Majestic Care of Flushing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to implement and operationalize a comprehensive Antibiotic Stewardship Program including documentation and treatment for four residents (#7, #35, #81, and #82) of four residents reviewed for antimicrobial treatment. Findings include: A review of facility provided infection control documentation for January 2025 was completed. The provided documentation did not include a summary and/or analysis of the infections for the month. The provided Monthly Infection Surveillance Report line list included multiple headings including one for Meets McGeers Criteria . A review of the line listing for January 2025 revealed the Meets McGeers Criteria section was blank for 15 of the 31 resident infections with treatment listed. An interview and review of facility provided infection control documentation was completed on 6/4/25 at 1:56 PM with IC RN K. When queried, IC RN K stated, McGeer is criteria used for infections. When queried if the infection on the line list did…

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 safe, functional, sanitary, and comfortable environment for one resident (Resident #58) and the facility's census of 91 residents and its staff resulting in an increased chance of harm. Findings include: Resident #58: On 6/3/2025 at 12:25 PM, Resident #58 was self-propelling around his room and in decent sprits. As the conversation continued, he asked this writer to look at this bathroom. Upon entering the bathroom, the left side corner of the baseboard was pushed inside the wall. The cement and debris were exposed, and it appears a baseball could fit within the hole. The right-side base of the toilet was cracked directly across the bolt that secured it to the floor. The crack extended transversely the length of the toilet base. The circumference of the toilet was riddled with a unknown brown substance. Resident #58 reported he is careful when using the bathroom as if he shifts his weight, he is nervous he could fall. On 6/3/2025…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure dignity by, Residents #23, #40 and #76, -not having call lights accessible and extended call light response times, Resident #43- not assisting with toileting and Resident #42- not toileting prior to meals and residents' verbal complaints from the confidential Resident Council group meeting (held on 6/23/25 at 1:19 PM), regarding call light response times, resulting in, fear of abandonment, anger, skin irritation (from having urine and feces on skin for an extended time), and embarrassment. Findings Include: Review of Resident Council anonymous meeting notes done by State Social Worker dated 6/3/25 at 1:19 p.m., stated they (call lights) are not being answered in timely manner they (staff) say they answer it timely and don't meet their needs; taking an hour to answer to come or more; the nurses will not answer the call lights. Resident #23: Review of the Face Sheet, care plans dated 3/23 through 5/25, and cognitive assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident showers were given and Activities of Daily Living (ADL) were given for 8 resident's (Resident's #23, #30, #35, #40, #50, #65 and #85, and per interviews done during the anonymous Resident Council (done on 6/3/25), resulting in verbalizations of anger, disappointment, unfair treatment, and embarrassment. Findings Include: Resident #23: Review of the Face Sheet, care plans dated 3/23 through 5/25, and cognitive assessment dated [DATE], revealed Resident #23 was [AGE] years old, alert, cooperative, admitted to the facility on [DATE], had a guardian in place due and was dependent on staff for all Activities of Daily Living/ADL's. The resident's diagnosis included, convulsions, tremors, opioid pain medication use, diabetes, attention-deficit, depression, chronic kidney disease, intellectual disabilities, adult failure to thrive, and stroke. Review of the resident's facility ADL care plan dated 3/23, revealed staff were to ensure…

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, in part, to Intake Number MI00153038. Based on observation, interview and record review, the facility failed to ensure that adequate staffing to meet residents' needs for Activities of Daily Living (ADL) was performed and respond to and provide care to meet the needs, resulting in complaints about showers not being provided, and frustration of residents' unmet needs. Findings include: During Resident Council held on 6/3/2025 at 1:15 PM, the residents were queried regarding staffing at the facility. The sixteen residents in attendance unanimously stated there was a shortage of staff at the facility and shared the following: Many times, there is only one aide working the floor and that makes it difficult to meet their needs. They take an extended amount of time to answer their call lights and once they arrive, they say it's because they are short staffed. If staff know someone is going to call-in, they are not going to pick up the shift as they don't want to work short. Many aides 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.

Based on observation, interview and record review, the facility failed to follow and/or revise care plans for Activities of Daily Living (ADL) for three (#35, #50, #85) residents, resulting in residents who verbalized concerns with missed bathing/showers, and with unkept appearances with body odor. Findings include: Record review of the facility 'Resident Rights' policy dated 10/2019 revealed that all residents will be treated with dignity and respect and resident rights will be followed. All care team members recognize the rights of residents at all times to enable dignity, respect, and proper delivery of care. Record review of the facility 'Comprehensive Care Plan' policy revision date of 5/16/2025 revealed the purpose was to develop and implement a comprehensive person-centered care plan for each resident Definition: Person-Centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. Resident #35: Observation on 06/03/25 at 12:33 PM of Resident #35 to be in need of shower, body…

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 offer meaningful activities for one resident (Resident #37) of two residents reviewed for activities, resulting in complaints of nothing to do and being bored. Findings include: Resident #37: On 06/03/25, at 10:10 AM, Resident #37 was resting in their bed. Their television was on, the volume was off and the remote was out of reach. Resident #37 was asked what they do for activities and Resident #37 complained there was nothing to do. Resident #37 was asked if they were bored and Resident #37 complained, Yes, very much. On 06/04/25, at 2:14 PM, an interview with Activity Director I was conducted regarding the activities that was provided for Resident #37. AD I offered they do have one on one activities and offer hydration cart/popcorn for the resident and food club. AD I was asked what the food club was and AD I offered the group makes fresh cookies and popcorn and take them to the residents room. AD I was asked if they have an activity…

