Villa at Beecher Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the interview and record review, the facility failed to ensure that the resident's dignity and respect were maintained when the call light was not answered in a timely manner and incontinence care was delayed, causing the resident to lie on a soiled linen for one resident (Resident, #503 [R503]) of 3 residents reviewed for dignity and respect.Findings include: Resident #503 (R503):A review of the record revealed that Resident (R503) was alert oriented with a Brief Interview of Mental Status (BIMS) Score of 15/15 assessed on October 9, 2025. She was originally admitted to the facility on [DATE], with a diagnosis of type 2 diabetes, morbid obesity, absence of right leg above the knee and absence of left leg below the knee in addition to other diagnoses. She is dependent on staff care for transfers and the lower-body activitiesR503 was interviewed in her room on 12/10/25 at 3:32 PM. R503 stated that a few months ago, she reported that she was left lying in bed with poop for almost 4 hours. She continued to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number 2597296.Based on observation, interview and record review, the facility failed to ensure that air conditioning units were operational and that the environment was clean and comfortable for eight residents (1, 2, 4, 5, 6, 7, 8 and 9) of nine residents reviewed for a comfortable environment.Findings include:On 9/12/25 at 12:25 PM, an observation was made of the 200-hall common area/dining area. There were six residents in the dining area and two staff. The room felt hot, and the air conditioning units were not running. There was a single stand-up fan, but it was not running. CNA E was asked about the temperature in the room. The CNA indicated that the air was not turned on at that time. The wall unit that controlled the heating/cooling unit was turned on by the CNA. The wall unit read 83 degrees. When asked about the high temperature in the room, the CNA reported that it had gotten hot recently. The CNA turned the stand-up fan on, but upon inspection of the fan with 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 2584838.Based on observation, interview and record review, the facility failed to protect Resident 101 (R101) and Resident 102 (R102)'s rights to be free from verbal and physical abuse and Resident 103 (R103) and Resident 104 (R104)from physical abuse during two resident-to-resident altercations, for four (R101, R102, R103, R104) of four residents reviewed for abuse, resulting in the potential for feelings of disrespect for R102; fear of an impending threat for R104 and an emergency room (ER) visit for R101 and R103 related to injuries sustained during the resident-to-resident altercations. Resident #103: A record review of the Face sheet and Minimum Data Set, indicated Resident #103 was admitted to the facility on [DATE] with diagnoses: History or a stroke, dementia, diabetes, right and left leg amputations below the knee, acquired absence of right fingers, peripheral vascular disease, neuropathy, depression, rosacea, folliculitis (a skin condition), adjustment disorder…

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#: MI00153447 Based on observation, interview and record review, the facility failed to ensure a wheelchair was safe and in good working condition for one resident (#1) of 3 residents reviewed for safety. Findings Include: Resident #1 A review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #1 was admitted to the facility on [DATE] with diagnoses: Diabetes, peripheral vascular disease, right and left below the knee amputations, COPD, alcohol abuse, Dementia, absence of 4 right fingers, depression, hypertension, and muscle weakness. The MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status/BIMS score of 15/15- full cognition and the resident needed some assistance with care. He was able to transfer self and motor his own wheelchair. On 6/5/2025 at 1:19 PM, Resident #1 was observed sitting outside in his wheelchair smoking a cigarette with other residents. The resident said he used to have his own wheelchair, but when he…

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 residents were treated in a dignified manner for five residents (R6, R14, R21, R31, R36, R45, R59, R70) and a confidential group of residents, resulting in residents being cold due to no blankets on the bed, soiled pillows, call lights not in reach, call lights not answered timely, needs not met timely and frustration Findings include: Resident #45 R45 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include dementia, reduced mobility, major depressive disorder and mood disorder. R45 is mostly non-verbal and will nod their head yes or no to certain questions. On 05/18/25 at 11:22AM, R45 was observed in bed, there was no blanket on the bed, there was a thin fitted sheet, and a top sheet bundled up in his hands, R45 was wearing only a gown and had no socks on. R45 had a soiled pillow under his ankles, it was stained yellow and red. R45 was observed shaking and his teeth were chattering as if he 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 provide a clean, comfortable and home like environment to ensure that residents' rooms on the 300 hall and 400 hall including room [ROOM NUMBER], were clean without foul odors, uncluttered, and in good repair, resulting in an unclean physical environment, resident dissatisfaction and complaints regarding the lack of cleanliness. Findings Include: FACILITY Environment On 5/18/2025 at 10:46 AM during a tour of the facility, the 400 hallway near room [ROOM NUMBER] had a strong ammonia smell of urine. Upon entering room [ROOM NUMBER], the smell was much more intense. The first bed in the room nearest the doorway was empty, with the top sheet and blankets pulled back in a pile near the footboard. The bed had visible urine stains on the bottom sheet and the blanket and top sheet. The smell was overwhelmingly foul. On 5/18/2025 at 10:49 AM, Nurse Aide Q entered the room and was asked about the smell of urine, and she pointed at bed-1. She 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 Based on observation, interview and record review the facility failed to ensure meaningful activities were provided to one resident (Resident #36) of one resident reviewed for activities, resulting in Resident #36 lying in bed without attending activities programs. Findings Include: Resident #36: Activities On 5/18/2025 at 12:15 PM, Resident #36 was observed in his room lying in bed, awake and talkative. When asked if he attended any of the facility's Activity programs, he said no one asked him if he would like to go. He said he likes bingo and would like to go to bingo. Resident #36 said he would like to go and talk and meet new people. When asked if he normally gets out of bed, he said he had not been up lately. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #36 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Acute respiratory failure, COPD, pneumonia, history of a heart attack, diabetes, chronic kidney disease, heart failure, muscle…

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 wound dressings were completed for three residents (Res.#17, Res.#21, and Res.#45) and failed to ensure that the resident was assessed and provided pain relief for one resident (Res.#70) who had recently underwent back surgery of four residents reviewed for quality of care resulting in the potential for wound infection, delay in wound treatment, and Res.#70 experiencing a delay in evaluation, and treatment and unnecessary pain. Findings include: Resident #70: Pain During an interview on 05/19/25 at 09:49 AM, R70 indicated that he fell from around the property by the bus [NAME] near the facility parking lot. He called 911 and went over to the hospital emergency room. R70 showed a bump on his left arm and scabs on his knee due to the recent fall. R70 stated, My legs gave up and came under me. When asked where he was going and what happened before the fall, R70 stated, I was upset because the nurse did not give me my pain medication,…

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 complete performance evaluations every 12 months for three certified nursing assistants (CNA, F, CNA G, CNA H) of five reviewed. Findings include: On 05/20/25 at 02:45PM, the human resources director provided the records of five CNA's for review. CNA D: No performance evaluation due to not being in the facility a year yet. CNA E: No performance evaluation due to not being in the facility a year yet. CNA F: No record of a performance evaluation. CNA G: No record of a performance evaluation. CNA H: No record of a performance evaluation. On 05/21/25 at 10:14AM, an interview was conducted with the Director of Nursing (DON). The DON was asked if they are currently doing yearly performance evaluations for the nursing staff. The DON replied that human resources (HR) usually does the evaluations, but currently there aren't any being done. The DON was asked if they had completed any performace evaluations for their staff. The DON replied no, the facility is not completing yearly evaluations.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that HS (evening/night time) snacks were provided on a regular basis to one resident (Resident #60) and a Confidential Group of Residents, resulting in residents verbalizing feelings of anger, frustration, going to bed hungry, and diabetic residents having the potential for low blood glucose levels. Findings Include: Nutrition Snacks Resident #60: A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #60 indicated admission to the facility on 4/30/2019 with diagnoses: Diabetes, chronic kidney disease, right below the knee amputation, protein-calorie malnutrition, peripheral vascular disease, history of seizures, and heart disease. The MDS assessment dated [DATE] indicated the Resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident was independent with most care. On 5/18/2025 at 10:21 AM, Resident #60 was observed lying in bed in his room. He said he was…

