assisted closure pump (Wound VAC) was applied to the left foot on 6/7/24 and required infectious disease for antibiotic treatment. R47 is care planned as a decline in ambulation, coordination, and strength related to falls and application of wound healing appliance. R47 required substantial/maximal assistance with one helper, including…

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 meal set-up and one-to-one feeding assistance for one resident (R89) of four residents reviewed for activities of daily living. Findings include: On 8/19/24 at 11:28 AM, R89 was observed in their bed asleep with a breakfast tray that appeared to be approximately 25% consumed. It was observed with food and beverage spilled on the plate and tray. At that time, R89's roommate said R89 was legally blind. They were asked if staff ever assisted R89 with eating and said staff set the tray up but do not assist them with eating. On 8/19/24 at 1:38 PM, R89 was observed in their bed attempting to consume their lunch meal. R89 was observed to be picking at their meal with their fingers and had food spilled on the tray, on their clothing, and in their bed. R89's roommate and roommate's family said the resident could not see and was legally blind. During the observation, R89 was observed struggling to open with plastic container containing…

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 #MI00145754. Based on observation, interview, and record review, the facility failed to provide consistent monitoring and assessment of changes in skin, and implementation of pressure-relieving interventions for two (R47 and R96) of five residents reviewed for pressure ulcer management. Findings include: A review of a complaint reported to the State Agency included an allegation the facility staff failed to provide adequate and appropriate care to prevent and/or treat pressure sores. R47 Clinical record review revealed R47 was admitted to the facility on [DATE] for hypertension, heart disease, peripheral vascular disease, diabetes, and multiple myeloma. R47 underwent debridement of nonviable tissue and a partial calcanectomy (removal of heel bone) of the left foot. A Vacuum assisted closure pump (Wound VAC) was applied to the left foot on 6/7/24 and required infectious disease for antibiotic treatment. R47 is care planned as a decline in ambulation, coordination, and strength.…

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 assessment, monitoring, and provision of supplies for two residents (R#'s 31 and 15) who used urinary catheters, of two residents reviewed for urinary catheters, resulting in the potential for the development of urinary tract infections. Findings include: R31 On 8/19/24 at 10:13 AM, an interview was conducted with R31 in their room and they said, I need some antibiotics. When queried about the need for antibiotics R31 said the facility was not regularly supplying them with new, sterile, intermittent straight urinary catheters. They further explained they had been re-using catheters and believed they developed a urinary tract infection (UTI). At that time, no catheter kits were observed in the resident's room. On 8/19/24 at 11:49 AM, a review of a progress note dated 8/14/2024 at 12:50 PM entered into the record by Nurse 'J' read, .While in care conference Resident c/o (complains of pain) pain in groin area and upon urinating also…

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 facility failed consistently monitor weights for one (R29) of two residents reviewed for nutrition resulting in the potential for undetected weight loss, and overall decline in functional status. Findings include: R29 was a long-term resident of the facility. R29 was originally admitted to the facility on [DATE]. R29 most recently was hospitalized and readmitted to the facility on [DATE]. R29's admitting diagnoses included seizures, hemiplegia (stroke), diabetes, and dysphagia (difficulty swallowing) and chronic pain. Based on the Minimum Data Set (MDS) assessment dated [DATE], R29 had a Brief Interview for Mental Status (BIMS) score of 7/15, indicative of severe cognitive impairment. R29 needed extensive staff with their mobility in bed and their Activities of Daily Living (ADLs) such as transfers, dressing, toileting, etc. An initial observation was completed on 8/19/24 at approximately 10:30 AM. This surveyor observed staff delivering the breakfast…

