Kith Haven

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to Intake Numbers: 2575687, 2577971, and 2580349. Based on interview and record review, the facility failed to develop and implement policies and procedures to ensure effective and appropriate communication and documentation for transfer to the hospital and failed to ensure readmission to the facility for one (#701) of three Residents reviewed for discharge rights and planning. Findings include: Review of documentation revealed three separate intakes with allegations pertaining to the facility refusing to readmit Resident #701 back to the facility after being in the hospital. Per the intake information, Resident #701 had a legal Guardian, was a long-term Resident of the facility, and was not provided with a bed-hold policy and/or eviction notice prior to being transferred to the hospital. An interview was completed with Resident #701's Guardian Representative Witness A on 8/12/25 at 10:38 AM. Witness A was queried regarding Resident #701's transfer to the hospital on 7/22/25 and revealed…

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 intakes MI00153289 and MI00153294. Based on interview and record review, the facility failed to provide supervision for three residents (R5, R6, R7) of three residents reviewed for supervision, resulting in multiple resident to resident altercations. Findings include: Resident #5: R5 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include Huntington's disease, adjustment disorder with anxiety, cognitive communication deficit and schizoaffective disorder, bipolar type. R5 has a brief interview for mental status (BIMS) score of 8, indicating mild cognitive impairment. Resident #6: R6 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include alcoholic cirrhosis of liver with ascites, adjustment disorder with depressed mood, chronic diastolic heart failure and pulmonary hypertension. R6 has a BIMS of 0, indicating severe cognitive impairment. Resident #7: R7 is [AGE] years old and admitted to the facility on [DATE] with diagnoses…

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 MI00149971. Based on observation, interview and record review, the facility failed to address hospital discharge recommendations for blood glucose monitoring and insulin administration and follow parameters for insulin administration for two residents (Residents #1 and Resident #3) of three residents reviewed for glucose monitoring. Findings include: Resident #1: A review of Resident #1's medical record revealed an admission into the facility on [DATE] and re-admission on [DATE] with diagnoses that included end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus with ketoacidosis. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 11/15 that indicated moderate cognitive impairment. The Resident went out of the facility for dialysis treatments. On 3/27/25 at 1:01 PM, an observation was made of Resident #1 dressed and sitting on the side of the bed with their lunch tray on the overbed table. 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 MI00151298. Based on interview and record review the facility failed to update care plans and implement interventions to prevent falls for one resident (Resident #2) of three residents reviewed for incidents and accidents, resulting in repeated falls. Findings include: Resident #2 (R2): R2 is [AGE] years old and was initially admitted to the facility on [DATE] with diagnoses that include above the knee amputation on the right leg, dementia, anemia and chronic obstructive pulmonary disease. R2 has a brief interview for mental status (BIMS) score of 5, indicating severe cognitive impairment. On 3/28/2025, a review of falls was completed for R2, it was revealed that R2 had sustained multiple falls in the facility. -On 1/5/25 at 04:03 AM, R2 was observed lying on his left side on the floor beside his bed. The fall was unwitnessed, and the care plan intervention was to perform a three-day sleep study. Results of the sleep study were unable to be located in the electronic…

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

Based on observation and interview the facility failed to maintain sanitary conditions in the kitchen, resulting in an increased potential for cross contamination of food, foodborne illness and improper kitchen sanitization, potentially affecting all residents who consume meals from the kitchen. Findings Include: On 1/29/2025 at approximately 10:00 AM, a tour of the kitchen was started with Assistant Administrator Q and concluded with Dietary Manager AA upon entering the kitchen, dietary staff were actively cleaning out the walk-in cooler. The following expired and/or unsanitary conditions were observed during the tour: Walk-in Cooler: -Floors had spills in different areas of what appeared to milk, and the floor was sticky in some areas. -There were miscellaneous items strewn across the floors such as lids and onion peelings. -18 cups of orange juice inside an extended white tray- some of the juices lids were off and there was spilled juice in the bottom of the tray. It was dated 1/26/25. -1 gallon of jalapenos with expiration date of 1/21/25 -Both fan covers in the walk-in cooler…

