Medilodge of Frankenmuth

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure sanitary storage of respiratory equipment for 1 resident (Resident #3) of 3 residents reviewed for respiratory care. Findings Include:Resident #3: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Amyotrophic Lateral Sclerosis/ALS, dysphagia (difficulty swallowing), need for a feeding tube, COPD, diabetes, sleep apnea, heart disease, GERD and PTSD. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed some assistance with all care. On 5/04/2026 at 9:39 AM, Resident #3 was observed lying in his bed, awake and talkative. He had a variety of oxygen equipment at the bedside including: an AVAPS (Average volume-Assured Pressure Support) machine providing oxygen used to assist in airway…

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 2993831.Based on observation, interview, and record review, the facility failed to ensure that nursing staff were reviewed for competency prior to caring for residents, for one of five staff reviewed for staffing education and competency.Findings include: On 05/05/2026 at 11:41Am, an e-mail request was sent requesting performance evaluations, competencies, education, license and certificates for 5 selected staff that included Nurse J. On 05/05/2026 at 10:45 AM, An observation of Nurse J was made independently working on the dementia unit and requested her assistance with resident identification in the dining/activities room. When asked Nurse J she said she had been a nurse about 1 year and was newer to the facility. On 05/05/2026 at 1:20PM, During an interview with Human Resources (HR) J she was asked to provide education, competencies, certificates and licensure requested for the 5 selected staff that included Nurse J. On 05/06/2026 a record review of Nurse J 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 ensure that the daily staff posting was accurate for all staff that provided care for all residents at the facility.Findings include: A record review of the facility daily staff postings revealed that it displayed CNA's, LPN/LVN and Med tech and No RN hours. It was requested for the last 2 weeks (April 21st through May 6th) be uploaded to the (computer document storage program).On 05/05/2026 at 1:20PM, during an interview with scheduler H was asked about the daily staffing posted that displayed CNA's, LPN/LVN and Med tech and No RN hours. She said she was new and that it was completed by HR. During the interview HR I entered the room and was asked about the posting and RN coverage, she said it was pulled from the (scheduling system) and maybe it was not pulling that information, She agreed that the format they posted did not show RN hours and that it was inaccurate.05/05/2026 at 3:20PM, requested copy of the posted staffing and that it be placed into (computer document storage program), 2nd request. Received paper copy of…