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 follow care-planned interventions, provide supervision and provide assistance with toileting for one resident (Resident #43) of three residents reviewed for supervision, resulting in unassisted toileting and unassisted ambulation. Findings include: Resident #43: On 6/03/25, at 1:27 PM, Resident #43 was sitting in their wheelchair in their room. Resident #43 stood up out of their wheelchair without locking the wheelchair and walked to their closet. CNA AA entered the room and assisted the resident to a seated position. Once CNA AA left out of the room, the resident removed their socks donned a new pair and then their slippers. Resident #43 propelled in their wheelchair towards the hallway. On 6/03/25, at 4:01 PM, Resident #43 was sitting in their wheelchair in their room with their black pants down below their bottom. Resident #43 stood up while holding their pants up and ambulated without assistance to their bathroom. The breaks to 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 clean Continuous Positive Air Pressure(CPAP) equipment for one resident (Resident #30) of one resident reviewed for respiratory equipment, resulting in visibly soiled respiratory equipment. Findings include: Resident #30: On 6/03/25, at 10:37 AM, Resident #30 was resting in bed. Their CPAP nasal mask was lying on their bed. The nasal piece had gross amount of dirty buildup. The coiled tubing had brown residue on the outside and on the inside of the tubing approximately 12 inches from the nasal mask into the tubing. The head strap was soiled with brown buildup. The resident complained nobody cleans it. On 6/03/25, at 1:52 PM, A record review of Resident #30's electronic medical record revealed an admission on [DATE] with diagnoses that included Obstructive sleep apnea, Heart Failure and Chronic Obstructive Pulmonary Disease. Resident #30 required assistance with Activities of Daily Living (ADL)'s and had impaired cognition. A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #40: Review of the Face Sheet, care plans dated 8/23 to 3/25, and cognitive assessment dated [DATE], revealed Resident #40 was [AGE] years old, alert and able to make own decisions regarding health, bed bound and dependent on staff for all ADL's. resident #40's diagnosis included heart disease with heart failure, Atrial Fibrillation, morbid obesity, chronic respiratory failure with oxygen decency. Review of the resident's facility Fall, Skin, and ADL care plans dated 8/1/23, revealed she had a flat round call light, was incontinent, and preferred bed baths 2 times weekly. The resident had refusals of medications and care; staff were to re-approach and encourage resident to accept care and medications and honor decisions and preferences. During an interview done on 6/3/25 at 11:45 a.m., Resident #40 stated It's (food on meal tray) is cold, it's bad; they have an issue here, I am allergic to caffeine, so they don't give me coffee. The other night they served egg salad and I got egg shells in mine, 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 observation, interview and record review, the facility failed to assess and monitor a percutaneous enteral tube (PEG) insertion site, provide enteral nutrition and obtain an admission weight timely for one resident (Resident #3) of three residents reviewed for enteral nutrition, resulting in a reddened area going unnoticed. Findings include: Resident #3: On 5/7/25, at 2:10 PM, Resident #3 was resting in their bed with family at their bedside. There was an enteral tube feeding pump that read clog in line down pump. The tubing was hooked to Resident #3's abdomen. Resident #3 had a slight scowl. Their family complained that the nurse had just hooked it up and now it was alarming. Resident #3's shirt was lifted slightly which exposed a white dressing at the PEG insertion site. The family member complained that they didn't feel the nurses were looking at the area. There was a split sponge on the insertion site that was undated. The family offered that they found the dressing on the nightstand and placed it…

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 provide medications timely for one resident (Resident #3) of three residents reviewed for pharmacy services, resulting in late and missed medications. Findings include: Resident #3: On 5/7/25, at 2:20 PM, a record review of Resident #3's electronic medical record revealed an admission on [DATE] with diagnoses that included Aphasia following cerebral infarction (stroke), right sided weakness (hemiplegia) and gastrostomy status. Resident #3 had intact cognition and required extensive assistance with Activities of Daily Living. On 5/7/25, at 2:50 PM, an interview and record review along with the Director of Nursing (DON) was conducted of Resident #3's electronic medical record. A record review of Resident #3's medication admission record was conducted. The DON was asked why there were numerous medications documented with a 9 or left completely blank and not signed out and the DON offered, they would check into it. On 5/8/25, at 10:35 AM, a further record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number MI00147096. Based on interview and record review the facility failed to assess and monitor one resident (Resident #1) with pressure ulcers upon admission of 3 residents reviewed for pressure ulcers, resulting in the facility not documenting on pressure ulcers upon admission. Findings Include: Resident #1 (R1): Resident #1 is a 56-yo female who was admitted to the facility on [DATE] with diagnoses that include, necrotizing fasciitis, end stage renal disease, type 2 diabetes, peripheral vascular disease, dependence on renal dialysis and bilateral above the knee amputations. On 09/23/24, record review of a progress note dated 09/10/24 revealed that R1 had pressure ulcers upon discharging the hospital located on the coccyx and right ischium area and was to continue receiving wound care. These pressure ulcers were not identified upon admission to the facility. On 09/23/24, record review of a Discharge summary dated [DATE] revealed that R1 had an active hospital diagnosis of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number MI00147096. Based on interview and record review the facility failed to monitor one resident (Resident #1) requiring dialysis services of 3 residents reviewed, resulting in the resident being discharged to the emergency room with hallucinations and confusion. Findings include: Resident #1 (R1): Resident #1 is a 56-yo female and admitted to the facility on [DATE] with diagnoses that include, necrotizing fasciitis, end stage renal disease, type 2 diabetes, peripheral vascular disease, dependence on renal dialysis and bilateral above the knee amputations. On 09/23/24, record review of R1's physician orders in the EMR (Electronic Medical Record) revealed that R1 was to receive Hemo-Dialysis three times a week on Monday, Wednesday and Friday. R1 admitted to the facility on a Thursday 09/12/24 and R1's first dialysis treatment in the facility should have been Friday 09/13/24. On 09/23/24, record review of a progress note dated 09/13/24 revealed that the facility had notified the…