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 MI00149049. Based on observation, interview and record review, the facility failed to ensure that residents' rights/dignity was maintained for Resident #'s 6, 38, 60, 81, 82, 94, 97 and 127, of a sample of 26 reviewed for residents' rights, dignity and ADL (activities of daily living) care, and two residents in room [ROOM NUMBER], resulting in long call light wait times, Resident complaints of food served at an unpalatable temperature, menu not followed, lack of assistance with dressing, lack of ADL care, long and jagged fingernails, complaints of staff rudeness with Resident interaction and the potential of unmet care needs, weight loss and dissatisfaction with care, services and meals. Findings include: Resident #6: A review of Resident #6's medical record revealed an admission into the facility on 4/25/13 and recent admission on [DATE] with diagnoses that included end stage renal disease, dependence on renal dialysis, acquired absence of right leg below knee, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that two Residents (#21, #83) received consistent pre and post dialysis weights, and failed to ensure that two Residents (#22, #107) received medications post dialysis when the residents returned to the facility from dialysis, resulting in the potential for decline in condition, lack of medication therapy, and prolonged health issues. Findings include: Record review of the facility 'Hemodialysis' policy dated 9/26/2023 revealed residents receiving hemodialysis will be assessed pre and post treatment and receive necessary interventions Record review of the facility 'Medication Administration' policy dated 10/17/2023 revealed resident medications are administered in an accurate, safe, timely and sanitary manner. Procedure: (6.) Administer medications within 60 minutes of the scheduled time. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule…

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 pharmacist medication regime reviews (MRR) were reviewed, acted upon and addressed in the residents' clinical record for five (#27, 40, 42, 86, 102) of five residents reviewed for MRR. resulting in medications not being adjusted with physician response to accept or decline the pharmacy recommendations. Findings Include: Resident #27 On 1/29/2025 at approximately 2:15 PM, a review was conducted of Resident #27's medical record and it indicated the resident admitted to the facility on [DATE] with diagnoses that included Alzheimer's, Adjustment Disorder, Delusional Disorder, Dementia, Adjustment Disorder and Major Depressive Disorder. On 1/30/2025 at approximately 4:00 PM, a review was conducted of Resident #27's monthly pharmacy recommendations from May 2025 to December 2024. The pharmacist noted an irregularity on 9/24/2024 but the specifics were not in the resident medical record. On 1/31/2025 at 10:13 AM, an interview was conducted with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that medications were appropriately stored in 3 of 3 Medication carts, and an unlocked treatment cart, resulting in a opened and unsecured treatment cart, opened and undated medications, lack of appropriate storage with loose tablets noted in carts, of temperature sensitive medications with irregular refrigerator temperature monitoring, and the potential for residents to receive medications with altered efficiency and potency. Findings include: Record review of the facility provided 'Medication Storage Guidance' form dated 2024, revealed that multi-dose vials for injection are dated when opened and discard unused portion after 28 days or in accordance with manufacture's recommendations . Record review of the facility 'Vaccine Storage Temperature Log' form dated January 2025 revealed instructions: Place a check in the box that corresponds with the temperature (rows), day of the month, and am or pm (columns) for your temperature…

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 Infection Prevention and Control standards of practice were followed for 1). Safe handling of ice and 2). Proper storage of personal items to prevent contamination, resulting in the potential for spread of infection, which could cause serious illness. Findings Include: FACILITY Infection Control On 1/31/2025 at 1:10 PM an Activity Aide entered the facility elevator carrying 2 large basins stacked on top of each other; each basin was filled with ice. Neither basin was covered, and the ice was open to the air with the aide's body leaning against the basins. The aide was asked what was in the basins and she stated, It's ice for daquiris. The aide exited the elevator and walked in to the resident activity area. On 1/31/2025 at 1:20 PM, Infection Prevention and Control/IPC Nurse A was interviewed related to the observation of an activity aide entering the elevator with 2 large uncovered basins each filled with ice. The IPC Nurse A said…

