Medilodge of Farmington

This citation pertains to intake #'s 2629174 and 2639760. Based on observation, interview, and record review, the facility failed to ensure ongoing assessment and accurate treatment orders for wound care for one resident (R22) of one resident reviewed for wound care, resulting in verbalized complaints with quality of care and the potential for wound complications. Findings include: On 1/27/26 at 11:02 AM, a phone call was placed to the complainant, and they expressed concerns over a new wound R22 developed to their left thigh/buttock area and did not think the facility was properly addressing the wound. On 1/27/26 at 12:16 PM, an observation of R22's wound was conducted with Nurse 'A'. Nurse 'A' peeled back the foam dressing, and the wound was observed to be a skin tear approximately 3 cm (centimeters) in length in the skin fold of their left gluteal sulcus (the spot where the thigh meets the buttock). At that time Nurse 'A' was asked about R22's treatment order and said the treatment was triple antibiotic ointment on the wound and cover with a foam dressing. On 1/27/26 at 12:28 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake(s): #2610189 and #2658977 Based on observation, interview, and record review, the facility failed to administer tube feeding according to physician's orders for one (R79) of five residents reviewed for tube feeding. Findings include:On 1/26/26 at 10:22 AM, R79 was observed lying in bed, sleeping. R79 was receiving breathing assistance via a mechanical ventilator. R79 had a Percutaneous Endoscopic Gastrostomy (PEG) tube which delivered nutrition directly into R79's stomach. A tube feeding pump was observed in R79's room and was hooked up to the resident. A bottle of tube feeding formula was hung and dated 1/25/26. 850 milliliters (ml) of formula remained in the bottle. The tube feeding pump was not running at that time and an error message was present on the screen that read, Pump inactive. Pump has been idle for 10 minutes. On 1/26/26 at 11:45 AM, R79's tube feeding pump remained with the same error message that it was inactive. 850 ml remained in the bottle. On 1/26/26 at 2:10…

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 medical provider was notified and an assessment/evaluation was completed for two residents that sustained severe weight loss (R2 and R80) of three residents reviewed for nutrition, resulting in the potential for further unplanned weight loss to occur. Findings include:R2 On 1/26/26 at 10:10 AM, R2 was observed lying in bed. R2 was receiving nutrition via a feeding tube and breathing assistance via mechanical ventilator. When addressed, R2 did not open her eyes. A review of R2's clinical record revealed R2 was admitted into the facility on 2/29/24 and readmitted on [DATE] with diagnoses that included: acute and chronic respiratory failure with hypoxia, accidental poisoning by heroin, chronic obstructive pulmonary disease, type 2 diabetes, and dysphagia. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R2 had severely impaired cognition, was dependent on staff for all activities of daily living, bed mobility,…

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 2610189.Based on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent. Three medication errors were observed (R72, R9) from a total of 32 opportunities resulting in an error rate of nine percent.Findings include:A complaint was received by the State Agency on 9/7/25 alleging a resident was given the wrong medication.On 1/27/26 at 8:08 AM, Licensed Practical Nurse (LPN) A was observed for medication administration. R72 was ordered Metoprolol (medication to treat high blood pressure) Extended Release (ER) 25 milligrams (mg) to be given by mouth and instructions to do not crush. LPN A was observed crushing the medication mixed with water and administered via a Percutaneous Endoscopic Gastrostomy (PEG) tube (tube surgically inserted into the stomach to deliver nutrition, medication).On 1/28/26 at 8:35 AM, LPN B was observed for medication administration. R9 was ordered Miralax (medication to treat irregular bowel movements and constipation)17 grams. LPN B was observed pouring 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 Physician ordered laboratory diagnostics (labs) were completed in a timely manner for three residents (R2, R33 and R80) of three residents reviewed for diagnostics. Findings include:A review of R2's clinical record revealed R2 was admitted into the facility on 2/29/24 and most recently readmitted on [DATE] with diagnoses that included: acute and chronic respiratory failure with hypoxia, cardiac arrest, type 2 diabetes mellitus, and hypertension. R2 was dependent on a mechanical ventilator to assist with breathing and a feeding tube to deliver all nutrition directly into her stomach. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R2 had severely impaired cognition and was dependent on staff for all ADLs (activities of daily living), bed mobility, transfers. A review of R2's Physician's orders revealed the following orders:12/8/25 - UA C&S (Urinalysis Culture and Sensitivity) R/T (related to) elevated WBC (white blood…

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 physician oversight for wound care for two residents (R#'s 906 and 903) of three residents reviewed for physician services, resulting in incomplete, comprehensive care. Findings include: R906 On 9/3/25 at 8:00 AM, a review of R906's closed clinical record revealed they originally admitted to the facility on [DATE] with diagnoses that included: traumatic brain hemorrhage, skull fracture, and diffuse traumatic brain injury due to a pedestrian motor vehicle accident. R906 was non-verbal and displayed severely impaired cognition. A review of R906's weekly skin assessments revealed an assessment dated [DATE] that documented a scar to their neck and a blister to their toe. It was noted the next weekly skin assessment was conducted on 6/6/25 and documented an “other” skin impairment to their left lateral malleolus (ankle bone). A review of R906's “Skin and Wound” evaluations was conducted and revealed the following: An evaluation dated 6/5/24 that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #2595964 and #2579668.Based on interview and record review, the facility failed to ensure wound treatments were provided for two residents (R905 and R906) of three residents reviewed for pressure uclers. Findings include: R906 On 9/3/25 at 8:00 AM, a review of R906's closed clinical record revealed they originally admitted to the facility on [DATE] with diagnoses that included: traumatic brain hemorrhage, skull fracture, and diffuse traumatic brain injury due to a pedestrian motor vehicle accident. R906 was non-verbal, and displayed severely impaired cognition. A review of R906's weekly skin assessments revealed an assessment dated [DATE] that documented a scar to their neck and a blister to their toe. It was noted the next weekly skin assessment was conducted on 6/6/25 and documented an “Other” skin impairment to their left lateral malleolus (ankle bone). The next skin assessment dated [DATE] only documented a right upper leg skin tear, and the assessment dated [DATE] indicated…

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 #2579668Based on interview and record review, the facility failed to ensure enteral feeding orders were accurately transcribed upon admission and administered correctly for one resident (R905) of two residents reviewed for enteral feeding. Findings include:On 9/2/25 a complaint submitted to the State Agency was reviewed that alleged R905 was fed an incorrect amount of enteral formula. On 9/2/25 the medical record for R905 was reviewed and revealed the following: R905 was initially admitted to the facility on [DATE], discharged on 8/3/25 and had diagnoses including Dysphagia and Gastrostomy status. A review of R905's initial admission hospice Physician orders revealed the following: Evaluate need for supplemental tolerance of Glucerna 1.2 at 40ml/hr (milliliters per hour) for 16 hours.A review of R905's transcribed admission enteral orders revealed the following: Enteral Feed Order every morning and at bedtime every shift Glucerna @45ml/hr (milliliters per hour) x 16hrs via peg…

