Briarwood Nursing and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number 2986995. Based on interview and record review, the facility failed to correctly assess the wound status of one resident (Resident #702) upon admission of three residents reviewed, resulting in a lack of timely and comprehensive identification, and the assessment and care of an alteration in skin integrity. Findings include:Resident #702: Review of intake documentation revealed a concern that Resident #702 was admitted to the facility on [DATE] with no alterations in skin integrity. The Resident was transferred back to the hospital on 4/15/26 due to a change in condition with skin tears and a black eye. An interview was completed with Family Member Witness A on 5/4/26 at 12:10 PM. When queried regarding Resident #702, Witness A responded that the Resident passed away. When asked, Witness A disclosed Resident #702 went to the facility on 4/11/26 for therapy after having a CVA (stroke) which resulted in their right side being flaccid and aphagia (difficulty speaking). Witness…

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 2986995. Based on interview and record review, the facility failed to identify, comprehensively assess, and document nutritional/hydration needs and intake for one resident (Resident #702) of three residents reviewed for quality of care resulting, in a lack of identification of risk for dehydration, timely initiation of a Health Care Provider (HCP) ordered diet, documentation of fluid intake, and a decline in health status. Findings include:Resident #702: Review of intake documentation revealed a concern that Resident #702 was admitted to the facility on [DATE] and transferred back to the hospital on 4/15/26 due to confusion and a change in condition. An interview was completed with Family Member Witness A on 5/4/26 at 12:10 PM. When queried regarding Resident #702, Witness A responded that the Resident passed away. When asked, Witness A disclosed Resident #702 went to the facility on 4/11/26 for therapy after having a CVA (stroke) which resulted in their right side being…

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 2709347. Based on interview and record review, the facility failed to implement and operationalize policies and procedures for advance care planning for three residents (#701, #704, and #706) of three residents reviewed, resulting in the lack of timely determination of decision-making capacity and arranging appropriate and legal representation for Resident #701 and Resident #706 and the lack of current guardianship documentation for Resident #704.Findings include:Review of intake documentation revealed a concern that Resident #701 is a vulnerable adult who requires total care. Per the intake, Resident #701 was transferred and admitted to the hospital due to an infection from a pressure ulcer (wound caused by pressure) and was in serious condition. The intake specified the Resident had been at the facility for several months and indicated they had been and were currently unable to make their own medical decisions and did not have guardian or POA (Power of Attorney).…

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 2709347. Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for the care of pressure ulcers for two residents (#'702 and #703) of three residents reviewed, resulting in a lack of accurate documentation of care and implementation of planned interventions. Findings include:Resident #702: On 1/14/26 at 3:30 PM, Resident #702 was observed laying in bed in their room. The Resident was positioned on their back with their heels directly against the mattress. Heel boots (cushioned, pressure-relieving positioning boots) were observed sitting on a table in the Resident's room. The Resident had one pillow on their bed, under their head. There were no pillows present in the room, including on the floor for positioning use. An interview was completed at this time. When queried if they had any pressure ulcers, Resident #702 replied, Just on my heels. When asked if they had pressure ulcers on both of their heels,…

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 # 2676612.Based on observation, interview and record review, the facility failed to ensure that 1) the sink used for hand hygiene in the kitchen maintained a hot water temperature of at least 85 degrees Fahrenheit and 2) the chemical strips used to test the dish machine were not expired, resulting in the potential for the spread of foodborne illness to all Residents receiving meal service from a census of 99 residents.Kitchen hand washing sinkOn 12/5/2025 at 9:00 AM, during a tour of the Kitchen with Dietary Supervisor B, a sink for employee hand hygiene was noted near the entrance to the kitchen from the service hall. Upon use of the hot water, it was identified to be very cold. The Dietary Supervisor B was asked about the hot water being cold, as she was observed performing hand hygiene and she said sometimes it had to run a bit for it to warm up. The hot water was left to run for approximately 1 minute and it was still cold, not warm or hot. The Dietary Supervisor B was asked if the hot water temperature for the sink was monitored and she said she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to Intake# 2678077Based on observation, interview and record review the facility failed to develop and implement a comprehensive care plan for one resident (#6) of 3 residents reviewed for wound care, resulting in Resident #6 lacking a care plan for a right leg brace. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: history of right knee replacement and post-surgical right knee infection, reduced circulation right leg, heart disease, and arthritis in knees. The resident had full cognitive abilities and made her own decisions. On 12/4/2025 at 10:00 AM, Resident #6 was observed sitting on the bed in her room, with her right lower leg wrapped in a dressing with a right lower leg brace on. The resident said she had previously had knee surgery, and it became infected. She said she was treated with antibiotics, and her knee was better, but she had other wounds on her right…