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 MI00149049. Based on observation, interview, and record review the facility failed to provide a clean, comfortable and home like environment to ensure that resident rooms were clean, uncluttered, and in good repair for 3 Resident's #30, #39, #115 including two resident rooms (103 and 119) , resulting in an unclean physical environment. FACILITY Environment: On 1/29/2025 at 10:48 AM, room [ROOM NUMBER]'s bathroom was observed to be very soiled. The white toilet seat had many smears of brown dirt on it and the floor was covered in discolored brown stains near the toilet. Resident #39 was asked if he used his bathroom and he said he did; he said he tried to provide his own care, as much as he could. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #39 was admitted to the facility on [DATE] with a tracheostomy, a feeding tube, heart disease, COPD, anxiety, depression, GERD, arthritis and venous insufficiency. The MDS assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to review and revise care plans for 2 Residents (#39, #64) of 3 residents reviewed, including Resident #39 with a swallowing deficit, and Resident #64 who had weight loss and a change in condition, resulting in the likelihood for missed interventions in treatment and unmet needs. Finding include: Record review of the facility 'Care Planning' policy dated 6/24/2021 revealed every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment that includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs identified in the comprehensive assessments and prepared by an interdisciplinary team who includes but not limited to; attending physician, a registered nurse who is responsible for the resident, a nurse aide, a member of food/nutrition services, the resident or resident…

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 care was provided for a resident with a Life Vest Resident #115, and 2. Ensure wound care was ordered and completed timely for Resident #383 of two residents reviewed for standards of practice. Findings Include: Resident #383: 01/30/25 around 12:15 PM, Resident #383 was observed in the dining area with other residents enjoying his lunch. A bandage was observed spanding the length of his left forearm that was dated 1/27- at 2130 with the initials SS. When the resident was queried on what happened to his arm, he stated it occurred while he was jumping a fence. Review was completed of this TAR (Treatment Administration Record) and there were no current orders specifically for his left arm. The order that was initiated for his left rear forearm was discontinued on 1/27/2025. Furthermore, there was no wound care treatment documented on TAR as completed for this resident on 1/27/2025. On 1/30/2025 at approximately 1:00 PM, Nurse N was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prevent a facility-acquired pressure ulcer/skin injury for one resident (Resident #64) of 5 residents reviewed for pressure/skin issues, resulting in Resident #64 developing two new facility-acquired pressure ulcers/skin injuries as a result of poor nutritional intake including a low protein diet and and also resulting in weight loss while residing in the facility. Findings include: Record review of facility 'Skin Management' policy, dated 9/19/2024, revealed it is the policy of the facility should identify and implement interventions to prevent development of pressure ulcers. Practice guidelines: (10.) A nutritional evaluation: a registered Dietitian will evaluate all residents identified with skin impairment for nutritional status in a timely manner. Review laboratory results pertinent to wound healing. (12.) If a new area of skin impairment is identified, notify the resident . Resident #64: In an interview on 01/29/25 at 11:24 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number MI00149049. Based on observation, interview and record review, the facility failed to implement a restorative therapy program and develop a plan of care for restorative therapy for one Resident #97 of one reviewed for rehab and restorative therapy, resulting in the potential for functional decline, reduction in range of motion, diminished mobility and decreased independence. Findings include: Resident #97: A review of Resident #97's medical record revealed an admission into the facility on 9/26/24 with diagnoses that included anxiety disorder, depression, lymphedema, and open wound of lower leg. A review of the MDS, dated [DATE], revealed the Resident had intact cognition and needed substantial/maximal assistance with shower/bathing, was dependent with toileting hygiene, lower body dressing and putting on/off footwear, needed partial/moderate assistance with personal hygiene and transfers. On 1/30/25 at 9:32 AM, an interview was conducted with Resident #97 who was lying in…