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 #2580612Based on observation, interview, and record review the facility failed to assess and provide tracheostomy care per physician's orders for one resident (R906), of one resident reviewed for respiratory care, resulting in the potential for tracheostomy complications. Findings include: On 9/3/25 at 10:44 AM, an interview was conducted with R904's responsible party and they expressed concerns regarding R904's tracheostomy care.On 9/3/25 at 11:25 AM, R904 was observed in bed. R904 was in a vegetative state, non-verbal, did not track with their eyes and was observed to have a tracheostomy.On 9/3/25 at 11:55 AM a review of R904's physician's orders, medication administration records (MAR) and treatment administration records (TAR) was conducted and revealed missing documentation for assessment of the stoma site under the tracheostomy collar and tracheostomy care on the following dates/times:Day shift 6/9/25, 6/22/25 thru 6/26/25, 6/29/25 and night shift 6/4/25 and 6/6/25.Day shift 7/22/25 and 7/23/25, and night shift 7/10/25.Day shift 8/7/25 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 pertains to intake #MI00153595 Based on observation, interview and record review, the facility failed to ensure an allegation of poisoning was reported to the Abuse Coordinator and State Agency in a timely manner for one resident (R903) of four residents review for abuse/neglect/exploitation. Findings include: On 6/24/25 a concern submitted to the State Agency was reviewed which indicated R903 went to the hospital because they alleged their roommate [R904] had poisoned them. On 6/24/25 at approximately 11:18 a.m., R903 was observed in their room, up in their wheelchair. R903 was queried regarding their allegation that they were poisoned by their old roommate [R904[They indicated that they had called the police about it and that they had felt dizzy and that previously R903's roommate (R904) said they wanted them to sleep. R903 was queried how they felt that they were poisoned by the roommate and they reported they didn't know they were just poisoned. R903 reported that after they had returned from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #'s MI00153092 and Intake #MI00153425. Based on interview and record review, the facility failed to ensure an appropriate admission per facility policy including physician orders and care directives for one Resident (R905) of one resident reviewed for admission. Findings include: Review of an Intake received by the State Agency on 5/30/25 revealed on 5/28/25 at 7:30 p.m., the complainant reported R905 was admitted to the facility from the hospital on 5/28/25 and received no medication during their stay, as the facility staff allegedly lost their paperwork from the hospital. The report revealed R905 said they watched an EMS (Emergency Medical Services) worker hand over their paperwork to facility staff, who reported it was not received. The complainant reported R905 had to leave the following morning when they did not receive their medications. The complainant reported the facility discharged R905 (AMA - Against Medical Advice) despite no medications being administered during…

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 MI00151473 Based on interview and record review, the facility failed to provide needed care and services to administer Total Parental Nutrition (TPN, a special formula given through a vein and provides nutrition) for one resident (R502) of one resident reviewed for TPN, resulting in weakness, fatigue, and a transfer to the hospital for dehydration and electrolyte replacement. Findings include: The State Agency received a complaint on 3/25/25 alleging the facility failed to provide R502 with their ordered TPN resulting in hospitalization. On 4/15/25, Clinical Record review revealed R502 had a past medical history of pancreaticobiliary (pancreas, gall bladder, and bile duct) cancer and was transferred from the hospital for status post paraoesophageal hernia surgery (restoring the normal anatomy of the esophagus and stomach by closing a defect in the diaphragm) and treatment of gastric outlet obstruction (blockage between the stomach and small intestine) and was dependent on nutritional support via Total Parental Nutrition (TPN). admission Nursing…

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 MI00151473 Based on interview and record review, the facility failed to ensure proper pumps and intravenous tubing was provided by Pharmacy to administer Total Parental Nutrition (TPN) (providing nutrition through a vein) per Physician orders for one resident (R502) of one reviewed for TPN resulting in R502 having concerns of weakness and fatigue resulting in hospitalization for dehydration and electrolyte replacement. Findings include: The State Agency received a complaint on 3/25/25 alleging the facility failed to provide R502 with their ordered TPN resulting in hospitalization. On 4/15/25, clinical record review revealed R502 was admitted to the facility on [DATE] and had a past medical history of pancreaticobiliary (pancreas, gall bladder, and bile duct) cancer and was transferred from the hospital for status post paraoesophageal hernia surgery (restoring the normal anatomy of the esophagus and stomach by closing a defect in the diaphragm) and treatment of gastric outlet…

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 Number(s): MI00149629, MI00149425, and MI00149174. Based on observation, interview, and record review, the facility failed to ensure there was an adequate supply of linens for three (R300, R301, and R305) of three residents reviewed for linens and the potential to affect all residents on the second floor. Findings include: A review of a complaint submitted to the State Survey Agency (SSA) revealed an allegation that the facility was short on wash cloths and that they were stained with feces. A review of a second complaint to the SSA revealed an allegation that the facility ran out of clean towels and wash cloths on a regular basis. In addition, it was alleged there was a limited number of blankets and they were not washed regularly. A review of a third complaint submitted to the SSA revealed an allegation that the facility is always short on linens. R300 On 2/4/25 at approximately 12:00 PM, an interview was conducted with R300's family member who reported a concern about the facility switching from using wipes to washcloths to clean residents up.…

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 # MI00149369 Based on interview and record review, the facility failed to ensure that residents medication orders were entered correctly upon admission for one (R302) of two sampled residents reviewed for antibiotics, resulting in R302 initially missing 10 days of their antibiotic, being sent to the hospital to correct an issue with their PICC (peripherally inserted central catheter) line and needed an extended stay at the facility to ensure they received all antibiotics prescribed. Findings include: A complaint was filed with the State Agency (SA) that alleged that the facility stopped providing IV (intravenous) antibiotics as ordered for R302. Additional allegations noted the failure to follow hospital ordered antibiotics resulted in R302 returning to the hospital on or about 1/1/25 for PICC line placement and then returning to the facility for an extended stay to complete their antibiotics. A review of the R302's clinical record detailed, in part, the following: 12/13/24:…

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: MI00148587. Based on observation, interview and record reviews the facility failed to treat the resident with respect/dignity and ensure to honor their rights per the facility policy, for one (R306) of one resident reviewed for dignity and respect. Findings include: On 2/4/25 at 11:19 AM, R306 was observed lying on their back in bed. When asked about their stay at the facility R306 stated in part, . The new administrator came on Friday and said I need to get it (refrigerator) out of here. It was rude and why all of a sudden when the prior Administrator approved it? I feel like they treat me differently maliciously and why? It really isn't necessary . she rudely said she will take my refrigerator out of here . I had this refrigerator for more than a year here . The resident went on to verbalize how they were a chef for over 30 years and maintained their refrigerator by ensuring the food containers were dated and the refrigerator was kept clean. A review of the medical record…