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

Based on observation, interview and record review, the facility failed to follow standards of practice for insulin administration and needle safety for one resident (Resident #29) of three residents reviewed for insulin administration, resulting in the likelihood of decreased dosage administered and infection. Findings include. On 5/06/2026, at 11:49 AM, Nurse L gathered Resident #29's insulin pen for administration. Nurse L pulled out a needle and attached it to the insulin pen without cleaning the insulin pen with an alcohol swab. Once Nurse L applied the needle to the pen, they turned the administration dial to 8 units and entered Resident #29's room. Nurse L administered the insulin pen without priming the needle with the required 2 units. On 5/06/2026, at 12:32 PM, the Director of Nursing (DON) was alerted that Nurse L did not clean the insulin pen with an alcohol swab prior to the needle attachment nor prime the required 2 units prior to administration.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 1) Ensure that corrective action was taken when out-of-range temperatures were identified on medication refrigerator temperature logs for one of one medication refrigerator and 2) Discard discontinued or expired topical medications for two of two treatment carts reviewed for medication storage, creating the potential for compromised integrity of temperature-sensitive and topical medications. Findings include: Medication Storage and Labeling: Observed on [DATE] at 8:52 AM with Registered Nurse (RN) [NAME] unit manager of the west resident care unit treatment cart revealed multiple-dose opened ointments and creams used for wound/skin care. Observation noted resident prescription treatments included: Resident #7 -Clotrimazole-Betamethasone .05% external cream. There was no date on the box ad when observed there was no date on the opened tube of medication. Record review of Resident #7's physician order recap noted that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number 2726226. Based on observation, interview and record review the facility failed to implement individualized interventions to address the dementia care needs of one resident (Resident #606) of six residents reviewed for dementia. Findings Include:Resident #606:On 4/6/2026 at 11:00 AM, a tour was completed of the locked memory care unit. We entered through the common room area where residents were observed at tables with two facility staff members. Once in the hallway there was no nursing staff observed. Upon entering room [ROOM NUMBER], a gentleman was observed sleeping in bed b and Supervisor A stated that was not Resident #603 but Resident #606. He stated he resides next door as their rooms connect via the bathroom and it's possible, he entered through the bathroom. Supervisor A left the room to locate a staff member to assist in redirecting Resident #606 back to his room. He returned a few moments later with a staff members observed earlier in the common area and as she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure dignity and privacy for five residents (#9, #24, #27, #35, #37) of 18 residents reviewed for dignity and privacy, resulting in feelings of being dismissed, forgotten and embarrassment. Findings include: Dining: On 4/02/25, at 12:05 PM, an observation of main dining room lunch meal service was conducted. There were two residents sitting at a table together. At 12:10 PM, there was a tray offered to the one resident from the east hall tray cart. Resident #9 was sitting at the table and was overheard saying where's my food. In response, CNA K was overheard stating to Resident #9, one moment (Resident #9). At another table, a resident was served their lunch meal at 12:11 PM. Resident #37 was sitting across and was not served their meal. On 4/02/25, at 12:21 PM, Resident #9 and Resident #37 still had not been served their meals while the two residents sitting at their tables finished their meals and was assisted out of the dining room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed complete assessments to determine the need for bed rails, monitor residents' continued use of bed rails, obtain physicians' orders, and implement care plans for 4 residents (#8, #14, #19, #43) and obtain consent prior to use for Resident #14, for 4 of 5 residents reviewed for entrapment. Findings include: Resident #8: Observation on 4/1/2025 between 9:00 AM and 10:00 AM during the initial screening process of Resident #8 was observed with silver metal bilateral half siderails in use. Resident #8 appeared confused and was not responding to questions related to the use of the siderails. Record review of resident #8' minimum Data Set (MDS) dated [DATE] revealed an elderly male with cognitive skills for daily decision making as severely impaired never/rarely make decisions. Medical diagnosis included: Dementia, cardiovascular accident (CVA), aphasia, hypertension, renal insufficiency, diabetes, seizure disorder and anxiety. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medication labeling, storage and discard of medications in 4 of 4 medication carts reviewed, resulting in a lack of dating of multi-dose medications with specified time frames for use after opening. Findings include: Observation and interview on [DATE] at 08:01 AM on the [NAME] unit medication cart with Licensed Practical Nurse (LPN) P revealed that: Unsampled female resident had Trelegy Ellipta 100mcg/62.5mcg/25 mcg multi-dose medication, opened/used and not dated with either open date or expirations date once opened. Resident #67- Ipratropium Bromide Inhalation 0.02%, ampules located within the box not in the foil packet. Resident #52- Ipratropium Bromide and Albuterol Sulfate 0.5mg & 3mg/3ml. 3 ampules located in box and not in foil packets. LPN P stated that the ampules are to be in the foil packets not loose. [NAME] with green lettering open and expiration date stickers on some medications were noted by the surveyor.…

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 food preparation and kitchen equipment in a sanitary and good working condition and 2) Maintain a correct thawing procedure for hamburger. Findings Include: Review of the Public Health Service 2009 Food Code, adopted by the Michigan Food Law, effective October 1, 2012, Chapter 4-501.14 directs that equipment cleaning frequency is to be throughout the day at frequency necessary to prevent recontamination of equipment and utensils. Review of the facility Food Receiving and Storage policy dated 1/1/2022, revealed food items open and partly used need opened on and use by dates. On 4/1/25 at 8:00 a.m., a kitchen walk through was done accompanied by [NAME] C. The following concerns were identified during the walk through: -At 7:55 a.m., observation of the large can opener sitting on the food prep table was noted sitting on the food cart to have dried on food on the blade and around the blade was found to also have dried food on it. -At 8:00 a.m., observed the small toaster with an excessive amount of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that fans were clean for Resident #41 and Resident #54 and oxygen tubing was stored appropriately for Resident #42. Findings Include: Resident #41: Review of the Face Sheet, MDS dated [DATE], nurses and social service notes dated 1/25 through 4/1/25 through, and care plans revealed Resident #41 was [AGE] years old, alert, admitted to the facility on [DATE], and required assistance with ADL's. The resident's diagnosis included, history of Guillain-Barre Syndrome, anemia, pulmonary embolism, diarrhea, encephalopathy, muscle weakness, depression, and anxiety. Observation done on 4/1/25 at approximately 9:45 a.m., revealed Resident #41's black fan on high blowing directly on him with an extensive amount of dust blowing on the front and back cover. During a second observation made of the Resident #41's done on 4/2/25 at 12:09 p.m., he was sitting on his bed and his fan was observed blowing on high directly toward the him. It had not been…