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 prevent weight loss for 1 resident (Resident #64) of 7 residents reviewed for nutrition, resulting in Resident #64 having a 5.6% weight loss, low protein diet with development of pressure ulcers. Findings include: Record review of the facility 'Nutritional Services Documentation' policy dated 9/19/2024 revealed that at least once a month and additionally as needed, the Nutrition Professional shall document in the dietary progress notes or appropriate assessment form the current nutritional status of residents with the following criteria: (e.) Stage 2 or higher-pressure injuries. Record review of the facility 'Weight Management' dated 9/22/2023 revealed residents will be monitored for significant weight changes on a regular basis. Residents are expected to maintain acceptable parameters of nutritional status, such as usual body weight and protein levels . The dietary manager and/or dietitian will calculate the monthly and weekly significant weight changes (5% in one month, 7.5% in three months, and 10% in six…

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 oxygen was provided as ordered for one resident (Resident #79) of 3 residents reviewed for respiratory care, resulting in the potential for inappropriate treatment with potential for adverse reactions . Findings include: Resident #79: A review of Resident #79's medical record revealed an admission into the facility on 2/26/24 with diagnoses that included dementia, diabetes, heart failure, pulmonary hypertension and chronic obstructive pulmonary disease (COPD). A review of the Resident's Minimum Data Set assessment revealed the Resident had severely impaired cognition and needed partial/moderate assistance with bathing, dressing, personal hygiene, sit to stand and bed to chair transfers. A review of Resident #79's orders revealed an order dated 1/22/25 for oxygen 2L (liters) to maintain oxygen saturation above 90% r/t (related to) COPD. A review of the Resident's care plan revealed a focus for .a potential for difficulty breathing and risk for respiratory complications . dated 2/27/24 with an intervention…

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 suicide precautions were ordered, for one Resident #32 of one resident reviewed for mood and behavior, resulting in the potential for a lack of continuity of care and an adverse outcome for Resident #32. Findings Include: Resident #32: Behavioral-Emotional On 1/29/2025 at 10:34 AM, Resident #32 was observed lying in bed. When asked where her call light was, she said the staff took it and gave her a bell to ring. A small bell was observed on the bedside table. When asked why they gave her the bell, she said she didn't know. On 1/29/2025 at 10:39 AM, Nurse Aide L was asked why Resident #32 did not have a call light and she said the resident was on suicide watch as of that morning 1/29/2025. She said a nurse took her call light so she did not have any long cords to hurt herself and gave her a bell. She said she didn't know any more than that. On 1/29/2025 at 10:45 AM, Nurse K was interviewed about Resident #32 being on suicide watch.…

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 informed consent was obtained prior to administration of psychotropic medications for three (#27, #90 and #102) of five residents reviewed for unnecessary medications. Findings Include: Resident #27 On 1/29/2025 at approximately 2:15 AM, a review was conducted of Resident #27's medical record and it indicated the resident admitted to the facility on [DATE] with diagnoses that included Alzheimer's, Adjustment Disorder, Delusional Disorder, Dementia, Adjustment Disorder and Major Depressive Disorder. Further review yielded the following: Physician's Orders: Risperidone Tablet 0.25 MG (milligram)- give one table by month two times a day for psychotic disorder with delusion due to known psychological. Ordered on 10/17/2024. On 1/30/2025 at 2:50 PM, Social Work Director E was asked about their process regarding psychotropic medication consents. It was explained they only complete consents for antipsychotic medications. Review was completed of Resident…

