Oakridge Manor Nursing and Rehabilitation Center L

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00145936. Based on interview and record review, the facility failed to protect the one resident (R902)'s right to be free from physical abuse a resident (R903). Findings include: A review of a Facility Reported Incident (FRI) intake MI00145936 revealed an allegation of resident-to-resident physical abuse involving R903 (perpetrator) and R902 (victim) that occurred on 7/23/24 at 5:45 AM. A record review revealed R902 was admitted to the facility on [DATE] with medical diagnoses including, diabetes, chronic kidney disease, hypertension, and psychomotor deficit following a stroke. A Brief Interview for Mental status (BIMS) score assessed on 8/8/24 scored 15/15 indicating R902 was cognitively intact. A clinical record review revealed R903 was admitted to the facility on [DATE] with right sided hemiparesis (weakness on right side of body) following a stroke, asthma, and heart disease. The BIMS assessed on 8/25/24 scored 13/15 indicating R903 was cognitively intact. On 10/8/24 at…

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

This citation pertains to Intake Number MI00145339 Based on interview, and record review, the facility failed to complete a comprehensive admission assessment for one resident (R701) of three residents reviewed for assessments. Findings include: A review of a complaint submitted to the State Agency revealed an allegation that noted R701 doesn't know when he needs to use the bathroom and can't control it because he's incontinent. Staff want to accompany him to the bathroom every few hours to see if he needs to go but he doesn't want to do that. He would rather use the brief and then alert staff when it needs to be changed . A review of R701's clinical record revealed R701 was admitted into the facility on 6/28/24 with diagnoses that included: type 2 diabetes mellitus. A review of R701's Minimum Data Set (MDS) assessments revealed he was not yet fully assessed. The MDS was noted to be in progress with a due date of 7/4/24 (14 days after admission). Some sections were complete, but others were not, including the assessment for bowel and bladder continence. On 7/16/24 at approximately…

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 MI00145339 Based on observation, interview, and record review, the facility failed to complete an assessment for incontinence for one (R701) of three residents reviewed for incontinence care. Findings include: A review of a complaint submitted to the State Agency revealed an allegation that noted R701 doesn't know when he needs to use the bathroom and can't control it because he's incontinent. Staff want to accompany him to the bathroom every few hours to see if he needs to go but he doesn't want to do that. He would rather use the brief and then alert staff when it needs to be changed . On 7/17/24 at 9:20 AM, 9:48 AM, and 10:30 AM, R701 was observed sleeping. R701 did not wake up when spoken to. A review of R701's clinical record revealed R701 was admitted into the facility on 6/28/24 with diagnoses that included: type 2 diabetes mellitus. A review of R701's Minimum Data Set (MDS) assessments revealed he was not yet fully assessed. The MDS was in progress and noted R701 had intact cognition, but was not assessed for urinary continence. 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 medications were administered and/or documented per professional standards of practice for three (R198, R196, R3 and R14) residents. Findings include: On 4/23/24 at 8:28 AM, A medication observation was conducted with Licensed Practical Nurse (LPN) H for R198. As R198 was taking medications, R198 requested more water from LPN H at which time, LPN H left remaining medications on the bedside table and exited the room. LPN H returned to R198 with another glass of water and commented that the remaining medications should have not been left unattended and further stated, You, (referring to this surveyor) were here, so it was alright. On 4/23/24 at 8:39 AM, A medication observation was conducted with LPN H for R 196. During administration, an Albuterol inhaler (medication inhaled to relax the airway) was observed inside a box of gauze sponges and a bottle of peroxide. When inquired if the inhaler was part of the medications ordered, R196…