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 and/or revise individualized, person-centered care plans to reflect changing care needs for 6 residents (#8, #14, #19, #28, #47, and #60) of 24 residents reviewed for care plans. Findings Include, Resident #28: Accidents On 4/01/2025 at 9:41 AM, Resident #28 was observed in the day room, sitting in a chair. The resident was awake and talkative, but confused. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #28 was admitted to the facility on [DATE] with diagnoses: Dementia, history of a stroke, hypertension, chronic pain, peripheral vascular disease, atrial fibrillation, weakness and unsteadiness on feet. The MDS assessments dated 11/27/2024 and 2/25/2025 revealed the resident had severe cognitive loss with a Brief Interview for Mental Status/BIMS score of 3/15 and needed assistance with all care including toileting. A record review of the Incident and Accident Reports for Resident #28…

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 accurate weights were obtained for 2 residents (#35 and #47) of 6 residents monitored for food or nutrition, resulting in Resident #35 and Resident #47 having inaccurate weights documented in the medical record. Findings Include: Resident #35: Nutrition A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, anxiety, history of intestinal cancer, and heart disease. The MDS assessment dated [DATE] revealed the resident had severe cognitive loss with a Brief Interview for Mental Status/BIMS score of 3/15 and the resident needed some assist with all care. On 4/01/2025 at 11:40 AM, during a review of the weights for Resident #35 in the electronic medical record Weights/Vitals tab, it indicated the resident had a 16 lb. weight gain in one day. The resident weighed 162.0 lbs on 3/31/2025 and 178.4 lbs. on 4/1/2025…

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 clean and dry storage of respiratory equipment for three residents (#25, #44, #54) of three residents reviewed for respiratory needs, resulting in unsanitary storage of respiratory equipment. Findings include: Resident #25: On 4/01/25, at 11:11 AM, Resident #25 was in their bed in their room. Their nebulizer mask was face down on their nightstand uncovered and without a barrier. Resident #25 was asked if they use their nebulizer and Resident #25 stated, yes. On 4/01/25, at 1:30 PM, a record review of Resident #25's electronic medical record revealed and admission on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) and muscle weakness. A review of the self-care performance deficit care plan revealed Interventions . BED MOBILITY: 1 person assist . TRANSFERS : 1 person assist . On 4/02/25, at 9:35 AM, Infection Control (IC) Nurse A was asked how nebulizer masks should be stored when not in use and IC…

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 adequately monitor antibiotic use and update the antibiotic line listing for one resident (#2) of 17 sampled residents. Findings include: Record review of the facility provided CMS-802 MDS Resident Matrix dated 4/1/2025 at 9:36 AM revealed Resident #2 to have antibiotic medication and an indwelling catheter. Resident #2: Record review on 04/01/25 at 11:56 AM of Resident #2's March 2025 Medication Administration Record noted Gentamycin sulfate 10mg/ml, 27 milligrams miscellaneous every evening shift every Monday, Thursday, Saturday. Administer while in the shower on Monday and Thursdays. Mix with 50ml normal saline. Irrigate the bladder with 50ml through the suprapubic catheter and clamp for 30 minutes dated 2/8/2025. In an interview on 4/01/25 at 01:35 PM at Licensed Practical Nurse M stated that Resident #2 had Gentamycin solution flushed into the catheter, ordered 3 x week but resident only lets us do it 2 times a week during his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to 1) Ensure consent for antipsychotic medications prior to administration for 1 resident (Resident #14) and 2) Ensure supporting documentation for use of Ativan for 1 resident (Resident #9) of 3 residents reviewed for antipsychotic medications (including anxiety medications), resulting in antipsychotic medications without appropriate consent and the use of Ativan daily at HS (night time). Findings include: Record review of the facility provided CMS-802 MDS Resident Matrix dated 4/1/2025 at 9:36 AM revealed Resident #14 to have AP (Antipsychotic) and (AA) Antianxiety medications. Resident #14: Record review of resident #14's March 2025 Medication Administration Record noted Quetiapine fumarate (Seroquel) antipsychotic medication 25mg give one tablet by mouth at bedtime related to anxiety disorder, unspecified. Start date 3/13/2025. Record review on 04/01/25 at 11:08 AM of Resident #14's electronic medical record revealed that there was no…