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

Based on interview and record review, the facility failed to: 1. Maintain an accurate infection control program, 2. Follow antibiotic stewardship consistently, 3. Ensure infection control policies were up to date and reviewed annually, and 4. Ensure staff were educated on proper infection control procedures. Findings include: On 5/21/24 at 2:30 PM, the infection control binder dated January 2024 through April 2024, was reviewed, and found to have several inconsistencies in tracking infections within the facility resident population as follows: a. January 2024 - Nineteen infections highlighted on the mapping, eighteen listed on the map as: five skin, one gastrointestinal, one eye, three respiratory, and eight urine infections. Review of the line listing revealed twenty-one infections, seven infections listed as not meeting antibiotic criteria were placed on antibiotics, and ten were urinary infections. Review of the summary revealed only thirteen infections and, in the trends, read in part, We had 9 UTI's [urinary tract infections], 3 were admit UTI's, 6 were facility acquired. 1 UTI…

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 relates to Intake Number MI00143452. Based on observation, interview, and record review, the facility failed to ensure resident rights pertaining to dignified care for six residents (R3, R13, R24, R39, R55, and R72) and six Confidential Group residents (C1, C2, C3, C4, C5, and C6). This deficient practice resulted in a lack of dignified dining for R55, untimely call light answering for R3, R13, R39, and R72, six confidential group residents, and a lack of dignity related to privacy for R24. Findings include: R39 Review of R39's Minimum Data Set (MDS) assessment, dated [DATE], revealed R39 was admitted to the facility on [DATE], with diagnoses including heart failure and respiratory failure. The assessment revealed R39 required set up with eating, and was dependent for toileting, bed mobility, and transfers. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, which showed R39 was cognitively intact. During an interview on [DATE] at 12:57 p.m , R39 stated the facility…

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 provide scheduled showers for four residents (R8, R17, R20, and R51) of four residents reviewed for activities of daily living (ADL). Findings include: Resident #8 (R8): Review of R8's care plan, dated 3/16/2017, read in part, .Focus: ADLs: [Resident #8's first name] has an ADL Self care deficit related to morbid obesity, right BKA [below the knee amputation] AEB [as evidence by] impaired balance & impaired mobility .Interventions: Bathing/Showering: staff assist to provide showers 2x/week and prn [as needed] Date initiated 12/26/2023 . Review of R8's task list, dated 4/23/24 through 5/17/24, revealed a task: Showers: Tuesday and Fridays 2nd shift and prn per resident preference and the lack of a shower provided to R8 on Friday 5/10/24 and Friday 5/17/24. Review of R8's progress notes, dated 4/22/24 through 5/22/24, revealed the lack of any documentation regarding the reasoning R8 was not provided a scheduled shower on 5/10/24 or 5/17/24. Review of shower sheet documentation, dated 4/15/24 through 5/22/24,…

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 a medication error rate less than 5% when two medication errors were observed for one resident (Resident #292) from a total of 25 observations, resulting in a medication error rate of 8%. This deficient practice resulted in the potential for adverse medication effects and decreased medication efficacy related to a lack of implementation of standards of practice for medication administration and incorrect administration dosage. Findings include: Record review of the facility 'Medication Administration' policy, dated 4/2019, revealed medications are administered in a safe and timely manner, and as prescribed. (4.) Medications are administered in accordance with prescriber's orders, including and required time frame. (21.) If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR (Medication Administration Record) space provided for the drug and dose. Observation on 05/21/24 at 07:39 AM with Licensed…

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.