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 an environment free from hazards. This deficient practice had the potential to affect multiple residents who reside on the first floor. Findings include: On 4/22/24 at approximately 10:02 a.m., a portable oxygen tank was observed in room [ROOM NUMBER] on the first floor propped up against the wall without being secured. On 4/22/24 at approximately 12:39 p.m., the portable oxygen tank was still observed in room [ROOM NUMBER] propped up against the wall without being secured. On 4/22/24 at approximately 2:38 p.m., a second oxygen tank that was free standing was observed behind the nursing station without any devices securing it such as a caddie or cradle On 4/23/24 at approximately 9:37 a.m., the oxygen tank in room [ROOM NUMBER] was still observed propped up against the wall without being secured. On 4/23/24 at approximately 9:40 a.m., Nurse Manager k was shown the oxygen tank in room [ROOM NUMBER] and they indicated that all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure expired medical supplies were removed, maintain daily log of refrigerator temperatures, and provide refrigerated medication at recommended temperature between 36-42-degree Fahrenheit (F) resulting in the potential for the decreased efficacy of medical supplies and medications. Findings include: [DATE] at 8:21 AM, An observation was conducted of the facility second floor medication storage room with Licensed Practical Nurse (LPN) L. Initial entrance to the room revealed the refrigerator had no lock. The thermometer located inside on the top shelf noted temperature of 30-degree F. LPN L was unable to continue with the observation and was temporarily ceased. On [DATE] at 9:35 AM, a second attempt of the medication room observation was requested and conducted with the Director of Nursing (DON). The DON unlocked the medication storage room and identified the refrigerator was not locked. The pad lock was outside of the room next to the computer 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 ensure dignity was maintained for three (R38, R43 and R6) of three residents reviewed for dignity. Findings include: R38 On 4/22/23 at 9:37 AM, R38 was observed walking in the hallway on the 2nd floor wearing a very thin, stretchy light pink shirt and not wearing a brazier. R38 was observed to have large breasts, and her areola and nipples were visible through the shirt. Multiple times throughout the day R38 was observed walking in the hallway wearing the pink shirt and no brazier. Review of the clinical record revealed R38 was admitted into the facility on 3/28/23 with diagnoses that included: metabolic encehalopathy, Alzheimer's disease and restlessness and agitation. According to the Minimum Data Set (MDS) assessment dated [DATE], R38 had severely impaired cognition. Review of R38's ADL (activities of daily living) care plan initiated 3/29/23 had an intervention that read, DRESSING: 1 person assist. On 4/23/24 at 9:50 AM, R38 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 interview and record review, the facility failed to evaluate, and clarify the residents advance directive code status for one resident (R4) of one resident reviewed for hospice services. Findings include: R4 was initially admitted to this facility on 2/16/22 with a medical history of chronic obstructive pulmonary disease (COPD), atrial fibrillation (abnormal heart rhythm) and coronary artery disease. On 2/7/24, R4 returned to the facility after a hospitalization, and was readmitted to hospice care. A Brief Interview for Mental Status (BIMS) was assessed on 2/13/24 and R4 scored an eight, indicating mildly impaired cognition. On 4/22/24, the Electronic Medical Record (EMR) and face sheet identified R4 as a hospice resident and designated code status was documented Do Not Resuscitate (DNR) (a legal document indicating in the event a person's heart or breathing stops, do not take measures to bring back to life). Further record review of the EMR identified an Advance Directive dated 9/9/2023, and revealed R4 elected for full resuscitation and life sustaining treatments. On…

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

This Citation pertains to Intake MI00142276. Based on record review and interview, the facility failed to provide a notification for transfer to the hospital for one resident (R19) resulting in R19's responsible party was not informed for the reason of transfer and admission to the hospital. Findings include: On 4/22/23, A clinical record review revealed that R19 was initially admitted to this facility on 7/20/20 with a diagnosis of coronary artery disease, hypertension, diabetes, stroke, dementia, anxiety, and depression. Further observation revealed R19 is bedbound, nonverbal, contracted and receives nutrition via a Percutaneous Endoscopic Gastrostomy (PEG) Tube (a surgically inserted tube placed into the stomach to receive nutrition). A Brief Interview for Mental Status (BIMS) summary score totaled three indicating R19 is severely cognitively impaired. Further record review revealed on 3/12/24, staff discovered the PEG tube for R19 was dislodged which required a transfer to the hospital to have a surgical procedure to replace. On 4/23/24 at 9:49 AM, The Nursing Home Administrator…