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 order laboratory tests timely for one resident (R31) who experienced signs and symptoms of a Urinary Tract Infection (UTI) and obtain physician ordered routine labs for one (R87) of two residents reviewed for laboratory service. Findings include: R87 Review of the clinical record revealed R87 was a long-term resident of the facility. R87 was originally admitted to the facility on [DATE]. R87's admitting diagnoses included osteoarthritis, bipolar disorder, anxiety disorder, and heart failure. Based on the Minimum Data Set (MDS) assessment dated [DATE], R87 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicative of intact cognition. R87 needed extensive staff assistance with their mobility in bed, transfers, and Activities of Daily Living (ADLs) such as grooming, dressing, toileting etc. Review of R87's clinical record revealed a physician order for Depakote oral tablet delayed release 125 mg (milligrams) two times a day. Further 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain and/or coordinate radiology services for an MRI (Magnetic Resonance Imaging) for one (R42) of one resident reviewed for radiology/other diagnostic services, resulting in verbalized concerns of the delay in obtaining the MRI, and the potential for delayed identification of any abnormalities which may require additional medical/treatment intervention. Findings include: On 8/19/24 at 11:38 AM, an interview was conducted with R42. When asked if they had any concerns, R42 reported they had pain all over, especially their left thigh and arm. They reported concerns with the lack of scheduling and coordination of an MRI and stated their cancer doctor wanted them to have an MRI done for their left thigh. The resident reported they gave that information to the facility to coordinate, but no one has contacted them about if/when that was scheduled. R42 was worried about their cancer diagnosis and also expressed concern that another part of their thigh is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00145663. Based on observations, interviews and record reviews the facility failed to ensure sufficient staffing was provided to ensure adequate care was provided for two (R's 303 & 304) of three residents reviewed for Activities of Daily Living (ADLs) and Staffing. This deficient practice had the ability to affect multiple residents that resided in the facility. Findings include: Review of a complaint submitted to the State Agency (SA) included the following concerns: the facility is short staffed on all shifts, residents are being left wet/soiled for extended periods of time and residents are not being showered. On 7/24/24 at 10:34 AM, R303 was observed sitting on their bed watching television. When asked about the facility's staffing R303 stated they don't get their showers regularly because they don't have enough staff. R303 pointed out their facial hair and stated they preferred not to have any facial hair, however the aides never have time to shave them because they were…

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

Based on interview and record review, the facility failed to ensure two of six staff members reviewed for criminal background checks were screened for eligibility to work in a nursing home, resulting in the potential for abuse or neglect to occur. This has the potential to affect all residents who reside in the facility. Findings include: On 5/22/24 at 8:30AM the facility was asked to provide the personnel file, all educations, trainings. Disciplines and background checks for six employees. On5/22/24 at 10:10AM a follow up request was initiated for employee's information. On 5/22/24 at 12:32PM The facility provided the files with completed background checks, educations and trainings for all employees except for two. The facility provided a personnel file for Nurse H, this file was not requested, however was reviewed due to identification of a missing background check clearance. A third request for Nurse B's file was made to the Administration staff. Nurse H's file was reviewed and it was missing educations, training, a background check with finger print results. On 5/22/24 at 2:00PM…

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 resident's guardian of changes of condition for one (R702) of two residents reviewed for notification of changes. Findings include: A complaint was filed with the State Agency (SA) on 3/14/24 that alleged in part, .no one called to tell me that (R702) had pulled his feeding tube out . found out when I was visiting him and happened to touch his stomach . (R702) had also been put on an IV (intravenous fluids) and I only found out because my friend was coming to visit him . Review of the closed record revealed R702 was admitted into the facility on [DATE] with diagnoses that included: diabetes, depression and stroke. According to the Minimum Data Set (MDS) assessment dated [DATE], R702 had severely impaired cognition and required the assistance of staff for activities of daily living (ADL's). Review of R702's January 2024 Medication Administration Record (MAR) revealed four Enteral Feed Orders (feeding through a tube into the gastrointestinal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00143505 Based on interview and record review, the facility failed to document and address resident grievances for one resident (R705) of one residents reviewed for grievance resolution, resulting in verbalized complaints and frustration. Findings include: On 4/2/24 a complaint submitted to the Stage Agency was reviewed which indicated R705 had been left wet and soiled and nobody from facility administration had followed up with R705's family pertaining to the verbalized concerns. On 4/2/24 at approximately 12:27 p.m., during a conversation with family member J (FM J), FM J reported that they had concerns about the care in the facility for R705 pertaining to being left wet and soiled for five hours of time and not being placed back into bed and being left in their wheelchair for hours. FM J reported that that they had discussed their concerns with Social Work Director K (SWD K) and that SWD K was going to let the Director of Nursing (DON) know about the concerns so that they…