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 an adequate amount and choice of evening snacks for a Confidential Group of residents reviewed, resulting in not getting snacks, enough snacks, feeling left out for a choice of snacks and an overall feeling of frustration. Findings include: On 4/2/25, at 2:15 PM, a confidential group of residents complained the facility doesn't restock the snack carts and the snack items are always the same. The following complaints were voiced: they don't pass snacks at night they took away the snack cart they only give us peanut butter and jellies, and that's if there are any left sometimes we get apples and oranges, but not often it would be nice if we could grapes we want more fruit choices there is a difference between center snack cart and west snack cart meat sandwiches are few and far between we don't get the refrigerator things we don't get certain snacks unless we get them before the kitchen closes we want egg salad, tuna and more meat…

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 #MI00147776 Based on interview and record review the facility failed to provide activities of daily living (ADL) care for one dependent resident (R2) of four residents reviewed for ADL care, resulting in poor skin conditions and lack of assistance with bed mobility and peri-care. Findings include: Resident #2: R2 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include spinal stenosis, history of falling, diarrhea and chronic obstructive pulmonary disease. R2 has a brief interview for mental status (BIMS) score of 15, indicating that they are cognitively intact. On 01/21/25 at 11:53am, R2 was observed sitting in the dining room getting ready to eat lunch. R2 was approached by this surveyor and an interview was conducted. R2 was asked if they had any issues or concerns with the care they were receiving in the facility. R2 stated that when he first admitted to the facility, he had some issues with the staff providing care after he had episodes of fecal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes #MI00147776 and #MI00149234. Based on interview and record review the facility failed to ensure that physician ordered medications were available for one resident (R1) and administered timely for one resident after admission (R2) of four residents reviewed for medication availability and timely medication administration, resulting in medications not being available and one resident not receiving their physician ordered medications timely. Findings include: Resident #1: R1 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include pathological fracture of the right femur, rib fracture, malignant neoplasm of the prostate and malignant neoplasm of the bones. R1 has a brief interview for mental status (BIMS) score of 15 indicating they are cognitively intact. On 01/21/25 at 9:30am, an interview was conducted with the complainant E. Complainant E stated that upon admission they were told that the pain medications were unavailable and that this went on for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Numbers MI00146717 and MI00147164. Based on observation, interview and record review, the facility failed to maintain a clean, safe and homelike environment on the Central Unit with an exit door latched shut, foul odors, windows not secure, disrepair of furniture, and on the East Wing Unit call lights were not in reach, for two of three Units/Wings reviewed for environmental concerns, resulting in a marked exit door not functional in case of an emergency, lack of resident, staff, and visitor safety and the potential for embarrassment, dissatisfaction with living conditions, frustration, and needs not being met. Findings include: On 9/19/24 at 10:19 AM, an observation was made in room [ROOM NUMBER]. The Resident in bed A was lying in bed, awake. The Resident indicated he wanted to get out of bed. When asked if he had a call light, the Resident reported he did not know where it was. An observation was made of the call light around the bed rail positioned at the junction of the bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number MI00146717. Based on observation, interview and record review, the facility failed to ensure that residents' rights/dignity were maintained when concerns/grievances were not addressed and call lights were not answered timely for four residents (Resident #2, Resident #3, Resident #6 and Resident #9), of five residents reviewed for call light response and grievances, resulting in incontinence, feelings of frustration and anger, and needs not met timely. Findings include: Resident #2: A review of Resident #2's medical record revealed an admission into the facility on 6/21/24 with diagnoses that included sprain of ligament of left ankle, obesity, diabetes, lymphedema, muscle weakness, difficulty in walking and shortness of breath. A review of the Minimum Data Set (MDS) assessment revealed the Resident had a Brief Interview of Mental Status (BIMS) score of 15/15 that indicated intact cognition, and the Resident needed partial/moderate assistance with oral hygiene, and…