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): MI00149262. Based on observation, interview, and record review, the facility failed to report an allegation of abuse to the State Agency within the required time frame for one (R303) of three residents reviewed for abuse. Findings include: A review of a Facility Reported Incident (FRI) submitted to the State Survey Agency (SSA) on 12/13/24 revealed an allegation was made by R303 that Certified Nursing Assistant (CNA) 'H' was rough with her while providing peri-care. On 2/4/25 at 10:15 AM, the Administrator was asked to provide the facility's investigation into the above alleged incident. A review of the investigation revealed, Administrator 'M' was first notified of R303's allegation against CNA 'H' on 12/11/24. According to the incident report submitted to the SSA, the allegation was not reported to SSA until 12/13/24. On 2/6/25 at 1:00 PM, R303 was observed lying in bed. R303 did not appear to be able to move in bed independently. When interviewed, R303 reported she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number(s): MI00149262, MI00148192, and MI00148747 Based on observation, interview, and record review, the facility failed to conduct a thorough investigation into allegations of staff to resident abuse, initiate interventions to prevent further abuse from occurring during the investigation period, and report the results of the investigation to the State Survey Agency (SSA) for three (R303, R310, and R305) of Findings include: R310 A review of a Facility Reported Incident (FRI) submitted to the State Survey Agency (SSA) on 11/6/24 revealed an allegation made by R310 that Certified Nursing Assistant (CNA) 'H' was rough with her and held her arm while providing care on the midnight shift .staff member was immediately suspended pending investigation. It was noted that as of 11/19/24, an investigation was not submitted to the SSA. On 2/4/25 at 10:15 AM, the Administrator was asked to provide the facility's investigation into the above alleged incident concerning R310 and CNA 'H'. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number(s): MI00149262 and MI00148747. Based on observation, interview, and record review, the facility failed to develop and implement care plans for activities of daily living and suicidal ideations/behaviors for two (R303 and R305) of 14 residents reviewed for care plans. Findings include: R303 A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) 12/13/24 revealed an allegation was made by R303 that Certified Nurse Assistant (CNA) 'H' was rough with her while providing peri-care. On 2/6/25 at 1:00 PM, R303 was observed lying in bed. R303 did not appear to be able to move in bed independently. When interviewed, R303 reported she required assistance from staff to reposition in bed and staff assisted with brief changes. When queried about what occurred with CNA 'H', R303 reported CNA 'H' was assigned to her, checked on her every two hours to see if she needed a brief change, and during his last rounds, R303 needed a brief change. R303 reported CNA 'H'…

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): MI00149629 and MI00149369. Based on observation, interview, and record review, the facility failed to follow nursing professional standards of practice related to wound treatment and entering medication orders for two (R301 and R302) of two residents reviewed. Findings include: On 2/4/25 at 11:00 AM, R301 was observed in bed. A dressing applied to R301's right foot was observed to be soiled in the area of his toes. The dressing was dated 2/3/25 with initials (discovered to be Licensed Practical Nurse - LPN 'Q') written with thick black marker which was written over thinner writing that was labeled 1/31/25. On 2/4/25 at 11:09 AM, an observation of the dressing on R301's right foot was conducted with Unit Manager, Registered Nurse (RN) 'U'. When queried about the date of 2/3/25 written on top of the date of 1/31/25, RN 'U' did not offer a response. On 2/4/25 at 11:19 AM, an observation of the dressing on R301's right foot was conducted with the DON who replied They just…

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 #MI00148240 Based on observation, interview and record review the facility failed to prevent, timely identify a pressure wound and ensure interventions were in place for one (R309) of three residents reviewed for pressure ulcers resulting in R309 sustaining a facility acquired stage III pressure ulcer to their right ear. Findings include: A complaint was filed with the State Agency (SA) that alleged on 10/16/24 they observed that a piece of skin was missing from R309's ear and blood was observed on the resident's pillow. The complainant further alleged that R309's ear appeared as if it turned black and thought it was because the resident was continuously lying on their right side and not turned frequently. On 2/4/25 at approximately 11:05 AM, R309 was observed lying in bed, a tracheostomy (artifical airway inserted in the windpipe) was present and their head was turned to the right side. Their right ear was not visible. The resident was alert, however not able to communicate.…

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 reviews the facility failed to timely review and report abnormal lab results to the Physician and/or Nurse Practitioner (NP) for one (R314) of three residents reviewed for death. Findings include: Review of the medical record revealed R314 was admitted on [DATE] with diagnoses that included: Dementia and Anemia. A review of the progress notes documented the following: A NP note (later identified as NP K) dated 12/24/24 at 3:41 PM, documented in part . recent hospitalization 12/6 - 12/11 for anemia (Hgb - Hemoglobin 5.2) . received 2 units of pRBC's (packed Red Blood Cells) and IV (intravenous) iron at the hospital and gastroenterology was consulted . A Nursing note dated 1/6/25 at 11:28 AM, documented in part . order STAT (immediate) redraw if HGB is still low send to ER (Emergency Room) . A NP K note dated 1/6/25 at 2:16 PM, documented in part . Anemia: Hgb 6.6 on 1/3. STAT CBC (Complete Blood Count) ordered. Patient to be transferred to ED (Emergency Department) if Hgb< (less…

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.

An interview with Nurse Practitioner (NP) T was completed on 10/24/24. During the interview they were queried if they were overseeing the care for ventilator dependent residents and they reported that they were only overseeing residents who were assigned to the medical director. They were queried about the ventilator settings and coordination of care with the pulmonologist for ventilator dependent residents. NP T reported that they did not handle that and they were only coordinating the care with the attending physician who was also the Medical Director. Based on interview and record review the facility failed to ensure the assigned medical director was aware of their job description and fulfilled their responsibility for the coordination of respiratory care for residents that required mechanical ventilation, this had the ability to affect 66 of 66 residents that resided in the facility at the time of the survey. Findings include: During the course of the survey, a systemic failure regarding the Pulmonologist services was identified in the facility that affect all residents that…

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

Based on observation, interview and record review the facility failed to ensure consistent standards of practice for Infection Control were implemented by all staff and ensure the implementation of an effective infection control surveillance program, this had the ability to affect all 66 of 66 residents that reside in the facility at the time of the survey. Findings include: On 10/21/24 at 9:05 AM, the Social Service (SS) personnel B was observed walking into the room of a resident with a signage on the door for Enhanced Barrier Precautions which required everyone who entered and exited to complete hand hygiene. SS B did not complete hand hygiene upon entering. Once inside, SS B conversed with the resident and then was seen exiting the room and heading into another residents room. SS B did not complete hand hygiene prior to exiting the room. SS B was interviewed and asked about the signage on the door and asked why they did not complete hand hygiene before entering and exiting the room. SS B replied they were not providing care to the resident. Additional observations of 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 interview and record review, the facility failed to ensure the correct resident/ legal representative signed Advanced Directives/DNR (do not resuscitate) form for one resident (R50) of one residents reviewed for advanced directives. Findings include: On 10/21/24 the medical record for R50 was reviewed and revealed the following: R50 was initially admitted to the facility on [DATE] and had diagnoses including Adult failure to thrive and Dementia. A review of R50's MDS (minimum data set) with an ARD (assessment reference date) of 8/19/24 revealed R50 needed assistance from facility staff with their activities of daily living R50's BIMS score (brief interview of mental status) was 15 indicating intact cognition. An advanced directives from signed by R50's son on 8/13/24 was reviewed that documented R50 was not to have any intubation or feeding tubes and was to have a DNR code status. Further review of the medical record did not reveal any documentation that R50 had been deemed mentally incapacitated 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 ensure feeding assistance/supervision and regular bathing were provided for three residents (R17, R20, and R174) of four residents reviewed for activities of daily living (ADL's). Findings include: R174 On 10/21/24 at approximately 9:18 a.m., R174 was observed in their room, laying in their bed. R174 was queried if they had any concerns regarding their care in the facility and they indicated they have not received any showers since being admitted to the facility and reported they did not feel clean. On 10/22/24 the medical record for R174 was reviewed and revealed the following: R174 was initially admitted to the facility on [DATE] and had diagnoses including Heart failure and Severe Calorie-protein malnutrition. A review of R174's MDS (minimum data set) with an ARD (assessment reference date) of 10/15/24 revealed R174 had a BIMS score (brief interview of mental status) of 13 indicating intact cognition. A review of R174's comprehensive…

