Willowbrook Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #81: Nutrition A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #81 was admitted to the facility on [DATE] with diagnoses: Heart failure, COPD, mild protein-calorie malnutrition, anxiety, and difficulty walking. On 6/24/2025 at 11:20 AM, Resident #81 was observed sitting in his room in bed. When asked about his meals at the facility, he said he was supposed to receive double portions of meat, but did not always receive them. He said he had talked to the Nurse Practitioner/NP and Unit Manager about it, but it didn't change anything. During the interview with Resident #81 on 6/24/2025 at 11:20 AM, he said the previous night, there were no hotdogs or hamburgers as an alternative to the regular menu. He said he was told by the staff they were out of them. The resident said he had to eat very greasy, grilled cheese. He said they gave him 2 grilled cheese, but he could only eat 1, because of the grease. The resident read the menu for 6/24/2025 and stated, Tonight 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.

This Citation pretains to Intake Number MI00153408. Based on observation, interview and record review, the facility failed to obtain dental services timely for a Resident who received a partial denture for the bottom teeth that were ill-fitting, and unable to be used by the resident who had problems with chewing some foods for one resident (#84) of two residents reviewed for dental services. Findings include: Resident #84: On 6/24/25 at 12:27 PM, an interview was conducted with Resident #84 who was in his room, seated in a wheelchair. The Resident was asked about food services and reported he had issues with eating some of the foods that included chicken and hamburgers. The Resident was asked about issues with eating and the resident reported he had dentures that were made for the bottom teeth that when he received them, they did not fit properly. The Resident reported he can not wear the dentures at all because They don't fit. An observation was made of the resident's mouth with two teeth observed and the Resident explained that the denture was to fit around the remaining teeth,…

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 MI00150954. Based on interview and record review the facility failed to timely obtain new prescription to reorder pain medication for one resident (#801) of two residents reviewed for pain management and pharmacy procedures, resulting in, Resident #801 going without her patch for three days and increased pain. Findings include: Resident #801: On 3/18/2025 at approximately 11:15 AM, a review was conducted of Resident #801's clinical record and it indicated she admitted to the facility on [DATE] with diagnoses that included, Acute Respiratory Failure, Depression, Hypertension and Amyloidosis. Resident #801 is cognitively intact and able to make her needs known to staff. On 3/18/2025 at 12:50 PM, Resident #801 reported her Fentanyl patch is supposed to be changed every three days but at the beginning of March she went without it for a few days, and no one could explain to her why. The resident shared the patch had fallen off and typically they would apply a new patch 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 This Citation pertains to Intake Number MI00147318. Based on observation, interview and record review the facility failed to assess and monitor intravenous medication therapy per professional healthcare standards and a provider's order for two residents (Resident #702 and Resident # 703) of two residents reviewed for intravenous antibiotic therapy, resulting in Resident #703 being administered two doses of Vancomycin after elevated levels were received and a lack of monitoring and dosing of Resident #702's Vancomycin. Findings Include: Resident #702: On 10/15/2024 at approximately 4:00 PM, a review was conducted of Resident #702's medical records and it revealed the resident admitted to the facility on [DATE] with diagnoses that included, Necrotizing Fasciitis, Hypertension, Peripheral Vascular Disease, Stage 3 Kidney Disease and Supraventricular Tachycardia. Resident #702 was alert and able to make his needs known to staff. Further review was completed and yielded the following results: Physician Orders:…

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

This Citation pertains to Intake Numbers MI00145623 and MI00145776. Based on observation, interview and record review, the facility failed to ensure that wounds were assessed, monitored, and appropriate interventions were in place for one resident (Resident #3) of 3 residents reviewed for wounds, resulting in Resident #3 developing a wound on the left foot great toe, left foot third toe and right foot third toe. Findings Include: Resident #3: On 9/16/2024 at 4:00 PM, Resident #3 was observed lying in bed in her room. She was awake, alert and very talkative. The resident was observed to have thick socks on. A review of the Face sheet and Electronic Medical Record (EMR) indicated that Resident #3 was admitted to the facility with the following diagnoses: Chronic kidney disease Stage 4, anemia, history of falls, fracture left ankle, diabetes, depression, history of seizures, anxiety, hypothyroidism, Dementia, and hypertension. A record review of an Orthopedic consult for Resident #3, dated 8/29/2024 at 10:00 AM, identified the following: Continue wound care for pressure sore on Left…

