Medilodge of Grand Blanc

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that physical restraints were not used for staff convenience for one resident (Resident #118) of one resident reviewed, resulting in restriction of mobility. Findings include: Resident #118:Resident #118 was observed in their room on 2/22/26 at 12:32 PM. The Resident was in bed, positioned on their back. The bed was at normal height and fall mats were in place. The two upper side rails on the Resident's bed were raised. Resident #118 was receiving mechanical ventilation via tracheostomy and did not respond when spoke to. Record review revealed Resident #118 was originally admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke) with resulting right sided hemiplegia/hemiparalysis (one sided paralysis) and dysphagia (difficulty swallowing), dementia, gastrostomy (surgically created opening in the abdomen to the to stomach for the administration of nutrition and medications), neuromuscular…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents' Minimum Data Set (MDS) assessments accurately reflected the residents' status for one resident (Resident #32) of one resident reviewed for MDS discrepancies.Findings include:Resident #32 (R32):A review of R32's medical record revealed an admission into the facility on [DATE] with diagnoses that included dementia, sciatica, and the history of falling. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) score of 3/15 that indicated severe problems with memory or thinking.A record review of R32's MDS assessment dated [DATE], section N-Medications indicated: N0300. Injections: Record the number of days that injections of any type were received during the last 7 days or since admission/entry. entry 7 (days). and N0350. A. Insulin injections: Record the number of days that insulin injections were received during the last 7 days. entry 7 (days); B. Orders for insulin: 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 Based on observation, interview and record review, the facility failed to implement planned interventions for contracture management for one resident (Resident #16) of three residents reviewed resulting in lack of application of splints. Findings include:Resident #16:On 2/22/26 at 12:09 PM, Resident #16 was observed in their room. The Resident was in bed, positioned on their back with their head turned slightly to the left. Resident #16 had a tracheostomy and was receiving mechanical ventilation. The Resident's eyes were closed, and they did not respond to verbal stimulation. Resident #16's hands were bent towards their inner arm at the wrist joint as though contracted and their legs were bent at the knees. The Resident did not have any devices including splints/braces in place on their upper and/or lower extremities. Record review revealed Resident #16 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included heart failure, right and left knee…

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 tube feeding was administered per professional standards of practice and the plan of care for one resident (Resident #40) of two residents reviewed. Findings include: Resident #40: On 2/23/26 at 10:40 AM, Resident #40 was observed in their room. The Resident was in bed, positioned on their back. The head of Resident #40's bed was elevated at 17 degrees per protractor tool, and they were receiving tube feeding via infusion pump at a rate of 43 milliliters (mL) per hour. At 10:47 AM on 2/23/26, Registered Nurse (RN) Z was asked to come into Resident #40's room. When asked how high the head of the Resident's bed was elevated, RN Z stated, I don't know. 20 or 30 degrees, I'm not good at that. RN Z was then asked was the head of the head should be elevated to when a resident is receiving tube feeding and replied, 30 degrees in a questioning tone. RN Z proceeded to elevate the head of Resident #40's bed and exit the room. 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 2607274.Based on observation, interview, and record review, the facility failed to obtain an appropriate resident assessment, physician's order, develop a care plan, and provide entrapment measurements to ensure that a resident is free from physical restraint for one resident (Resident #107) (R107) of 3 residents reviewed for use of side rails. Findings include:Resident #107 (R107):R 107 was observed in his room on September 10, 1925, at 2:00 PM. R107 was awake, lying in bed with an ongoing continuous tube feeding via pump being delivered, while R107 was restless in bed. The bed was observed in the lowest position; however, R107 appeared to be attempting to get out of bed, but the side rail was preventing him from falling out of the bed. It was noted that the floormat was placed on the floor on his right side. R107 had a padded full rail attached to the bed.During observation, Nurse K on 9/10/25 at 2:05 PM, was asked why R107 had a bedrail. Nurse K revealed he is a fall…