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 #MI00142508 and Intake #MI00142954 Based on interview and record review, the facility failed to accurately complete assessments for one resident (R703) of three reviewed for change in condition resulting in R703 developing intense pain from a blood clot requiring hospitalization. Findings include: A Clinical record review revealed R703 was admitted to the facility on [DATE] for rehabilitation from back surgery performed on 1/5/24. Medical history includes, chronic obstructive pulmonary disease (COPD), hypertension, diabetes, chronic pain, morbid obesity, and overactive bladder. Brief Interview of Mental Status (BIMS) score total is 15/15 indicating R703 was cognitively intact. On 4/2/24 at 9:38 AM, a telephone interview was conducted with R703 and they reported on 01/17/24 around 1:00-2:00 AM they woke up with severe intense pain, swelling, and warm sensation in the left leg. The call light was pressed, and nobody came in. R703 placed their self into the wheelchair and saw 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 This citation pertains to intake#: MI00142528 Based on interview and record review, the facility failed to ensure the timely completion and submission of a comprehensive assessment after significant change in status for one resident (R901) of one reviewed for resident assessments, resulting in the potential for unmet care needs. Findings include: R901 was admitted to the facility on [DATE] after hospitalization for a fall at home. R901's admitting diagnoses included: Contusion of scalp, osteoarthritis, metabolic encephalopathy, and history of achondroplasia. R901 was transferred to hospital on 1/26/23 for further weight loss and PEG (Percutaneous Endoscopic Gastrostomy tube - a tube directly placed on stomach to provide nutrition and hydration) tube placement and worsening wounds. Review of R901's Electronic Medical Record (EMR) revealed a Minimum Data Set (MDS) comprehensive Assessment with an Assessment Reference Date (ARD) of 11/18/23. Section K (nutrition and swallowing section) of the MDS 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 facility failed to assist with repositioning/off-loading to relieve prolonged pressure for two (R906 and R907) of two Residents, with multiple pressure ulcers, who were dependent upon staff for turning/repositioning, during multiple observations. This deficient practice has the potential to result in worsening of pressure ulcers with decline in overall health condition and hospitalization. R906 R906 is a long-term resident of the facility. R906 was originally admitted to the facility on [DATE] and had recent hospitalization and they were readmitted back to the facility on 1/9/24. R906's admitting diagnoses included multiple sclerosis, decubitus ulcers (pressure sores), and paraplegia (paralysis of both legs). Based on the Minimum Data Set (MDS) assessment dated [DATE], R906 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicative of intact cognition. R906 needed extensive (2 -person) assistance to assist with their mobility in bed, turning and…

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

This citation Pertain to Intake#: MI00142528 Based on interview and record review, the facility failed to: 1) implement appropriate action to correct quality deficiencies; and 2) sustain a system to ensure corrective measures related to prevention and treatment of pressure ulcers/injuries for two (R906 and R907) of three residents reviewed. Findings include: The facility's QAPI (Quality Assurance and Performance Improvement) failed to identify quality issues as evidenced by facility's failure to effectively implement and consistently monitor preventative measures for pressure ulcer prevention for R906 and R907. R906 and R907 needed extensive staff assistance with their repositioning/off-loading in bed. Staff failed to assist with repositioning/off-loading to relieve prolonged pressure on the area with wounds for R906, during seven different observations completed during this survey. R906 had multiple pressure ulcers that included a facility acquired a stage 4 pressure ulcer. Staff also failed to assist with repositioning/offloading R907 during five different observations. R907 had…

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 #MI00139090 Based on interview and record review, the facility failed to protect the resident's (R701) right to be free from physical abuse by Certified Nurse Aide 'C'. On 1/17/24 at 11:00 AM, a review of a facility reported incident investigation file provided by the facility was conducted. The file contained a typed document that summarized the incident and read, .On 6.21.23 the administrator was made aware of an incident involving (R701) and staff member (CNA, Certified Nurse Aide 'C'). The staff member allegedly struck (R701) in the face .The administrator interviewed the assigned staff member (CNA 'C') regarding this alleged allegation .When asked if she hand <sic> touched the resident in her face, or near her face in anyway <sic>? She replied 'no'. She continued I take care of my residents .The administrator interviewed (Nursing student 'D') a nursing student who is in her clinical rotation, was training with the assigned staff member (CNA 'C'). (Nursing Student 'D') reported, that (R701) .motion as if she was going to hit and spit on her (CNA…