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 MI00145623. Based on observation, interview and record review, the facility failed to provide necessary management of an indwelling urinary catheter for one resident (Resident #4) of 3 residents reviewed for urinary catheters, resulting in staff being unaware if Resident #4 had a urinary catheter. Findings Include: Resident #4: A record review of the Face sheet and Minimum Data Set (MDS) assessment, indicated Resident #4 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses: Heart disease, Bipolar disorder, diabetes, left leg below the knee amputation, peripheral vascular disease, COPD, asthma, history of seizures, hypertension, neuromuscular dysfunction of the bladder, chronic pain, depression and anxiety. The MDS assessment dated [DATE] indicated the resident had full cognitive abilities and needed some assistance with care. The MDS section H identified the resident had an indwelling urinary catheter. A review of the physician orders for Resident #4…

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 a sanitary kitchen, and maintain equipment and plumbing in good repair, resulting in an increased risk of food borne illness, affecting all residents that consume food from the kitchen. Findings include: On 5/29/24 at 1:43 PM, two wire racks, located in the walk-in cooler, were observed to have white mold-like accumulation. According to the 2017 FDA Food Code Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 5/29/24 at 1:54 PM, the steamer, located on the cookline, was observed to be leaking water out of the front door on to multiple clean…

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 accurate advance directive information was in place for two residents (Resident #88, Resident #182) of two residents reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time) from a total sample of 24 residents, resulting in potential for a resident's preferences for medical care not to be followed by the facility. Findings Include: Resident #182 (R182): Review of the medical record revealed R182 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive, repeated falls, dementia, pain in right leg, peripheral vascular disease (PVD), heart failure, hyperlipidemia (high fat content in blood), hypothyroidism (low activity of thyroid gland), muscle weakness, and anemia (low red blood cells). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed R182 had a Brief Interview for Mental…

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 for one out of one residents (Resident #81) an assessment was completed for a half lap tray, and including the rational for the use of the lap tray. Findings Include: \Resident #81 (R81): Resident #81 (R81) was observed to have a half lap tray attached to his wheelchair on 5/30/2024 at 1:36 PM. In an observation on 6/04/2024 at 10:40 AM, R81 was observed to have a half lap tray attached to his wheelchair. Review of a Physician's order dated 9/7/2021, revealed R81 was ordered to have a half lap tray on his wheelchair at all times every day and evening shift for lap tray. The order did not specify what medical symptom the half lap tray was being used for R81. Record review of a Treatment Administration Record (TAR) dated 9/7/2021, revealed R81 was to have a half lap tray on his wheelchair at all times every day and evening shift for lap tray. The TAR did not specify why R81 required the use of the lap tray. No physical restraint…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for two out of 24 residents (Resident #26, Resident #81). Findings Include: Resident #26 (R26): Review of Physician's orders revealed R26 was ordered to receive Seroquel (treats schizophrenia, bipolar disorder, and depression), 25 mg (milligrams) once a day for mood disorder. The orders also revealed R26 was ordered to receive Zoloft (treats depression, obsessive-compulsive disorder, posttraumatic stress disorder, anxiety, and panic disorders) 50 mg one time a day. Review of R26's diagnoses list revealed R26 had diagnoses of visual hallucinations and depression. Review of R26's care plans revealed a care plan with a Focus of (R26) is at risk for adverse reactions and side effects r/t (related to) receiving an Antidepressant and Antipsychotic. The care plan interventions list side effects to be observed for, but were not specific to Seroquel or Zoloft, and did not reveal R26…

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 appropriate care for Activities of Daily Living (ADL) for three of three residents reviewed for ADL care of dependent residents (R80, R91 and R32), from a total of 24 sampled residents, resulting in not achieving and/or maintaining their highest practicable well-being. Findings include: Resident #91 (R91): Review of the medical record revealed Resident #91 (R91) was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included Alzheimer's, Gastrostomy, Psychotic Disorder with Delusion and Adjustment Disorder with Anxiety. According to Resident #91 (R91)'s Minimum Data Set (MDS) dated [DATE], revealed R91 scored 04 out of 15 (severely cognitively impaired) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had behaviors. R91 is dependent of toileting, showering/bathing, getting dressed and personal hygiene. During an interview on 05/29/24 at 04:30 PM, R91's daughter…