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 record review and interview, the facility failed to document within the medical record for two residents (R19, R20) that an identified irregularity identified from the medication regimen review (MMR) was acknowledged by the Physician/Prescriber to prevent adverse consequences related to medication therapy. Findings include: Review of the facility policy Medication Regimen Review, dated 11/1/22 states.The Medication Regimen Review is a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and adverse consequences .The MRR includes collaboration with other members of the interdisciplinary team .Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities . R19 On 4/23/24, A clinical record review revealed R19 was admitted to the facility on [DATE] for stroke, dysphagia (difficulty swallowing food and liquid), dementia, anxiety, depression, and dependent on parental nutrition via 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 obtain a Physician ordered laboratory (lab) test for one resident (R27) of one resident reviewed for laboratory diagnostics, resulting in the potential for abnormal lab results to go unreported to the Physician. Findings include: On 4/22/24 at approximately 9:22 a.m., R27 was observed in their room, laying in their bed. R27 was queried if they had any concerns and they indicated they weren't feeling well. On 4/22/24 the medical record for R27 was reviewed and revealed the following: R27 was initially admitted to the facility on [DATE] and had diagnoses including Cerebral infarction, Paranoid schizophrenia and Neuromuscular dysfunction of bladder. A review of R27's MDS (Minimum data set) with an ARD (assessment reference date) of 3/6/24 revealed R27 needed assistance from facility staff with most of their activities of daily living. A Physicians's evaluation dated 4/11/24 revealed the following: .Following for complaint of dysuria. Patient has recently…

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 enhanced barrier precautions (EBP) were implemented and staff were educated on proper procedures for two (R15 and R27) residents. Findings include: R15 On 4/22/24 at 9:47 AM, R15 was observed sitting in a wheelchair in their room. A urinary catheter bag was observed hanging from the wheelchair. No signs for EBP were observed on the door to the room, no personal protective equipment (PPE) was observed in or near R15's room. Throughout the day, no staff was observed to don PPE when providing care to R15. Review of the clinical record revealed R15 was admitted into the facility on 8/6/23 and readmitted [DATE] with diagnoses that included: heart disease, schizoaffective disorder and urinary retention. According to the Minimum Data Set (MDS) assessment dated [DATE], R15 had moderately impaired cognition, and had an indwelling urinary catheter. Review of R15's indwelling urinary catheter care plan initiated 3/19/24 revealed no mention of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00141572. Based on interview and record review, the facility failed to thoroughly follow-up and communicate resolutions on grievances expressed by one resident (R901) of one resident reviewed for grievances resulting in frustration and ongoing concerns with communication. Findings include: A record review revealed that R901 was originally admitted to the facility on [DATE]. R901 was recently hospitalized and readmitted back to the facility on [DATE] with diagnoses including Human immunodeficiency virus, severe malnutrition, respiratory failure, and encephalopathy (brain disease, damage, or malfunction). R901 had a Brief Interview for Mental Status Score of 3/15, indicative of severe impairment based on Minimum Data Set (MDS) assessment dated [DATE]. It must be noted that R90's cognition had significantly improved since this assessment and an updated BIMS assessment was not available in R901's Electronic Medical Record (EMR). An initial observation was completed on 12/27/23, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00141572. Based on interview and record review the facility failed to ensure that a resident received the anti-viral treatment consistently as ordered by the physician and failed to follow up with the physician or practitioner when the ordered medication was not administered for one (R901) of two Residents reviewed for quality of care resulting in potential to result in complications from an infection. Findings include: A record review of the Electronic Medical Record (EMR) revealed that R901 was originally admitted to the facility on [DATE]. R901 was recently hospitalized and readmitted back to the facility on [DATE]. R901's admitting diagnoses included Human immunodeficiency virus, severe malnutrition, respiratory failure, and encephalopathy (brain disease, damage, or malfunction). R901 had a Brief Interview for Mental Status Score of 3/15, indicative of severe impairment based on Minimum Data Set (MDS) assessment dated [DATE]. It must be noted that R90's cognition had…