On 5/21/2024 at 4:33 PM, the North Hall medication cart was inspected in the presence of Nurse B. The following expired or undated medications were found on the cart: -Timolol Mal sol 0.5% OP eye drops- opened 4/10/24 with no use by date. -Brimonidine Sol 0.2 op eye drops -opened on 4/9/24 with use by date of 5/7/24. -Novolog Solution- with no open or use by date. -2 vials of Insulin Glargine YFGN Sol- with no open or use by date. Nurse B contacted pharmacy and they informed her the Timolol eye drops are good for 28 days after opening. Nurse B stated all expired medications should be discarded of and insulin should have open and use by date indicated on the labels. Review was completed of the facility policy entitled, Administering Medications, revised April 2019. The policy stated, .12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container . Based on observation, interview and record review, the facility failed to ensure proper labeling of medications, loose…

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) Maintain sanitary conditions in the kitchen, 2) Label and store foods in coolers properly, and 3) Ensure that a beard restraint was worn in the food preparation area, resulting in the potential for cross-contamination of food, spoilage and foodborne illness, to all residents that consume food and beverages from the kitchen in a census of 88 residents. Findings include: Record review of the facility 'Food: Preparation' policy, dated 2/2023, revealed all foods are prepared in accordance with the FDA food code. (1.) All staff will practice proper hand washing techniques and glove use. Record review of the facility 'Kitchen Attire' policy, dated 10/2023, revealed all employees wear approved attire for the performance of their duties. (1.) All staff members have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. Record review of the 'Michigan Modified Food Code, U.S. Public Health Service' 2009 Food Code effective 10/1/2012, page 48 noted food employees shall wear…

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

Based on interview and record review, the facility failed to maintain an effective vaccination program for four residents (R59, R72, R74, and R86) of five residents reviewed for vaccinations. Findings include: Resident #59 (R59): Review of EMR for R59, revealed his guardian had signed a consent for pneumococcal vaccination on 4/14/24, but never received the vaccination, he had received the Prevnar-13 vaccination on 4/1/2021, and the consent form indicating R59 refused the Pnuemovax-23 vaccine lacked a date. Resident #72 (R72): Review of EMR for R72, revealed the lack of an influenza and pneumococcal consent and lacked any immunizations administered. Resident #74 (R74): Review of electronic medical record (EMR) for R74, revealed her guardian / daughter had signed a consent for her to receive a pneumococcal, influenza, and Covid-19 vaccinations on 3/27/24, but never received the vaccinations. Resident #86 (R86): Review of EMR for R86, revealed the lack of any immunization consents and lacked any immunizations administered. On 5/22/24 at 9:00 AM, an interview was conducted 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 Based on observation, interview, and record review, the facility failed to properly maintain resident equipment in safe operating condition including four residents' beds, one wheelchair, and one overhead light in residents' rooms. This deficient practice resulted in four residents' beds being unsafe, one resident's wheelchair not repaired, and one resident's overhead light fixture left broken, resulting in the risk of accidents, skin tears, and other adverse outcomes. Findings include: room [ROOM NUMBER]A: During an interview on 5/20/24 at 12:31 p.m., R42 in room [ROOM NUMBER]A stated, I almost had a fall today as my bed didn't lock. When it sways, I get caught, trying to get to the bathroom [walking], and I almost fell. We have told them [R42 and their family], and we have showed them, and they just haven't fixed it .I have been here long enough, and it should be working . R42 stated they received the new bariatric bed a few months prior and reported about two weeks ago she fell in her room, when the bed moved…

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 the misappropriation of narcotic pain medication for one resident (Resident #58) reviewed for storage, acquisition, destruction, and reconciliation of narcotics. This deficient practice resulted in misappropriation of a resident's pain medication and gross inaccuracies with narcotic documentation on the controlled substance log and medication administrator record. Findings include: On 5/21/2024 at 4:33 PM, the North Hall medication cart was inspected in the presence of Nurse B. The controlled substance book was reviewed for accuracy and a discrepancy was found with Resident #58's Tramadol 50 HCL (hydrochloride) MG (milligrams) as one pill was not accounted for. The facility was dispensed 30 pills by their pharmacy, and he was administered one pill on an as needed basis. The following was listed on the controlled substance form: 5/15 at 0125- 29 remaining 5/15 at 800- 28 remaining 5/15 at 2100- 27 remaining 5/16 at 2100 - 26 remaining 5/17 at…

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

Based on interview and record review, the facility failed to report an injury of unknown source to the State Agency (SA) for one resident (Resident #17) of one resident reviewed for incident reporting. This deficient practice resulted in the potential for undetected abuse or neglect. Findings include: Resident #17 (R17): Review of R17's Progress Notes read, in part, 5/5/24 Resident was assisted to Central unit by another nurse who said resident was visiting another resident and fell. Resident was sitting in his wheelchair with his right hand wrapped in ice. Resident tip of right finger was ben upward .resident to be transferred to ER (Emergency Room) .5/6/24 patient transferred back to facility via w/c (wheelchair) .X-ray results to right hand indicating has fractures to the third and fourth metacarpals. Cast noted to right hand up to arm is intact . An interview with the Director of Nursing (DON) on 5/21/24 at approximately 4:30 p.m. confirmed R17's injury of unknown source was not reported to the SA. Review of the facility's Abuse Prevention Program revised March 2022 revealed,…