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 perform dressing changes as ordered and 2) Failed to follow physician's orders for removal of a peripherally inserted central catheter (PICC) for one resident (Resident #74) of 24 residents reviewed for quality of care, resulting in the potential for an infection and feelings of frustration and worthlessness. Findings include: Resident #74 (R74): Review of the admission Record reflected that Resident #74 (R74) was admitted to the facility on [DATE], with diagnoses that included neurogenic bladder and sepsis. R74 was cognitively intact. On 05/30/24 at 11:33 AM, R74 was observed in his room and resting in his bed. R74 was playing on a gaming console. A peripherally inserted central catheter (PICC line- a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) was observed on his left upper arm. R74 stated that the PICC line was being used for antibiotic infusions. R74 had stated…

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 implement interventions to promote pressure ulcer healing and prevent the worsening of pressure ulcers for one resident (Resident #37) and 2) Failed to prevent a pressure ulcer for two residents (Resident #37, Resident #91) of three residents reviewed for pressure ulcers, resulting in facility-acquired pressure ulcers and the potential for delayed wound healing and/or the worsening of wounds. Findings include: Resident #37 (R37):: Review of the admission Record reflected that R37 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included gout, alcoholic liver disease, type two diabetes without complications, and degeneration of nervous system due to alcohol The Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 3/8/24, reflected that R37 scored a 14 out of 15 on the Brief Interview for Mental Status (cognitively intact). R37 required partial assistance of one person…

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 necessary behavioral health care interventions were implemented for one resident (Resident #32) of 1 resident reviewed for behavioral and emotional needs, resulting in the potential for worsening signs and symptoms of depression, ongoing mental distress, isolation, and the potential for a decline in physical functioning. Findings include: Resident #32 (R32): Review of the admission Record reflected that R32 admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus without complications, heart failure, cerebral infarction (stroke) without residual deficits, chronic kidney disease stage 2, contracture, weakness, anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, attention deficit hyperactivity disorder, restlessness and agitation bipolar disorder, and major depressive disorder. R32 was cognitively intact and easily conversant. 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 observation, interview, and record review the facility failed to ensure that the medication error rate was less than 5% when six medication errors were observed form a total of 29 opportunities for two residents (Resident #64, Resident #186) of five residents reviewed for medication administration, resulting in a mediation error rate of 20.69% Findings Included: Resident #186 (R186): Review of R186 Medication Administration Record (MAR) demonstrated Insulin Lispro 100 unit/ml (milliliter) VL (vial) 10 ml. Inject as per sliding scale: if 100-150=0 units; 151-200=2 units; 201-250=4 units; 251-300=6 units; 301-350=8 units; 351-400=10 units if blood sugar is less than 70 or greater than 400 contact physician. Subcutaneously before meals and at bedtime for DM II (Diabetes Mellitus). R186 (MAR) also demonstrated Fenofibrate Oral Tablet 145 MG (milligrams) Give 1 tablet by mouth one time a day for hyperlipidemia was to be given at 09:00 a.m. During observation of medication administration on 05/31/2024 at 08:54 a.m. Registered Nurse (RN) U was observed to enter R186's room and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent a significant medication error for one resident (Resident #33) of 1 resident reviewed for medication errors resulting in Resident #33 not receiving a prescribed medication and the potential for a worsening infection. Findings include: Resident #33 (R33): Review of the admission Record reflected that R33 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included cerebral infarction (stroke), gastrostomy status, and heart failure. The Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 3/8/24, reflected that R33 scored a 1 out of 15 on the Brief Interview for Mental Status (cognitive impairment). On 5/31/24 at 2:36 PM, R33 was observed in bed. R33 had a tube feeding infusing. Adjacent to R33's bed was an intravenous line (IV) pole and IV infusion pump. Review of a Progress Note dated 4/12/2024 revealed R33 was being seen by her medical provider for a follow up of a right heel…

