WellBridge of Fenton

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure comprehensive skin care (assessments, treatment order, and documentation) for one resident (R#55) of 2 residents reviewed for skin and wound care of 41 total samples, resulting in the potential for severe pain, infection, and further delay in appropriate treatment. Findings include: Resident# 55 (R55): R55 was [AGE] years old, admitted to the facility on 4//26/24 with the diagnosis of Chronic Diastolic Congested Heart Failure (CHF), Severe Morbid Obesity, Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure with hypoxia in addition to other diagnoses. R55's Minimum Data Set (MDS), dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of 13/15, which indicates that a person's cognition is intact. Section GG of the MDS, dated [DATE], revealed that R55 required Substantial/ Maximal assistance with the following activities: Toileting Hygiene, shower, and upper body dressing. However, the assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement policies and procedures to mitigate risk of injury during wheelchair transport for one resident (Resident #45) of five residents reviewed for accidents resulting in the potential for injury. Findings include: Resident #45: On 12/11/24 at 1:30 PM, Resident #45 was observed being pushed down the hallway in a wheelchair by Certified Nursing Assistant (CNA) S. The wheelchair did not have footrests, and the Resident was attempting to hold their legs up. Resident #45's feet were observed getting closer to the floor the further they were pushed. An interview was completed with CNA S on 12/11/24 at 1:40 PM. When queried if they were pushing Resident #45 in the hallway without footrests, CNA S confirmed they were. CNA S was then asked about the facility policy/procedure related to pushing residents in wheelchairs without footrests and replied, We do. CNA S then stated, Not really supposed to but they (residents) want help and don't have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that a physician's order was in place for indwelling catheter changes and that the indwelling catheter changes were documented for one resident (R69) of one resident reviewed for catheters, resulting in the absence of a physician's order for indwelling catheter changes and the absence of documentation of indwelling catheter changes. Findings include: Resident #69 (R69): R69 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include kidney failure, depression, hypertension and encounter for surgical aftercare following surgery on the genitourinary system. On 12/10/24 at 03:37 PM, record review revealed that there was a care plan in place for the use of the catheter, an order is present to care for the catheter every shift with the size of the catheter and catheter balloon size. There was no order present for intervals for changing the catheter. On 12/10/24 at 03:50 PM, R69 was asked when the last time their catheter had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to enter a physician's order timely for dialysis perma-cath care and follow a physician's order to complete dialysis documentation for one resident (R289) of one resident reviewed for dialysis care, resulting in incomplete and missing dialysis record forms and the absence of documentation of the dialysis perma-cath site being monitored. Findings include: Resident #289 (R289): R289 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include, acute kidney failure, chronic kidney disease, congestive heart failure and dependence on renal dialysis. R289 has brief interview for mental status (BIMS) score of 14, indicating that R289 is cognitively intact. On 12/09/24 at 03:27 PM, record review revealed that R289 attends dialysis at [NAME] Davita on Tuesdays, Thursdays and Saturdays with a chair time of 02:15 PM. On 12/10/24 at 01:48 PM, record review revealed a physician's order to monitor the dialysis perma-cath to the right chest wall…

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 1) Maintain food preparation and kitchen equipment in a sanitary and good working condition, and 2) Ensure proper maintenance of kitchen equipment (dishwasher), resulting in an increased likelihood for food borne illness with hospitalization, and cross contamination affecting 81 residents who consumed oral nutrition from the facility kitchen of a total census of 82 residents. Findings Include: Review of the Public Health Service 2009 Food Code, adopted by the Michigan Food Law, effective October 1, 2012, Chapter 4-501.14 directs that equipment cleaning frequency is to be throughout the day at frequency necessary to prevent recontamination of equipment and utensils. On 12/9/24 at 10:05 a.m., during the initial tour of the kitchen accompanied by Culinary Specialist H and Executive Chief I, the following was observed: -At 10:07 a.m., the inside door of the ice machine was found to have a build-up of calcium-like hard white substance coating the door gasket on the left side, directly over the ice when the door was…