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

Based on interview and record review, the facility failed to conduct a thorough investigation for an injury of unknown origin for one resident (Resident #17) of one resident reviewed for incident reporting. This deficient practice resulted in the potential for undetected abuse and/or neglect and the potential for unmet care needs: Findings include: Resident #17 (R17): Review of R17's Electronic Medical Record (EMR) revealed admission to the facility on 8/24/23 with diagnoses including dementia with other behavioral disturbances. According to the 3/1/24 Quarterly Minimum Data Set (MDS) assessment, R17 received a 4/15 on the Brief Interview for Mental Status (BIMS) score indicating severely impaired cognition. Review of R17's Progress Notes read, in part, 5/5/24 Resident was assisted to Central unit by another nurse who said resident was visiting another resident and fell. Resident was sitting in his wheelchair with his right hand wrapped in ice. Resident tip of right finger was ben upward .resident to be transferred to ER (Emergency Room) .5/6/24 patient transferred back to facility…

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 MI00143579 Based on interview and record review the facility failed to administer and document medications per professional standards of practice for two residents (Resident #58 and Resident #293) reviewed for accuracy of medication administration, resulting in misappropriation of Resident #58's narcotics and erroneous medication documentation and administration. Findings include: Resident #58: On 5/21/2024 at 4:33 PM, the North Hall medication cart was inspected in the presence of Nurse B. The controlled substance book was reviewed for accuracy and a discrepancy was found with Resident #58's Tramadol 50 HCL (hydrochloride) MG (milligrams) as one pill was not accounted for. The facility was dispensed 30 pills by their pharmacy, and he was administered one pill on an as needed basis. The following was listed on the controlled substance form: 5/15 at 0125- 29 remaining 5/15 at 800- 28 remaining 5/15 at 2100- 27 remaining 5/16 at 2100 - 26 remaining 5/17 at 2100- 24 remaining…

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 care and services according to facility policy and standards of clinical practice for two residents (Resident #290 and Resident #292) of two residents reviewed for a Peripheral Inserted Central Catheter (PICC) line, resulting in non-occlusive dressings with no admission measurements, timely site dressing changes, discrepancies in documentation and the potential for infection. Findings Include: Resident #290: During initial tour on 5/20/2024, Resident #290 was observed resting in bed and was in good spirits. This writer observed residents PICC line dressing that was not occlusive, dated 5/8 and had no initials. Resident #290 reported her IV (intravenous) antibiotic was already administered this morning. 05/21/24 at 08:32 AM, the ADON (Assistant Director of Nursing) and surveyor observed Resident #290's left upper arm PICC line site, dated 5/8/24. The resident stated it (the dressing) was done at the hospital. The ADON reported 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 observation, interview, and record review the facility to obtain informed consents for the usage of psychotropic medications for two residents (Resident #60 and Resident #84) of five residents reviewed for unnecessary medications, resulting in Resident #60 being administered an antipsychotic medication for 8-weeks and Resident #84 being administered two antipsychotics, an antidepressant, and Alzheimer's medications for one month without proper consent and with the potential for an unnecessary drug regimen and adverse side effects. Findings include: Resident #60: On 5/20/2024 at 7:26 AM, Resident #60 was observed in her room, she informed this writer that she will not take her seizure medications as the facility has her under the wrong identity. On 5/20/2024 at 9:55 AM, a review was completed of Resident #60's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included Paranoid Schizophrenia, Diabetes, and Myocardial Infarction. Resident #60 has a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number MI00135839. Based on interview and record review, the facility failed to complete yearly PASSAR's and/or Level II evaluations for three residents (Resident #602, Resident #603 and Resident #604), resulting in the lack of yearly follow-up and PASSAR/Level II documentation with the likelihood of unmet mental health needs. Findings include: Resident #602: On 3/19/2024, at 1:30 PM, a record review of Resident #602's electronic medical record (EMR) revealed an original admission on [DATE] with diagnoses that included Depression, Anxiety and Heart Failure. Resident #602 had intact cognition. A review of the most recent COMPREHENSIVE LEVEL II EVALUATION March 12, 2021 revealed . If the above named individual remains in the nursing facility, a Level II Evaluation is needed by March 11, 2022. A review of the most recent PASSAR (77/78) document revealed the Mental Illness was check marked. The document was dated 05/17/2023. Three was no other PASSAR correspondence for the year of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00135041 and MI00138477. Based on interview and record review, the facility failed to notify the responsible party and physician of a change in condition for two (Resident #4 and Resident #7) of four reviewed. Findings include: Resident #4 (R4) Review of the medical record revealed R4 admitted to the facility on [DATE] with diagnoses that included epilepsy and anxiety. R4 was not his own decision maker. Review of the eInteract SBAR Summary for Providers dated 3/3/23 at 5:45 PM revealed R4 had abnormal vital signs, altered mental status, uncontrolled pain, and shortness of breath. The physician was notified and ordered STAT (immediate) labs, urinalysis, and a new intervention of oxygen. The note did not indicate R4's responsible party was notified of the change in condition or the new orders. Review of the eInteract Change In Condition Evaluation dated 3/3/23 at 5:45 PM revealed the physician was notified on 3/3/23 at 10:00 AM. The section for Resident Representative…