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 2607274.Based on observation, interview, and record review, the facility failed to ensure that Enhanced Barrier Precautions (EBP) were implemented according to the plans of care for two residents (Resident #107 and Resident #104) of the three residents reviewed for Infection Prevention and Control. Findings include: Resident #107 (R107): A review of the Electronic Medical Record (EMR) was conducted on 9/10/25 at 12:00 PM. R107 was [AGE] years old and was admitted to the facility on [DATE], with the diagnosis of End Stage Renal Disease with dependence on Renal Dialysis. R107 had a gastrostomy, a hemodialysis port, difficulty walking, and muscle weakness in addition to other diagnoses. R107's Brief Interview of Mental Status (BIMS) Score assessed on 6/24/25 was 04/15. A BIMS score of 4 /15 indicates severe cognitive impairment. R107's Care Plan was noted: Activities of Daily Living (ADLs) required two-person assistance for Bathing, Bed Mobility, Dressing, Personal Hygiene,…

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 #1223361Based on observation, interview, and record review the facility failed to ensure that an adequate supply of clean linen was distributed and consistently delivered to residents' areas on a daily basis.Findings include:An observation tour with the Administrator was conducted on [DATE], between 2:55 PM and 3:15 PM. All six linen closets were checked. The Administrator agreed there was not a lot in each closet for the census of 125 residents in the facility, considering the time of day. She stated she is unsure of the laundry department schedule for hall deliveries.On [DATE] at 3:30 PM, an interview with Certified Nursing Assistant B (CNA B).CNA B has worked at the facility for 2 years and stated, Linen is a problem every day. I have to look for linen all the time. I go to the basement to find the linens I need because it is not in the closet. We had to go to nearby units, and sometimes they are all empty or lack the necessary items. I work a 12-hour shift from 7:00 AM to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to Intake Number MI00153753. Based on observation, interview and record review, the facility failed to ensure measures were in place to prevent constipation for two Residents (#1 and #3) of 3 reviewed for constipation, resulting in the potential for discomfort, restlessness and adverse reactions. Findings Include: Resident #1: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Diabetes, End stage renal disease, renal dialysis, Cardiac arrest, seizures, Hepatitis B, anemia, acute and chronic respiratory failure, dysphagia, feeding tube, hypertension and pneumonia. The MDS assessment dated [DATE] revealed the resident had cognitive loss and needed assistance with all care. On 7/3/2025 at 11:25 AM, Resident #1 was observed lying in bed in his room, sleeping. Nurse Aides A and B assisted the resident to reposition in bed. They said he would wiggle lower in the bed. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number MI00152171. Based on interview and record review, the facility failed to notify the resident's representative of a change in condition for one resident (Resident #2) of three residents reviewed, resulting in the family not being notified of a change in condition. Findings include: Resident #2 (R2): R2 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include cerebrovascular disease, hypertension, apnea and peripheral vascular disease. R2 had a brief interview for mental status (BIMS) score of 15, indicating they are cognitively intact. On 04/24/25 record review of a progress noted dated 12/30/24 at 11:09 revealed, Resident is extremely tired this morning. He refused breakfast and has not gotten dressed or out of bed as he usually does. Resident also will not speak to nurse he was able to mumble that he was tired. Resident tested for Covid and flu A and B, all negative. Resident is afebrile and vitals are wnl. Provider aware. On 04/24/25 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 Resident #705: A review of Resident #705's medical record revealed an admission into the facility on 4/8/11 and re-admission on [DATE] with diagnoses that included acute and chronic respiratory failure, dependence on respirator status, Muscular Dystrophy and tracheostomy status. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 15/15 that indicated intact cognition, the Resident had limited range of motion of bilateral upper extremities and was dependent on helper for activities of daily living, mobility and transfers. A review of the Facility Reported Incident investigation for Resident #703 of an interview written by Nurse C for Resident #705, dated 3/10/25 at 8:35 AM, that revealed: (Resident #705) asked for yankauer, she refused stating she doesn't do that you need to get respiratory to do it. I don't do respiratory job. (Resident #703) asked are you serious? She said yes and didn't do it. Then (Resident #705) asked her to cut the TV on and she mumbled to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number MI00148741 Based on observation, interview and record review the facility failed to maintain sanitary conditions in the kitchen, resulting in improper kitchen sanitization of all kitchenware utilized to prepare and plate resident meals, soiled floors and ice machine potentially affecting all residents who consume meals from the kitchen Findings include: On 1/8/2025 at 10:05 AM, a tour of the kitchen was completed in the presence of Registered Dietitians E & F. The following was observed: other bilateral handles to the reach in refrigerator had debris amassed inside the handles. other bottom of the individual toaster was [NAME] with dried on food reside and other large brunt like particles. oGreen speaker was sitting atop of the clean/ready to use dishware. Registered Dietitian E & F both stated that should not be there. [NAME] the storage rack were 11 sheet pans that were still wet, as water droplets were still visible. When asked about this area it was explained dishware…