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

Based on observation, interview, and record review, the facility failed to maintain the exterior trash/refuse area in a sanitary manner, resulting in the increased potential for odors and the attraction of pests and rodents. This deficient practice had the potential to affect all residents, staff, and visitors. Findings include: On 5/16/23 at 8:00 AM, the exterior trash/refuse area was observed. The side doors on both dumpsters were open, and there were bags of garbage on the ground near the dumpsters. In addition, there was trash debris scattered on the ground around the dumpsters. On 5/16/23 at 11:15 AM, Certified Dietary Manager was queried about the exterior dumpster area, and stated that Maintenance was responsible for keeping the area clean. According to the 2013 FDA Food Code section 5-501.113 Covering Receptacles, Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT. According to the 2013 FDA Food Code section 5-501.115 Maintaining Refuse Areas 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.

Based on interview and record review, the facility failed to implement an effective Quality Assurance Performance Improvement (QAPI) program and plan that ensured an interdisciplinary approach to have identified, developed, and implemented appropriate plans of action to correct quality deficiencies, resulting in the reoccurrence of deficient practices related to the facility's physician services and facility's failure to develop and implement policies and procedures that identified high-risk problems within the facility, ensure data collection for all departments within the facility, and failed to establish procedures that focus on high-risk problems, resident safety and quality of care. This deficient practice had the potential to affect all 44 residents that resided within the facility at the time of survey. Findings include: During the recertification survey conducted 5/16/23 to 5/19/23, concerns were identified regarding the timeliness of the required physician visits and the timeliness of the physician documentation into the resident electronic records for all of the residents…

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

Based on observation, interview and record review, the facility failed to maintain a clean, comfortable, homelike environment for all 23 residents who resided on the second floor, including R10, R30, R5, R17, R24, R2, and R37. Findings include: On 5/16/23 at 8:00 AM, a strong, foul urine odor was observed upon entrance to the second floor of the facility. There was a loud beeping noise that came from the smoke alarm in the dining room and in multiple other areas of the 2nd floor unit. On 5/16/23 at 8:20 AM, R10's room was observed to have dirty and stained privacy curtains. On 5/16/23 at 8:34 AM, R30 was observed lying in bed. A beeping sound was observed coming from the smoke alarm installed on the ceiling. R30 reported they had not been sleeping well and they Can't stand the beeping!. On 5/16/23 at 8:41AM, R5's room was observed. A urinal was observed hung on the door knob. The nightstand next to R5's bed was observed to have a piece of cake placed directly on the nightstand (with no plate). A urinal was hung behind the head of R5's bed that contained urine and trash. The floor…

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 operationalize their abuse prohibition policy to ensure contracted nursing staff had appropriate background checks and fingerprints done before working in the facility for 13 of 13 contracted staff reviewed for criminal background checks. Findings include: Review of a facility policy titled, Background Investigations dated 11/1/22, revealed, in part, the following: .The Human Resource department will conduct all applicable background investigation(s) on each individual making application for employment with this company . Review of a facility policy titled, Abuse, Neglect and Exploitation dated 11/1/22, revealed, in part, the following: .'Staff' includes employees .contractors .caregivers who provide care and services to residents on behalf of the facility .Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property .Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff .Screenings may be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure services provided to three residents (R's 13, 17, 30) of three residents reviewed met professional standards of nursing practice. Findings include: Medication Administration Observation On 5/17/23 at 8:19 AM, Registered Nurse (RN) I was observed prepping the morning medications for R13. At 8:24 AM, RN I entered into the room of R13 and administered their morning medications. RN I was then observed to wash their hands, make a phone call to the physician, and then begin to prepare medications for the next resident. RN I failed to document the administration of R13's medications after administering the medications to R13 and before preparing the medications for the next resident. Review of R13's May 2023 MAR on 5/17/23 at 9:22 AM, confirmed that RN I had not signed off on any of R13's morning medications that was administered. RN I' failed to follow the policy of the facility regarding the administration of medications. On 5/17/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure physician visits/assessments were completed and documented for four (R's: 2, 28, 29, 38 & 39) of six residents reviewed for physician visits, resulting in the lack of documentation and increased potential for coordination of care due to lack of documentation. Findings include: According to the facility's policy titled, Medical Records dated 3/22/22: .Healthcare practitioners will comply with requirements for medical records completion .The administrator and medical records coordinator will advise the medical director about issues related to medical records documentation and completion .Healthcare practitioner documentation will be timely, legible, and clinically pertinent .As part of medical QA/PI (Quality Assurance/Process Improvement) activities, the medical director will selectively review open medical records for appropriate and timely physician and other healthcare practitioner documentation, signatures, and record completion .Through the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure timely physician visits for five (R2, R38, R29, R39 and R27) of five residents reviewed for frequency of physician visits. Findings include: Review of a facility policy titled, Physician Visits and Physician Delegation dated 11/1/22 read in part, .The Physician should: a. See resident within 30 days of initial admission to the facility. b. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegates appropriate by State law. c. Review the resident's total program of care including medications and treatments at each visit . R2 Review of the medical record revealed R2 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included: seizures, metabolic encephalopathy and heart disease. According to the MDS (Minimum Data Set) assessment dated [DATE], R2 had modified independent cognition,…