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

Based on observation, interview and record review, the facility failed to implement and ensure hand hygiene per professional standards of practice during medication administration for two residents (#32 and #48) of six residents reviewed during medication pass observation resulting in the potential for cross contamination and spread of microorganisms. Findings include: A medication pass observation for Resident #32 was completed with Registered Nurse (RN) Q on 12/10/24 at 1:50 PM. RN Q did not perform hand hygiene prior to entering Resident #32's room and/or preparing the Resident's medications. Following completion of medication pass administration, RN Q exited Resident #32's room without completing hand hygiene. RN Q did not complete hand hygiene prior to entering Resident #48's room at 2:00 PM on 12/10/24. RN Q was observed obtaining Resident #48's medications from the in-room medication cabinet and then administering the medications without performing hand hygiene. An interview was completed with Clinical RN F on 12/11/24 at 11:23 AM. When queried regarding hand hygiene prior to…

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 Numbers MI00146582, MI00146860, and MI00147441. Based on observation, interview and record review, the facility failed to ensure Residents were treated with respect and dignity by not ensuring call lights were in reach and answered timely, ensure respectable customer service and ensure the provision of Resident rights with care planning that included Resident representative input/awareness of resident's care, for Residents (#1, 3, 6, 7, 8, and 10) of eight reviewed for call lights, abuse, and resident rights, resulting in care needs not met timely, lack of Resident/resident representative awareness in Resident's received care, feelings of frustration and anger and the potential for unmet care needs and lack of psychosocial wellbeing. Findings include: Resident #1: A review of Resident #1's medical record revealed an admission into the facility on 9/22/23 with re-admission on [DATE] with diagnoses that included stroke, hemiplegia and hemiparesis following a stroke affecting 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 Numbers MI00146860 and MI00147441. Based on interviews and record review, the facility failed to monitor and inform the physician promptly regarding the declining status post-fall for one resident (Resident #5), resulting in the delay in treatment and hospitalization for Resident #5, who sustained a brain bleed post-fall. Findings include: Resident #5 (R5): According to the review of records conducted on 1023/24 at 10:00 AM, R5 was [AGE] years old and admitted to the facility on [DATE], with the primary diagnosis of Atrial Fibrillation, Anxiety, Depression, and Chronic Respiratory Failure in addition to other diagnoses. R5 was discharged from the hospital after a fall on 8/6/24. The resident was assessed, alert, and oriented according to records on the 8/4/24 Incident Report. The list of medication orders dated August 2024 revealed that R5 was taking an anticoagulant (Eliquis) for a history of Atrial Fibrillation as a diagnosis. R5 Care plan interventions dated 8/31/2023 were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to IntakeNumber MI00146582 Based on observation, interview and record review the facility failed to enter a physician's order for wound care and update a skin integrity care plan timely for one resident (Resident #7) of three residents reviewed for pressure ulcers, resulting in late physician's orders for wound care and late revision of a skin integrity care plan. Findings include: R7 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include cerebral infarction, contractures, dementia and age-related physical debility. R7 has a BIMS (Brief Interview for Mental Status) score of 0, indicating R7 has a severe cognitive impairment and during the survey was not observed to communicate with anyone and would occasionally moan out in pain during care. On 10/23/24 at 12:00PM, R7 was observed sleeping in bed, dressings were noted to the left and right elbows. Bilateral elbows were propped up on pillows for pressure reduction, pressure reduction mattress was in place 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 store nebulizer equipment per facility policy and follow a physician's orders for oxygen administration for two residents (R3, R10) of three residents reviewed for nebulizer equipment, resulting in nebulizer equipment being stored on a bedside table and the medication chamber having fluid in it and not receiving the physician's ordered amount of oxygen administration. Findings include: Resident #3: R3 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include CHF (Congestive Heart Failure) chronic respiratory failure, pulmonary hypertension and major depressive disorder. R3 has a BIMS (Brief Interview for Mental Status) score of 15 indicating they are cognitively intact. On 10/23/24 at 11:30AM, R3 was observed sitting in a wheelchair in the room and watching television. R3 was observed to be receiving oxygen at 3 liters per minute via a nasal cannula and a nebulizer machine was sitting on the nightstand with…