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 follow standards of practice and physician orders of parameters for blood pressure (BP) and heart rate (HR) when administering medication to one resident (Resident #22), of six residents reviewed for medication regimen review, resulting in the potential for adverse medication reactions, bradycardia (low heart rate), and re-hospitalization. Findings include: Resident #22: A review Resident #22's medical record revealed an admission into the facility on 8/16/18 and readmission on [DATE] with diagnoses that included chronic kidney disease with dependence on renal dialysis, dementia, bradycardia, seizure disorder or epilepsy, and hypertensive chronic kidney disease. A review of the Minimum Data Set assessment dated [DATE] revealed the Resident had severely impaired cognition and needed substantial/maximal assistance with eating, toileting hygiene, bathing, dressing, roll left and right, sit to lying, lying to sitting. A review of Resident #22's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure timely dental services were provided and communicate with dental services regarding the need for dental x-rays for one resident (Resident #97), of one resident reviewed for dental services, resulting in a broken tooth not repaired/extracted, pain, infection and the Resident's lack of knowledge of the plan of care. Findings include: Resident #97: A review of Resident #97's medical record revealed an admission into the facility on 9/26/24 with diagnoses that included anxiety disorder, depression, lymphedema, and open wound of lower leg. A review of the MDS, dated [DATE], revealed the Resident had intact cognition and needed substantial/maximal assistance with shower/bathing, was dependent with toileting hygiene, lower body dressing and putting on/off footwear, needed partial/moderate assistance with personal hygiene and transfers. On 1/30/25 at 9:32 AM, an interview was conducted with Resident #97 who was observed to be in bed with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure adaptive equipment was provided for meals and hydration for one resident (Resident #14), of one resident reviewed for adaptive equipment during meals, resulting in frustration with attempting to feed self, spilling water from Styrofoam cup and the potential for weight loss and dehydration. Findings include: Resident #14: A review of Resident #14's medical record revealed an admission into the facility on 6/8/23 and re-admission on [DATE] with diagnoses that included depression, contractures of right and left lower legs, aphasia, dysphagia, muscle weakness, adult failure to thrive, and need for assistance with personal care. A review of the Minimum Data Set assessment dated [DATE], revealed the Resident had moderately impaired cognition and needed set-up or clean-up assistance with eating and was dependent on staff for oral hygiene, toileting hygiene, bathing, dressing, personal hygiene and mobility and transfers. On 1/30/25 at 9:08…