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 act on positive influenza laboratory results timely and operationalize policies and procedures for an influenza outbreak with two Residents (#30 and 45), of two residents reviewed for positive influenza, resulting in the potential for the spread of infection to residents, staff, surveyor and visitors. Findings include: During Resident Council on 1/9/2025 at 1:45 PM, Resident Council was held in the 400 Hall sitting room. There were nine residents in attendance two being Resident #30 & #45; of the nine residents the surveyor hosting the meeting and Resident #45 were the only two with masks on due to the outbreak status of the facility. At the conclusion of resident council, Resident #30 was observed in his room directly across the hall from the sitting room, as we spoke pleasantries at the doorway the droplet precaution sign was noticed hanging on his door that was completely ajar. It was further discovered from the doorframe name plates that his roommate is Resident #45. Upon review of their records, 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.

Based on interview and record review the facility failed to curate an activities program that met the interest and needs of the facility residents, resulting in, activity programming being monotonous and lacking originality. With nine residents from resident council expressing feelings of frustrations, discontentment, and unimportance. Findings include: During Resident Council on 1/9/2025 at 1:45 PM, the nine residents in attendance were queried regarding the facility activity programming. The overarching tone of the group was they would enjoy a wider variety of activities that was of interest to residents that are cognitively intact. They shared the rarely attended resident council as they did not feel comfortable sharing their concerns as they were not confident they would be addressed. They were unanimous with the following areas of concern for the activity program as well: -Many of the programs are boring, and they have no interest in attending them. They provided an example of decorating the ashtray the day prior. -The activities are not well organized which causes undue…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain a clean/sanitary, safe, and homelike environment with soiled privacy curtains in rooms 207, 505, 507, 509; Call lights not within reach for Resident #3, #35, #105 and room [ROOM NUMBER]-1; Respiratory equipment not stored properly for Resident #102, #57 and #407 soiled wheelchairs, geri chairs and walker stored in the common/dining area on the 300 hall; ceiling tile coming down in the bathroom between rooms [ROOM NUMBERS]; multiple bathrooms on the 300 hall with personal wash basins stored improperly and not labeled with resident information; denture cups in room [ROOM NUMBER] not properly labeled with resident information; and a lack of paper towel available in room [ROOM NUMBER], of 6 halls/units reviewed for environmental concerns, resulting in a lack of resident and staff safety, and the potential of needs not met, spread of infectious disease, and dissatisfaction of living conditions. Findings include: Common area/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 This Citation Pertains to Intake MI00148741 Based on observation, interview and record review, the facility failed to ensure dignified and respectful care and treatment for two (# 4 and 61) of two residents and five of five residents observed during the dining task resulting in lack of supervision during meals as care planned for one resident (R39) and availability of equipment during dining, Resident #4 being exposed during care, and Resident #61 expressing delayed staff response to needs, unnecessary incontinence, discourteous and rude staff, lack of adaptive communication devices, and Resident verbalization of feelings of fear, anxiety, and frustration. Findings include: Resident #61 On 1/8/25 at 12:04 PM, Resident #61 was observed in their room laying in in bed with their eyes open wearing a hospital style gown. Resident #61 was receiving mechanical ventilation via a tracheostomy. When spoke to, Resident #61 responded by mouthing words without making sound. Resident #61 had a cell phone on their bed. When…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive activity care plan for one (#61) of one resident reviewed resulting in the potential for lack of meaningful activities and decreased quality of life. Findings include: Resident #61: On 1/8/25 at 12:04 PM, Resident #61 was observed in their room laying in in bed with their eyes open wearing a hospital style gown. Resident #61 was receiving mechanical ventilation via a tracheostomy. When spoke to, Resident #61 responded by mouthing words without making sound. When asked if they were able to write and/or type, Resident #61 indicated they could. A method for written communication such as a white board and/or paper, pen and/or pencil were not present in the room. When queried about level of assistance needed to get out of bed and facility activities, Resident #61 revealed staff are not responsive to call lights and/or requests for assistance. At 12:50 PM on 1/8/25, an interview was completed with Resident #61. When…