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

Based on observation, interview and record review, the facility failed to ensure that a clean, sanitary kitchen was maintained and monitor food temperatures prior to serving. This deficient practice could affect all Residents that eat meals served from the facility kitchen of a census of 108. Findings include: On 5/18/25 at 10:00 AM, a review of the kitchen area was started with facility [NAME] W. At approximately 10:30 AM, Dietary Manager N came into the facility kitchen and proceeded with the tour of the kitchen. The items identified prior to the Dietary Manager arrived were reviewed. The following observations were made in the kitchen: -Condiments in a bin under the coffee makers. There was no date on the mayonnaise, ketchup, and salad dressings. There was no receive by date or use by date for the condiments. -Hot cocoa mix in a stained box that was not labeled with an open or use by date and there was not a manufacture's use by date on the box. [NAME] W was asked about the procedure for labeling the condiments and hot cocoa mix but was unsure of the facility policy. -Robot Coupe…

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 residents' rooms were free from flying insects for three rooms on the 3rd floor, potentially affecting the residents who reside on the 3rd floor/300 Unit, resulting in the potential for pest-transmitted diseases to a vulnerable population. Findings include: On 5/18/25 at 12:21 PM, an observation was made in room [ROOM NUMBER] or a strong odor of urine. There were two residents that resided in the room. Inside the bathroom, it was noted to have a strong foul odor of urine and had a dozen counted flies/gnats flying around in the bathroom and positioned on the counter, walls, and mirror. Housekeeper U was at the room next to room [ROOM NUMBER]. When asked about the flies and odor, the Housekeeper reported it was from wet briefs and clothes that were in a basin on the counter and stated, It needs a deep clean that's for sure. An observation was made, with the Housekeeper, of resident's clothing in a basin on the sink and basins 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the accuracy of advance directives for one resident (R315) of two residents reviewed for advance directives, resulting in the potential for unmet life sustaining needs. Findings include: Resident #315 (R315): R315 is [AGE] years old and originally admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease (COPD), dementia, major depressive disorder and dependence on supplemental oxygen. On 05/19/25 at 11:55AM, review of the electronic medical record (EMR) revealed that R315 had a physician's order for a full code dated 05/13/25. Review of the documents of the EMR revealed R315 had a signed do not resucitate (DNR) form dated 02/25/25. On 05/19/25 at 01:25 PM, an interview was conducted with Unit Manager (UM) A. UM A was asked if the nurses station had a code status book they used to know the code status of the residents. UM A replied that they use 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 interviews and record review, the facility failed to thoroughly and accurately conduct an investigation of a fall, which resulted in hospital admission for one resident (Resident #70) of three sampled residents reviewed for the fall. Findings include: The Incident Report (IR), dated 4/17/25, was reviewed on 5/19/25 at 12:00 PM. The incident occurred on 4/17/25 at 8:00 PM. Nursing Description: Nursing did not witness the event. Resident Description: Resident stated that he fell at the bus [NAME] while waiting on the bus and covered his face with his left arm to protect himself from hitting his forehead. Injuries Observed at the Time of Incident: Bruise Left Lower Leg (Front), Bruise Right ankle (inner), bruised Right forearm, Bruise left toe (s), Bruise left forearm, Hematoma Right lower leg (front), hematoma right forearm, scratch left lower leg (front). The IR (Post Incident) described: No injuries observed Post Incident. Page 2 of 3 of the IR was not filled, and all boxes were left empty. On page 3 of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were administered per standards of practice for 2 residents (R#60 and R#70) reviewed for medication administration, resulting in the administration of medications outside of the physician-prescribed orders for Resident #60 and Resident #70 who were left to self-administer without an appropriate self administering of medication assessment from IDT and careplans, which could lead to adverse effects. Findings Include: Medication Administration Resident #60: A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #60 indicated admission to the facility on 4/30/2019 with diagnoses: Diabetes, chronic kidney disease, right below the knee amputation, protein-calorie malnutrition, peripheral vascular disease, history of seizures, and heart disease. The MDS assessment dated [DATE] indicated the Resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and 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 that activities of daily living (ADL) care was completed for one dependent resident (R17) of five residents reviewed, resulting in long dirty fingernails and a splint not being applied as ordered. Findings include: Resident #17 (R17): Resident #17 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include multiple sclerosis, paraplegia, muscle weakness and adjustment disorder with mixed anxiety and depressed mood. On 05/18/25 at 10:41AM, R17 was observed to have long, dirty nails on both hands. R17 was also observed to have a right-hand contracture, no splint in place, R17 opened his right hand with his left hand and revealed the palm of his right hand to be dirty. R17 was asked if anyone had performed nail care on him or applied his splint recently and he stated no. R17 was asked if he refuses to have his splint put on or his fingernails cut, he stated no. On 05/18/25 at 11:47AM, an interview 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 ensure breakfast was offered, prior to leaving for dialysis, to one resident (Resident #75) of 8 residents reviewed for food and nutrition, resulting in Resident #75 buying his own food for breakfast which led to feelings of frustration and anger. Findings Include: Resident #75: Nutrition A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #75 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Diabetes, End stage renal disease, dependence on dialysis, pressure ulcers, peripheral vascular disease, right below the knee amputation, anemia, hypertension, respiratory failure, and pneumonia. The MDS assessment dated [DATE] revealed the resident had full cognitive ability with a Brief Interview for Mental Status/BIMS score of 13/15 and the resident needed some assistance with care. On 5/19/2025 at 9:28 AM, Resident #75 was not observed in his room. A breakfast meal tray 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 ensure that oxygen orders were followed as ordered and oxygen therapy care plans were updated for one resident (R315) of two residents reviewed for respiratory care, resulting in the resident receiving the incorrect amount of oxygen and an inaccurate care plan. Findings include: Resident #315 (R315): R315 is [AGE] years old and readmitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease (COPD), atrial fibrillation, anxiety disorder and peripheral vascular disease. On 05/18/25 at 12:58PM, R315 was observed lying in bed, complaining of a headache. R315 was observed to be receiving 8L of oxygen via a nasal cannula. On 05/19/25 at 08:37AM, review of the electronic medical record revealed a physician's order for oxygen to be administered at 3 Liters Per Minute, dated 05/13/2025. Record review revealed a care plan for oxygen therapy that revealed R315 was to receive 4L of oxygen, last updated…

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). ensure dialysis communication forms were complete and included pre-dialysis and post-dialysis assessment for 1 resident (#75); and 2.) accommodate the resident's medication regimen with the dialysis treatment schedule for 1 Resident (# 27) of 2 residents reviewed for Dialysis care, resulting in the potential for a decline in condition and the inability for a prompt response to care needs, medication not given as prescibed and exacerbation of medical conditions. Findings Include: Dialysis Resident #75: On 5/19/2025 at 9:28 AM, Resident #75 was not observed in his room. A breakfast meal tray was observed on the bedside table. Nurse K was interviewed on 5/19/2025 at 9:30 AM, she said Resident #75 was at dialysis. The nurse said he went to dialysis on Monday, Wednesday and Friday and the transport service picked him up about 5:00 AM and he returned about 9:30 AM. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated 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 the observation, interview and record review, the facility failed to ensure food temperature and palatability were maintained for 3 Residents (Res.#6, Res.# 70, & Res.# 74) of 6 residents reviewed for food temperature and palatability. Findings include: Resident #6 (R6): Food R6 R6 was admitted to the facility on [DATE] with the diagnosis of spondylolysis lumbar region, sarcopenia, Chronic Obstructive Pulmonary Disease (COPD), bipolar disorder, and morbid (severe) obesity due to excess calories. R6 Brief Interview for Mental Status BIMS Score dated 3/31/2025 was 15/15. A score of 15 means the individual is cognitively intact. Although the Minimum Data Set (MDS) Section GG dated 3/31/25 revealed that R6 depended on staff with most Activities of Daily Living (ADLS), especially with toileting, hygiene, and showers. Still, she required set-up and clean-up assistance from staff with eating. During a brief interview on 05/18/25 at 01:05 PM, R6 revealed that the facility's food is an issue. It is not hot or…

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 follow facility policy of storing food brought into the facility by family, visitors and/or residents affecting residents using the 2nd, 3rd, and 4th floor refrigerators out of a census of 108 residents. Findings include: On 5/18/25 at 10:46 AM, the floor unit refrigerators were reviewed with Dietary Manager (DM) N. Starting on the 4th floor, an observation was made of a refrigerator in the common area that was locked. The DM retrieved the keys and opened the refrigerator. There was a Gatorade that was open and partially consumed that did not have an open date, use by date or name. The DM indicated that he did not know who it belonged to and that it could be staff. When asked if staff were to keep items in this refrigerator, the DM reported items in the refrigerator should have a name on it. There was a Cracker Barrel bag with food inside the bag, but there was no date of when the food came in and when it should be used. Ranch dressing was opened but did not have an open date, use by date or resident name 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.