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 serve food at the preferred temperature for one resident (Resident #57) of two residents reviewed for food palpability, resulting in dissatisfaction during meals. Findings Include: Resident #57 (R57): Review of the medical record revealed R57 was admitted to the facility on [DATE] with diagnoses that included insomnia, depression, heart failure, arthritis, peripheral vascular disease (PVD), chronic pain syndrome, history of falling, weakness, hypertension, hyperlipemia (high fat content in blood), and anxiety. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/15/2024, revealed R57 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 05/29/2024 at 01:45 p.m. R57 was observed sitting up in her wheelchair at the side of her bed. She explained that the food, at the facility was poor and that the food is frequently cold. During observation 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 coordinate hospice services for one resident (Resident #59) of one resident reviewed for Hospice Services, resulting in the potential of care not being provided to a resident receiving hospice services and the potential for residents not to be fully informed of hospice services provided. Findings Included Resident #59 (R59): Review of the medical record revealed R59 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), dysphagia (difficulty swallowing), weakness, gastro-esophageal reflux, seizures, hypotension (low blood pressure), anxiety, traumatic brain injury, and malignant neoplasm of prostate (cancer of the prostate). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/12/2024, revealed R59 had a Brief Interview for Mental Status (BIMS) of 10 (moderately impaired) out of 15. Section O-Special Treatments, Procedures, and Programs (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.

This Citation pertains to Intake MI00141928. Based on observation, interview and record review, the facility failed to ensure monitoring and accessibility of non-expired and necessary emergency medical equipment and supplies in two of two emergency medical response carts resulting in expired and unsanitary emergency medications and medical supplies, lack of easily accessible, critical, and consistent equipment and supplies during an emergency situation and the likelihood for delay of care and deterioration of all resident(s) experiencing an emergency medical situation. Findings include: Review of intake documentation, received 1/5/24, revealed the facility crash cart was not fully stocked and the supplies on cart were outdated resulting in a delay in care. On 5/22/24 at 11:30 AM, an observation of the emergency medical cart (Crash Cart) in the central (long term) area of the facility, directly across from the nurses' station revealed the number on the plastic lock did not match the number documented on the Crash Cart May 2024 log. The Crash Cart log included the sections, AED…

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 MI00144106 and MI00143864. Based on observation, interview, and record review, the facility failed to ensure an environment free of abuse by a staff member for three residents (Resident #702, Resident #709, and Resident #711) of three residents reviewed, resulting in a lack of administrative oversight to identify and monitor for increased risk of abuse by staff, and prevent abuse. As a result of this deficient practice, Resident #709 experienced verbal abuse and neglect, and Resident #702 and Resident #711 experienced physical abuse, including intimidation, and the likelihood for feelings of fear and emotional distress utilizing the reasonable person concept. Findings include: Resident #709: Review of intake documentation dated received 4/10/24 revealed Resident #709 told Hospice Registered Nurse (RN) F that Certified Nursing Assistant (CNA) G had tried to touch them sexually on 4/9/24 and they did not want CNA G to take care of them. Hospice RN F notified their…

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 MI00141348. Based on observation, interview and record review the facility failed to 1) Implement meaningful fall interventions; 2) Complete a Neurological Record and 15-minute checks after falls; and 3) Investigate and complete root cause analysis of falls for one resident (Resident #901), resulting in, Resident #901 falling three times in short succession, without appropriate investigation, intervention and follow through. Findings Include: Resident #901: On 12/19/2023 at 4:15 PM, Resident #901 was observed sleeping peacefully in this room with a facility sitter in the chair next to him. The CNA (Certified Nursing Assistant) stated the resident is 1:1 on all shifts due to his falls. On 12/19/2023 at approximately 4:25 PM, an interview was conducted with Nurse A regarding Resident #901's fall. It was reported he just returned to the facility after being admitted to the hospital and is on a 1:1 due to his impulsivity and inability to see his need for assistance. After 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.