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 assess/follow-up change in condition, obtain an order and transfer resident(s) (R275) to a hospital in a timely manner, for one of four residents sampled for hospitalization, resulting in prolonged suffering and illness with continued decline in health of the resident(s) resulting in death of one (R275) resident and hospitalization of the other (R64) resident. Findings include: R275 Record review revealed R275 was long-term resident admitted to the facility on [DATE]. R275 had a most recent hospitalization between [DATE] and they were readmitted to the facility on [DATE]. R275's admitting diagnoses included sepsis, failure to thrive, pneumonia, respiratory failure and dementia. Based on the Minimum Data Set (MDS) assessment dated [DATE], R275 had a Brief Interview for Mental Status (BIMS) score of 8/15, indicative of moderate cognitive impairment. R275 had a public guardian who was making decisions for the resident. Review of R275…

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 implement range of motion/splinting interventions for two (R4 and R43) of two residents with contractures reviewed for positioning/range of motion resulting in the potential for extreme pain, discomfort, and worsening of contractures. Findings include: R4 Record review revealed that R4 was a long-term resident admitted to the facility on [DATE]. R4's admitting diagnoses included head injury, encephalopathy, seizures, and history of right knee pain. Based on the Minimum Data Set (MDS) assessment dated [DATE], R4 had a Brief Interview for Mental Status (BIMS) of 0/15, indicative of severe cognitive impairment. R4 needed substantial assistance from staff with her Activities of Daily Living (ADLs) and mobility. The MDS assessment also revealed that R4 had limited range of motion in both lower extremities. An initial observation was completed on 10/21/24 at approximately 10:55 AM. R4 was observed in their bed, lying on their back with their eyes…

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 sufficient staffing for one resident (R274) of one reviewed for staffing needs, resulting in the potential for unmet care needs of residents who reside in the facility. Findings include: R274 Record review revealed R274 was admitted to the facility on [DATE] with diagnoses including heart failure, atrial fibrillation and Chronic Obstructive Pulmonary Disease. R274 had a recent hospitalization and they were admitted to the facility for skilled nursing and rehabilitation needs. An initial observation was completed on 10/22/24 at approximately 8:20 AM. R274 had their call light on and this surveyor was walking down the hallway. R274 waved and called this surveyor and asked if they could assist. R274 was sitting on their bed and reported that they had been waiting for someone to help them and it had been a while and appeared upset. When queried further they reported, That light (call light) doesn't mean anything. A staff member…

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 non-pharmacological interventions were attempted prior to PRN (as needed) psychotropic mediation administration for one resident (R68) of five residents reviewed for unnecessary psychotropic medications. Findings include: On 10/21/24 the medical record for R68 was reviewed and revealed the following: R68 was initially admitted to the facility on [DATE] and had diagnoses including Liver disease and Spinal stenosis. A review of R68's MDS (minimum data set) with an ARD (assessment reference date) of 9/9/24 revealed R68 needed some assistance from facility staff with most of their activities of daily living. R68's BIMS score (brief interview for mental status) was eight indicating moderately impaired cognition. A Physician's order dated 10/11/24 revealed the following: ALPRAZolam Oral Tablet 0.25 MG (milligrams) (Alprazolam) *Controlled Drug* Give 1 tablet by mouth every 12 hours as needed for for anxiety. Further review of the order…

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 proper sanitation and disposal of medication tablets for one of two medication carts reviewed. Findings include: On 10/22/24 at approximately 8:35 AM, the medication cart from the 2 [NAME] hallway was reviewed with Licensed Practical Nurse (LPN) N. Upon observation of the first medication drawer, three unidentified pills (peach, white and tan colored round tablets) were laying on the bottom of the drawer. Review of the second drawer revealed seven white and one peach tablet on the bottom of the second drawer. Review of the third drawer revealed one green and one blue round tablet at the bottom of the drawer. LPN N was questioned about the pills found, however was unable to identify the medication and whom it belonged to. During the review of the 2 [NAME] hallway medication cart the Director of Nursing (DON) was asked to observe the pills identified on the bottom of each drawer. The DON stated the medication drawers should be kept clean and the pills should have been discarded per the facility policy. No…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a Physician ordered laboratory (lab) diagnostic was completed for one resident (R50) of one residents reviewed for diagnostics. Findings include: On 10/21/24 the medical record for R50 was reviewed and revealed the following: R50 was initially admitted to the facility on [DATE] and had diagnoses including Adult failure to thrive and Dementia. A review of R50's MDS (minimum data set) with an ARD (assessment reference date) of 8/19/24 revealed R50 needed assistance from facility staff with their activities of daily living R50's BIMS score (brief interview for mental status) was 15 indicating intact cognition. A Physicians order dated 9/22/24 revealed the following: CBC (complete blood count) , BMP (basic metabolic panel), AND Troponin. Further review of the medical record did not reveal any results form the labs that were ordered on 9/22/24. On 10/22/24 at approximately 12:45 p.m., Nurse Manager E (NM E) was queried regarding the labs results from…

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 off observations, interviews, and record review the facility failed to provide accurate medical record documentation for services provided for one(R49) resident of four residents reviewed for medical records. Findings include: On 10/21/24 at 10:00AM, R49 was observed in bed with tube feeding running. There were no splints or other adaptive devices present on R49. On 10/21/24 at 1:08 PM, R49's legal guardian(LG) was interviewed regarding care rendered to R49. The LG stated they did have a few concerns. LG stated that R49 was supposed to be on restorative services and that they were afraid that R49 was not getting the services because their hands were becoming more contracted due to it not being enough staff to apply their splints. The LG continued to explain that R49 did not get out of bed on a regular basis because they had a pressure injury on their coccyx and would like to see the Resident up more to promote wound healing. On 10/22/24 at 10:55AM, an interview with the Therapy Manager was conducted and he was asked if R49 was on their case load. The Therapy manager explained…

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 reviews the facility failed to implement an effective antibiotic stewardship program for three R's 46, 3, 223 of three sampled residents reviewed. This deficient practice had the ability to affect multiple residents that resided in the facility who was prescribed an antibiotic. Findings include: Review of the Center for Disease Control's (CDC) The Core Elements of Antibiotic Stewardship for Nursing Homes, dated 2015: .Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use .Antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics when followed over a year .studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harms…