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 MI00135041. Based on interview and record review, the facility failed to obtain timely laboratory services for one (Resident #4) of one reviewed, resulting in the potential for delayed treatment. Findings include: Review of the medical record revealed R4 admitted to the facility on [DATE] with diagnoses that included epilepsy and anxiety. R4 was not his own decision maker. Review of the eInteract SBAR Summary for Providers dated 3/3/23 at 5:45 PM revealed R4 had abnormal vital signs, altered mental status, uncontrolled pain, and shortness of breath. The physician was notified and ordered STAT (immediate) labs and urinalysis. Review of the eInteract Change In Condition Evaluation dated 3/3/23 at 5:45 PM revealed the physician was notified on 3/3/23 at 10:00 AM. Review of the Physician's Order dated 3/3/23 at 1:30 PM revealed and order for STAT CBC and CMP (complete blood count and comprehensive metabolic panel). Review of R4's lab results revealed the lab work was collected 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 This Citation pertains to Intake Number MI00140688. Based on observation, interview, and record review the facility 1) Failed to document administration of homemade enteral formula, 2) Failed to enter physician's orders upon admission for the administration of seizure medication, and 3) Failed to assess, educate, and document the spouse's ability to administer enteral formula and complete wound care treatment in accordance with current nursing standards of practice for one resident (Resident #701), resulting in, several omissions in enteral nutrition charting, a two-day delay in entering and administration of seizure medication that led to hospitalization and the development of facility processes to address administration of medications and wound care by family members. Findings include: Resident #701: On 11/14/2023 at 10:10 AM, Resident #701 was observed resting in bed with the television on for background noise. Resident #701 is unresponsive and facility staff provide all care needs. CNA (Certified Nursing…

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 #10: On 4/26/23 at 11:30 AM, Resident #10 was observed in their room in bed with their eyes closed. The Resident was positioned on their back with their heels directly on the mattress. The Resident did not provide meaningful responses when asked questions. The Resident had an unkept appearance and their hair was uncombed and oily in appearance. A urinary catheter drainage bag was present on the right side of the Resident's bed (away from the doorway) with the drainage bag positioned directly on the floor. Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis (one sided paralysis) following cerebral infarction (stroke), bipolar disorder, epilepsy, dysphagia (difficulty swallowing), and gastrostomy (tube inserted into the stomach through a surgically created opening in the abdominal wall for the insertion of food). Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required…

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 ensure adequate staffing for residents' needs for Activities of Daily Living (ADL) care for 4 of 8 Residents in the confidential Resident Council meeting, and for five residents (Resident #14, Resident #18, Resident #33, Resident #37, and Resident #46) 2) Failed to ensure adequate staffing to respond to call lights for residents' needs for 7 of 8 residents in the confidential Resident Council meeting and for three residents (Resident #14, Resident #29, and Resident #45) and 3) Failed to ensure that ensure staff competencies check-off forms were accurate and completed, resulting in the confidential Resident Council meeting voicing concerns of not receiving showers and/or baths consistently and call lights being turned off without staff returning to perform the requested care and staff competencies to be incomplete. Findings include: Record review of the facility 'Call Lights: Accessibility and Timely Response' policy dated 3/2023,…

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 ensure that food preparation and kitchen equipment were maintained in a sanitary manner and in good working condition, and 2) Failed to ensure that the kitchen refrigerators and freezers maintained a daily temperature log, resulting in an increased potential for food borne illness with possible hospitalization and with the potential to affect the census of 54 residents who consume nutrition from the facility kitchen. Findings include: During the initial kitchen tour on 4/25/23 at 9:50 a.m , accompanied Dietary Aide's B and C, the following was observed: -The whole kitchen floor was observed to have food, papers and dust on it. There was a black dust pan sitting near the refrigerator with dirt and food in it. -The resident microwave was found to have dried food on the bottom and top of the inside. -Several small flying black bugs were observed flying around in the dish room and by the 2 white handwashing sinks. During an interview done…

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 institute and operationalize policies and procedures to ensure comprehensive administrative oversight of facility programs and knowledge of residents' conditions and care needs for all 92 residents residing in the facility. This deficient practice pertains to multiple levels of facility management and oversight and resulted in a lack of administrative knowledge of resident care practices and needs within the facility including but not limited to lack of knowledge of pressure ulcers (wounds caused by pressure), Preadmission Screening and Resident Review (PASRR) completion, the provision of Activity of Daily Living (ADL) care, safe medication administration and storage, oversight and the assurance of the provision of nutritional services in a safe and sanitary manner, competent and sufficient staffing to meet resident needs, and the likelihood psychosocial distress, utilizing the reasonable person concept, and decline in the overall health…

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 implement a comprehensive Infection Control program that included: 1) Failure to properly store Immunization/vaccines, 2) Failure to log employee illness and analysis for three months, 3) Failure to clean a glucometer after using on a resident and before using on another resident, 4) Failure to have enhanced barrier precautions and cross contamination during wound dressing change for Resident #37, and 5) Failure to ensure PEG tube dressings for Resident #37 and Resident #79, resulting in the likelihood for ineffective Immunization/vaccines therapy, lack of analysis of employee illness, and the likelihood of cross contamination of organisms from improper glucometer cleaning and for open wounds, with likeliness of prolonged illness and hospitalizations. Findings include: Record review of the facility 'Standard Precautions Infection Control' policy with copyright date 2022, revealed all staff are to assume that all residents are potentially…