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 reviews the facility failed to consistently acknowledge and respond to the pharmacist consultant's recommendations for three residents (R's 16, 24 & 29) of five residents reviewed for unnecessary medications. Findings include: R#16 On 5/16/23 at 9:44 AM, R16 was observed sitting in their wheelchair in the dining room. An interview was conducted with the resident at that time. Review of the medical record revealed R16 was admitted to the facility on [DATE] with a readmission date of 10/11/22 and diagnoses that included: Liver cell carcinoma, type 2 diabetes mellitus, peripheral vascular disease, metabolic encephalopathy, hyperlipidemia, and hypertension. Review of the pharmacist consultant's progress notes documented irregularities noted after completion of the medication regimen review (MRR) for the following dates: On 4/11/23- . This resident has diabetes. Please consider adding the following monitoring to follow this therapy: LABS ON THE CHART ARE A YEAR OLD . HgbA1c…

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 dress one (R5) of one resident reviewed for dignity, in clean clothing. Findings include: On 5/16/23 at 8:41 AM, R5 was observed propelling themselves in a wheelchair. R5's clothing appeared to be unclean with a dusty appearance and multiple stains on their shirt and pants. On 5/17/23 at 1:00 PM, R5 was observed wearing the same dirty clothing as the previous day. When queried about whether they had clothing to change into each day or how often staff assisted them with their clothing, R5 asked, Can you ask them? On 5/17/23 at 1:56 PM, an interview was conducted with Certified Nursing Assistant (CNA) 'D'. When queried about when the last time R5 changed into clean clothing, CNA D reported that if R5's clothing was stored in the closet in their room, their roommate put all the clothing on and urinated in it. CNA 'D' explained that laundry was asked to bring one outfit a day up so that R5 had clean clothing. CNA 'D' reported it did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one (R24) of one resident reviewed for accommodation of needs had their call light accessible to them. Findings include: On 5/16/23 at 8:52 AM, R24 was observed lying in bed. Their call light was not visible and in reach of the resident. The remote used to adjust the bed was observed at the foot of the bed. On 5/16/23 at 10:45 AM, R24 was observed lying in bed. Their call light was not visible. The remote used to adjust the bed was observed at the foot of the bed. R24 asked for the head of their bed to be adjusted. When queried about using their call light to get assistance, R24 did not know where it was. At that time, Certified Nursing Assistant (CNA) 'J' was asked where R24's call light was. CNA 'J' reached behind the head of the bed and pulled up the call light. When queried about how R24 was supposed to alert staff if they needed assistance or if there was an emergency, CNA 'J' stated, He just tells me what he needs when I come…