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 MI00146860. Based on Interviews and record review, the facility failed to obtain Physician visit documentation of one resident (Resident #5) in a timely manner of three residents reviewed for physician visits, resulting in delayed implementation of treatment orders and the potential for inappropriate physician's orders. Findings include: Resident # 5 (R5): According to the review of records conducted on 1023/24 at 10:00 AM, R5 was [AGE] years old and admitted to the facility on [DATE], with the primary diagnosis of Atrial Fibrillation, Anxiety, Depression, and Chronic Respiratory Failure in addition to other diagnoses. R5 was discharged from the hospital after a fall on [DATE]. R5 medication orders reviewed revealed that she was taking an anticoagulant (Eliquis) for the history of Atrial Fibrillation as a diagnosis. R5 Care plan interventions dated [DATE] were noted under anticoagulant therapy. Resident R5 fell twice on [DATE] and [DATE]. R5 was sent to a nearby emergency…

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 facility policy for EBP (enhanced barrier precautions) for one resident (R7) of one resident reviewed for EBP, resulting in the nurse performing wound care without the required PPE (personal protective equipment) for a resident on EBP. Findings include: Resident #7 (R7): R7 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include cerebral infarction, contractures, dementia and age-related physical debility. R7 has a BIMS (Brief Interview for Mental Status) score of 0, indicating R7 has a severe cognitive impairment and during the survey was not observed to communicate with anyone and would occasionally moan out in pain during care. On 10/24/24, record review revealed a physician's order for Enhanced Barrier Precautions as directed. This includes gowns and gloves for high-contact resident care activities. Specify why: foley, peg tube, pressure wound. The order was dated 9/5/24. On 10/24/24, wound care was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Numbers MI00143332 and MI00146115. Based on interview and record review the facility failed to document post-fall monitoring, complete neurological checks and implement appropriate interventions for two residents (Resident #701 and Resident #703) of two residents reviewed for falls, resulting in, Resident #701 sustaining a fall without facility post-fall monitoring and neurological checks and Resident #703 sustaining three falls with subsequent injuries, one day apart, without meaningful interventions implemented, consistent neurological checks and post-fall monitoring/documentation. Findings Include: Resident #701: On 8/21/2024 at approximately 2:00 PM, a review was completed of Resident #701's medical record. It revealed the resident completed a hospice respite stay from 1/12/2024 to 1/15/2024 with diagnoses that included, Alzheimer's Disease, Dementia, Seizures and Anorexia. Resident #701 required the assistance of staff for ADL (Activities of Daily Living)'s and had severe…

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: MI00142837, MI00142926 Based on observation, interview and record review, the facility failed to ensure communication between clinical services and social services to develop a person-centered care plan for one resident (Resident #501) of 4 residents reviewed for behavioral care, resulting in unmet care needs and a lack of individualized approaches to care with the likelihood of emotional and behavioral care needs being unassessed. Findings Include: Resident #501: A review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #501 revealed the resident was admitted to the facility on [DATE] with diagnoses: history of a brain bleed, schizophrenia, GERD, visual loss, urinary retention and hypertension. The MDS assessment dated [DATE] indicated the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 14/15 and the resident needed some assistance with most care. A record review of the progress notes revealed Resident #501…

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 Numbers MI00138923 and MI00139581. Based on interview and record review, the facility failed to 1) Ensure that four residents' (Residents #6, Resident #19, Resident #56, and Resident #323) call lights were answered timely, and 2) Ensure that food was served warm for one resident (Resident #19), and 6 of 6 confidential residents from the Resident Council group meeting (held on 11/29/23) verbalizing complaints regarding staff answering their call lights, resulting in verbalizations of not wanting to eat cold food, embarrassment, accidents due to not being able to get to a toilet in time, shame and the potential of unmet care needs. Findings Include: Review of the facility Resident Rights/Dignity policy (un-dated), revealed all residents have the right to receive services in the facility with reasonable accommodation of their needs and preferences. Review of the facility Answering the Call Light policy (un-dated) reported, Answer the resident's call light as soon as possible. If you…