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 by 1) Not ensuring staff assisted 2 residents with the noon meal (Resident's #30 and Resident #45), 2) Not offering drinks and/or food while 6 residents were waiting to be served the noon meal in the main dining room, 3) Not serving the correct monthly menu, 4) Not answering call lights in a timely manner for 4 residents (Resident #14, Resident #25, Resident #29 and Resident #30), and 5) Complaints regarding food preferences not being honored for 4 of 8 residents in the the confidential Resident Council meeting of a total of 20 residents reviewed for dignity, resulting in the likelihood for weight loss, anger, shame, embarrassment, and isolation with decreased socialization. Findings Include: Review of the facility Dignity policy dated 3/23, reported It is the practice of this facility to protect and promote residents rights and teat each resident with respect and dignity as well as care for each resident in a…

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

Based on interview and record review, the facility failed to update Preadmission Screening and Resident Review (PASARR), mental health screening, for 10 residents of a census of 92 residents reviewed for PASARR screenings, resulting in the potential for unmet mental health and psychiatric care needs. Findings Include: Review of the facility list of facility residents who do not have timely PASARR's, dated 4/27/23, and given to this surveyor on 4/28/23 at 11:20 a.m., from the Director of Nursing revealed a total of 10 residents out of a total census of 96 residents whose PASARR was not done at all or late to be done. During an interview done on 4/28/23 at 8:15 a.m., Social Worker H stated About November or December (of 2022) when I got here (started at the facility), I had no access to get into OBRA (Budget Reconciliation Act) to do the PASARR's. I contacted OBRA web site when I got here. The social worker before me who had left was still in the system. Neither of us (2 facility social workers) have access to get in and do the PASARR's, so they (the facility resident's) are behind. I…

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 or implement comprehensive care plans for four residents (Resident #37, Resident #45, Resident #46, and Resident #79) of 20 residents reviewed for care plan implementation, resulting in care plans not being comprehensive with interventions of Activities of Daily Living, accommodations for the blind, and monitoring of weight loss, Findings include: Record review of the facility 'Comprehensive Care Plans' policy dated 3/2023, revealed it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Resident #37: Observation and interview on 04/25/23 at 01:47 PM of Resident #37's room noted Resident #37 sitting with head of bed slightly up and the resident to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5% when three medication errors were observed for three residents (Resident #248, Resident #249, and Resident #250) from a total of 25 observations, resulting in a medication error rate of 12%. This deficient practice resulted in the likelihood for adverse medication effects including hypoglycemia (decreased blood sugar), hypotension (low blood pressure), bleeding, and decreased medication efficacy related to incorrect administration dosage. Findings include: Resident #248: A medication pass observation for Resident #248 was completed on [DATE] at 10:08 AM with Licensed Practical Nurse (LPN) QQ. Per LPN QQ, Resident #248's blood glucose level was 212 and required subcutaneous (SQ- injection into fatty tissue under skin) insulin per sliding scale. Review of the Resident's sliding scale insulin order revealed Resident #248 should receive six units of Insulin Aspart (rapid active insulin 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 operationalize policies and procedures to ensure medication storage, labeling, and disposal per professional standards of practice for four of five medication carts and two of two medication rooms resulting in medications without resident identifiers, opened and undated medications, expired medications and medical supplies, and the potential for all Residents receiving medications from those medication carts, to receive medications with altered efficiency. Findings include: A tour of the North Hall Medication Cart was completed with Licensed Practical Nurse (LPN) MM on 4/26/23 at 8:33 AM. The following were present in the medication cart: - Glucose Control Solutions; Dated as Opened 7/20/22 - Carboxymethyl 0.5% Solution Eye Drops; Labeled for administration to Resident #249; Opened and undated - Proair HFA 8.5 gm (gram) inhaler; Open and undated; Labeled for administration to Resident #247 - Ipratropium Bromide HFA inhaler; Open and undated; Labeled for administration to Resident #247 - Proair HFA 8.5 gm…

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 implement supportive interventions for blind residents regarding the environment, safety, Activities of Daily Living (ADL) and food service for 1 resident (Resident #25) of 20 Residents reviewed for accommodation of needs, resulting in the potential for unmet care needs, food safety concerns and weight loss, falls with injury, isolation with feelings of frustration, and anger. Findings include: Resident #45: Review the Face Sheet, Minimum Data Set (MDS, dated [DATE]), care plans dated 1/24/23 through 4/27/23, revealed Resident #45 was 57 years-old, admitted to the facility on [DATE], was alert and making her own healthcare decisions, required staff assistance with all Activities of Daily Living and was blind in the right and left eyes. The resident's diagnosis included, Right and Left eye blindness (category 5, only see's close-up shadows), glaucoma secondary to eye disorder, stroke, high blood pressure, chronic heart and lung disease,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that guardianship documentation was present in the medical record for one resident (Resident #10) of one resident reviewed, resulting in a lack of review and confirmation of legal guardianship prior to implementing the decision maker, and the potential for inaccurate guardianship and care decisions. Findings include: Resident #10: On 4/26/23 at 11:30 AM, Resident #10 was observed in their room in bed with their eyes closed. The Resident was positioned on their back with their heels directly on the mattress. The Resident did not provide meaningful responses when asked questions. Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis (one sided paralysis) following cerebral infarction (stroke), bipolar disorder, epilepsy, dysphagia (difficulty swallowing), and gastrostomy (tube inserted into the stomach through a surgically created opening in the abdominal wall for the…