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 MI00148741 Based on observation, interview and record review, the facility failed to ensure the provision of the necessary services to ensure timely response and assistance for completion of Activity of Daily Living (ADL) care for three (#'s 39, 43, and 61) of seven residents reviewed resulting dependent residents not receiving timely care including repositioning, toileting, and hygiene and resident verbalization of discomfort and feelings of frustration and embarrassment. Findings include: Resident #43: On 1/09/25 at 7:59 AM, Resident #43 was observed in bed, positioned on their back with the head of the bed elevated in a high seated position. Upon entering the room, the distinct odor of urine and bowel movement were noted. The odor grew in intensity closer to Resident #43. The Resident was receiving mechanical ventilation via a tracheostomy. When asked how they were, Resident #43 replied, My neck hurt. Resident #43 was asked how long their neck had been hurting and if they had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to treat a change in condition timely for one resident (Resident #30) of one resident reviewed for delay in treatment, resulting in the potential for exacerbation of signs and symptoms of pneumonia, sepsis, extended illness and wellbeing. Findings include: Resident #30: A review of Resident #30's medical record revealed an admission into the facility on 1/11/24 and readmission on [DATE] with diagnoses that included chronic obstructive pulmonary disease, influenza, and sepsis. A review of Resident #30's medical record of progress notes revealed the following: 12/29/24 at 6:54 PM, Progress Notes, Note Text: pt (patient) had c/o (complaints of) cough and chills this evening I took pt temp. it was 98. I did a Covid and influenza test they all came back negative. Pt requested cough syrup for his cough on on-call messaged and gave order for prn (as needed) cough syrup QID (four times a day). I put in house stock cough syrup and gave it to the pt. 12/31/2024 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to enact care-planned interventions for safety/monitoring/supervision for Residents (#4, 35 and 39) of 9 reviewed for accident hazards and feeding assistance, resulting in the potential for injury for Resident #4 transferred with a mechanical lift with one staff assist, fall with injury for Resident #35 who did not have a call light within reach and a fall mat placed at the bedside, and the potential for choking or aspiration of food for Resident #39. Findings include: Resident #4: A review of Resident #4's medical record revealed an admission on [DATE] and readmission on [DATE] with diagnoses that included multiple sclerosis (MS), dementia, muscle wasting and atrophy and Alzheimer's disease. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) score of 9/15 that indicated moderately impaired cognition, and the resident was dependent with most activities of daily living and transfers. On 1/10/25…