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

This Citation pertains to Intake Numbers MI00146717, MI00147164, MI00147177 and MI00147178. Past Non-Compliance (PNC) was presented by the facility during investigation of the allegations and was accepted by the survey team upon exit from the facility for this citation. Following discussion with the State Manager, Past Non-Compliance was accepted. The Compliance Date was 09/26/2024. Based on observation, interview and record review, the facility 1) Failed to ensure that one resident (Resident #11) was assessed and monitored after a fall with a head injury and who was returned back to the facility after hospital evaluation, 2) Failed to ensure that an incident report was completed for one resident (Resident #12), who sustained an injury of unknown origin and failed to treat the occurrence as a fall, and 3) Failed to report an injury of unknown origin for two residents (Residents #11 and Resident #12) of 6 residents reviewed for falls and injuries of unknown origin, resulting in the potential for signs and symptoms of a head injury to go undetected and left untreated for Resident #12,…

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 Resident #5 had an adequate supply of oxygen while up and using the portable oxygen, 2) Failed to ensure the proper storage of nebulizer treatment equipment, and 3) Failed to replace oxygen tubing, nasal cannula, nebulizer apparatus for three residents, (Resident #2, Resident #5 and Resident #8), of 3 residents reviewed for respiratory care, resulting in potential for exacerbation of respiratory conditions, lack of oxygen, respiratory infections and diminished health and well-being. Findings include: Resident #2: A review of Resident #2's medical record revealed an admission into the facility on 6/21/24 with diagnoses that included sprain of ligament of left ankle, obesity, diabetes, lymphedema, muscle weakness, difficulty in walking and shortness of breath. A review of the Minimum Data Set (MDS) assessment revealed the Resident had a Brief Interview of Mental Status (BIMS) score of 15/15 that indicated intact cognition, 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.

This Citation pertains to Intake Number MI00146646. Based on observation, interview and record review, the facility failed to properly store medication and needles/sharps on the East Wing Unit, of three units reviewed for safe environment, resulting in the potential for medication ingestion, diversion of medication and needles, and injury. Findings Include: On 9/19/24 at 10:06 AM, an observation was made of the nurses' station. There were no staff in the area. Residents were in the vicinity and nearby in the common area. The Nurses' Station had a counter that was accessible from the hall and wheelchair accessible in height. An observation was made of a bag of multiple antibiotic IV (intravenous) medication on the counter of the Nurses' Station. There was a tube of Derma fungal cream (an antifungal cream for skin treatment of a fungal infection), Assure glucometer control solution used to calibrate glucose monitor, vial of Ertapenem 1 gram vial (antibiotic medication) and Assure ID Pen needles. The needles were in an open box on the counter. While waiting for staff to return 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.

Based on observation, interview and record review, the facility failed to follow policies and procedures for medication labeling and medication storage in 2 of 2 medication carts involving 14 residents (#3, #4, #6, #9, #13, #14, #22, #24, #32, #33, #39, #40, #44) medications and 1 of 1 medication rooms reviewed, resulting in opened and undated multi-dose medications, and the likelihood for altered medication efficiency. Findings include: Record review of the facility 'Medication Storage' policy dated 1/30/2024 revealed it is the policy of the facility to ensure all medications housed on the premises will be stored according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. General guidelines: (1.a.) All drugs and biological's will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. (b.) Only authorized personnel will have access to the keys to locked compartments. (c.) During 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 and interview the facility failed to maintain sanitary conditions in the kitchen, resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 45 residents who consume meals from the kitchen. Findings Include: On 4/29/2024 at 9:35 AM, a tour of the kitchen was completed in the presence of Regional Dietitian L. The following expired/outdated times were found: Dry Storage Room: - 5- Minnehaha Mills Sugar Free Raspberry Gelatin packets expired 3/16/2023 - 6- Hard shell tacos in Ziploc bag, expired 3/20/24 - 5lb (pound) bag of Corn Muffin mix, expired on 12/15/2023. - ¼ full- 50-pound container of rice, expired on 2/3/2024 - ½ full-3-gallon container of Cheerios cereal, expired on 4/2/2024 - ½ full-3-gallon container of Cornflakes, expired on 4/2/2024 - ½ full- 3-gallon container of [NAME] Krispies, expired on 4/2/2024 Cook Refrigerator: - 5-quart container of salad mix, use by date 4-5-2024 Walk-in Cooler: - Gallon size bag of frozen turkey or pork with no open or use by date - Gallon size bag of frozen ground…