Based on interview and record review, the facility failed to analyze and respond to elevated Legionella water sample levels per Infection Prevention and Control Standards of Practice, resulting in the potential for an unidentified outbreak of infectious illness for a facility census of 108 residents. Findings Include: Based on interview and record review, the facility failed to analyze and respond to elevated Legionella water sample levels per Infection Prevention and Control Standards of Practice, resulting in the potential for an unidentified outbreak of infectious illness for a facility census of 108 residents. Findings Include: FACILITY Infection Control Centers for Disease Control and Prevention (CDC): Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings- A Practical Guide To Implementing Industry Standards, dated June 24, 2021, Legionnaires' disease is a serious type of pneumonia caused by bacteria, called Legionella, that live in water. Legionella can make people sick when they inhale contaminated water from building water systems that are…

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 MI00151112 and MI00151113. Based on observation, interview, and record review, the facility failed to provide adequate and appropriate wound care: Percutaneous Endoscopic Gastrostomy (PEG) tube site, assess, monitor, document wound status, and provide interventions as care planned for three residents (R#501, R#502 and R#503) of 4 residents reviewed for wound care, treatments and interventions. Findings include: Resident #501 (R501): During wound observation on 3/18/25 at 1:45 PM, the Wound Nurse (RN A) was observed while providing R501's unstageable wound area, measured as 0.4 cm (in length) and 0.2 cm (in width). The wound depth was not measured. R501 was lying in bed, and her bare feet were cold and exposed, not in an elevated position, and she had no preventive protectors as care was planned to prevent pressure ulcers from developing. There were no pillows under her lower extremities to keep both heels off the pressure.R501's Percutaneous Endoscopic Gastrostomy…

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 MI00148880 Based on interview and record review the facility failed to contrive a plan to maintain the safety of one resident ((Resident #704) of one resident reviewed for wandering, after his Wanderguard was removed resulting in him eloping from the facility six days later. Findings Include: Resident #704: On 12/12/2024 at 11:15 AM, Resident #704 was observed sleeping peacefully in bed, hisWanderguard was affixed to his right ankle. On 12/12/2024 at approximately 12:00 PM, record review was completed of Resident #704's chart and it revealed he admitted to the facility on [DATE] with diagnoses that included, Vascular Dementia, Diabetes, Hypertension, Mood Disorder and Diabetes. Further review was completed of Resident #704's records and it yielded the following: Physician Orders: Wanderguard order was initiated in July 22, 2024 Care Plan: I am at risk for elopement r/t (related to): Resident makes statements regarding wish to leave, go home, or actions such as packing…

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 MI00148300. Based on observation, interview and record review, the facility failed to document a urinary catheter change and follow up on a positive urinalysis for one resident (Resident #706) of three residents reviewed for urinary catheters, resulting in a positive urinalysis, bluish purple tinged Foley catheter tubing and urinary drainage bag. Findings include: Resident #706: On 12/12/24, at 12:03 PM, Resident #706 was resting in their bed. There was a strong smell of urine in the room. Their urinary catheter tubing was bluish purple in color. The urinary collection bag was hooked to the bed with white clips. The bag manufacture name of Medline was on the bag. Nurse E entered the room. Nurse E removed the dignity cover to reveal the entire bag to be bluish purple in color. The area where the urine drained into the collection bag was a deeper blue color. Nurse E was asked how they assess the color of the urine and Nurse E stated, you can't see the urine until you dump…

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 MI00144608. Based on observation, interview and record review, the facility failed to prevent the development of a pressure wound and implement timely interventions and documentation for two residents (Resident (#9 and Resident #10) of three residents reviewed for pressure ulcers, resulting in Resident #10 developing an unstageable facility-acquired pressure wound to the left plantar foot and the potential for worsening of wounds, infection, pain and decline in overall well-being for Resident #9 and Resident #10. Findings include: Resident #10: A review of Resident #10's medical record revealed an admission into the facility on 4/29/22 and readmission on [DATE] with diagnoses that included heart failure, diabetes, and acquired absence of right great toe. A review of the Minimum Data Set (MDS) assessment, dated 4/30/24, revealed the Resident had moderately impaired cognition and the Resident was dependent on helper for toileting hygiene, bathing, lower body dressing,…

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 MI00144249. Based on observation, interview and record review the facility failed to provide sufficient staffing levels, including days with less than eight hours of Registered Nurse (RN) coverage, to meet the residents' needs for the facility census of 118, 6 residents (#27, #33, #49, #62, #101, #104) and a Confidential Group of residents, resulting in late medication administration, long call light wait times and unmet care needs. Findings include: On 05/28/24 at 10:57 AM, record review of nurse staffing assignments and time cards revealed that there were multiple days where the facility had less than eight hours of RN coverage. Reviewed staffing for eight hours of RN coverage: -01/01/24 5.51 hrs -01/15/24 0 hrs An interview was conducted with the Nursing Home Administrator (NHA). The NHA was asked why the facility did not have an RN in the building on those days and if they were aware of this. The NHA stated they were unsure why there were less than eight hours of RN…

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 maintain a sanitary kitchen by not properly cleaning and drying cookware/food containers/food trays/hot plate dispenser prior to stacking/storing, and ensuring dish machine sanitation of washed items; 2) Failed to dispose of expired food items; 3) Failed to ensure that plates were safe for use; and 4) Failed to maintain sanitary and safe cereal containers, resulting in the potential contamination of food, bacterial harborage, the increased potential for food borne illness and injury from chipped plates. This deficient practice had the potential to affect all residents that consume food prepared in the kitchen. Findings include: On 5/19/24 at 9:55 AM, an initial tour of the kitchen was conducted with Dietary Manager Y. The following observations were made: -Stacked dirty plastic food storage containers. The Dietary Manager was asked if the stacked items were ready for use, and he indicated they were and removed the items with debris on them. -Large drink dispenser containers, wet inside, not allowed to air…

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 has 2 Deficient Practice Statements (DPS): Deficient Practice Statement #1: Based on interview and record review, the facility failed to follow Standards of Practice for Infection Control, including collection of infection surveillance data, analysis of surveillance data to identify trends and patterns, and routine reporting of the surveillance findings to aid in preventing the spread of infection, which could result in infectious illness and unidentified outbreaks. Findings Include: FACILITY Infection Control On [DATE] at 11:17 AM, the Infection Prevention and Control program was reviewed with the Director of Nursing/DON and the new Infection Prevention and Control/IPC Nurse I. The DON said IPC Nurse I was new to the role and had been working in it about 1 month. He said over the past year, there had been 3 or 4 staff in the role. During the interview, the DON said the facility used McGeer's Criteria for surveillance of infections, to determine a Healthcare Associated Infection/HAI vs a Community…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an effective pest control program, resulting in uncontrolled pests throughout the entire facility, affecting all residents. Findings include: During the revisit survey conducted 7/22/24 to 7/24/24, countless gnats were observed throughout the entire facility, including resident rooms, hallways, dining rooms, offices, and conference rooms. Additionally, observations included drain flies and houseflies, some of which were observed on and around resident's bare skin, wounds, tracheostomy, and bedding. Observations included: room [ROOM NUMBER]: On 7/22/24 at 3:40 PM, there were several large gnats flying around the room and the resident laying in bed. room [ROOM NUMBER]: On 7/23/24 at 8:50 AM, the resident was observed seated in a wheelchair, eating breakfast. There were multiple gnats observed flying around the room, as well as landing on the resident's food. The resident reported that was an issues that had been going on for a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Residents dignity was maintained for Resident #'s (5, 16, 49, 58, 59, 62, 71, 72, 102,104 and R#223) and a group of Residents that attended a Resident group meeting, of a sample of 25, resulting in thread bare gowns, long call light wait times, Residents not provided a snack when the meal was late, unaware of an appointment, lack of snacks available, frustration, positioned in bed with the head of the bed lower than feet with no bed controller, call light in reach, and the potential for unmet care needs, hunger and embarrassment. Findings include: Resident Group Meeting On 5/21/24 at 10:02 AM, a group meeting was held with 10 Confidential Residents. The group was asked about care provided with dignity. The group indicated that personal phone use was an issue with staff watching a movie on their phone while giving medication. Two Residents indicated that staff use ear buds in their ears and talk to someone, one Resident said she was…