Based on observation, interview, and record review, the facility failed to maintain 1) sanitary non-food contact surfaces, 2) plumbing in good repair, 3) properly cool food, and 4) maintain food temperature logs for serve ready foods, resulting in potential contamination of food and the physical facility, affecting all residents who consume food from the kitchen. Finding include: On 6/14/23 at 8:35 AM, a white mildew-like substance was observed to be accumulating on multiple tiers of the wire racks in the walk-in cooler. At this time, Dietician K was queried on the cleaning frequency of the wire racks and was unaware. According to the 2017 FDA Food Code Section 4-601.11 Equipment, Food-Contact Surfaces, NonfoodContact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number MI00134303. Based on observation, interview and record review, the facility failed to ensure that residents were treated with respect and dignity by not answering call lights timely, meals not served at a palatable temperature and dislikes not taken into account, care not provided with dignity and respect, and that a change of clothing was provided, for four residents (Resident #13, Resident #42, Resident #49, Resident #53) on the initial tour of the survey, and resident from the Confidential Group of Residents, of 22 Residents reviewed for treatment with dignity and respect, resulting in long call light wait times for care, staff use of personal phone while providing resident care, unmet care needs, meals not eaten, feelings of frustration, embarrassment, worthlessness and being belittled, and the potential for weight loss, dissatisfaction with living conditions and lack of psychosocial wellbeing. Findings include: On 6/14/23 at 9:56 AM, during the initial tour of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, 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 and equipment were clean, uncluttered, in good repair and free of ants resulting in an unclean physical environment, resident dissatisfaction and complaints regarding the lack of cleanliness. Findings Include: On 6/14/23 at 9:45 AM, during the initial tour of the building and again on 6/15/2023 and 6/16/2023, multiple resident rooms on the 400 hall were extremely cluttered with clothes and other items piled on the floor and surfaces. Some residents had containers and cartons of food and drink stored on the floor and some residents had trash on the floor. Some of the room had little space to walk beside some sides of the bed as items were piled on the floor. During the initial tour of the building on 6/14/2023, the following rooms were observed to have a significant amount of clutter on the floor and surfaces 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 observation, interview and record review the facility failed to develop and implement comprehensive care plans for three residents (Resident #16, Resident #28 and Resident #61) of 30 residents reviewed, resulting in Resident #16 lacking a care plan to address a need for dental services due to a cracked tooth; Resident #28 did not have a care plan to address breathing treatments, and Resident #61 lacked a care plan to address oxygen therapy and a left leg cast. Findings Include: Resident #16 : On 6/14/23 at 9:54 AM, Resident #16 was observed in her room lying in bed awake. She said she had a cracked tooth and pointed into her mouth. Resident #16 said she was supposed to go to the dentist today, but the bus did not show up. Nurse AA entered the resident's room and said the resident's son had scheduled the appointment and transportation. She said the transportation company confused the dates and the appointment was canceled, and the resident's son was to reschedule. The resident was not sure about this. 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 update care plans in a timely manner with changes of condition for three residents (Residents #4, Resident #71, Resident #262), resulting in missed revision and interventions necessary for care and services not being care planned with the likelihood of unmet care needs. Findings include: Record review of the facility 'Care planning' policy dated 6/24/2021 revealed that every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the residents' rights, based on the comprehensive assessment that includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs . (9.) The care plan and resident Kardex will be updated . this includes adding new focuses, goals, and interventions . Resident #4: Purple urinary bag syndrome Observation and interview on 06/14/23 at 09:02 AM of Resident #4 was seated up in wheelchair at bedside with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 1) Sanitary storage of nebulizer equipment for Residents # 28, #48, #84 and #312 and 2) Monitoring during respiratory treatment through a tracheostomy tube for Resident #48, of seven residents reviewed for respiratory care, resulting in the potential exposure to infectious organisms, respiratory infections, and adverse reactions left unnoticed and untreated. Findings include: Resident #48: A review of Resident #48's medical record revealed an admission into the facility on 5/7/18 with readmission on [DATE] with diagnoses that included chronic respiratory failure, pneumonia, diseases of bronchus, atrial fibrillation, and tracheostomy status. The review of the Minimum Data Set (MDS) assessment revealed the Resident had intact cognition and needed extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. On 6/14/23 at 9:17 AM, an observation was made of Resident #48 sleeping in bed. The Resident was observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to transmit discharge Minimum Data Set (MDS) assessments timely for three residents (Resident #55, Resident #89 and Resident #94), resulting in late MDS transmissions. Findings include: Resident #55: On 6/16/23, at 10:37 AM, a record review of Resident #55's electronic medical record revealed a discharge date : [DATE]. A review of the MINIMUM DATA SET (MDS 3.0) SUMMARY revealed ARD/Target Date: 2023-02-20 . MDS Export Ready . A review of the MDS list revealed . Date 2/20/2023 Discharge Return Not Anticipated Status Export Ready . Resident #89: On 6/16/23, at 10:45 AM, a record review of Resident #89's electronic medical record revealed a discharge date : [DATE]. A review of the MINIMUM DATA SET (MDS 3.0) SUMMARY revealed ARD/Target Date: 2023-02-01 . MDS Export Ready . A review of the MDS list revealed . Date 2/01/2023 Discharge Return Not Anticipated Status Export Ready . Resident #94: On 6/16/23, at 10:50 AM, a record review of Resident #94's electronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number MI00134303. Based on observation, interview and record review, the facility failed to ensure that Restorative Nursing services were documented as provided and evaluated to maintain and promote the Resident's abilities to maintain optimal physical functioning for two residents (Resident#13 and Resident #30) of three residents reviewed for range of motion, resulting in not receiving planned services to maintain their current level of functionality and mobility and the potential to have a decrease in physical mobility, range of motion and an overall decrease level of functioning. Findings include: Resident #13: A review of Resident #13's medical record revealed an admission into the facility on 8/26/21 and readmission on [DATE] with diagnoses that included heart failure, diabetes, hemiplegia, and hemiparesis following stroke affecting right dominant side, atrial fibrillation, depression, and muscle wasting and atrophy. A review of the Minimum Data Set assessment, dated…