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 catheter care in accordance with current clinical standards for one (#50) resident of 1 resident reviewed for catheters, resulting in, Resident #50 returning from the emergency room with a urinary catheter unbeknownst to the facility and without proper assessment, monitoring and ongoing care. Findings Include: Resident #50: During initial tour on 1/8/2025, Resident #50 was observed in bed conversing with his wife. Observed hanging on the bed frame was a catheter drainage bag that was partially full of urine. Resident #50 explained he recently was evaluated at the Emergency Room, and they placed a catheter. On 1/8/2024 at approximately 3:45 PM, a review was completed of Resident #50's medical record and it indicated he admitted to the facility on [DATE] with diagnoses that included, Fracture of left tibia shaft, left fibula shaft, right and left patella, right talus, epilepsy, heart disease and dysphagia. Resident #50 is dependent on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure enteral tube feeding (liquid nourishment provided directly into the stomach through a feeding tube) administration was per Health Care Provider orders and professional standards of practice for one resident (#55) of three Residents reviewed, resulting insufficient head of bed elevation during tube feeding administration and the potential for aspiration, infection, and decline in overall health. Findings include: Resident #55: On 1/9/25 at 8:31 AM, Resident #55 was observed in their room in bed, positioned on their back. Resident #55 was receiving mechanical ventilation via a tracheostomy and tube feeding via pump. The Head of the Resident's bed at a 24-degree angle per the measurement device on the bed and correlated with a angle measurement device. When spoke to, Resident #55 did not make eye contact and did not provide a verbal response. Record review revealed Resident #55 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 observation, interview and record review, the facility failed to implement and operationalize policies and procedures for management and care of a Peripherally Inserted Central Catheter (catheter line inserted into the arm and extends to the heart for long term administration of intravenous [IV] medications- PICC) line for one (#280) of one Resident reviewed resulting in a PICC line not being flushed following medication administration and the potential for malfunction, occlusion, blood clot formation, and infection. Findings include: Resident #280: On 1/9/25 at 8:49 AM, Resident #280 was observed laying in their bed in their room. Registered Nurse (RN) P was present in the room. When asked, RN P revealed they had just finished administering the Resident's medications. Resident #280 made eye contact when spoke to but did not provide verbal or meaningful non-verbal responses to questions. An IV pump was in place on the left side of the bed. The pump was turned off with an empty bag of IV Cefepime…

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 acquire medication timely from pharmacy services or obtain from back-up medication storage for one resident (Resident #45), of seven reesidents reviewed for medication regimen review, resulting in medication Bumetanide and Spironolactone not administered as ordered and the potential of exacerbation of medical conditions. Findings include: Resident #45: A review of Resident #45's medical record revealed an admission into the facility on 7/22/24 with diagnoses that included congestive heart failure, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, diabetes, dependence on supplemental oxygen, atherosclerotic heart disease, and acute kidney failure. A review of medication orders for Resident #45 revealed the following: Bumetanide 1 mg (milligram). Give 1 tablet by mouth one time a day for fluid retention related to chronic obstructive pulmonary disease, with a start date on 7/23/24 and discontinued on 1/6/24. Bumetanide 1 mg. Give 1 tablet by mouth two times a day for fluid retention, ordered on…

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

Based on interview and record review, the facility failed to administer medication as ordered by the practitioner for one resident (Resident #45) of seven residents reviewed for medication administration, resulting in Resident #45 not receiving the medication Bumetanide (a diuretic often used to reduce extra fluid in the body caused by conditions such as heart failure, liver disease, and kidney disease) and the medication Spironolactone (a diuretic often used to treat heart failure and high blood pressure), the residents need to have increased dosage of the medication Bumetanide and the potential for exacerbation of medical conditions. Findings include: Resident #45: A review of Resident #45's medical record revealed an admission into the facility on 7/22/24 with diagnoses that included congestive heart failure, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, diabetes, dependence on supplemental oxygen, atherosclerotic heart disease, and acute kidney failure. A review of medication orders for Resident #45 revealed the following: -Bumetanide 1 mg…

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 #MI00148741. Based on observation, interview and record review the facility failed to promptly dispose of 24 pills of oxycodone (opioid used to manage pain) and maintain accurate and legible controlled medication reconciliation records for one (#61) resident of eight resident residents reviewed for narcotic reconciliation. Findings Include: On 1/14/2025 at 1:50 PM, Vent Medication Cart 3 in the presence of Wound Care Nurse R and Nurse S. While reviewing Resident #61's Controlled Substance Log for Oxycodone IR (immediate release) 5 MG (milligram) Tab (tablet) received on 5/19/2024. The sheet was found to have rows of crossed out entries, with what appeared to be multiple witnessed initials, but they were difficult to match up to the specific row given the disorganization of the narcotic form. The form showed Resident #61 was administered an oxycodone on 1/9/2025 at 0700, but there are no nurse initials. Observation was made of the blister pack and pill bubble #11 was circled in…