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 effectively maintain a backup for the facility's resident call system during a partial power outage (for approximately 12 hours) affecting all residents (R26, R33 and R44) on the one west hall resulting in the potential for a delayed emergency response and/or negative resident outcome. Findings include: R26 Record review revealed R26 was a long-term resident of the facility. R26 was residing in the one [NAME] Hall. R26 was admitted to the facility on [DATE]. R26's admitting diagnoses included heart failure with presence of pacemaker, atrial fibrillation, chronic pain, and chronic kidney disease. Based on the Minimum Data Set (MDS) assessment dated [DATE], R26 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicative on intact cognition. R26 needed extensive staff assistance with their mobility in bed and transfers. During an initial interview with R26 completed on [DATE] at approximately 9:10 AM. During the interview R26 reported that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00146596 Based on observation, interview, and record review, the facility failed to ensure indwelling urinary catheter care, proper positioning of urinary catheter drainage bags, and the use of catheter anchors for three residents, (R#'s 501, 502, and 504) of three residents reviewed for indwelling urinary catheters resulting in the the potential for the development of infection and genitourinary injury. Findings include: R502 On 9/17/24 at 9:28 AM, R502 was observed in their bed. R502 was not responsive to attempts at verbal communication. R502 was further observed to have an indwelling urinary catheter with a drainage bag to the right side of the bed. The bag was observed to be in contact with the tile floor. On 9/18/24 at 10:06 AM, R502's urinary catheter drainage bag was observed on the right side of the bed in contact with the tile floor. A review of R502's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: acute respiratory…

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 #MI00146596. Based on observation, interview, and record review, the facility failed to address tube feeding pump errors in a timely manner for two residents (R#'s 503 and 507) of three residents reviewed for tube feeding, resulting in the delay of delivery of tube feeding nutrition and the development of a clogged feeding tube. Findings include: R503 On 9/17/24 at 9:53 AM, R503 was observed in their room. R503 was not responsive to attempts at verbal communication. It was observed R503 had a tube feeding pump and pole with a bottle of feeding formula and an empty bag that was to contain water for hydration and flush connected to the pump. The pump was audibly beeping and the digital screen on the front of the pump indicated there was a, Flush error. On 9/17/24 at 10:42 AM, R503's tube feeding pump remained audibly beeping, the water bag was empty, and the pump indicated a, Flush error. Observations from the hallway were conducted from 10:42 until 11:06 AM and the beeping pump in R503's room could be heard from the hallway. Multiple staff members…

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 #MI00146293 Based on observation, interview, and record review, the facility failed to ensure tracheostomy and ventilator care was performed and respiratory medications were administered per physician's orders for three residents (R#'s 502, 503 and 504) of four residents reviewed for respiratory care and services, resulting in the potential for respiratory complications. Findings include: R502 On 9/17/24 at 10:40 AM, R502 was observed in their bed with a tracheostomy receiving mechanical ventilation. R502 was not responsive to attempts at verbal communication. A review of R502's clinical record revealed they admitted to the facility on [DATE] and re-admitted on [DATE]. Their diagnoses included: acute respiratory failure, anoxic brain damage, sepsis, quadriplegia, tracheostomy, and dependence on mechanical ventilation. R503's Minimum Data Set assessment date 7/13/24 indicated they had severely impaired cognition and required assistance from staff for all activities of daily…

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

This citation pertains to intake #MI00146596 Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services for pressure ulcers for one resident (R504) of three residents reviewed for pressure ulcers, resulting in the potential for worsening of pressure ulcers. Findings include: On 9/17/24 at 10:05 AM, R504 was observed in their bed uncovered. R504 was positioned slightly on their right side exposing their left trochanter. An undated border foam dressing was observed to be applied and shadowing from wound drainage was present. On 9/17/24 at 12:05 PM, a review of R504's clinical record was conducted and revealed they admitted into the facility on 8/2/24 with diagnoses that included: stroke, respiratory failure, diabetes, presence of a tracheostomy and feeding tube. Continued review of the record further revealed R504 developed a stage III (full-thickness tissue loss that extends through the skin into deeper tissue and fat, but does not expose bone, tendon, or muscle) during their stay in the facility. On 9/17/24 at 12:15 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.

This citation pertains to intake #MI00146596 Based on observation, interview, and record review, the facility failed to ensure safe wheelchair transport for two residents (R#'s 505 and 506) of two residents reviewed for accidents, resulting in the potential for injury. Findings include: On 9/17/24 at 10:42 AM, Certified Nurse Aide (CNA) 'B' was observed transporting R505 back to their room from the shower room. R505 was seated in a shower chair facing backward and CNA 'B' was observed to be pulling the chair in a forward motion, as opposed to having R505 in the chair facing forward and the chair being pushed from behind. On 9/17/24 at 10:46 AM, CNA 'C' was observed transporting R506 to their room from the shower room. R506 was seated in a geri-chair facing backward and CNA 'C' was observed to be pulling the chair in a forward motion, as opposed to having R506 in the chair facing forward and the chair being pushed from behind. On 9/18/24 at 10:30 AM, an interview with the facility's Director of Nursing was conducted and they were asked if it was appropriate to have a resident in 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 Number(s): MI00145374 Based on observation, interview, and record review, the facility failed to maintain the building at a safe and comfortable temperature on the second floor for 15 (R701, R703, R704, R705, R706, R707, R709, R710, R711, R712, R713, R714, R715, R716, and R717) of 17 residents reviewed for a safe, clean, comfortable, homelike environment, resulting in expressions of physical discomfort. Findings include: On 7/31/24 at 8:45 AM, upon entrance into the facility, the Director of Nursing (DON) reported she had to set the surveyors up in the day room on the first floor because it was too hot in the day room on the second floor. Upon entrance to the first floor day room, it was observed to be hot and humid. On 7/31/24 at approximately 11:00 AM, an interview was conducted with R701 in his room. The room was very hot despite a portable air condition (A/C) unit running. R701 reported it was uncomfortable in his room and has been going on for some time. R701 pointed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00144465. Based on observation, interview, and record review, the facility failed to ensure an allegation of misappropriation was reported to the State Agency (SA) for one resident (R902), of one resident reviewed for misappropriation of funds. Findings include: Review of a complaint submitted to the SA documented concerns of $500.00 to have been taken out of R902's bank account on 5/7/24 and transferred to a prepaid credit card by a facility staff person. Review of the medical record revealed R902 was initially admitted to the facility in 2022, with a readmission date of 4/11/24 and diagnoses that included multiple sclerosis. A Minimum Data Set assessment dated [DATE], documented a Brief Interview for Mental Status score of 13, indicating intact cognition and required staff assistance for Activities of Daily Living. On 6/11/24 at 10:27 AM, R902 was observed in bed with a nebulizer treatment being administered. Once the treatment was completed, R902 was asked about the missing…