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: (1) Ensure proper cleaning of therapy gym equipment for all residents utilizing the equipment; (2) Ensure the timely removal of Resident #2's soiled gown, blanket and linen , (3) Ensure the timely disposal of daily hygiene products of a discharged resident (Resident #15) and the cleaning of the room prior to admittance of a new resident and (4) Ensure the decluttering of residents' items throughout the rooms on the 100 Hall. Findings Include: Therapy Gym During initial tour a resident shared a peddle on the bike in the therapy room gym, was not safe for residents to utilize and requested it be observed for functionality and safety. On 4/24/2025 at 1:10 PM, an observation was conducted of the facility therapy gym. Therapy Director S provided an overview of the equipment and stated each machine is wiped down between each resident, but deep cleaning is completed by housekeeping. The following was observed: 2- Nu Step Machines: -Foot pedals…

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 that the clinical staff posting was completed and available for review for multiple days from October 2024- April 2025, resulting in the inability of residents and visitors to know what clinical staff were working on those days. Findings Include: FACILITY Sufficient and Competent Nurse Staffing On 4/24/2025 at 9:17 AM, the Administrator was asked where the posted nurse staffing was located. She said the document was on the wall near the entry to the facility. Upon review of the posted document it said Tuesday, 4/24/2025. The Administrator, viewed the document; discussed with her the dated was correct but the day was wrong. It was not Tuesday; It was Thursday. She said the staff member N responsible for completing the document would correct it. The Administrator said the posted staffing documents were to be posted daily. Requested to review the prior year's posted staffing. The Administrator said Staff N would provide the binder with the documents. The posted nurse staffing binder was reviewed. The posted…

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) including showers, nail care and hair care for two residents ( #52 and #139), from a sample of 20 residents. Findings Include: Resident #52: Activities of Daily Living On 4/23/2025 at 1:15 PM, Resident #52 was observed lying in bed in her room. She said she had itching on her face and leg and said it was horrible. She said they gave her something for the itching, but the itching would come back frequently. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, depression, anxiety, diabetes, chronic kidney disease, arthritis, blindness right eye and hypothyroidism. The MDS assessment dated [DATE] revealed the resident had moderate cognitive loss with a Brief Interview for Mental Status/BIMS score of 10/15 and the resident was independent with most care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to monitor weights timely for a Resident who had a hospitalization and return with a Percutaneous Endoscopic Gastrostomy ) (PEG) tube for feeding for one resident (Resident #62) of two residents reviewed for weight loss. Findings include: Resident #62: A review of Resident #62's medical record revealed the Resident had an admission into the facility on 6/26/24 and readmission on [DATE] with diagnoses that included intracerebral hemorrhage (stroke), gastrostomy, abdominal aortic aneurysm, dysarthria, aphasia, hemiplegia and hemiparesis affecting the left non-dominant side, Alzheimer's disease, and muscle wasting and atrophy. A review of the Minimum Data Set assessment revealed the Resident had severely impaired cognition and was dependent on staff for activities of daily living. A review of the medical record revealed the Resident had a change in condition on 3/10/25 and was transferred to the hospital and returned on 3/20/25 with a PEG tube…