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

Based on observation, interview, and record review, the facility failed to ensure that call lights were easily accessible and within reach for three residents (Resident #16, Resident #46, and Resident #55) of four residents reviewed for call light placement, resulting in the inability to summons help when needed. Findings include: R16: On 7/22/24 at 3:40 PM, R16 was observed laying in bed. The adaptive call light was observed placed on the upper right side of the bed (near their head) and when asked if they were able to reach the call light if they needed assistance, the resident attempted to use their arms to reach up and stated they couldn't reach it. R46: On 7/23/24 at 9:05 AM, the resident was observed seated in bed with HOB elevated. Tube Feeding was running via a pump. The resident's call light was observed clipped to the tube feeding pole that was approximately three feet away from the bed. When asked if they needed to call for assistance, could they reach the call light and R46 began to search around their body and along the mattress and reported they couldn't see (blind)…

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 MI00144249. Based on observation, interview, and record review the facility failed to provide a clean, comfortable and home like environment to ensure that hallways, resident rooms, floors and other facility areas were clean, uncluttered, and in good repair for one Resident #33 and four resident rooms (401, 410, 413, 421), resulting in an unclean physical environment, resident dissatisfaction and complaints regarding the lack of cleanliness. Findings Include: FACILITY Environment A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #31 indicated admission to the facility on 8/2/2023 with diagnoses: Diabetes, kidney disease, left ankle pressure ulcer Stage 3, spine disorder, depression, history of seizures, prostate enlargement, right leg amputation below the knee, hypertension, and anemia. The MDS assessment dated [DATE] revealed the resident had moderate cognitive decline with a Brief Interview for Mental Status (BIMS) score of 9/15 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 Resident #12 Accidents On 5/28/24 at 12:30 PM, R12's Electronic Medical Record (EMR) revealed that he was admitted on [DATE] with a diagnosis of Aphasia secondary to Cerebral Infarction, Hemiparesis, and Hemiplegia affecting the dominant left side and Dementia in addition to other diagnoses. The Brief Interview for Mental Status (BIMS) Score dated 5/21/24 assessment was four. A score of zero to seven indicates the person is severely impaired. R12's Determination of Decision-Making Ability, signed on 2/15/2024 by the attending physician and psychologist, determined that R12 was NOT able to make decisions to participate in medical treatment decisions and handle his own financial affairs. Smoking Assessment according to review of records on 5/21/24 at 12:30, R12's Smoking Assessment was last performed dated 8/22/22. No recent assessment was done after 8/22/22. A review of R12's Care Plan date created on12/19/2019 revised dated 08/19/2021 revealed: .Focus: I am a supervised smoker. Interventions: 1. I wear a smoking…

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's) including showers, bathing, dressing, transferring to wheelchair, nail care and shaving for 8 residents (#16, #22 #27, #35, #40, #46, #49, and #101), from a sample of 12 residents reviewed for ADL care, resulting in residents' feelings of frustration, discouragement, and embarrassment. Findings Include: Resident #35 Activities of Daily Living A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #35 was admitted to the facility on [DATE] with diagnoses: Diabetes, COPD, anxiety, depression, hypertension and cataracts. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 14/15 and the resident was independent with most care and needed some assistance with transfer and showers, and supervision with mobility. On 5/19/24 at 10:56 AM, Resident #35 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 1.) correctly document a fall timely and complete neurological monitoring for Resident #104, who had a fall with a head injury; 2.) ensure fall prevention interventions were in place for Resident #58; 3.) ensure supervision and safety interventions were in place for Resident #12, who went out of the facility to smoke; and 4.) ensure safe water temperatures, of four reviewed for accident and falls and one reviewed for smoking safety, resulting in the lack of documentation accuracy in the medical record and the potential for signs and symptoms of a head injury to not be detected or treated, falls to reoccur, injury, burns and pain. Findings include: Resident #104 A review of Resident #104's medical record revealed an admission into the facility on 1/16/24 with diagnoses that included heart disease, chronic obstructive pulmonary disease, diabetes, bipolar disorder, and need for assistance with personal care. A review of Resident #104's MDS…

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 reconcile narcotic medication storage, maintain accurate and legible documentation of four medication cart Narcotic Count Sheets of four carts reviewed for narcotic storage and ensure narcotics were secured in the medication refrigerator on the third-floor medication room of two medication rooms reviewed, resulting in the potential for narcotic diversion. Findings include: On 7/23/24 at 1:20 PM, the medication room on the 3rd floor was observed for medication storage with Nurse U. An observation was made of lorazepam (benzodiazepine-antianxiety, sedative-hypnotic medication that was a DEA Schedule IV controlled substance) in the medication room refrigerator and was in a hard plastic box. When asked about the key to the narcotic box, Nurse U explained that the key was in the back-up medication system and had to be signed out in the system computer. The box was not secured in the refrigerator and could be removed from the refrigerator. There was an injectable vial of lorazepam and an oral liquid solution 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.

Based on observation, interview, and record review the facility failed to store and handle medications in accordance with acceptable pharmaceutical standards of practice: 1.) for three of three (3 or 3) medication rooms 2.) ensure medication refrigerator temperatures outside of acceptable parameters were addressed; 3.) ensure medication carts and treatment carts were secured and locked when unattended; 4.) ensure medications were not expired in all three medication (med) storage room and med carts; and 5.) ensure the freezer in the 4th floor med room was maintained regularly without ice build-up, resulting in the potential for contamination of medications, incorrect administration of medications, a lack of therapeutic benefits necessary to promote healing for residents, increased potential for adverse effects, and resident, staff or visitor access to unsecured medication cart. Findings Include: During the observation tour on the Fourth (4th) Floor on 05/21/24 at 09:52 AM, the following were observed: Fourth Floor 4th Floor Med Storage Room: On 5/21/24 at 09:52, during an observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a substantial evening snack was consistently offered to one Resident (#55) and a group of confidential residents that attended the Resident group meeting, potentially affecting all residents who receive meals in the facility with 14 or more hours between the last evening meal and breakfast the next day, resulting in Resident dissatisfaction, frustration and potential uncontrolled blood sugars, signs and symptoms of hypoglycemia, feelings of hunger, and weight loss. Findings include: Resident Group Meeting On 5/21/24 at 10:02 AM, a group meeting was held with 10 Confidential Residents. The group was asked about nighttime snacks being available. The Residents expressed that snacks were not consistently brought up and that other Residents would raid the snacks leaving nothing left for others. Three of the Residents voiced that they were diabetics, and a substantial snack was not always available before they went to bed due to other…

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

Based on interview, and record review the facility failed to ensure that resistance patterns of infectious organisms were identified, analyzed and reviewed in the Antibiotic Stewardship Program, potentially affecting all residents with exposure to unnecessary medications, antibiotic resistance and infection. Findings Include: FACILITY Infection Control On 5/21/24 at 11:17 AM, the Infection Prevention and Control program was reviewed with the Director of Nursing/DON and the new Infection Prevention and Control/IPC Nurse I. The DON said IPC Nurse I was new to the role and had been working in it about 1 month. He said over the past year, there had been 3 or 4 staff in the role. During the interview, the DON said the facility used McGeer's Criteria for surveillance of infections, to determine a Healthcare Associated Infection/HAI vs a Community Acquired Infection/CAI. He said they had identified that some providers were ordering antibiotic treatment for resident infections, but the nurses weren't documenting signs and symptoms of the infections. The DON said the facility met monthly for…