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 immediately report an instance of neglect by a staff member affecting multiple residents on the first floor to the Abuse Coordinator and State Agency. Findings include: On 5/2/24 during interview with staff, several residents reported concerns regarding a Certified Nursing Assistant (CNA) walking off the job last Friday (4/26/24). According to the facility's policy titled, Abuse, Neglect and Exploitation dated 1/10/2024: .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to .neglect .Identification of Abuse, Neglect and Exploitation .Possible indicators of abuse include, but are not limited to .Failure to provide care needs…

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

Based on interview and record review, the facility failed to ensure the protection of residents and investigate an instance of neglect affecting multiple residents on the first floor, resulting in the potential for additional instances of neglect to go unidentified and not be thoroughly investigated. Findings include: On 5/2/24 during interview with staff, several residents reported concerns regarding a Certified Nursing Assistant (CNA) walking off the job last Friday (4/26/24). According to the facility's policy titled, Abuse, Neglect and Exploitation dated 1/10/2024: .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to .neglect .Identification of Abuse, Neglect and Exploitation…

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 #MI00143778. Based on observation, interview and record review, the facility failed to ensure timely care and monitoring of a surgical wound for one (R804) of one resident reviewed for skin management. Findings include: Review of a complaint received by the State Agency alleged the facility was not providing proper monitoring of R804's surgical incision following placement of a pacemaker. On 5/1/24 at 9:00 AM, R804 was observed laying in bed, naked from the waist up with a bedsheet around their waist. There was a healed surgical scar over their upper left chest. When asked about the surgical scar, R804 reported it had healed but had concerns there was a delay in the care of it when they returned from the hospital. Review of the clinical record revealed R804 was initially admitted into the facility on 4/15/19, been discharged to the hospital on 3/25/24 and readmitted into the facility on 3/31/24 with diagnoses that included: chronic diastolic (congestive) heart failure 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 pertains to intake #MI00144134. Based on observation, interview, and record review, the facility failed to secure smoking materials and implement a safe smoking assessment per policy for one (R805) of one resident reviewed for smoking. Findings include: Review of a complaint filed with the State Agency included allegations that a resident was told by staff they needed to go further away from the building to smoke, but staff were allowed to smoke on the property. On 5/1/24 at 8:30 AM, the Vent Unit Administrator (acting as the point person since the current Administrator was unavailable) was asked to provide a list of residents that smoked. They further reported that the Administrator was out of the building for a court hearing, the Director of Nursing (DON) was out of the building for a training, and the Social Service Director was on vacation until next Tuesday. Review of the documentation provided for smoking revealed a document dated 5/1/24 which read, There are no smokers in the facility.…

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(s) MI00142095 MI00142376, and MI00141953 Based on observation, interview and record review the facility failed to ensure needed respiratory therapists were available to provide care and services to those residents receiving tracheostomy and ventilation services. This deficient practice had the potential to affect all residents (including R702,R704 and R705) receiving tracheostomy and ventilation services. Findings include: Complaints were filed with the State Agency (SA) that alleged the facility did not have respiratory therapists providing services for 19 ventilator/tracheostomy residents on 1/5/24. In addition, the facility had limited respiratory therapy services on the night shifts. Further allegations noted that nurses have not been fully educated to care for respiratory residents and that the Vent Administrator was not able to cover services to the residents. On 2/13/24 at approximately 1:09 PM, an interview was conducted with RT A. When asked about RT staffing at the facility, they reported that staffing has been difficult given the increase…

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 #MI00142478. Based on observation, interview and record review the facility failed to ensure professional standards of practice were followed for one (R701) of six residents reviewed for professional standards. Finding include: A complaint was filed with the State Agency (SA) that alleged R701 was not getting their medication as needed. On 2/13/24 at approximately 11:17 AM, R701 was observed in the hallway in their wheelchair. The resident was seeking assistance back into bed and appeared upset that there was no one to help at that time. At approximately 11:35 AM, R701 was transferred into bed. On their tray table were three cups of what appeared to be medication. Two had liquids in them (one clear and one yellowish) and the other contained approximately seven to ten pills of different colors/sizes. Unit Manager Nurse A was in the room by the resident's bed. R701 asked Nurse A if they knew what the medications were. Nurse A stated that they were not sure and noted 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 Based on interview and record review the facility failed to ensure a sanitary and comfortable environment for one (R701) of two three reviewed for environment. Findings include: On 2/13/24 at approximately 11:35 AM, R701 was observed in their room. Two staff members were present in the residents' rooms attempting to transfer the resident into bed. The resident noted that they had not had their linen changed in over a week. R701's roommate also noted that they were not getting the linen changed in a timely manner and on a number of occassions they sat in a wet bed. A review of R701's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure, adjustment disorder and sepsis. The resident Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (cognitively intact). On 2/13/24 at approximately 12:17 AM, the linen closet located on the hall where R701 resided had one top sheet and no bottom sheets.…

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 #: MI00140679 Based on observation, interview, and record review, the facility failed to ensure food was held and served at a palatable temperature. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 11/28/23 at 12:15 PM, the temperature of the hash browns on the steam table was measured, with the temperatures ranging between 108-111 degrees Fahrenheit. An entire cart had already been loaded with trays of food served from the steam table. When queried about the temperature on the steam table, Dietary Staff looked down at the temperature control knob, and noticed that it was turned off. Dietary Staff stated the steam table controls should have been set to high. According to the 2017 FDA Food Code section 3-501.16 Potentially Hazardous Food (Time/Temperature Control for Safety Food), Hot and Cold Holding, 1. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as…

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

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. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 11/28/23 between 7:05 AM-7:30 AM, during an initial tour of the kitchen, the following items were observed: The paper towel dispenser at the handwashing sink was observed to be empty. Dietary Staff BB confirmed that there were no towels in the dispenser. According to the 2017 FDA Food Code section 6-301.12 Hand Drying Provision, Each handwashing sink or group of adjacent handwashing sinks shall be provided with: (A) Individual, disposable towels;. In the walk-in cooler, there was an opened, undated package of deli turkey, 3 cases of 2% milk cartons with a use-by date of 11/27/23, and 1 case of 2% milk cartons with a use-by date of 11/26/23. According to the 2017 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24…

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 resolve concerns expressed by the resident council group for nine of nine residents who attended the resident council interview who wished to remain anonymous. Findings include: On 11/29/23 at 11:00 AM, an interview was conducted with members of the resident council and other residents who wished to attend a resident group interview. When queried about how the facility addressed and resolved concerns expressed by the resident council, multiple residents reported that the facility did not resolve many concerns they brought up. The residents explained that they report the concerns during resident council meetings, but the concerns are not fixed. Multiple residents explained that they had issues with their toilets not working and/or clogging. Two residents who shared a room reported their toilet had not worked for over a month and there was an attempt to fix it, but it did not resolve the issue. The residents reported the toilet did not flush. All nine residents in attendance reported fresh water was not passed…