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 1) Monitor a PICC (Peripherally Inserted Central Catheter) line placement for Resident #8; 2) Monitor antibiotic administration and notify the physician of three missed doses for Resident #289; and 3) Document the clinical rationale for an increase in the Vancomycin dose for Resident #84 for three of four residents reviewed for PICC lines. Findings Include: Resident #84: On 4/23/2024 at approximately 3:35 PM, Resident #84 was observed ambulating down the hallway into her room. She stated she developed osteomyelitis and is here for IV antibiotics. On 4/24/2025 at approximately 9:30 AM, a review was conducted of Resident #84's medical records and it indicated she readmitted to the facility on [DATE] with diagnoses that included, Osteomyelitis, Diabetes, Asthma, Heart Disease and Atrial Fibrillation. Resident #84 is her own person and able to make her needs known to staff. Further review of her record yielded the following: Physician Orders:…

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 1) Identify a medication order discrepancy and 2) Address the pharmacy monthly medication regimen review timely for one resident (Resident #18) of five residents reviewed for medication regimen review, resulting in a medication ordered with the previous order not discontinued. Findings include: Resident #18: A review of Resident #18's medical record revealed an admission into the facility on 6/11/24 with diagnoses that included hypertension (high blood pressure) atherosclerotic heart disease, atrial fibrillation and presence of coronary angioplasty implant and graft. A review of the Minimum Data Set assessment revealed the Resident had intact cognition and needed partial/moderate assistance with eating, oral hygiene, dependent on a helper for other activities of daily living, mobility and transfers. A review of Resident #18's medication orders revealed an order dated 6/11/24, Diltiazem 60 mg (milligrams), take 1 tablet by mouth four times daily. A review of Resident #18's Physician/Practitioner Progress Note dated 2/1/25…

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 1) Obtain a signed consent for treatment with antipsychotic medications for Resident #52 and 2) Prevent the duplication of medications administered to Resident #18. Findings Include: Resident #52: Unnecessary Meds, Psychotropic Meds, and Med Regimen Review A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, depression, anxiety, diabetes, chronic kidney disease, arthritis, blindness right eye and hypothyroidism. The MDS assessment dated [DATE] revealed the resident had moderate cognitive loss with a Brief Interview for Mental Status/BIMS score of 10/15 and the resident was independent with most care but needed some assistance and oversight with bathing/showering. A review of the physician orders for Resident #52 revealed the resident received Fluoxetine/Prozac for depression, start date 11/15/2024. A review of the medical…

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 that 3 medication carts (Halls 300, 400 and 500) of 4 medication carts observed were maintained clean and sanitized, free of crushed pills, pieces of loose papers and dust in the drawers. Findings Include: Observation of facility medication carts done on 4/23/25 starting at 10:55 a.m., revealed the following: 500 Hall Med Cart: Observation was done on 4/23/25 at approximately 10:40 a.m., accompanied by Nurse, RN B revealed the following: -The second and third drawer's had pieces of crushed medications/meds and paper on the bottom back. During an interview done on 4/23/25 at 10:45 a.m., Nurse B stated Third shift cleans it, but we can all clean it. During an interview done on 4/23/25 at approximately 10:55 a.m., Nurse, LPN C was asked by this surveyor if the drawers of the med cart could have been cleaned better and she stated ya, a bit; third shift cleans it and anyone can clean it. 400 Hall Med Cart: Observation was done on 4/23/25 at 11:09 a.m., accompanied by Nurse, LPN D revealed the following: -The…

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

Based on observation, interview and record review, the facility failed to maintain food preparation and kitchen equipment in a sanitary and good working condition, resulting in an increased likelihood for food borne illnesses with hospitalization, and cross contamination affecting 82 residents who consumed oral nutrition from the facility kitchen and ice machine of a total census of 84 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 4/23/25 at 10:15 a.m., a kitchen tour was done accompanied by Dietary Manger A. The following concerns were identified during the walk-through: -At 10:15 a.m., the large can opener was observed to have a dark colored sticky substance directly behind the blade. -At 10:18 a.m., the large counter mixer that was clean and ready for use had dried batter-like substance on the attachment directly over the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number MI00146446. Based on interview and record review, the facility failed to ensure that a complete nursing assessment was done after a condition change (a fall at the facility on 7/2/24) for one resident (Resident #101) of 3 residents reviewed for assessing/monitoring after a change in condition (a decline in therapy due to increased pain), resulting in incomplete nursing and physician documentation, and delayed hospitalization with a CT (Computed Tomography). Findings Include: Resident #101: Review of the Face Sheet, Nurse Practitioner and Nursing and Physician note's dated 7/1/24 through 7/12/24, emergency room and Hospital notes dated 7/12/24 through 7/14/24, care plans dated 6/24, and MDS (nursing assessment tool) dated 7/24, revealed Resident #101 was 67 years-old, alert and able to make his own medical decisions, admitted (last admission) to the facility on 6/27/24, after a fall at home with several fractures and post surgical repair of spine. The resident was a fall…