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

Based on interview and record review, the facility failed to ensure immunizations were reviewed and offered for/to Resident #45, of six residents reviewed for immunizations, resulting in the potential for lack of protection against infectious diseases and illnesses and spread of infection. Findings include: On 1/14/25 at 8:55 AM, a review of Resident immunizations was conducted for the infection control task of the survey. Six residents were included in the review of immunizations. Resident #45 had been laboratory tested for Influenza with respiratory panel swab collected on 1/1/25 that resulted in positive results for influenza. A review of Resident #45's medical record revealed an admission into the facility on 7/22/24 with diagnoses that included congestive heart failure, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, diabetes, dependence on supplemental oxygen and influenza. A review of Resident #45's medical record of Immunizations, revealed TB 2 Step Mantoux Skin Test date administered 10/3/24, Sars-Cov-2 (Covid-19) Moder date administered…

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 MI00143979. Based on observation, interview and record review, the facility failed to prevent staff-to-resident abuse for one resident (Resident #604) of 3 residents reviewed for abuse, resulting in a staff member using verbally abusive language towards Resident #604. Findings Include: Resident #604: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #604 was admitted to the facility on [DATE] with diagnoses: Paranoid schizophrenia, hypothyroidism, heart failure, anxiety, depression and intellectual disabilities. The MDS assessment dated [DATE] indicated the resident had moderate cognitive decline with a Brief Interview for Mental Status score of 8/15. The resident also needed assistance with all care. On 9/25/2024 at 10:00 AM, during an interview with the Administrator, she said there had been a Facility Reported Incident on 3/27/2024 for Resident #604 related to Staff Member J telling Resident #604 to Shut your mouth. The incident…

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 will have two Deficient Practice Statements (DPS). DPS #1: This Citation pertains to Intake Number MI00147169. Based on interview and record review the facility failed to assess, monitor and implement substantial interventions to prevent Resident #608's overdose, resulting in Resident #608 admitting with a Polysubstance abuse disorder of 40 + years without further facility follow-up, assessment or increased monitoring,and a fentanyl patch being applied in a reachable area resulting in subsequent ingestion of the patch, which resulted in an overdose. Findings Include: Resident #608: On 9/25/2024 at approximately 2:00 PM, a review was completed of Resident #608's medical records and it revealed he admitted to the facility on [DATE] with diagnoses that included, Femur Fracture, Major Depressive Disorder, Hypertension, Adjustment Disorder with mixed anxiety and depressed mood and diabetes. Further review of the resident's chart revealed the following: Discharge Hospital Records: .Pt (patient) 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 MI00146559. Based on observation, interview, and record review, the facility failed to ensure proper Personal Protection Equipment (PPE) gowning for treating one resident (Resident #605), resulting in the likelihood of contamination during Percutaneous Endoscopic Gastrostomy (PEG) tube site care and the spread of infection. Findings include: Resident #605 (R605): On 9/29/24 at 1:00 PM, Nurse D was observed during a PEG tube care dressing change for R605, who was on an Enhanced Barrier Precaution (EBP) due to the resident's tracheostomy and gastrostomy status. On 9/28/24 at 3:00 PM, a review of R605's Electronic Medical Record revealed that R605 was [AGE] years old and admitted to the facility on [DATE] with tracheostomy status, quadriplegia, Gastrostomy, and Chronic Respiratory Failure with hypoxia in addition to other diagnoses. Although R605's Brief Interview of Mental Status (BIMS) was not performed, R605's Care Plan, initiated on 8/16/2023, was reviewed. The 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 This Citation pertains to Intake Number MI00146121. Based on observation, interview, and record review, the facility failed to ensure that pain assessment was completed consistently and medication was administered as ordered over an extended period for one resident (Resident #901) of two residents (with acute displaced fracture of right ankle) reviewed for pain management. This deficient practice has the potential for reduced efficacy of the pain management regimen with prolonged pain. Findings include: Resident #901 (R901): R901 was admitted the facility on 5/14/24 for short-term skilled nursing and rehabilitation services after hospitalization. R901 was hospitalized for cellulitis of lower extremities and heart failure. Based on the Minimum Data Set (MDS) assessment dated [DATE], R901 had Brief Interview for Mental Status (BIMS) score of 15/15, indicative of intact cognition. R901 was living at home with their spouse and had a fall at home prior to the admission and hospital. A complaint received by the State…