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 a clean, comfortable, homelike environment for eight (R39, R36, R41, R38, R40, R44, R48, R61) residents and nine of nine residents who attended the resident council interview who wished to remain anonymous. Findings include: On 11/28/23 at 8:16 AM and 1:45 PM, R40 was observed in bed and not responsive to verbal communication. The floor in the room was dirty and soiled and the rubber coating from the wheel of the bed had disintegrated and separated littering the floor with black debris. On 11/28/23 at 8:27 AM, R48 was in bed. The floor in the room had multiple yellowish/brown sticky stains. It was further noted R48 had no personal items in the room to create a homelike environment. On 11/28/23 at 8:35 AM and 10:55 AM, R44 was observed in their bed awake, but not responsive. A large brown stain soiled the floor under their bed. R38's bed controls on the foot of the bed were broken with exposed wires hanging from them. R38 had no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure nursing services met professional standards for medication administration and pain assessments for four residents (R#'s 41, 33, 48, and 21), of four residents reviewed for professional standards. Findings include: R41 On 11/29/23 at 9:01 AM, Registered Nurse (RN) 'O' was observed preparing medications for administration to R41. During the course of the preparation, RN 'O' was observed to use an insulin syringe to draw two units of insulin from a Novalog Flex Pen (a specialized pen style insulin delivery syringe with attached vial and disposable needles that contains a dial to manually program the dosage for administration). RN 'O' then prepared two additional syringes of insulin for scheduled administration. At the completion of the medication preparation RN 'O' was observed to place all three insulin syringes in their shirt pocket and enter R41's room. RN 'O' removed the syringes after entering the room and placed them 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to protect Protected Health Information (PHI) for three (R4, R22 and R49) residents residing on the 1 [NAME] Unit from being displayed in a public area. Findings include: On 11/30/23 at 11:15 AM, the door to R4 and R22's room on the 1 [NAME] Unit was observed closed, and signs were posted on the door titled, Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19. On 11/30/23 at 11:17 AM, the medication cart on the 1 [NAME] Unit was observed against the East wall approximately halfway down the hall. The computer was on, R49's electronic medical record was open and PHI information could be seen. The nurse was not observed anywhere in the hallway. Then the nurse was observed coming around the corner onto the hall. Review of the clinical record revealed R4 was admitted into the facility on 2/9/17 and had tested positive for COVID-19 on 11/29/23. Review of the clinical record revealed R22 was admitted…

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 report an injury of unknown origin to the facility's abuse coordinator for one resident (R48) of two residents reviewed for abuse. Findings include: A review of a facility provided policy titled, Abuse, Neglect and Exploitation revised 10/2022 was conducted and read, IV. Identification of Abuse, Neglect, and Exploitation .3. Physical injury of a resident of unknown source .VIII Reporting/Response .1. Reporting of all alleged violations to the Administrator . On 11/28/23 at 8:27 AM, R48 was observed in their bed. R48 did not respond to attempts at verbal communication but tracked with their eyes. It was further observed R48 had a tracheostomy, was on a ventilator, was receiving tube feeding via a pump and had bilateral hand contractures. At that time, it was also observed R48 had approximately a two inch abrasion that appeared scabbed over underneath their right eyebrow. On 11/28/23 at 11:32 AM, a review of R48's orders revealed an order placed by Nurse Practitioner 'R' on 11/27/23 for bacitracin (antibiotic…

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: MI00140679 Based on observation, interview, and record review the facility failed to provide appropriate and resident preferred activity of daily living (ADL) care for fingernails and facial hair for two residents, (R#'s 48 and 12) of three residents reviewed for ADL's. Findings include: A review of a facility provided policy titled, Activities of Daily Living (ADLs) revised 1/2022 was conducted and read, .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . On 11/28/23 at 8:27 AM, R48 was observed in their bed. R48 had a tracheostomy, was receiving mechanical ventilation, and nutrition through a feeding tube. R48 was non-verbal and did not respond to attempts at communication. At that time, R48's bilateral hands appeared clenched and contracted with fingernails that appeared to exceed greater than a half an inch in length beyond the nail bed with large…

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 a program of meaningful activities that supported the needs, interests, and capabilities of four (R33, 61, and 48) of four residents reviewed for activities. Findings include: On 11/28/23 at 9:45 AM, R61 was observed lying in bed positioned on their right side facing the wall. There was no music or television or any visually stimulating items in the room. When addressed, R61 did not respond and only groaned. On 11/28/23 at 11:48 AM, R61 was observed lying on their right side facing the wall. No stimulating activities such as staff interaction, music, or television were observed. On 11/30/23 at 9:15 AM, R61 was observed lying in bed, wearing a hospital gown. No music, television, or staff interacting with the residents were observed. Upon entrance to R61's room each time, their roommate complained about anyone entering the room and demanded that the door be left closed. Review of R61's clinical record revealed the following: R61…

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-up timely on a lost hearing aid for one (R26) of one resident with hearing loss, reviewed for ancillary services resulting in unmet care needs, frustration, with potential for worsening of their hearing. Findings include: R26 R26 was originally admitted to the facility on [DATE]. R26's admitting diagnoses included depression, heart failure, gout, and hearing loss. R26 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicative of intact cognition, based on the Minimum Data Set (MDS) assessment dated [DATE]. An initial observation was completed on 11/28/23, at approximately 12:15 PM. R26 was observed in their bed. An interview was completed during the initial observation. During the interview R26 reported that they were hard of hearing and asked the surveyor to speak louder. R26 reported that they had been at the facility for several months. They had lost their left hearing aid while they were being transferred to this…

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: MI00139850. Based on observation, interview, and record review, the facility failed to implement effective interventions to prevent the development of new pressure ulcers and implement treatment in a timely manner after a new skin impairment was identified for one (R61) of three residents reviewed for pressure ulcers, resulting in the development of an unstageable pressure ulcer (obscured full-thickness skin and tissue loss) that required surgical debridement (removal of dead or devitalized tissue) to R61's left hip and a deep tissue injury (DTI - Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue that results from intense and/or prolonged pressure and shear forces at the bone-muscle interface) to the right hip. Findings include: On 11/28/23 at 9:45 AM, R61 was observed lying in bed positioned on their right side facing the wall. A heel protector boot was observed on R61's right foot.…