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

Based on observation, interview and record review, the failed to issue a beneficiary notice (ABN/Nomnic) for one resident (Resident #28) and notify eligible residents in writing of the items and services which are or are not covered under Medicaid or by the facility's per diem rate, including the cost of those items and services, resulting in Resident #28 having no documentation of beneficiary notices (ABN of NOMNIC) found with in her electronic record or in a paper format within the facility resulting in the likelihood for financial hardship. Findings include: Record review of facility 'Advanced Beneficiary Notices' policy dated 3/23/2023 revealed it is the policy of the facility to provide timely notices regarding Medicare eligibility and coverage. The business office manager is responsible for issuing notices. To ensure the resident or representative has enough time to make a decision whether or not to receive services in question and assume financial responsibility, the notice shall be provided at least two days before the end of the Medicare covered Part A stay or when all 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 1) Failed to ensure that Resident #1's advanced directive care plan was updated when the resident received hospice services, 2) Failed to ensure that Resident #46's antipsychotic medication care plan was updated with a new order on 05/03/2023, and 3) Failed to ensure that Resident #79 weight loss/re-weights were care planned, resulting in a failure to review and update care plans timely for three residents (Resident #1, Resident #46, and Resident #79), resulting in a failure to that ensure interventions were in place necessary for care and services to maintain the highest level of well-being. Findings include: Record review of the facility 'Care Plan Revisions Upon Status Change' policy dated 3/2023, revealed the purpose of the procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2.) (d.) The care plan will be updated 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 ensure an appropriate documentation, assessment, and diagnosis for psychotropic medication use for one resident (Resident #84) of one resident reviewed, resulting in Seroquel (antipsychotic medication frequently used to treat Bipolar, caution use in individuals with dementia) being administered without a consent, a comprehensive assessment, and a documented diagnosis for use. Findings include: Resident #84: On 4/25/23 at 12:29 PM, Resident #84's room door was closed. Upon knocking and entering the room, an overwhelming foul body odor was instantly noted. Resident #84 was observed in their bed with their eyes open. The Resident had an unkept and ungroomed appearance. An interview was completed at this time. When queried regarding the medications they receive in the facility, Resident #84 revealed they did not know and just take what the nursing staff give them. Record review revealed Resident #84 was originally admitted to the facility on [DATE] 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 implement and operationalize guidelines and procedures for the enactment of a Durable Power of Attorney (DPOA) for one resident (Resident #90) of one resident reviewed, resulting in the enactment of a DPOA without determination of legal incompetency and the potential for inappropriate enactment of a DPOA and unwanted care decisions. Findings include: Resident #90: Record review revealed Resident #90 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure, heart failure, and lung cancer. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required extensive to total assistance to complete all Activities of Daily Living (ADL's) with the exception of eating. Resident #90 passed away in the facility on [DATE]. Review of Resident #90's Electronic Medical Record (EMR) revealed the following active and discontinued Health Care Provider (HCP) orders:…

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

Based on observation, interview and record review, the facility failed to place tube feed dressings for two residents (Resident #37 and Resident #79) per standards of practice and facility policy, resulting in the likelihood for cross contamination to PEG tube sites and prolonged illness. Findings include: Record review of the facility 'Gastrostomy Site Care' dated 3/2022, revealed that the facility policy to perform gastrostomy site care as ordered and per current standards of practice: Verify there is a physician order for gastrostomy site care, Review the plan of care . (10.) Apply any other PPE (Personal Protective Equipment) as needed to protect self from any exposure to infectious material and to comply with any isolation precautions ordered. (11.) Maintain clean technique. (12.) Remove old dressing if applicable and discard in appropriate container. (13.) Wash hands and don gloves. (14.) Using soap and water, gently clean the area around the tube and continue in an outward circular fashion, ensuring that under the bolster is cleaned. (15.) Assess the area for any excoriation,…

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 implement and operationalize a comprehensive nursing orientation program to ensure staff competency prior to working independently with residents, resulting in nursing staff providing care to residents without demonstrated and documented competency, medication administration errors, and the likelihood of additional errors, inaccurate and incomplete resident assessments, and the potential in alteration in overall health status for all 92 facility residents. Findings include: A medication pass observation was completed on 5/3/23 at 10:08 AM with Licensed Practical Nurse (LPN) QQ. Prior to beginning the medication pass observation, LPN QQ was asked if they were off of orientation as they had been previously observed training with another facility nurse. LPN QQ indicated they were still on orientation and stated, I'm training with (LPN XX). LPN XX was observed working on a different hall in the facility and passing medications in that hall prior to approaching LPN QQ. When queried if they had their own cart 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 ensure that informed consents were obtained for psychotropic medications prescribed for four residents (Resident #1, Resident #46, Resident #79, and Resident #84), resulting in Residents #1, #46, #79, and #84 being administered antipsychotic medication without appropriate consent and risk-versus-benefit analysis of the medications explained to the resident and/or the responsible party with the increased likelihood for serious side effects and adverse effects. Findings include: Record review of the facility 'Use of Psychotropic Medication' policy dated 3/2023, revealed residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed ad documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. A psychotropic drug is any drug that affects brain activities associated with 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.