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

This Citation pertains to Intake Number MI00136186. Based on observation, interviews and record reviews, the facility failed to document neuro checks after an unwitnessed fall for one resident (Resident #210), resulting in the likelihood for a decline in overall health status. Findings include: Record review of the facility 'Fall Management' policy dated 8/18/2022 revealed a fall as an unintentional coming to rest on the ground, floor, or other lower level. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. If a potential head injury is present, complete the Neurological Record. Record review of the facility presented 'Neurological Assessment, Long-Term Care' web article/policy dated 2/20/2023, no page numbers and no web address noted. The web article/policy revealed a neurological assessment is an indispensable tool for quickly evaluating a resident's neurological status. This procedure supplements the routine measurements of vital signs, such as temperature, pulse,…

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 urinary catheters for two residents (Resident #4, Resident #53) of three residents reviewed for urinary catheters, resulting in cross contamination, purple bag syndrome with the likelihood of infection. Findings include. Resident #53: On 6/14/23, at 10:30 AM, Resident #53 was sitting in their wheelchair in their room their urinary catheter bag was hooked under their wheelchair. Approximately 4 inches of the catheter tubing was resting on the floor. On 6/15/23, at 3:30 PM, a record review of Resident #53's electronic medical record revealed an admission on [DATE] with diagnoses that included Stroke, Dementia and Urinary tract infection. Resident #53 had impaired cognition and required extensive assistance with Activities of Daily Living (ADL.) On 6/16/23, at 11:00 AM, the Director of Nursing (DON) was asked if Resident #53's catheter tubing should be on the floor and the DON stated, no. Resident #4: Purple urinary bag…

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

Based on observation, interview and record review, the facility 1) Failed to ensure narcotic reconciliation was completed accurately, 2) Failed to ensure a medication narcotic drawer was free of pre-drawn narcotics (Morphine) and 3) Failed to to ensure the 300-Hall medication cart was free of loose pills, resulting in unkept medication carts, the likelihood of narcotic drug diversion going unnoticed and the likelihood of medication errors. Findings include: On 6/15/23, at 9:06 AM, an observation of the 300-hall medication cart along with Infection Control (IC) Nurse G was conducted. There were loose whole pills and broken half pieces of pills scattered on the bottom of the main medication drawer totaling to 9. IC Nurse G gathered the pills, was asked what they planned to do with them and IC Nurse G stated, I am going to discard them. IC Nurse G locked the medication cart and handed the medication cart keys to Nurse E in the hallway. On 6/15/23, at 9:16 AM, Nurse E took the keys from IC Nurse G walked towards the 300-hall medication cart and unlocked the cart with the keys. Nurse E…

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 operationalize the Infection Control program; 2) Failed to ensure proper PPE in a contact isolation for Resident #26; 3) Failed to prohibit the use of multidose soap for resident care going room-to-room, and 4) Failed to assess purple bag syndrome (urinary catheter) for Resident #4, resulting in the lack of data analysis of the Infection Control program for the month of March 2023, likelihood for cross contamination of organisms and the identification of purple bag syndrome in a urinary catheter. Findings include: Record review of the facility 'Infection Prevention Program Overview' policy dated 9/9/2022 revealed the facility establishes a program under which it investigates, identifies, prevents, reports and controls infections and communicable diseases for all residents and staff . The major activities of the program are surveillance of infections with implementation of control measures and prevention of infections. Infection Preventionist responsibilities may include collecting, analyzing, and providing…

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.