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 On 05/19/24 at 9:55 AM, an initial tour of the 200 unit was conducted: -It was noted the 200 unit had a strong smell of urine upon exiting the elevator near the nurses station. -room [ROOM NUMBER] had a strong scent of urine, no resident was present during observation. The hallway outside of room [ROOM NUMBER] had a strong smell of air freshener to mask the urine smell. -room [ROOM NUMBER]-1 had a mattress in poor condition, the top coating was cracked and chipping off. -room [ROOM NUMBER]-2 had a bedside table in poor repair, the top of it was bubbled and peeling. There was mold noted on the floor by the bathtub. -room [ROOM NUMBER]-2 had a mattress in poor condition, the top coating was cracked and peeling. The bathroom needs drywall repair over the toilet. the toilet was turned on an angle and not secured to the floor, no bag in the garbage can. -The second floor shower room revealed no bag in the garbage can and no paper towels in the holder by the sink. -One of the elevators had cracked moulding near the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Code Status was assessed, documented and accessible in the medical record for 2 residents (#'s 35 and 55) of 3 reviewed for Advance Directives, resulting in the potential for the resident's lack of informed knowledge related to options for code status and miscommunication of code status which could lead to a lack of appropriate interventions for care. Findings Include: Resident #35 Advance Directives A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #35 was admitted to the facility on [DATE] with diagnoses: Diabetes, COPD, anxiety, depression, hypertension and cataracts. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 14/15 and the resident was independent with most care, needing some assistance with showers, and supervision mobility. A review of the Medical Treatment Decision Form, for Resident #35 identified Full…

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 complete and transmit a discharge minimum data set (MDS) assessment timely for one resident (#60) of one resident reviewed for MDS assessments, resulting in the late completion and transmission of an MDS discharge assessment. Findings include: Record review revealed that R60 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, acute respiratory failure, depression and hypoxemia. R60 discharged from the facility on 12/04/23. On 05/21/24 at 11:30 AM, record review revealed a discharge MDS assessment was completed late on 04/30/24 and not transmitted to the Centers for Medicare and Medicaid Services (CMS) for R60. R60 discharged from the facility on 12/04/23. On 05/21/24 at 11:54 AM, and interview was conducted with MDS Coordinator 'D'. MDS Coordinator 'D' was asked why the discharge MDS assessment was completed late and not transmitted for R60. MDS Coordinator 'D' stated that they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete yearly PASARR (Pre-admission Screening/Annual Resident Review) Level II Screening and/or exemption criteria certification for one Resident #6 of two reviewed for PASARR documentation, resulting in the lack of yearly follow-up PASARR and the possibility for the Resident to forgo specialized behavior/mental health services. Findings include: A review of Resident #6's medical record revealed an admission into the facility on 2/20/18 and readmission on [DATE] with diagnoses that included schizophrenia, major depressive disorder and unspecified dementia, severe, with other behavioral disturbance. A review of Resident #6 medical record revealed a PASARR dated 6/26/22, Form DCH-3877 that revealed Section II-Screening Criteria that marked Yes for The person has a current diagnoses of Mental Illness and Dementia and Yes for The person has received treatment for Mental Illness and Dementia with instruction to Explain any Yes DX (diagnosis): Dementia,…

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 comprehensive care plans were developed and implemented for two residents (#41,#62) of 23 residents reviewed for comprehensive care plans resulting in incomplete care plans, dignity concerns and potential for unmet care needs. Findings include: Resident #41 On 05/20/24 at 11:24 AM, observation revealed a catheter bag uncovered and full of urine. On 05/20/24 at 04:09 PM, record review revealed there was no care plan in place for the catheter. On 05/21/24 at 09:50 AM, observation revealed the catheter bag was uncovered with urine present in it. On 05/21/24 at 09:56 AM, an interview was conducted with the Licensed Practical Nurse (LPN) 'L' providing care for R41. LPN 'L' was asked about the indwelling catheter that R41 has in place. LPN 'L' was asked if there was a diagnosis, order or a care plan for the catheter. LPN 'L' stated they believe the resident had some issues with urinary retention but could not locate an order, diagnosis or…

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 promptly identify changes in skin, complete accurate skin and wound assessments, and implement timely interventions for one resident (Resident #5) of one resident reviewed for non-pressure injury wounds, resulting in the lack of assessment, monitoring and potential worsening of the condition and delayed healing. Findings include: Resident #5 (R5): On 7/22/24 at 3:38 PM, R5 was observed laying in bed on their back, with a thin top sheet covering them. Their feet were crossed at the ankles and both feet were observed barefoot with heavily flaking, dry skin. The top second toe of the right foot was observed to have a large, dried scab about the size of a nickel, and the third toe had a smaller scab area on top of the toe. There was no treatment observed in place. The resident responded by looking when addressed, but responses were very difficult to understand. Certified Nursing Assistant (CNA 'G') was observed entering in and out of 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 appropriate interventions were in place to prevent facility acquired pressure ulcers for 2 residents (#'s 31 and 55) and interventions were utilized as ordered to promote prevention and healing for 3 resident (#31, #55 and #101) of 5 reviewed for skin and pressure ulcers, resulting in Resident's # 31 developing a pressure ulcer on his toe; Resident #55 developing multiple pressure ulcers and Resident #101 lacking positioning devices to aid in pressure ulcer prevention. Findings Include: Resident #31 Pressure Ulcer/Injury A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #31 indicated admission to the facility on 8/2/2023 with diagnoses: Diabetes, kidney disease, left ankle pressure ulcer Stage 3, spine disorder, depression, history of seizures, prostate enlargement, right leg amputation below the knee, hypertension, and anemia. The MDS assessment dated [DATE] revealed the resident had moderate…

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 identify and implement interventions, to address changes in Range of Motion/ROM for one resident (#31) of one reviewed for range of motion, resulting in Resident #31 developing limited movement in 4 fingers and his thumb on the right hand. Findings Include: Resident #31 Position, Mobility A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #31 indicated admission to the facility on [DATE] with diagnoses: Diabetes, kidney disease, left ankle pressure ulcer Stage 3, spine disorder, depression, history of seizures, prostate enlargement, right leg amputation below the knee, hypertension, and anemia. The MDS assessment dated [DATE] revealed the resident had moderate cognitive decline with a Brief Interview for Mental Status (BIMS) score of 9/15 and needed some assistance with eating and hygiene and dependence with all other care. On [DATE] at 10:17 AM Resident #31 was observed lying in bed watching TV. He showed…

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 assess and maintain an indwelling urinary catheter for three residents (#30, #41, #55) of three residents reviewed for indwelling catheters, resulting in unmet care needs, missing dignity bags and the potential for infection. Findings include: Resident #41 Record review revealed that R41 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, chronic kidney disease, peripheral vascular disease and type 2 diabetes. On 05/20/24 at 11:24 AM, observation revealed that R41 had an indwelling catheter, the catheter bag was uncovered and full of urine. R41 was asked about the indwelling catheter and how long they had it in for. R41 would not respond to the surveyor. On 05/20/24 at 04:09 PM, record review revealed no physicians order, no care plan, no justification and no certified nursing assistant (CNA) tasks in the electronic health record (EHR) for the indwelling catheter. 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 promote nutrition and prevent weight loss for two residents (# 30 and #70) and provide hydration for one resident (#55), of 7 reviewed for food, nutrition, and hydration, resulting in Resident # 30 developing significant weight loss, #70 developing weight loss and Resident #55 lacking access to fresh water, which could lead to a decline in condition and a decreased quality of life. Findings Include: Resident #55 Hydration On 5/19/24 at 12:04 , Resident #55 was observed lying in bed, awake. The resident said he was waiting for lunch. The resident was observed to have no water at the bedside, when asked about it he stated, Why don't they bring me water anymore. He had an empty clear cup on the bedside table. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Multiple sclerosis, severe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 1. Enteral nutrition (tube feeding/nutrition through a feeding tube into the stomach or intestines) was provided as ordered for Resident #46; 2. the feeding tube was managed and documentation provided per standards of care for 1 resident # (62); and 3. Enteral feeding equipment was properly labeled for Resident #62, resulting in Resident #46 receiving the wrong dose of Enteral feeding, Resident's #62 lacking documentation of care of the Enteral feeding and Resident #62 had unlabeled/dated equipment that could lead to infection. Findings Include: Resident #46 Tube Feeding A review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #46 indicated the resident was readmitted to the facility on [DATE] and again on 8/16/2023 with diagnoses: history of a stroke, dysphagia, irritable bowel syndrome, epilepsy, dementia, depression, hypertension diabetes, atrial fibrillation, bipolar disorder, COPD, gastrostomy tube/feeding…