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 implement the facility's policy on an Against Medical Advice (AMA) discharge to ensure a safe discharge for one (R43) of two residents reviewed as a closed record. Findings include: Review of the medical record revealed R43 was admitted to the facility on [DATE] and discharged from the facility six days later on 4/3/23. Review of the preadmission paperwork from the hospital provided to the facility upon R43's admission documented R43 was sent to the facility for rehabilitation and therapy after multiple falls that resulted in multiple fractures. Review of the progress notes revealed no documentation on why the resident was discharged from the facility on 4/3/23. Review of the medical record revealed a form titled Release From Responsibility For Discharge dated 4/3/23 at 9:45 AM, which documented in part, . This is to certify that I (R43's name), understand the consequences and acknowledge that I am leaving (facility name) against the advice of 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, record review, the facility failed to ensure a level I Preadmission Screening (PAS)/Annual Resident Review (ARR) Mental Illness/Intellectual Disability/Related Conditions Identification was completed accurately and sent to local community mental health for a level II OBRA (Omnibus Budget Reconciliation Act of 1993) evaluation for one (R27) of four residents reviewed for PASARRs. This deficient practice resulted in the potential for the resident to be excluded from receiving necessary care and services appropriate to meet their mental health and intellectual disability needs. Findings include: On 5/16/23 at 9:47 AM, R27 was observed sitting in the dining room. Upon initial interview the resident appeared on guard regarding the interview questions, by responding with why do you want to know? Who did you say you are again? And asking why after every question asked. After a while, the resident warmed up a bit and began to participate in the interview. 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 Based on observation, interview and record review, the facility failed to develop comprehensive care plans which addressed targeted behaviors and symptoms for the use of antipsychotic medication for one (R29) of five residents reviewed for care planning. Findings include: According to the facility's policy titled, Care Planning - Interdisciplinary Team dated 11/21/2022: .The facility's Care Planning/Interdisciplinary Team is responsible for development of an individualized comprehensive care plan for each resident . On 5/16/23 at 9:11 AM and 5/17/23 at 11:00 AM, R29 was observed seated in wheelchair and was non-verbal. At each of these observations, R29 was observed to have significant puckering/smacking of their lips. Review of the clinical record revealed R29 was admitted into the facility on 7/2/22 with diagnoses that included: aphasia following other cerebrovascular disease, Alzheimer's disease, anxiety disorder due to known physiological condition, depression, and suspected adult sexual abuse. According 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 Based on observation, interview, and record review, the facility failed to ensure one (R5) of one resident reviewed for activities of daily living (ADLs) received a shower on a regular basis. Findings include: On 5/16/23 at 8:41 AM, R5 was observed propelling in a wheelchair. Their face appeared oily with scruffy facial hair. When queried about their preference for shaving, R5 reported they preferred to be clean shaven, but did not want to ask staff to do it. R5 reported they would need some assistance with shaving. On 5/17/23 at 1:00 PM, R5 was observed wearing the same dirty clothing as the previous day. The scruffy facial hair remained and their face appeared oily. When queried about how often they received a shower, R5 asked, Can you ask them (the staff)? On 5/17/23 at 1:56 PM, an interview was conducted with Certified Nursing Assistant (CNA) 'D'. When queried about when the last time R5 received a shower or bath, CNA 'D' reported they really needed to give R5 a shower and planned to do it that day. CNA 'D'…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure accurate administration of tube feeding formula in accordance with the physician order for one (R25) of one resident reviewed for tube feeding. Findings include: On 5/16/23 at 9:21 AM, R25 was observed lying in bed. Tube feeding formula, Jevity 1.5 CAL, and water for flush and hydration was being delivered via a tube feeding pump. The pump indicated the Jevity 1.5 CAL feeding formula was being delivered at 50 mL/hr (milliliters per hour) and the water was being delivered at 40 mL/hr. Review of the clinical record revealed R25 was admitted into the facility on 2/16/22 and readmitted [DATE] with diagnoses that included: dysphagia (difficulty swallowing), severe protein-calorie malnutrition and Alzheimer's disease. According to the Minimum Data Set (MDS) assessment dated [DATE], R25 had severely impaired cognition, and required the extensive to total assistance of staff for all activities of daily living (ADL's). The MDS assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that a resident who was a trauma survivor received care and services that accounted for experiences and identified and implemented interventions to mitigate triggers for one (R29) of one resident reviewed for trauma informed care, resulting in the potential for re-traumatization due to staff not being informed and knowledgeable of the resident's past trauma and lack of individualized care plan interventions. Findings include: According to the facility's policy titled, Trauma Informed Care dated 11/1/2022: .Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotional harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. Common sources of trauma may include, but are not limited to .Physical, sexual, mental, and/or emotional abuse (past or present) .The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide medically related social services to address mood, behavior, psychosocial well-being and/or trauma-informed care for two (R29 and R42) of five residents reviewed for social services, resulting in the increased potential for ongoing unaddressed physical, mental and psychosocial needs of the resident. Findings include: According to the facility's Social Worker job description dated 4/2/2021: .identifying each resident's social, emotional and psychological need .Developing and carrying out a plan to develop the resident's full potential during their stay .Core Responsibilities: Complete and document Social Work and Psychosocial assessments for all residents within 3 days of their admission or readmission .Completes, reviews and updates Care plans including: Psychosocial .Behavioral .Monitor the behavior log book and follow up on any new or changed behaviors noted .Monitor high risk residents including but no limited to .Psychiatric dx…