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 1.) Failed to ensure that food products were properly labeled with an Opened and/or Use by date and dispose of expired food items; 2.) Failed to monitor/document temperatures of a refrigerated unit; 3.) Failed to properly wash and dry cookware/bakeware/food containers before stacking/storage; and 4.) Failed to maintain sanitary cooking equipment, resulting in the potential contamination of food, bacterial harborage and the increased potential for food borne illness. This deficient practice had the potential to affect all residents who consume food prepared in the kitchen with a census of 73. Findings include: Initial tour of the Kitchen: On 4/15/24 at 9:27 AM, an initial tour of the facility kitchen was conducted with Dietary Manager L. The following observations were made: -Two knives were found in the knife holder that had debris on them. The Dietary Manager was asked if the items were ready for use and the Dietary Manager indicated they were. -Muffin tins ready for use were found to be oily, had baked on oil residue…

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 Resident #6 Activities of Daily Living Resident #6 (R6) on 04/15/24 02:20 PM, was observed lying on his bed with his wife visiting on the bedside. R6 was observed wearing a white T-shirt that appeared one size larger on him and a gray jogging pants that was too short and too tight for his size. When asked if he felt comfortable, he did not answer. R6 wife explained that R6 is very hard of hearing and may not have heard the question. R6 was observed with beard growth all over his face. The hair growth stood out because it was gray in color, on the R6's jaw, chin, upper lip, lower lip, cheeks and neck. Meanwhile, R6 wife was holding on to a shaving cream and razor. When asked, R6 wife revealed that she and her daughter had been taking turns shaving R6 beard and was not sure if the facility does it or them. She indicated that it seems that they were not doing it so they assumed that it is her and her daughter's responsibility. Resident's family had indicated that they have been shaving the residents all this time…

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 that residents received their mail on Saturdays, resulting in residents not being able to exercise their right to receive mail and access communication. Findings Include: FACILITY On 4/16/24 at 2:30 PM, during an interview with a Confidential Group of Residents, when asked if the residents received Mail on Saturdays, the residents stated, The Mail doesn't run on Saturday. The Mail lady has weekends off. During further discussion, the residents said they did not receive mail on Saturday but did receive mail during the week. On 4/17/24 at 2:32 PM, the Activity Director I was interviewed related to resident mail delivery on Saturday, she said the post office was to deliver it to the front desk receptionist and the receptionist was to put it in the activities mailbox and then the activities aide who works on the weekend delivered it. The Activity Director I said she had worked on the weekend for the last several weeks and didn't recall if there was mail in the Activities mailbox. The Activities Director showed the room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 1.) Resident rooms were clean and in good repair and free of chipped paint and broken tiles; 2) Resident lift equipment was clean; and 3.) Wash basins were properly stored and labeled, affecting room numbers #101, 103, 104, 105, 203, 204, 209, and 211, and residents using the sit-to-stand lift, resulting in an unsanitary environment, potential spread of infection, and dissatisfaction with living conditions. Finding include: On 4/15/24 at 11:43 AM, an observation was made of a Sit-to-Stand mechanical lift in the 100-unit hallway. An observation was made of whitish/yellowish debris on the pads where the lower leg rest against when the mechanical lift was in use. An observation was made of the base, where the Resident's feet would be placed, of dirt and debris. On 4/15/24 at 11:57 AM, an observation was made during the initial tour of the facility, of the bathroom between room [ROOM NUMBER] and 103, with two Residents in each room that…