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): MI00141886 and MI00141946 Based on interview and record review, the facility failed to implement interventions to prevent falls in a timely manner for one (R707) of one resident reviewed for falls. Findings include: Review of R707's clinical record revealed R707 was admitted into the facility on [DATE] and discharged home on [DATE] with diagnoses that included: encephalopathy and dementia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R707 had severely impaired cognition and required partial/moderate assistance for transfers and to walk 10 feet. The MDS revealed R707 had a history of falls prior to admission and had two or more falls since he was admitted into the facility. Review of R707's progress notes revealed he fell on [DATE] and 12/9/23. On 1/17/24 at 12:21 PM, an interview was conducted with Licensed Practical Nurse (LPN) 'G' via the telephone. When queried about R707 and the fall documented on 12/9/23, LPN 'G' stated, He fell many times…

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 store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to label and date food in the walk in cooler and freezer and failing to discard expired food items timely and 2. Failing to discard kitchen refuse in appropriate trash/refuse receptacles. These deficient practices have the potential to result in food borne illness among any or all the 98 residents of the facility. Findings include: An initial kitchen tour was completed with the staff member I on 5/21/23, at approximately, 8:45 AM. Dietary management team was not present at the facility and initial kitchen observation was completed in the presence of Staff member I. The following observations were made during the initial kitchen rounds: 1. Observed a carton of opened milk in the refrigerator in which dairy products were stored. Observed two containers, one with blueberry jelly and the other one with strawberry jelly that expired on 5/19/23 in a different refrigerator. 2. Observed a tray…

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 measures were in place to 1) ensure proper disposal of soiled Personal Protection Equipment (PPE) for two (R239 and R241) and 2) proper hand hygiene was performed after removal of soiled PPE for residents (R241) who were observed for transmission-based precautions. These deficient practices have the potential for spread of infections to all residents residing in the facility. Findings include: R241 R241 was admitted to the facility on [DATE] for short-term rehabilitation and skilled nursing services. R241's admitting diagnoses from the hospital included cellulitis of left leg, hepatitis-C. R241 tested positive for COVID-19 on 5/22/23 during their stay at the facility. An observation was completed on 5/23/23 at approximately 8:45 AM, R241's room had signages outside the room indicating that they were on transmission-based precautions. A PPE cart was observed outside the door in the hallway. An open trash…

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 self-administration of medication assessment for one (R241) of one resident reviewed for the self-administration of medications. Findings include: On 5/21/22 at 10:17 AM, R241 was observed in their wheelchair in their room. A tube of triamcinolone acetonide was observed on the bedside table next to R241's bed. When asked, R241 stated they are supposed to have it applied to their left leg, however the staff have not consistently applied it. On 5/22/23 at 11:57 AM, R241 was not observed in their room, however the tube of triamcinolone acetonide was still observed on the resident bedside table. Review of the medical record revealed R241 was admitted to the facility on [DATE] with a diagnosis that included cellulitis of the left lower limb. Review of the physician orders documented in part . Triamcinolone Acetonide External Ointment 0.1%, Apply to LLE (Lower Left Extremity) topically every shift for cellulitis . Review of the care…

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 choices was provided for two (R's 240 & 37) of three residents reviewed for choices. Findings include: On 5/21/23 at 9:41 AM, R240 was observed sitting in their wheelchair in their room, an interview was conducted with the resident at that time. During the interview, R240 picked up a meal ticket from their breakfast tray and stated . Look, they have me down as eats in room, they didn't ask me! It just says eat in room . I'm sociable. I would love to eat in the dining room . Review of the medical record revealed R240 was admitted into the facility on 5/12/23 with diagnoses that included depression. Review of a Diet History/Food Preferences dated 5/18/23, documented Breakfast, Lunch & Dinner, and the Location of the resident preferences. This section was left blank for all three meals. On 5/22/23 at 3:59 PM, Dietician B was interviewed and asked who assesses the resident preference for dining options as it pertains to eating in their…