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 accurately document administration of a controlled medication; pull medication from the back up supply when it was not available for administration; ensure medications were ordered timely and accurately; and failed to verify medications delivered by the pharmacy matched the physicians order for one (R30) resident. Findings include: Review of a facility policy titled, Controlled Substance Administration & Accountability, dated 11/1/22, revealed, in part, the following: .All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided .The Controlled Drug Record .serves the dual purpose of recording both narcotic disposition and patient administration .The Controlled Drug Record is a permanent medical record document and in conjunction with the MAR (medication administration record) is 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 R38 On 5/16/23 at 9:36 AM and multiple observations throughout the survey, R38 was observed either sitting or lying on the bed, or self propelling himself in a wheelchair. At each of these observations, the interactions with R38 revealed the resident was alert, and readily initiated conversation with staff and peers. There were no observations of any hallucinations, delusions or paranoia. Review of the clinical record revealed R38 was admitted into the facility on 9/24/22 and readmitted [DATE] with diagnoses that included: psychoactive substance abuse with unspecified psychoactive substance-induced disorder, bipolar disorder and major depressive disorder. According to the MDS assessment dated [DATE], R38 was cognitively intact and received antipsychotic medications. Review of R38's medications revealed an admission order of Aripiprazole (an antipsychotic) 15 mg (milligrams) one time a day was increased to 20 mg one time a day on 11/15/22. An additional antipsychotic, Quetiapine (Seroquel) 50 mg was ordered as 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.

Based on interview and record review, the facility failed to ensure laboratory reports were contained in the clinical record for one (R29) of two residents reviewed for laboratory services, resulting in the increased potential for inability to effectively monitor changes in resident's condition due to lack of supporting documentation. Findings include: According to the facility's Laboratory Services and Reporting dated 11/2/2022: .The facility must provide or obtain laboratory services to meet the needs of its residents .The facility is responsible for the timeliness of the services .All laboratory reports will be dated and contain the name and address of the testing laboratory and will be filed in the resident's clinical record .Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. Review of the clinical record revealed R29 was admitted into the facility on 7/2/22 with diagnoses that included: aphasia following other cerebrovascular disease, anorexia,…

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 maintain an effective Antibiotic Stewardship program that included consistent implementation of protocols for appropriate antibiotic administration and ensured that infection criteria were met for two (R24 and R46) of seven residents reviewed for antibiotic use. Findings include: Review of the Center for Disease Control's (CDC) The Core Elements of Antibiotic Stewardship for Nursing Homes dated 2015, documented in part, .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…

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 accurate tracking and administration of the pneumococcal vaccinations for residents residing in the facility for two (R10 and R20) of five residents reviewed for pneumococcal vaccinations. Findings include: Review of a facility policy titled, Pneumococcal Vaccine (Series) dated 11/1/22 read in part, .Each resident will be assessed for pneumococcal immunization upon admission . Each resident will be offered a pneumococcal immunization unless it it is medically contraindicated or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician approved 'standing orders' . R10 Review of the clinical record revealed R10 was admitted into the facility on [DATE]. The Preventative Health Record did not reveal evidence of a pneumococcal vaccination. Review of a facility provided Michigan Care Improvement Registry (MCIR) report dated 5/18/23 revealed 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.