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 proper label and dating of foods with 69 residents consuming meals from the kitchen (34 residents receive nothing by mouth) resulting in increased risk of contaminated foods and the risk of food borne illness. Findings include: During an initial tour of the kitchen on 01/02/2024 at 9:44 AM, the following was observed in the reach in refrigerator: Salsa and sour cream in a deep pan with a use by date of 12/24/2023 Cheese slices in a plastic container with a use by date of 12/26/2023 8 ham and cheese sandwiches in a pan with a use by date of 12/26/2023 During the initial tour, the Registered Dietitian (RD) E stated that the food items found should have been thrown out and pulled them out of the refrigerator and put them by the sink to be discarded. During an interview on 01/03/2024 at 11:45 AM, Dietary Supervisor (DS) L stated that RD E told her about the food items found the day before during the initial kitchen tour and said that these items were thrown out. Review of the Facility's Facts in Fifteen,…

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 maintain complete and accurate medical records for one Residents (#81) of 21 residents reviewed for accurate medical records resulting in missing, incomplete, and inaccurate information intentionally put in all 103 residents' medical charts routinely every Wednesday morning, pertinent to care needs with the potential for negative outcomes and the inability to accurately assess, monitor and update progress related to resident centered plans of care for this vulnerable population. Findings include: Resident #81 (R81) Review of the medical record revealed Resident #81 (R81) was initially admitted to the facility on [DATE] and then re-admitted on [DATE] with diagnoses that included Chronic respiratory failure, Sepsis, End stage renal disease, vent dependent, atrial fibrillation, diabetes 2, muscle wasting, gastrostomy, dependent on renal dialysis, pressure ulcers and tracheostomy. According to Resident #81 (R81)'s Minimum Data Set (MDS) dated [DATE],…

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 required transfer and discharge documentation was completed for one (#81) of two residents reviewed for discharge. Resulting in the potential for ineffective or mismanaged continued care, as care plan goals were omitted from the transfer paperwork. Findings include: Resident #81 (R81) Review of the medical record revealed Resident #81 (R81) was initially admitted to the facility on [DATE] and then re-admitted on [DATE] with diagnoses that included Chronic respiratory failure, Sepsis, End stage renal disease, vent dependent, atrial fibrillation, diabetes 2, muscle wasting, gastrostomy, dependent on renal dialysis, pressure ulcers and tracheostomy. According to Resident #81 (R81)'s Minimum Data Set (MDS) dated [DATE], revealed R81 scored 12 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R81 is dependent on eating, oral hygiene, toileting,…

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 meet transfer/discharge documentation requirements for one of one reviewed (Resident #81) from a total of 21 sampled residents, resulting in the potential for residents and/or their representatives not obtaining their due rights. Findings include: Resident #81 (R81) Review of the medical record revealed Resident #81 (R81) was initially admitted to the facility on [DATE] and then re-admitted on [DATE] with diagnoses that included Chronic respiratory failure, Sepsis, End stage renal disease, vent dependent, atrial fibrillation, diabetes 2, muscle wasting, gastrostomy, dependent on renal dialysis, pressure ulcers and tracheostomy. According to Resident #81 (R81)'s Minimum Data Set (MDS) dated [DATE], revealed R81 scored 12 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R81 is dependent on eating, oral hygiene, toileting, showering/bathing, getting dressed and personal…

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 complete and provide a baseline a care plan within 48 hours of admission 1 resident (resident # 401) of 4 reviewed for care plans, resulting in anxiety, frustration and the potential for unmet needs to be addressed in their plan of care. Findings include: Review of the clinical record, including the Minimum Data Set (MDS) with an assessment reference date of 12/21/23, reflected Resident #401 (R401) was a [AGE] year old male with multiple medical comorbidities including a new tracheostomy. R401 admitted to the facility on 12/20, returned to the hospital on 12/21 and readmitted to the facility on [DATE]. R401 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) dated 01/03/23. R401 was his own decision maker and had no legal representative in place. On 01/02/24 at 02:44 PM, R401 was interviewed at bedside, he reported he wanted to be discharged home on 1/05/23 but facility staff had not spoken to him about…