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 and interview, the facility failed to provide a safe and comfortable home like environment for one of one resident (R3) resulting in the potential for resident dissatisfaction with their living conditions. Findings include: A record review revealed R3 was a long-term resident of the facility. An initial observation was completed on 5/21/23 at approximately 1:35 PM. R3 was observed in their room, lying on their bed. R3 reported that they needed help in getting back to their home. The Nurse assigned to care for R3 was notified. During this observation two large holes measuring approximately over five inches were observed behind R3's bed on the dry wall. The holes were visible from the sides of the R3's bed. A second observation was completed approximately two hours later that day. On 5/22/23 three observations were completed at approximately 8:30 AM, 1:00 PM, and 3:30 PM. R3 was observed in their room, in their bed. Two large holes on the wall were visible from the sides and were not fixed. On 5/23/23, at approximately 7:30 AM, the facility Administrator 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 ensure regular care planning review conferences were held with the legally authorized resident representative for one resident (R64) of one residents reviewed for Comprehensive Care plans. Findings include: On 5/21/23 at approximately 11:42 a.m., R64 was observed in their room up in their wheelchair with R64's legal guardian at the bedside who indicated they have not had a care conference (a meeting with the interdisciplinary team to review the comprehensive plan of care) in a long time. On 5/22/23 the medical record for R64 was reviewed and revealed the following: R64 was last admitted to the facility on [DATE] and had diagnoses including Dementia, Muscle weakness and Muscle wasting. A review of R64's MDS (minimum data set) with an ARD (assessment reference date) of 2/14/23 revealed R64 needed extensive assistance from facility staff with most of their activities of daily living. R64's BIMS score (brief interview for mental status) was four, indicating…

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) grooming, feeding assistance and showers for two (R36 and R54) of three Residents reviewed for ADL care resulting in the potential for negative physical, psychosocial outcomes, and potential loss of dignity for residents who are dependent on staff for assistance. Findings include: R36 R36 was a long-term resident of admitted to the facility on [DATE]. R36's diagnoses included Dementia and difficulty with walking. R36 had a Brief Interview of Mental Status (BIMS) score of 8, indicative of moderate cognitive deficits. R36 needed staff assistance with dressing and personal hygiene. On 5/21/23 at approximately 2:35 PM or 36 was observed in bed. R36 disheveled, had dry and flaky skin on their face and arms, facial hair not shaved, with long hair, not groomed. R36 was wearing a pajama pant and a white T-shirt with stains on it. Multiple observations were 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 wound care was completed per Physician's orders for one resident (R56) of three residents reviewed for wound care. Findings include: On 5/21/23 at approximately 11:55 a.m., R56 was observed in their room up in bed. R56 was observed with dressings on their bilateral feet. The dressings on the left and right feet were dated 5/18/23. R56 was queried how often the Nursing staff are completing their wound dressings and they reported staff were supposed to do new dressings every other day, but have not. R56 indicated they have not had their dressings changed since they moved to their new room. On 5/21/23 the medical record for R56 was reviewed and revealed the following: R56 was initially admitted to the facility on [DATE] and had diagnoses including Urinary tract infection, Adult failure to thrive and Morbid obesity. A review of R56's MDS (Minimum Data Set) an ARD (Assessment Reference Date) of 5/3/23 revealed R56 needed extensive…