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 MI00141996 and MI00143446. Based on observation, interview and record review, the facility failed to have call lights within reach or respond to in a timely manner for three residents (Resident #6, Resident #15, Resident #200) and one resident (Resident #100) being left exposed, in a review of 12 residents reviewed for dignity, resulting in residents verbalizing complaints, frustration, and likelihood for mental anguish. Findings include: Record review of the facility 'Promoting/Maintaining Resident Dignity' dated 10/26/2023 revealed it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Record review of the facility 'Resident Rights' policy dated 1/1/2022 revealed employees shall treat residents with kindness, respect, and dignity.…

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 the standards of practice for administration of oral Coumadin anti-coagulant and intravenous Vancomycin antibiotic medications for two residents (Resident #100, Resident #200), resulting in an excessive dose of Coumadin anti-coagulant and intravenous Vancomycin antibiotic medications therapy with the likelihood for prolonged illness and/or hospitalization. Findings include: Record review of facility 'admission Contract' page 8 of 12, section 13.2 Nursing staff (licensed nurses and nurse aides) work in the Center seven days a week, 24-hours a day. These staff are assigned to provide the reasonable and customary nursing home nursing and personal care. The services of the Nursing Department are provided under the supervision of a Director of Nursing or his/her designee. Record review of the American Nurses Association (ANA) statement of The Standards of Practice describes a competent level of nursing care as demonstrated by 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 implement and operationalize policies and procedures to ensure timely completion and assessment of diagnostic/laboratory testing as well as comprehensive assessment, monitoring, and treatment following a change in condition for two residents (Resident #49, and Resident #100) reviewed, resulting in a lack of laboratory monitoring of medications for Resident #100 and Resident #49 experiencing a change in condition, a lack of comprehensive assessment, laboratory testing/results, and resident involvement in care decisions. Findings include: Resident #49: Record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses which included Covid-19, pneumonia, Congestive Heart Failure (CHF), and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was [AGE] years old, cognitively intact, and required supervision to moderate assistance to complete Activities of Daily Living…

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 interventions timely to prevent an Unstageable (full-thickness pressure injury in which base is covered by eschar and/or slough) Coccyx Pressure Ulcer for one resident (Resident #6), resulting in a new unstageable pressure ulcer with the likelihood of further skin complications. Findings include: Resident #6: ON 4/29/24, at 9:34 AM, Resident #6 was lying on their back in their bed. They complained that they have a wound on their bottom. Resident #6 stated, they didn't have it when they got there. On 4/29/24, at 3:22 PM, Resident #6 was lying in their bed on their back. On 4/30/24, at 9:00 AM, a record review of Resident #6's electronic medical record revealed an admission on [DATE] with diagnoses that included Diabetes, Anemia and Heart Failure. Resident #6 required extensive assistance with Activities of Daily Living (ADL) and had intact cognition. There were no lab results for review in the record. A review of the ADL self-care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to timely assess, investigate, implement appropriate interventions, and notify practitioners and the dietitian of significant weight loss for one resident (Resident #13) of one resident reviewed for excessive weight loss, resulting in a significant weight loss of 32.3 pounds (12.52%) with delayed facility assessment and intervention for Resident #13. Findings Include: Resident #13: During initial tour, Resident #13 was observed in the dining room perusing a magazine. The resident was asked about her weight loss in January 2024, and stated she had to lose some weight as she is a basketball player. On 4/30/2024 at 9:00 AM, a review was completed of Resident #13's medical records and it revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included, Diabetes, Atrial Fibrillation, Schizophrenia, Anxiety, Dementia, Eating Disorder, Hemiplegia and Hemiparesis. Further review yielded the following: Care Plan:…