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 care plans were updated and revised appropriately with new interventions for one (R81) out of 21 residents reviewed for care plan revision out of a total sample of 21 residents. This deficient practice resulted in lack of revision and implementation for a bowel regimen following a hospital stay for surgical removal of a bowel impaction. Findings include: Resident #60 (R60) Review of the medical record revealed Resident #60 (R60) was initially admitted to the facility on [DATE] and then re-admitted on [DATE] with diagnoses that included cerebrovascular disease, hemiplegia, atrial fibrillation, muscle wasting, constipation, pain and incontinence of bowel and bladder. According to Resident #60 (R60)'s Minimum Data Set (MDS) dated [DATE], revealed R60 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R60 is dependent on transfers, getting dressed,…

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 Activity of Daily Living (ADL), including bathing/showering and nail care, for one resident (R#75) of three reviewed for ADL care completion resulting in missed bathing/showers, inadequate nail care and potential for feelings of embarrassment. Findings include: According to the clinical record, including the Minimum Data Set (MDS) dated [DATE], Resident # 75 (R75) was a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease, end stage renal disease and aphasia. On 01/02/24 03:28 PM, R75 was observed resting in bed, his right hand was resting on his chest and was observed to have long fingernails that extended past his fingertips, under the nails dark debris was observed. R75 did not respond to verbal questions. On 01/04/24 at 08:41 AM, R75 was observed in bed, Certified Nursing Assistant (CNA) D was present, R75's bilateral hands observed, CNA D uncurled R75's fingers from right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate care, management, and documentation for one (R60) of one resident reviewed for bowel and constipation, of a total sample of 21, resulting in lack of appropriate monitoring and treatment, increasing the potential for another bowel impaction causing surgical removal and decline in overall health status. Findings include: Resident #60 (R60) Review of the medical record revealed Resident #60 (R60) was initially admitted to the facility on [DATE] and then re-admitted on [DATE] with diagnoses that included cerebrovascular disease, hemiplegia, atrial fibrillation, muscle wasting, constipation, pain and incontinence of bowel and bladder. According to Resident #60 (R60)'s Minimum Data Set (MDS) dated [DATE], revealed R60 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R60 is dependent on transfers, getting dressed, toilet use and bathing.…

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 for 1 out of 5 residents (Resident #90) the Physician was made aware of, and addressed medication monitoring requirements, resulting in the potential for adverse affects to occur. Findings Included: Per the facility face sheet Resident #90 (R90) was admitted on [DATE]. R90 had a listed diagnosis of, DEPENDENCE ON RENAL DIALYSIS. Review of Physician's orders (ordered by R90's primary physician) revealed that on 12/27/2023 at 11:35 AM, Vancomycin was ordered for R90 as follows, . (Vancomycin HCl [hydrochloride]) Use 1 gram intravenously one time a day every Mon, Wed, Fri, Sun for antibiotic until 01/05/2024 23:59 (11:59 PM) to be given on dialysis day by dialysis nurse, in dialysis. The order revealed the Vancomycin was discontinued on 12/28/2023. Review of R90's medication administration report (MAR) for the month of December 2023 revealed, (Vancomycin HCl) Use 1 gram intravenously one time a day every Mon, Wed, Fri, Sun for antibiotic until…

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 offer pneumococcal vaccines as recommended by Centers for Disease Control, in three of five residents reviewed for immunizations (Resident #2, #33 and #68) resulting in increased risk of acquiring, transmitting, or experiencing complications from pneumococcal disease. Findings include: Resident #2 (R2) R2's Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/30/23, revealed he was [AGE] years old, was admitted to the facility on [DATE], and had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 12 (08-12 Moderate Impairment). The same MDS indicated R2's pneumococcal vaccination was not up-to-date and was offered and declined. Informed Consent for Pneumococcal Vaccine signed 3/09/23, revealed in 2019 Advisory Committee on Immunization Practice recommended two pneumococcal vaccines for adults [AGE] years of age or older) pneumococcal conjugate (PCV13) or pneumococcal polysaccharide (PPSV23)…

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.