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 catheter care, monitoring and documentation was completed for three residents (R56, R80 and R190) of three residents who were reviewed for catheter care/Urinary tract infections. Findings include: Resident #56 On 5/21/23 at approximately 11:55 a.m., R56 observed in their room up in their bed. R56 was queried if they had any concerns regarding their care in the facility and they reported they were having a problem with their catheter and they were having urinary burning. On 5/21/23 the medical record for R56 was reviewed and revealed the following: R56 was initially admitted to the facility on [DATE] and had diagnoses including Urinary tract infection, Adult Failure to thrive and Morbid obesity. A review of R56's MDS (Minimum Data Set) an ARD (Assessment Reference Date) of 5/3/23 revealed R56 needed extensive assistance with most of their activities of daily living. R56's Brief Interview for Mental Status (BIMS) score 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 observation, interview and record review the facility failed to ensure adequate monitoring of weights for one resident with weight loss (R64) of six residents reviewed for Nutrition. Findings include: On 5/21/23 at approximately 11:42 a.m., R64 was observed in their room up in their wheelchair with R64's legal guardian at the bedside who indicated that R64 was not eating and had experienced weight loss. On 5/22/23 the medical record for R64 was reviewed and revealed the following: R64 was last admitted to the facility on [DATE] and had diagnoses including Dementia, Muscle weakness and Muscle wasting. A review of R64's MDS (minimum data set) with an ARD (assessment reference date) of 2/14/23 revealed R64 needed extensive assistance from facility staff with most of their activities of daily living. R64's BIMS score (brief interview for mental status) was four, indicating severely impaired cognition. Section K indicated that R64 had weight loss of 5% or more in the last month or loss of 10% more in 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 ensure enteral feeding (nutrition delivered from a surgically placed tube in the stomach) was provided according to physicians orders for one (R80) of three residents reviewed for enteral feeding and one (R15) additional resident. Findings include: R80 On 5/21/23 at 9:30 AM, R80 was observed in bed. When asked how they were doing, R80 stated, I need water. There were no cups observed at R80's bedside. When R80 opened their mouth, a tan substance was pooled at the front of their mouth. R80 was receiving nutrition via a PEG (Percutaneous Endoscopic Gastrostomy - a tube surgically inserted into the stomach used to deliver nutrition). A bottle of Glucerna 1.5 was hung on the tube feeding pole and it was infusing at 65 milliliters per hour (ml/hr) according to the tube feeding pump. The label on the Glucerna bottle indicated the tube feeding was started at 6:00 PM on 5/20/23 and the rate was documented as 75 ml/hr. At that time, 809 ml had…

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 there was sufficient nursing staff to provide care and services to the residents. This had the ability to affect all residents in the facility. Findings include: On 5/21/23 at 8:44 AM, during a tour of the facility, Nurse 'Y' was asked about staffing in the facility. Nurse 'Y' reported the facility had an ongoing problem with adequately staffing the night shift. Nurse 'Y' stated, If you look at the schedule for last night they had four aides for the whole building and we usually have eight aides. Nurse 'Y' further reported that due to inadequate staffing it was difficult to provide quality care. On 5/22/23 at approximately 11:05 AM, during the group interview, the group was queried if they had any concerns regarding staffing in the facility. A resident who preferred to remain anonymous reported there were not enough Certified Nursing Assistants (CNAs) during the midnight shift and on the weekends and the aides that do show up to work were overworked. The anonymous resident indicated that during the…

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

Based on observation, interview and record review the facility failed to ensure expired medications, Pneumococcal vaccines and a TB solution was removed from the facility's medication rooms and discarded for two of three medications storage rooms reviewed and failed to ensure a treatment cart was secured/locked of three carts reviewed. Findings include: On 5/21/23 at 8:41 AM, the treatment cart located on Unit 1 was observed to be unlocked. The cart contained various topical medications used to treat wounds. At approximately 8:45 AM, Nurse 'F' exited a resident's room. When queried about the treatment cart being unlocked, Nurse 'F' reported it should have been locked. On 5/23/23 at 8:33 AM, an observation of the medication storage room on Unit 1 was completed with the Assistant Director Of Nursing (ADON) A. Upon review of the medication storage room four bottles of the slow-release iron 21 century slow-release mineral supplement was identified to have expired in April of 2023, however still remained in the facility medication supply. Further observation of the medication storage…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain accurate documentation in the residents' medical records for one (R56) resident. Findings include: On 5/21/23 at approximately 11:55 a.m., R56 was observed in their room up in bed. R56 was observed with dressings on their bilateral feet. The dressings on the left and right feet were dated 5/18/23. R56 was queried how often the Nursing staff are completing their wound dressings and they reported staff were supposed to do new dressings every other day, but have not. R56 indicated they have not had their dressings changed since they moved to their new room. On 5/21/23 the medical record for R56 was reviewed and revealed the following: R56 was initially admitted to the facility on [DATE] and had diagnoses including Urinary tract infection, Adult failure to thrive and Morbid obesity. A review of R56's MDS (Minimum Data Set) an ARD (Assessment Reference Date of 5/3/23 revealed R56 needed extensive assistance with most of their…

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.