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

Based on observation, interview and record review, the facility failed to properly dispose of wasted medications and secure treatment carts that contained prescription treatment medications and medical supplies, resulting in the potential for drug diversion and ingestion of medicated substances. Findings include: On 4/16/24 at 2:42 PM, an observation was made with Unit Manager, Nurse A during a review of concerns in the 100 Hall Unit and 200 Hall Unit. While approaching the 200 Hall Unit with Nurse A an observation was made of the treatment cart in the 200 Hall, unattended by a Nurse. The cart had a drawer that was partially open. Upon observation of the cart, the drawer was able to be pulled open with skin and wound treatments in the drawer. The Unit Manager indicated that the cart should be locked. Upon locking the cart, it was found to be locked but that the drawer was not pushed in all the way, leaving access to that drawer. The Unit Manager closed the drawer and made sure it was then secure. On 4/17/24 at 7:53 AM, an observation was made during medication administration task 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 ongoing surveillance of infectious illnesses for employees was maintained, documented, analyzed and reported, resulting in the potential for a lack of guidance to ensure compliance with infection control standards of practice and exposure to infectious organisms, which could lead to an unidentified outbreak. Findings Include: FACILITY Infection Control On 4/17/24 at 10:20 AM, during a review of the Infection Prevention and Control Program with Infection Preventionist/IP H, he was asked about surveillance for employee illnesses. The IP said the facility had an employee call in log, that identified staff call-ins from work. He said during the morning Interdisciplinary Team Meeting, he would look at the employee call in logs. The IP was asked if he collected the data and analyzed for similar infections during the week or month. He said he looked at the information but did not write anything down. The IP did not have any written data to compare…

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 review and revise care plans with resident changes to ensure interventions necessary for care and services were provided for one resident (Resident #45) reviewed for care plans, resulting in the potential for unmet care needs. Findings Include: Resident #45 Activities of Daily Living On 4/15/24 at 12:04 PM, during a tour of the facility a Confidential Resident stated, Resident #45, Never bathes/showers and it makes the room smell. The Confidential Person said they couldn't bring visitors in because of that. On 4/15/2024 at 12:15 PM, Resident #45 was observed lying in bed, awake with soiled clothes with brown stains. The resident appeared disheveled, his hair unwashed and the bed linens were soiled with brown stains. There were papers all over the bed. The resident did not readily answer questions. On 4/16/2024 at 4:20 PM, during an interview with Certified Nurse Aide R about Resident #45, she said she was familiar with this resident, and had taken care of him in the past. Upon entering the resident's room, he was observed…

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 medications were administered per the physician's order for two residents (Resident #53 and Residednt #273) resulting in multiple medication administrations not being documented in the Electronic Health Record (EHR)(Resident #53) and a lidocaine patch not being removed prior to administering another patch(Resident #273) with potential for adverse reactions and skin irritation. Findings include: Resident #53 (R#53): On 04/15/24 at 01:00 PM, R#53''s facesheet was reviewed and revealed that they are [AGE] years old and admitted to the facility on [DATE]. Pertinent diagnoses on admission include discitis, endocarditis, osteomyelitis, alzheimers, hypertension, hyperlipidemia and methicillin resistant staphylococcus aureus (MRSA). On 04/15/24 at 01:03PM, record review revealed a physician's order for Daptomycin(antibiotic) 500mg intravenously (IV) one time a day for endocarditis until 04/24/24. On 04/15/24 at 01:06 PM, record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that proper communication/documentation of Hospice services were provided to one resident (Resident #37) of two residents reviewed for Hospice services, resulting in the lack of receipt of progress notes/assessments to resident medical record with ineffective communication and collaboration of services between the facility and hospice service, lack of residents and staff aware of hospice schedule and the potential for unmet care needs. Findings include: Resident #37: A review of Resident #37 medical record revealed an admission into the facility on 9/11/19 and readmission on [DATE] with diagnoses that included chronic obstructive pulmonary disease, depression, anxiety and dependence on supplemental oxygen. A review of the Resident's MDS revealed a BIMS score of 14/15 that indicated intact cognition and the Resident was independent with self-care. On 4/15/23 at 12:43 PM, Resident #37 was observed sitting on her bed. The Resident 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.