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.) emergency tracheostomy equipment was readily available at the Resident's bedside, ensure tracheostomy equipment was properly dated and oxygen humidification and tracheostomy equipment was discarded timely for Resident #62 and 2.) nebulizer equipment was stored in a sanitary manner for Resident #33, of four reviewed for tracheostomy and respiratory care, resulting in tracheostomy cannula not readily available for emergent use for decannulation and the potential for respiratory distress, exposure to infectious organisms, and respiratory infections. Findings include: Resident #62 A review of Resident #62's medical record revealed an admission into the facility on 3/5/21 and readmission on [DATE] with diagnoses that included Parkinson's disease, acute respiratory failure, tracheostomy status, diabetes, muscle weakness and gastrostomy. A review of the Resident's Minimum Data Set assessment revealed a BIMS score of 14/15 that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure coordination of dialysis care for one Resident (#2) of 1 reviewed for Dialysis services, resulting in a lack of assessment for the left arm Dialysis fistula, dressing and site, resulting in the potential for unidentified complications. Findings Include: Resident #2 Dialysis A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Respiratory failure (5/14/2024), COPD, end stage renal disease, dependence on renal dialysis, heart disease, anemia, atrial fibrillation, pain, depression, hypothyroidism, history of venous thrombosis and GERD. The MDS assessment dated [DATE] indicated the resident had moderate cognitive loss with a Brief Interview for Mental Status (BIMS) score of 10/15 and the resident needed some assistance with all care. On 5/20/24 at 9:22 AM, during a tour of the facility, Resident #2 was observed lying…

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 upon interview and record review, the facility failed to act upon recommendations regarding medication irregularities timely and produce pharmacy recommendation reports from monthly medication regimen reviews for two Residents (#42 and 49), of five reviewed for unnecessary medication regimen reviews, resulting in the potential for inadequate monitoring, missed gradual dose reductions of psychotropic medications, medication side effects and adverse reactions. Findings include: Resident #49 A review of Resident #49's medical record revealed an admission into the facility on 6/6/23 and re-admission on [DATE] with diagnoses that included acute respiratory failure, diabetes, altered mental status, depression, neurocognitive disorder with lewy bodies, bipolar disorder, anxiety and dementia. A review of Resident #49's prescription medication orders, in the Order Summary Report, revealed the Resident was on Duloxetine for depression, gabapentin for neuropathy, insulin for diabetes, Lamictal that did not have 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 residents were 1) consistently assessed for Influenza, Pneumococcal and COVID-19 immunization on admission, 2) offered Influenza, Pneumococcal and COVID-19 vaccinations, , 3) documented the vaccinations were accepted or declined for one (Resident #2), of 5 residents reviewed for respiratory care and immunizations, resulting in a potential for widespread Influenza, Pneumonia and COVID-19 exposure and infection throughout the facility. Findings Include: FACILITY Infection Control Resident #2 A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Respiratory failure (5/14/2024), COPD, end stage renal disease, dependence on renal dialysis, heart disease, anemia, atrial fibrillation, pain, depression, hypothyroidism, history of venous thrombosis and GERD. The MDS assessment dated [DATE] indicated the resident 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 1) Failed to store and reconcile narcotics properly and legibly for the facility and 2) Failed to ensure proper disposal of discontinued narcotics, resulting in narcotic counts not reconciled accurately, undated and scribbled counts, unsigned reconciliation documents and 1919.5 doses of various narcotics disposed of with no documented proof and the likelihood of narcotic diversion going unnoticed. Findings include: On 4/17/24, at 8:20 AM, an observation along Nurse EE of the 3rd Floor medication room refrigerator was conducted which revealed a clear plastic locked box with 2 bottles of Ativan one being oral consumption and the other being injectable. The clear plastic box was not affixed to refrigerator and was quickly pulled out. Nurse P offered that the Ativan in the refrigerator was for back up stock. Nurse P was asked to provide the narcotic reconciliation document for the Ativan in refrigerator and Nurse P offered, it's not for a certain resident and we don't count it. Nurse P was asked who reconciled the narcotics…

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 maintain a sanitary kitchen and resident dining room, Failed to maintain the plumbing system, 3) Failed to ensure an air gap for the ice machine, and 4) Failed to maintain cleanliness of food contact surfaces and appliances, resulting in sewage back up on the kitchen floor, dirty blenders and cooking appliances, unkept walls, no air gap to the ice machine with an increased risk of contamination of waterborne and foodborne illnesses and /or hospitalization. Findings include: On 4/15/2024, at 10:00 AM, an observation of bed blankets laying on the floor at the base of the wall in the main dining room. Multiple residents complained that the kitchen had been leaking into the dining room. There were 2 white blankets that appeared stained with dirty water stains. There was a yellow wet floor sign notes near the blankets. On 4/15/2024, at 10:20 AM, an observation of the kitchen along with Kitchen [NAME] J was conducted. There was active water on the floor upon entering the kitchen door near the cooking appliances…

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 MI00142019. Based on observation, interview and record review the facility failed to administer medications timely for one resident (Resident #126), resulting in Resident #126 being administered more than twenty-five medications over ten hours late. Findings Include: Resident #126: On 4/16/2024 at approximately 11:30 AM, an interview was conducted with Resident #126 regarding medication administration and staffing. Resident #126 explained her medications are frequently late when there is only one nurse for their floor. She indicated when a nurse works the 7 PM-11 PM their medications are timelier. On Sunday, the resident waited from 7:30 PM to 10:30 PM to be changed as there were only two aides working. Resident #126 stated she was saturated with urine by the time they arrived she had urinated two more times. On 4/16/2024 at approximately 1:30 PM, a review was completed of Resident #126's medical records and it indicated she was admitted to the facility on [DATE] 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 interview and record review, the facility failed to assess and monitor a Percutaneous Inserted Central Catheter (PICC) for one resident (Resident #122), resulting in no ongoing documented assessments, flushes and dressing changes for the PICC with the likelihood of complications going unnoticed. Findings include: Resident #122: On 4/16/2024, at 11:00 AM, a record review of Resident #122's electronic medical record revealed an admission on [DATE] and a discharge on [DATE] with diagnoses that included Sepsis, endocarditis and Intravenous drug use. Resident #122 had intact cognition and was independent with all Activities of Daily Living. A review of the Admission/readmission Assessment Date: 2/29/2024 revealed . Does the resident have a vascular access device? (PICC .) a. Yes . Any signs of infection at insertion site? B. No Dressing is clean, dry and intact? A. Yes Length of catheter (PICC) 38 Number of lumens: 1 . A review of the admission Note 2/29/2024 14:40 (2:40 PM) revealed Resident arrived 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.