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 observations, interview and record review, the facility failed to assess and monitor Percutaneous Inserted Central Catheter (PICC/a central line placed into a vein in the upper arm guided into a large vein above the heart) per standards of practice and failed to notify the physician of an inward migration of the PICC for two residents (R#39, 200), resulting in a complication of a 3.5 centimeter (CM) inward migration going unassessed, missed dressing changes, flushes, end cap changes with the likelihood of further complications such as further inward or outward migration, swelling, site infection going unassessed and/or unnoticed. Findings include: Resident #39: On 4/29/24, at 11:45 AM, Resident #39 was resting in their room. They had a PICC line to their left upper arm. The dressing was dated 4-27-24 and was intact. On 4/29/24, at 3:30 PM, a record review of Resident 39's electronic medical record revealed an admission on [DATE] with diagnoses that included Osteomyelitis, Diabetes and mood disorder.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that one resident (Resident #100) was free of an unnecessary dose of Coumadin anti-coagulation with elevated laboratory Protime (PT) and International Normalized Ratio (INR) levels, resulting in the likelihood for excessive bleeding and hospitalization. Findings include: Record review of the facility 'Medication Administration' policy, dated 1/17/2023, revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so on this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The facility medication administration policy had no instructions for nurses to monitor therapeutic laboratory levels prior to administration of high-risk medications or to address Black Box Warnings of medications. Record review of the 'Nursing 2017 Drug Handbook' page 1512-1515, revealed Coumadin anticoagulant with oral…

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 7 late administrations of medications were observed and 2 medication errors from a total of 30 opportunities for two residents (Resident #100, Resident #200) of 5 residents reviewed. This deficient practice resulted in a medication error rate of 30% and the likelihood for the risk of adverse medication effects and decreased medication efficacy. Findings include: Record review of the facility 'Medication Administration' policy dated 1/17/2023 revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so on this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. (#11.) Compare medication source with the MAR (Medication Administration Record) to verify resident name, medication name, form, dose, route, and time of administration. (a.) Refer to drug reference materials if unfamiliar with the medication, including 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 observation, interview and record review, the facility failed to prevent significant medication errors for two residents (Residents #100, Resident #200) of five residents reviewed for medication errors, when a nurse administered an anticoagulant (Blood thinner) with an elevated International Normalization Ratio (INR) to Resident #100, and another nurse administered the wrong strength of Vancomycin antibiotic medication with an elevated Vancomycin laboratory level, resulting in the likelihood for prolonged illness and hospitalization. Findings include: Record review of the facility 'Laboratory and Diagnostic Guidelines' policy dated 10/26/2023 revealed the guideline is set up to track the timely completion, reporting and monitoring of laboratory and diagnostic tests, results, and notifications which are used to monitor resident status and/or therapeutic medication levels. Record review of the facility 'Medication Administration' policy dated 1/17/2023 revealed medications are administered by 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive infection control program, encompassing outcome and process surveillance and accurate data collection/documentation/analysis including potential infections, pneumococcal vaccination tracking, and call-in/illness tracking for contracted staff resulting in lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis, and the likelihood for spread of microorganisms and illness to all 45 facility residents. Findings include: A review of the facility provided line listing data for March 2024 revealed the line listing did not include any carry over infections from the prior month (s), the Resident room number and/or room changes, any transmission-based isolation precautions, if the infection meet criteria for treatment, diagnostic testing including results/dates, and antimicrobial medication treatment duration. The line listing included a header titled,…

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 MI00138469. Based on interview and record review, the facility failed to ensure appropriate measures were in place to prevent wound development and promote wound healing for one resident (Resident #1) of three residents reviewed for wounds, resulting in Resident #1 developing a Stage II decubitus ulcer to the right buttock and a wound on the right foot with worsening of the wounds, the wound on the right foot becoming infected, pain, decline in health status that included dehydration and acute kidney injury, the Resident was unable to tolerate surgical procedures to the right foot was placed on comfort measures and hospice services. Findings include: Resident #1: A review of Resident #1's admission Record revealed an admission into the facility on 5/15/23 with diagnoses that included diabetes, hypertension, muscle weakness, pain in left knee, anxiety disorder, and a history of poliomyelitis. A review of the Minimum Data Set (MDS) assessment, dated 5/21/23, revealed a Brief…

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