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 interviews and record review, the facility failed to provide the residents an opportunity to choose their own attending physician and failed to honor their choice for an alternate physician for five of seven confidential residents during the Resident's Council group meeting, resulting in a lack of confidence and trust in health and medical decisions, lack of information and follow-up about their health status, feelings of intimidation and hopelessness on their rights to choose an attending physician for their best health and wellbeing. Findings include: On 11/29/23 at 1:15 PM, a group of seven Confidential Residents were interviewed during the survey task for the Resident Council. Meeting minutes for past Council meetings were reviewed before the group meeting. The group was asked about individual issues and concerns not brought to the Resident Council meetings. Five of seven confidential residents expressed dislike and frustration with their assigned attending physician. During the meeting, five residents queried the surveyor about how to go about getting a physician 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 interview and record review, the facility failed to ensure that medication was supplied from the pharmacy or that the medication dispensing system was utilized to obtain the needed intravenous (IV) medication, Vancomycin, for one resident (Resident #221) of one resident reviewed for IV medication administration, resulting in IV medication not given as ordered, an interruption in the antibiotic treatment of an infection, with the potential for worsening of an infection and deterioration of health and well-being. Findings include: Resident #221: A review of Resident #221's medical record revealed an admission on [DATE] with diagnoses that included diabetes, acute respiratory failure, acute kidney failure, cellulitis of right lower limb, and Methicillin resistant Staphylococcus aureus (MRSA) infection. A review of the Minimum Data Set assessment dated [DATE], revealed the Resident had a Brief Interview of Mental Status (BIMS) score of 14/15 that indicated intact cognition and the Resident needed…

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 handle medications in accordance with acceptable pharmaceutical standards of practice: 1.) for one medication room, one narcotics cupboard and 2 resident rooms (Resident #1 and Resident #41); 2.) ensure medication refrigerator temperatures outside of acceptable parameters were addressed; 3.) ensure narcotic keys for the 100 hall were secured; 4.) ensure two nurses sign that they completed a shift to shift narcotics count; 5.) ensure medications stored in a resident's room are not returned to the medication room for use on other residents, resulting in the potential for contamination of medications, incorrect administration of medications, a lack of therapeutic benefits necessary to promote healing for residents, increased potential for adverse effects, and resident, staff or visitor access to unsecured medications. Findings Include: FACILITY Medication Storage and Labeling On 11/28/23 at 1:57 PM, during a tour of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number MI00138923. Based on observation, interview, and record review, the facility failed to ensure that one resident's (Resident #22 [R#22]) authorized financial representative was able to make decisions regarding their choice for ancillary health insurance of one resident reviewed for rights exercised by representatives, resulting in the feeling of fear of exploitation and that the facility failed to uphold the resident's rights and ensure that the resident was protected from financial exploitation and/or misappropriation. Findings Include: Resident #22 (R#22): A record review was conducted on 11/29/23 at 4:30 PM. According to the Electronic Medical Record (EMR), R#22 was admitted to the facility on [DATE]. According to the most recent PASARR (dated 7/29/23), R#22 had the following diagnoses: adjustment disorder with depressed mood, Generalized Anxiety Disorder, Dementia, Alzheimer's Disease, Psychotic Disorder with Delusions in addition to other diagnoses and was receiving…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR), Level 1 and Level 2, was completed for one resident (Resident #13) of two residents reviewed, resulting in the potential for inappropriate admissions and the absence of available services for mental disorders or intellectual disability. Findings Include: Medicaid.gov: Preadmission Screening and Resident Review: Preadmission Screening and Resident Review (PASARR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASARR requires that Medicaid-certified nursing facilities: 1. Evaluate all applicants for ser Evaluate all applicants for serious mental illness (SMI) and/or intellectual disability (ID) 2. Offered all applicants the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings) 3. Provide all applicants the services they need in those settings PASARR is an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide timely assistance with Activities of Daily Living (ADL) showers and nail care for one resident ( Resident #25) of five residents reviewed for ADL's, resulting in Resident #25 not receiving showers/baths as scheduled or nail care. The lack of care caused the resident to feel frustrated, discouraged and lowered their quality of life. Findings Include: Resident #25: Activities of Daily Living: A record review of the Face Sheet and the Minimum Data Set MDS) assessment indicated Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, congestive heart failure, Crohn's disease, COPD, Atrial fibrillation, anxiety, chronic pain, history of strokes, hypothyroidism, GERD. The MDS assessment, dated 9/24/2023, revealed the resident had moderate cognitive loss with a Brief Interview for Mental Status (BIMS) score of 10/15. The resident was able to feed self but needed assistance with all other…