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 fresh drinking water for two residents (R#'s 47 and 43) of two residents reviewed for hydration, as well as for multiple residents who participated in the group meeting, resulting in verbalized feelings of frustration from lack of fresh drinking water. Findings include: A review of a facility provided policy titled Hydration revised 10/2023 was conducted and read, .The facility offers each resident sifficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health . On 11/28/23 at 8:21 AM, R47 was observed in bed with an undated foam cup of liquid on their bedside table. They were asked what was in the cup and they said it was lemonade. They were asked if they had been provided with drinking water and said no. They were asked if staff routinely provided fresh drinking water and said they did not. R43 On 11/28/23 at 10:39 AM, R43 was observed in bed. R43 was able to communicate via cellphone and nodding/shaking of their head.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY R13 On 11/28/23 at 10:42 AM R13 was observed in bed sleeping with an alarm for tube feeding administration was going off, the Jevity bag was hanging, but not infusing. On 11/28/23 at 10:56 AM, upon exiting the room, the tube feeding alarm was still going off. On 11/28/23 at 12:02 PM, the tube feeding was noted to still not be running, the alarm continued to sound, and per interview with roommate, it had been alarming since last observation (the roommate communicates by nodding/shaking her head, hand gestures or via typed notes on her cellphone). On 11/28/23 at 1:33 PM, the tube feeding was no longer alarming and was noted to be infusing at the correct rate of Jevity 50 mls(milliliters)/hour with an additional 25mls of water for flush (per review of physician orders on 11/28/23 at 11AM). On 11/29/23 at 10:30 AM, (Jevity) tube feeding was observed to be running at 50mls with 25ml flush. On 11/29/23 at 10:40 AM Per review of physician orders, the tube feeding should be Jevity at a rate of 65mls/hour and 50ml/hr of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure assessment and dressing changes for a midline catheter (long flexible catheter inserted into a large vein in the arm for the delivery of intravenous fluids or medications) for one resident (R48) of one resident reviewed for midline catheters, resulting in the potential for blood infections. Findings include: On 11/28/23 at 10:45 AM, and 11/29/23 at 8:10 AM, R48 was observed in their bed. R48 was non-verbal, and did not respond to attempts at verbal communication. During the observation, it was noted R48 had a midline catheter in their right upper arm and the transparent dressing covering the insertion site was dated 11/19/23. On 11/29/23 at 12:35 PM, a review of R48's clinical record revealed the most recently re-admitted to the facility on [DATE] with diagnoses that included: anoxic brain damage, respiratory failure with dependence of mechanical ventilation, tracheostomy, presence of a feeding tube, epilepsy, pressure ulcers,…

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 appropriate hand hygiene and glove use during medication pass for one resident (R41) of two residents reviewed during the medication pass observation, resulting in the potential for the spread of infection. On 11/29/23 at 09:01 AM, Nurse 'O' was observed preparing multiple medications (pills, liquids, subcutaneous injections, inhalers, and a nebulized medication) for administration to R41. Nurse 'O' prepared multiple medications including a Spiriva inhaler (an inhaler that contains a capsule with powder that when the the inhaler is activated the capsule pill is pierced releasing the powder for inhalation). Nurse 'O' was observed to remove the capsule from it's foil packaging with their bare hand and place it into the inhaler. Nurse 'O' also prepared three different insulin syringes at that time. After the insulin was drawn up into the syringes, RN 'O' capped all the needles and placed them in the top pocket of their uniform top. At the end of the medication prep, Nurse 'O' entered R41's room from 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.

This citation pertains to intake: MI00138580. Based on observation, interviews, and record reviews the facility failed to ensure weekly weights were obtained and collaboration for weight loss was completed with the physician for one R802 of three residents reviewed for tube feedings. Findings include: On 9/29/23 at 10:56 AM, R802 was observed sitting up in bed. A skin observation was conducted with the facility staff. An interview was attempted but could not be conducted due to the resident's current cognitive status. Review of the Weight Summary documented the following: 6/6/23- 103 lbs. (pounds) 9/20/23- 94.8 lbs. This indicated a -8.14% weight loss within three and a half months of being admitted to the facility. Review of a progress note dated 7/7/23 at 7:50 AM, documented in part . Nursing request for RD (Registered Dietician) to review TF (Tube Feeding) and significant weight loss . Recommends continuing with weekly weight monitoring to determine efficacy of new TF regimen . Review of a Pertinent Charting- Nutrition/Hydration note dated 8/4/23 at 4:28 AM, documented in part .…

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): MI00139188. Based on observation, interview, and record review, the facility failed to ensure there was sufficient nursing staff for the 2 East Unit for two (R805 and R806) of three residents reviewed for staffing. This had the potential to affect all 23 residents who resided on the 2 East Unit. Findings include: Review of a complaint submitted to the State Agency revealed an allegation that the facility was short staffed. Review of a facility policy titled, It is the policy of this facility to provide sufficient staff .to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment . On 9/28/23 at approximately 9:45 AM, Licensed Practical Nurse (LPN) 'H' was observed on the 2 East Unit. LPN 'H' was switching back and forth between two medication carts. When queried, LPN 'H'…

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): MI00138253. Based on observation, interview, and record review, the facility failed to report allegations of neglect to the State Agency for two (R807 and R808) of four residents reviewed for abuse and neglect. Findings include: Review of a complaint submitted to the State Agency revealed allegations that when Certified Nursing Assistant (CNA) 'G' works on the 2 East unit, they left the unit, did not let anyone know they were leaving so that residents could be supervised, and did not come back until over an hour at times. It was further alleged that CNA 'G' did not do regular checks and changes, raised their voice at residents, and neglected to change their clothing at times. On 9/27/23 at 2:55 PM, a phone interview with the complainant was conducted. The complainant reported they had notified previous and current management multiple times about their concerns regarding CNA 'G' not changing residents and leaving the unit without notifying anyone. The complainant…

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): MI00138253. Based on observation, interview, and record review, the facility failed to provide evidence of a thorough investigation into allegation of neglect for two (R807 and R808) of four residents reviewed for abuse and neglect. Findings include: Review of a complaint submitted to the State Agency revealed allegations that when Certified Nursing Assistant (CNA) 'G' works on the 2 East unit, they left the unit, did not let anyone know they were leaving so that residents could be supervised, and did not come back until over an hour at times. It was further alleged that CNA 'G' did not do regular checks and changes, raised their voice at residents, and neglected to change their clothing at times. On 9/27/23 at 2:55 PM, a phone interview with the complainant was conducted. The complainant reported they had notified previous and current management multiple times about their concerns regarding CNA 'G' not changing residents and leaving the unit without notifying anyone.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake(s): MI00138907 & MI00139261. Based on observation, interviews, and record reviews the facility failed to ensure non pharmacological interventions were implemented and behavioral health services was provided for one (R804) of one resident reviewed for psychotropic medications. Findings include: On 9/28/23 at 2:33 PM, R804 was observed lying on their back in bed, the resident was connected to a mechanical ventilator and was observed to have a tracheostomy in place. R804 was able to shake their head yes or no to interview questions. A brief interview was held with the resident at that time. Review of the medical record revealed R804 was admitted to the facility on [DATE] with a readmission date of 9/22/23 and diagnoses that included: acute respiratory failure with hypercapnia, chronic obstructive pulmonary disease, tracheostomy status, gastrostomy status, generalized anxiety and major depressive disorder. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview…

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 store and maintain tube feeding supplies in a sanitary manner for two (R805 and R806) of three residents reviewed for tube feeding. findings include: On 9/28/23 at 11:20 AM, R805 was observed lying in bed. R805 was observed to have a tracheostomy tube (a tube surgically inserted into a person's windpipe used to assist with breathing) and was receiving oxygen through it. R805 was receiving nutrition via a PEG (percutaneous endoscopic gastrostomy) tube (a tube surgically inserted into the stomach to deliver nutrition). An irrigation syringe (used to administer medications and flush water via the PEG tube) was observed in a plastic bag labeled 9/27/23. In the bottom of the bag was yellow fluid and in the syringe there was clear and yellow fluid). On 9/28/23 at 11:23 AM, R806 was observed lying in bed. R806 was receiving nutrition via a PEG tube and was receiving oxygen via a tracheostomy tube. R806 did not speak or make eye contact. 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.