Based on interview and record review, the facility failed to provide Physician-ordered medications timely for one resident (Resident #120), resulting in complaints of late medications, pain and disappointment with the likelihood of ongoing symptoms of health conditions such as pain, wheezing, and gastrointestinal complaints. Findings include: Resident #120: On 4/17/24, at 9:00 AM, a record review of Resident #120's electronic medical record revealed an admission on a 2/08/2024 at 1:48 PM with diagnoses that included Hypertension, Cauda Equina Syndrome, and Low back pain. Resident #120 had intact cognition. On 4/18/2024, at 9:00 AM, Resident #120 was interviewed regarding their concerns with not getting their mediations timely. Resident #120 complained they didn't get their pain medication until the second day being in the facility and was in pain. Resident #120 complained they ultimately decided to go home and complained of disappointment in getting their medications late. A review of the physician orders revealed the above medication were ordered to start 02/08/2024 and/or…

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, the facility failed to provide a 14 day stop date for a PRN (as needed) psychotropic drug (Alprazolam) for one resident (Resident #123), resulting in the ongoing PRN use of the medication and unassessed ongoing need longer than 14 days. Findings include: Resident #123: On 4/16/24, at 10:00 AM, a record review of R#123's electronic medical record revealed a readmission on [DATE] with diagnoses that included Quadriplegia, Depression and Anxiety. Resident #123 had intact cognition and required extensive assistance with all Activities of Daily Living. A review of the Physician's orders revealed ALPRAZolam Oral Tablet 0.25 MG (milligrams) Give 1 tablet by mouth every 8 hours as needed for anxiety Start Date 04/01/2024. There was no stop date. A review of the MEDICATION ADMINISTRATION RECORD 4/1/2024 - 4/30/2024 revealed the resident received 15 doses starting on 4/2/24 through 4/17/24.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Numbers MI00142411 and MI00142450. Based on observation, interview, and record review the facility failed to provide monitoring and supervision to prevent the elopement from the facility of one resident (Resident #701) of three residents reviewed for wandering/elopement, resulting in Resident #701 exiting the facility with the independent smokers unbeknownst to facility staff. Facility residents alerting facility staff he had eloped from the facility. The facility is being cited at Past Non-Compliance. The Compliance Date is [DATE]. Findings Include: Resident #701: On [DATE], a review was conducted of Resident #701's medical records and it revealed he was admitted to the facility on [DATE] with diagnoses that included, Cerebral Infarction, Adjustment Disorder and Dementia. Resident #701 has a guardian and was assessed as being cognitively impaired. Further review of Resident #701's records revealed the following: Progress Notes: [DATE] at 15:30: Nurse was informed that 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 This Citation pertains to Intake Number MI00139793 Based on observation, interview, and record review the facility failed to prevent misappropriation and exploitation of one resident (Resident #512) by Certified Nursing Assistant (CNA) J, resulting in CNA J allowing Resident #512 to believe they were in a relationship with one another to incentivize him to complete daily care tasks and accepting gifts from the resident with a high probability of decline in current quality of life and psychosocial harm. The surveyor confirmed by observation, interview, and record review that the deficient practice was corrected on 09/26/2023, prior to the start of the survey, and, therefore, past noncompliance was granted. Findings Include: Resident #512: On 9/28/2023 at approximately 4:15 PM, a review was completed of Resident #512's medical records, and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included, Metabolic Encephalopathy, Diabetes, Major Depressive Disorder and Schizophrenia.…

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 dish machine, maintain a sanitary kitchen, and maintain nourishment refrigerators, resulting in the potential contamination of food and equipment, affecting all residents who consume food from the kitchen. Findings include: On 4/18/23 at 11:52 AM, a leak was observed behind the dish machine, with water accumulating on the floor. At this time, Dietary Manager HH stated that the dish machine was new and they will have the service technician out to fix it. Additionally, the exhaust hood for the hot water sanitizing dish machine was observed to not be functioning. Steam was observed to be rolling out from the dish machine during the wash cycle. According to the 2017 FDA Food Code Section 5-205.15 System Maintained in Good Repair. A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; P and (B) Maintained in good repair. On 4/18/23 at 12:00 PM, the shelf underneath the coffee machine was observed to have dry coffee stains and splashes. Additionally, coffee carafes stored under the coffee machine…

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 specify testing protocols and acceptable ranges for control measures for the Water Management Plan and document the results of testing and corrective actions taken when control limits are not maintained, resulting in potential resident exposure to Legionella bacteria, affecting all residents in the facility. Findings include: During an interview on 4/19/23 at 3:18 PM, Interim Maintenance Director C was queried on the facility's control measures to reduce the risk of Legionella growth in the domestic water supply and stated that they flush the water at sinks and tubs once a month and monitor water temperatures. When asked if they document the control measure efforts, Interim Maintenance Director C stated, No, I don't have a system to get into yet. During an interview on 4/20/23 at 10:32 AM, Retired Maintenance Director, GG was queried on the routine Legionella test and stated that they test quarterly and treat the domestic water system with chemicals as needed. A review of a Legionella test result provided by [Laboratory],…

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 maintain a sanitary, home-like environment, resulting in the potential contamination of the facility and equipment, and a non-home-like environment, affecting the residents on the 2nd and 3rd floors. Findings include: On 4/18/23 at 2:10 PM, the floor, at the bathroom entrance of room [ROOM NUMBER], was observed to be peeling up and chipped. On 4/18/23 at 2:11 PM, the floor by Bed 2, of room [ROOM NUMBER], was observed to be soiled with debris. The wall by the headboard of Bed 2 was observed to have an unknown dried splatter. Additionally, the bathroom of room [ROOM NUMBER] was observed to have brown staining on the toilet paper holder. On 4/18/23 at 2:23 PM, the bathtub faucet, in the bathroom of room [ROOM NUMBER], was observed to be running and could not be turned off. Additionally, the bathroom hand sink drain line was observed to be leaking, with water accumulating on the floor. On 4/18/23 at 2:24 PM, the walls near Bed 1 of room [ROOM NUMBER] were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to review and revise care plans with resident-centered changes, to ensure that interventions necessary for care and services were provided for 2 residents (Resident #8 and Resident #20) of 67 residents reviewed, resulting in the potential for unmet care needs. Findings Include: Resident #8: Activities of Daily Living: A record review of the Face Sheet and Minimum Data Set (MDS) assessment indicated Resident #8 was originally admitted to the facility in 2015 and readmitted [DATE] with diagnoses: history of a stroke, dementia, left sided weakness, history of seizures, difficulty swallowing, has a feeding tube, GERD, malnutrition, a history of septic shock, depression, hypertension and chronic pain. The MDS assessment dated [DATE] revealed the resident had severe cognitive decline, with a Brief Interview for Mental Status (BIMS) score of 3/15 and the needed 2-person total assistance with bed mobility and transfers 1-person total assistance with eating,…

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 #27: A review of Resident #27's medical record revealed an admission into the facility on 2/15/18 with diagnoses that included multiple sclerosis (MS), muscle weakness, paraplegia, diabetes, depression, and dementia. A review of the Minimum Data Set assessment, dated 3/10/23, revealed a Brief Interview of Mental Status score of 15/15 that indicated intact cognition and the Resident needed extensive assistance with bed mobility, transfers, dressing, personal hygiene and was total dependent of one-person physical assist for bathing. On 4/18/23 at 11:46 AM, an observation was made of Resident #27 lying in bed and dressed in a gown. The Resident is interviewed, answered questions and conversed in conversation. The Resident was asked about bathing. The Resident indicated he gets bed baths but would prefer showers and reported they just come in and do the bed bath. The Resident was asked about nail care and an observation was made of the Resident's right hand in a fist. The Resident was able to spread his…

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 assess and monitor weight changes, implement timely nutritional interventions for weight loss, complete nutritional assessment and obtain weights per facility policy for three residents (Resident #50, Resident #63 and Resident #220) reviewed for nutrition, resulting in, substantial weight loss, lack of assessment and interventions for Resident #50 and Resident #63 and failure to obtain weekly admission weights for Resident#220 with the potential for continued weight loss, facility inaction and death. Findings include: Resident #50: During initial tour on 4/19/2023, Resident #50 was observed resting in bed as the housekeeper began to clean her room. The resident did not appear to be any distress and was well groomed. On 4/20/2023 at approximately 8:45 AM, a review was completed of Resident #50's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included, Huntington's Disease, Dysphagia,…