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 that wounds were assessed, monitored, wound care was provided and appropriate interventions were in place for one resident (Resident # 25) of 9 residents reviewed for wounds, resulting in Resident #25 developing a wound on the right knee and left ankle with no treatment or monitoring ordered after identification. Findings Include: Resident #25: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, congestive heart failure, Crohn's disease, COPD, Atrial fibrillation, anxiety, chronic pain, history of strokes, hypothyroidism, GERD. The MDS assessment dated [DATE] revealed the resident had moderate cognitive loss with a Brief Interview for Mental Status (BIMS) score of 10/15. The resident was able to feed self but needed assistance with all other ADL's. During a tour of the facility on 11/28/23 at 10:11 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to Intake Number MI00140875. Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place and supervision was provided after a fall with injury for one resident (Resident #2) of 4 residents reviewed for falls, resulting in Resident #2 falling out of bed while reaching for the call light, hitting her head and suffering a femur fracture. Findings Include: Resident #2: Accidents: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #2 was admitted to the facility on [DATE] with diagnoses: Cerebral Palsy, Diabetes, asthma, depression, bipolar disorder, hypertension, Chronic pain syndrome, GERD, and anxiety. The MDS assessment, dated 09/05/2023 indicated that the resident had full cognitive abilities, with a Brief Interview for Mental Status (BIMS) score of 14/15 and was able to feed self and needed assistance with all other care. The resident was readmitted on [DATE] after hospitalization for a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the integrity of the intravenous (IV) tubing was maintained during administration of IV antibiotics, flush a Midline IV while the Midline IV was not in use and document the changing of the dressing and measurements for the Midline IV for one resident (Resident #221) of one resident reviewed for IV care, resulting in the potential for infection, malfunction of the PICC line and lack of documentation of performed procedures in the medical record. Findings include: Resident #221: A review of Resident #221's medical record revealed an admission on [DATE] with diagnoses that included diabetes, acute respiratory failure, acute kidney failure, cellulitis of right lower limb, and Methicillin resistant Staphylococcus aureus infection. A review of the Minimum Data Set assessment dated [DATE], revealed the Resident had a Brief Interview of Mental Status (BIMS) score of 14/15 that indicated intact cognition and the Resident needed…

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 nebulizer treatment equipment in a clean and sanitary manner for one resident (Resident #222) of two residents reviewed for oxygen therapy, resulting in the potential exposure to infectious organisms, respiratory infection and deterioration of health and well-being. Findings include: Resident #222: A review of Resident #222's medical record revealed an admission into the facility on [DATE] with diagnoses that included acute and chronic respiratory failure, acute pulmonary edema, cardiac arrest, diabetes, heart failure, sepsis, pneumonia, bacteremia, and acute and subacute infective endocarditis. A review of the Minimum Data Set assessment, dated 11/26/23, revealed the Resident had intact cognition and needed partial/moderate assistance with eating, oral hygiene, and personal hygiene and was dependent on staff for toileting hygiene, bathing, and dressing upper and lower body. A review of Resident #222's Medication Administration…

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 monitor sedating medications for one resident (Resident #41) of 5 residents reviewed for unnecessary medications, resulting in Resident #41 repeatedly requesting not to take the medications and having lethargy and falls. Findings Include: Resident #41: Unnecessary Meds, Psychotropic Meds, and Med Regimen Review A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #41 was admitted to the facility on [DATE] with diagnoses: Dementia, diabetes, heart disease, hypertension, hypothyroidism, cardiac defibrillator, anxiety history of falls with right fibula fracture prior to admission, and pain left hip. The MDS assessment dated [DATE] revealed the resident had full cognitive ability with a Brief Interview for Mental Status (BIMS) score of 15/15 and the resident needed some assistance with all care. On 11/29/2023 at 12:19 PM, during a tour of the facility, Resident #41 was observed with her door closed. There…

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 a medication administration error rate of less than 5% when 2 medication errors were observed from a total of 28 opportunities for two residents (Resident #221 and Resident #223) of four residents observed for medication administration, resulting in an error rate of 7.14% with the potential for adverse reactions, uncontrolled pain and the change in medication regimen related to the omission of the 4% Lidocaine patch (topical medication used to help relieve pain, works as a local anesthetic and can be used for nerve pain) for Resident #223 and the medication Tramadol (medication used for moderate to severe pain) 50 mg (milligrams) not given at the appropriate time for Resident # 221. Findings include: On 12/1/23 at 9:03 AM, an observation was made of Nurse O during medication administration for Resident #221. The medications were given as ordered except for the Tramadol was not given with the other ordered medications at this time. On 12/1/23 at 9:15 AM, an observation was made of Nurse O 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.