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 assistance with obtaining an appointment to fix broken eye glasses for Resident #3; 2.) ensure call lights were accessible for Residents #2, 25, 48, 70, 72, 80, 97, 107, 117, and 118; and 3.) ensure menus met resident preferences for Resident #73 and a Confidential group of Residents, resulting in impaired vision, frustration, unmet care needs, and unpalatable food. Findings include: Initial Tour of the Covid-19 Unit Resident #25 On 1/30/24 at 2:04 PM, an initial tour of the Covid-19 unit was conducted. Resident #25 was in bed, answered questions and engaged in conversation. An observation was made of the call light on the floor and the cord was not positioned on the bed. The call light was not in reach for the Resident. An observation was made of Resident #25's roommate (Resident #118) without the call light in reach and the door closed. The Resident was asked about his call light. The Resident stated, I would use it if it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to Intake MI00138079. Based on observation, interview and record review, the facility failed to ensure linens were sufficiently available and in good condition for Residents #40, 75, 117 and 375, of 13 reviewed for safe, clean and homelike environment, resulting in a potential for contamination and illness, embarrassment and dissatisfaction with their living conditions. This deficient practice had the potential to affect Residents residing in the facility with a census of 115. Findings include: Resident #75 01/29/24 02:45 PM, an observation was made of Resident #75 lying in bed on his back. The Resident's head of the bed was elevated with two pillows beneath his head. The Resident was interviewed, answered questions and engaged in conversation. The Resident indicated that he had multiple wounds on his buttock and had a wound vac and that he did not have use of his legs. An observation was made of another pillow on a chair in the Resident's room that was ripped in multiple places 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 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 3 residents (#'s 23, 67, 95) of 34 reviewed, resulting in the potential for unmet care needs. Findings Include. Resident #23 Accidents A review of the Face sheet and Minimum Data Set (MDS) assessment indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: History of a stroke, with left side weakness, hypertension, history of seizures, diabetes, depression, dementia, end stage kidney disease, received dialysis, difficulty talking, feeding tube, and difficulty swallowing. The MDS assessment dated [DATE] indicated the resident had severe cognitive loss with a Brief Interview for Mental Status (BIMS) score of 2/15 and the resident needed total assistance with care. During a tour of the facility on 1/29/2024 at 2:18 PM, Resident #23 was observed lying in bed; it was a low bed, with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake #MI00134673, MI00134692, MI00136760, and MI00133158. Based on observation, interview and record review, the facility failed to provide activities of daily living (ADL) care for Residents dependent on assistance from staff to provide care for Residents # 3, 23, 25, 36, 59, 67, 95, and 375 of 14 reviewed for ADL care, resulting in a lack of bathing, nail care, shaving, hair care and dressing, with the potential for body odor, infection, embarrassment, and lack of self-esteem. Findings include: Resident #25 A review of Resident #25's medical record revealed an admission into the facility on 6/29/16 with readmission on [DATE] with diagnoses that included multiple sclerosis, depression, anxiety, diabetes, chronic pain syndrome, and polyarthritis. A review of the Minimum Data Set assessment for Resident #25 revealed a Brief Interview of Mental Status (BIMS) score of 14/15 that indicated intact cognition and the Resident needed substantial/maximal assistance with toileting hygiene, 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 observation, interview and record review, the facility failed to 1.) properly dispose of expired medication and medical supplies; 2.) properly label medication containers; 3.) sign out narcotic medication timely; and 4.) properly secure medication carts for four of five medication and treatments carts and 3 of 3 medication rooms reviewed for medication storage and labeling, resulting in the potential for administration of expired medications with decreased efficacy, medical procedures and treatments performed with expired medical equipment/treatments and medication diversion. Findings include: On 2/1/24 at 9:26 AM, a review of the 3 South medication room with Unit Manager, Nurse B was conducted. A bottle of Bisacodyl tablets were expired on 1/2024. A container of urinalysis reagent strips was opened with a date labeled 6/28/23. The container of urinalysis reagent strips revealed to be used within 90 days of being opened. Nurse B removed the container of urinalysis reagent strips and the Bisacodyl medication. The 3 South treatment cart was reviewed with Unit Manager, Nurse…

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 serve, store, and prepare food under sanitary conditions in the facility kitchen, resulting in the increased potential for foodborne illness. This deficient practice had the potential to affect all residents who ate meals prepared by the facility out of a census of 115 residents residing in the facility. Findings include: An initial tour observation of the kitchen was conducted with the Dietary Manager (DM M) and the Assistant Administrator (Staff T) on 1/29/2024 at 12:30 PM. While the kitchen staff were preparing the lunch trays for the residents, the following items were observed: During tray line at approximately 12:42 PM, the DM M was asked to take the temperature of the food in the tray line. After a couple of food temperatures were checked, DM M was asked to refrain from checking the food temperature because DM M was observed checking the food temperature with her bare hands and not putting disposable gloves on. Staff T was present and observed that DM M did not wear gloves during the food temperature…

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 #MI00133396. Based on observation, interview and record review, the facility failed to follow evidence-based practices for Infection Control, including Transmission Based Precautions to prevent the spread of the Covid-19 virus. The failure to maintain infection control practices resulted in a likelihood for a serious adverse outcome including the spread of infectious illness. Findings Include: FACILITY Infection Control CDC: Centers for Disease Control and Prevention: Isolation and Precautions for People with Covid-19, updated May 11, 2023, If you have COVID-19, you can spread the virus to others. There are precautions you can take to prevent spreading it to others: isolation, masking and avoiding contact with people who are at high risk of getting very sick. Isolation is used to separate people with confirmed or suspected COVID-19 from those without COVID-19 . On 1/30/2024 at 2:32 PM, a Confidential Group of residents voiced concerns about rooms designated for Covid-19 positive…