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, in part, pertains to Intake Number MI00135512. Based on interview and record review, the facility failed to ensure that licensed nurses and Certified Nursing Assistants (CNA) received yearly training/competencies to assure resident care and safety, and attain or maintain the highest practicable physical, mental and psychosocial well-being of residents in accordance with the facility assessment and residents' plans of care for two nurses and five CNA's reviewed for yearly competencies, affecting all 117 Residents residing in the facility, resulting in potential nursing staff lacking necessary training and competencies to adequately care for the needs of the residents residing in the facility and unmet resident needs. Findings include: Based on interview and record review, the facility failed to ensure licensed nurses and certified nursing assistants (CNAs) received yearly skills evaluation and competencies for four nurses of four reviewed and four CNAs of five reviewed for education and yearly competencies, resulting in the potential for nursing staff to lack 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, in part, pertains to Intake Number MI00135512. Based on observation, interview and record review, the facility failed to ensure appropriate narcotic medication practices including: destruction of narcotics, administering medications late, storage of narcotics with the nurses personal belongings, medications found unattended on the floor, administration of back up medication, and nursing failure to observe the resident consume medication, for five residents (Resident #1, Resident #27, Resident #35, Resident #48 and Resident #68) and residents on the 2nd and 4th floors from a census of 117 residents, resulting in the potential for resident, staff and visitor access to medications including narcotics, residents not receiving medications as ordered, and a lack of therapeutic effect or adverse side effects. Findings Include: Medication Administration: On 4/20/2023 at 9:40 AM, during a medication administration observation with Nurse O, the nurse opened the narcotics drawer to remove a narcotic for…

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) Ensure proper labeling of medications, 2) Maintain clean and sanitary medication storage, and 3) Dispose of expired medication and medical supplies for two medication carts, one medication room and one treatment cart on the 200 Halls reviewed for medication labeling and storage, resulting in the lack of clean space to store and prepare medications, and the potential for residents to receive expired medication with altered potency and efficacy and medical procedures completed with outdated supplies. Findings include: On 4/20/23 at 11:29 AM, an observation was made during medication labeling and storage task of the survey with Nurse H of the East Medication Cart on the 200 Hall. An observation was made of Novolog insulin opened and used without a date when the insulin was opened. The Nurse was asked how long the insulin was good for after opening and the Nurse responded with 21 to 28 days depending on the insulin and indicated they should be labeled with an open date. A review of liquid stock medication 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 interview and record review, the facility failed to develop and implement baseline care plans to guide the care provided to two residents (Resident #220 and Resident #221) of 67 residents reviewed for care plans, resulting in the failure to provide instructions to the staff for effective and person-centered care to promote well-being and manage the nutritional status for Resident #220 and provide a plan for showers and bathing for Resident #221. Findings Include: Resident #220: Nutrition: On 4/18/23 during a tour of the facility at 1:10 PM, Resident interviewed in his room, he was eating lunch, chicken potatoes, greens, he said lunch was ok today, but it had not been every day and he was losing weight. Resident #220 said he has been in the facility for about 3 weeks. He said he went from about 140 lbs. to 115 lbs. He showed his shoulders, arms, stomach, and he appeared very thin. He said he was worried. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #220 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 interview and record review, the facility 1) Failed to assess, monitor, and provide timely interventions for one resident (Resident # 118) reviewed for a change of condition and 2) Failed to ensure that a Boston Heart Monitor was at bedside and in use for one resident (Resident #46) from a census of 117, resulting in unassessed Heart Rhythm and in Resident's #118 developing vomiting and diarrhea without nursing assessments, monitoring or interventions to aid in identifying the cause or relieving discomfort. Findings Include: Resident #118: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #118 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Bipolar disorder, diabetes, arthritis, asthma, dementia, schizophrenia, hypertension, and syncope and collapse. The MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status Score (BIMS) of 10/15 moderate cognitive decline and needed supervision with 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, interview and record review, the facility failed to ensure that Restorative Nursing services and the management and monitoring of a left arm brace were provided to one resident (Resident #76) of one resident reviewed for range of motion, resulting in Resident #76 lacking consistent placement of the brace and monitoring to determine if it was meeting the resident's needs. Findings Include: Resident #76: Position, Mobility A record review of the Face sheet and MDS assessment indicated Resident #76 was admitted to the facility on [DATE] with diagnoses: history of a stroke, left side weakness, difficulty swallowing, heart disease, and depression. The MDS assessment dated [DATE] revealed the resident had moderate cognitive loss and needed extensive 2-person assistance with transfers and 1-person assistance with bed mobility, dressing, eating, hygiene, showers, and toileting. On 4/18/23 at 2:48 PM, during a tour of the facility, Resident #76 was observed lying in bed in her room. She patted her…

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 appropriate interventions were enacted and supervision was provided to prevent a fall with injury for one resident (Resident #19) and neurological assessments were completed after a fall for one resident (Resident #61) of 4 residents reviewed for falls, resulting in Resident #19 falling out of bed and sustaining a femur fracture and Resident #61 with the potential for serious complications or injury. Findings Include: Resident #19: Accidents: A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #19 indicated she was admitted to the facility on [DATE] with diagnoses: history of a stroke, history of myocardial infarction, peripheral vascular disease, left leg above the knee amputation, right leg above the knee amputation, morbid obesity, heart disease, depression, hypertension, GERD, and Bipolar disorder. The MDS assessment dated [DATE] revealed the resident had mild cognitive loss with a Brief…

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 assess, monitor and care for a urinary catheter per standards of practice for one resident (Resident #30) of two residents reviewed for urinary catheters, resulting in no documented assessment or care of the catheter with the likelihood of signs or symptoms of catheter associated infection or problems going unnoticed. Findings include: Resident #30: On 4/18/23, at 12:14 PM, Resident #30 was resting in their bed. There was urinary catheter tubing dangling out of the blanket. The tubing had a mucus cloudy appearance with what appeared to be dried white particles (sediment) to the inside of the tubing. The urinary collection bag had a large amount of dried white sediment to the inside of the bad where the urine drains in. The urine color was amber yellow and cloudy. On 4/20/23, at 11:30 AM, an observation of Resident #30's catheter and tubing was conducted along with Nurse A. Nurse A pulled back the blanket to reveal the catheter tubing which…

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 1) Enteral nutrition (tube feeding/nutrition through a feeding tube into the stomach or intestines) formula was provided as ordered for Resident #50, 2) The feeding tube was managed per standards of care and the facility policy for Resident #8 and 3) Dressing changes were performed at the feeding tube insertion site into the abdomen as ordered for Resident #46 of 4 residents reviewed for enteral nutrition, resulting in the potential for Resident #50 to not receive the appropriate amount of Enteral formula and Residents #8 and Resident #46 to experience adverse effects from a lack of management of the feeding tube. Findings Include: Resident #8: Tube Feeding A record review of the Face Sheet and Minimum Data Set (MDS) assessment indicated Resident #8 was originally admitted to the facility in 2015 and readmitted [DATE] with diagnoses: history of a stroke, dementia, left sided weakness, history of seizures, difficulty swallowing,…

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 MI00135512. Based on observation, interview and record review, the facility failed to administer prescribed narcotic medication as ordered by the physician and ensure effective pain management to alleviate pain from an infection of the left hand and lancing of the area, for one resident (Resident #48) of one resident reviewed for pain management, resulting in a lack of pain assessment and administration of narcotic medication with the potential for unrelieved pain and discomfort. Findings include: Resident #48: A review of Resident #48's medical record revealed an admission into the facility on [DATE] and re-admission on [DATE] with diagnoses that included chronic obstructive pulmonary disease with exacerbation, diabetes, obesity, acute and chronic respiratory failure, epilepsy, hypoxemia, cellulitis, nicotine dependence, stroke, and tracheostomy status. A review of the Minimum Data Set assessment, dated 2/28/23, revealed a Brief Interview of Mental Status score of 13/15…

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 Based on observation, interview and record review, the facility 1) Failed to follow policy on performing/monitoring quality control of glucometers for three glucometers on the 200 Hall, 2) Failed to label glucometer control solutions when opened, failed to dispose of expired glucometer control solutions and 3) Failed to perform glucose monitoring consistent with professional standards of practice that would provide the most accurate results of blood glucose monitoring for Resident #27, affecting residents who reside on the 200 Hall needing glucose monitoring, resulting in the potential for inaccurate test results and inappropriate or lack of treatment governed by the test results. Findings include: Resident #27: A review of Resident #27's medical record revealed an admission into the facility on [DATE] with diagnoses that included multiple sclerosis (MS), muscle weakness, paraplegia, diabetes, depression, and dementia. A review of the Minimum Data Set assessment, dated [DATE], revealed a Brief Interview 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.