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 MI00138079. Based on observation, interview and record review, the facility failed to ensure dignified treatment during dining and ensure the provision of Resident rights for two Residents (#71 and 228), of a sample of 24, resulting in potential feelings of embarrassment, decreased self-worth, lack of knowledge of Resident rights and to act upon deprivation of rights. Findings include: Dining Observation On 2/1/24 at 9:05 AM, an observation was made of Resident #71 seated in a wheelchair in the hallway across from the Nurses' Station. There were other Residents seated in wheelchairs up against the wall with Resident #71. Resident #71 had a meal tray on a table that was infront of the Resident. An observation was made of a CNA (certified nursing assistant) standing in front of the table to the right side of the Resident and feeding the Resident the food. The CNA was not seated next to the Resident but stood and gave the Resident multiple spoonfulls of food. The observation was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Numbers MI00133967, MI00135210 and MI00140848. Based on the interview and record review, the facility failed to allow the resident's family to visit the facility regularly per resident legal representative's preference for one resident (Resident #43) of two sampled residents reviewed for visitation rights in a total of 24 sampled residents resulting in feelings of sadness, loneliness, isolation from a relative and lack of socialization. Findings include: Resident #43 (R43): A review of Resident #43 (R43) record revealed that R43 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses of Hemiplegia, Hemiparesis following unspecified Cerebrovascular Disease affecting the right dominant side, Adjustment Disorder, Major Depression, and Eczema, in addition to other diagnoses. R43 was nonverbal and had a legal representative living outside the state. R43's Brief Interview for Mental Status (BIMS) score dated 12/16/2023 was 2 out of 15.…

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 MI00134673. Based on interview and record review, the facility failed to implement and operationalize timely assessment, care, and transfer following a change in condition for one resident (Resident #76) of one resident reviewed resulting in a delay in transfer and care following feeding tube dislodgment, delayed provision of nutrition/hydration, and medications, untreated pain, and the likelihood for gastrostomy (surgically created opening in the abdominal wall to the stomach for the introduction of nutrition- commonly called a PEG or G-tube) malfunction. Findings include: Resident #76: On 1/30/24 at 12:07 PM, Resident #76 was observed sitting in a geri-chair (reclining, high back wheeled chair used for positioning) in their room. When spoke to, Resident #76 made eye contact and stated, To much pressure on my stomach. When asked questions, Resident #76 did not provide meaningful responses. Record review revealed Resident #76 was most recently admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure interventions were enacted to prevent a fall and assess the resident post fall for neurological changes for one Resident (#30), of five reviewed for accident hazards/falls, resulting in Resident #30 having a multiple falls, hospitalization, dislocation and fracture to the left arm, pain, decreased mobility and the lack of assessment of potential change in mental status to go undetected and untreated. Findings include: A review of Resident #30's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included Alzheimer's disease, anxiety, delusional disorders, difficulty in walking, weakness, and need for assistance with personal care. A review of the Minimum Data Set assessment dated [DATE], revealed a Brief Interview of Mental Status score of 3/15 that indicated severely impaired cognition and the Resident needed partial/moderate assistance with lying to sitting on side of bed,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to properly label the enteral nutritional solution (nutrition provided by means of surgically placed percutaneous endoscopic gastrostomy tube-PEG tube) and infusion tubing set for one Residents (#118), of three reviewed for tube feeding, resulting in the potential for food borne illness from ingesting contaminated enteral feeding solution. Findings include: A review of Resident #118's medical record revealed an admission into the facility on [DATE] with diagnoses that included osteomyelitis of right ankle and foot, anxiety disorder, stroke, muscle weakness, dysphagia, aphasia, and need for assistance with personal care. Further review of the medical record revealed the Resident had a PEG tube and received enteral feedings of Jevity at 90 ml (milliliters) per hour for 16 hours or until 1440 ml infused. On 1/30/24 at 2:04 PM, an initial tour of the Covid-19 unit was conducted. During the initial tour, Resident #117 was observed in bed with eyes…

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