WellBridge of Grand Blanc

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide palatable food products and meet residents' food preferences, for 7 residents (24, 61, 72, 74, 89, 121 and 143) of 7 residents reviewed for food and choices and a Confidential Group of Residents, resulting in residents' feelings of frustration and anger. Resident #61 (R61) A review of R61's medical record revealed an admission into the facility on 9/2/25 with diagnoses that included cystitis, heart failure, diabetes, and heart disease. A review of R61's Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 9/15 that indicated moderately impaired cognition, and the Resident used a wheelchair for mobility. On 9/24/25 at 9:46 AM, Resident 61 was observed in his room, seated in a wheelchair. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about any concerns he had about his care at the facility and was asked about any issues with the food served. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that appropriate communication between the hospice agency and the facility was accessible in a timely manner for one resident (Resident #39) of the three sampled residents reviewed for hospice care.Findings include: Resident #39 (R39): On 09/23/25 at approximately 11:45 AM, during the initial tour, the surveyor observed R39 with a caregiver and verified that she was the hospice nurse caring for R39 today. However, upon entering the facility at 10:00 AM, the CMS Form 802 submitted to the surveyors indicated that Resident R39 was not coded as receiving hospice care services. A review of records on 9/24/25 at 11:30 AM revealed that R39 was [AGE] years old, admitted to the facility on [DATE] with the diagnosis of Senile Degeneration of Brain, Transient Ischemic Attack (TIA), Vascular Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety in addition to other diagnoses. R39' Brief interview of Mental Status BIMS Score dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number MI00152519. Based on interviews and record review, the facility failed to ensure that the GLP-1 (Glucagon-like peptide-1) injection medication was protected from staff misappropriation for one resident (Resident #601) of three residents reviewed for misappropriation of medication. Findings include: According to Cleveland Clinic, myclevelandclinic.org, dated 7/3/23, the prescribed GLP-1 medication states, GLP Agonists are medications that help lower blood sugar levels and promote weight loss .They mainly help manage blood sugar levels in people with Type 2 diabetes. Some GLP-1 agonists can help treat obesity. Resident #601 (R601): A review of R601's medical record conducted on 4/29/25 at 11:30 AM revealed an admission into the facility on [DATE], with the diagnosis of Type 2 Diabetes Mellitus, Chronic Kidney Failure, Heart Failure, and Obesity in addition to other diagnoses. R601 Physician's order for R601's Type 2 diabetes regimen revealed: Insulin Lispro Injection…

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 employ a qualified social worker on a full-time basis to meet the psychosocial, mental, and behavioral health care needs of the residents. This deficient practice had the potential to affect all 124 residents that reside within the facility. Findings Include: On 10/1/2024 at 12:05 PM, an interview was conducted with Transitional Care Coordinator D regarding her role at the facility. Coordinator D explained while she does assist with social work roles, she is not a qualified Social Worker but is currently enrolled in a Bachelor of Social Work program. She shared a Social Worker from a sister facility does review assessments she completes and sends edits if needed. On 10/1/2024 at 1:15 PM, an interview was conducted with the Administrator regarding fulfilling their social worker position. The Administrator stated their Social Worker resigned with no notice on December 21, 2023. On August 29, 2024, a new social worker was hired with the start date of September 23, 2024, but she never showed up for orientation and informed the…

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

Based on interview and record review, the facility failed to ensure that a comprehensive person-centered care plan was established for two residents (Resident #32, Resident #41) of twenty-five residents reviewed for care planning, resulting in Resident #32, a hemodialysis resident, to continue to gain weight with no updated care plan interventions and the likelihood for unmet care needs. Findings include: Record review of the facility 'Care Plans-Comprehensive' 2001 MED-PASS, Inc. (revised October 2010) policy revealed an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs is developed for each resident. Policy Interpretation and Implementation: 3.) Each resident's comprehensive care plan is designed to: incorporate identified problem areas, incorporate risk factors associated with identified problems. #5.) Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes Record review of the facility 'Policy:…

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 timely comprehensive activity assessments and ongoing programming to meet the interests of one resident (Resident #77) one resident reviewed for activities, resulting in, Resident #77's activity assessments not being completed since 03/2023 and a lack of activity programming to meet the resident's independent leisure pursuits. Findings Include: Resident #77: During initial tour on 10/1/2024 at 8:33 AM, Resident #77 was observed resting quietly in her room. When asked about activities she participates in, she stated many of the activities she physically cannot complete due to limited mobility in her hands. Resident #77 expressed prior to being admitted she was very active and always on the go and now she just lays in bed everyday with nothing to do. Resident #77 stated they have asked her to come to activities and watch the others participate as there would have been no adaptations made so she could fully participate. On 10/1/2024…

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 a urinary drainage bag and tubing was properly placed off the floor for one resident (Resident #46) of two residents reviewed for urinary catheters, resulting in the likelihood of cross-contamination and infection. Finding include: Resident #46: On 10/01/24, at 9:34 AM, Resident #46 was resting in their bed. Their urine drainage bag was hooked to bed frame and resting on the floor. A loop of the catheter tubing was on floor as well. On 10/01/24, at 9:40 AM, an observation along with CNA J of Resident #46's drainage bag and tubing was conducted. CNA J was asked if the bag and tubing was supposed to be on the floor and CNA J stated, no. On 10/01/24, at 9:45 AM, CNA J was observed placing a basin under the drainage bag and tubing. On 10/01/24, at 3:30 PM, a record review of Resident #46's electronic medical record revealed an admission on [DATE] with diagnoses that included Dementia, Quadriplegia and stroke. Resident #46 required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure timely re-weighs for weight loss or weight gain for two residents (Residents #32, Resident#41), resulting in a lack of weight monitoring completion, follow-up of abnormal weights, and the potential for unidentified nutritional deficiencies and a decline in overall health. Findings include: Record review of the facility 'Policy: Obtaining Weights and Re-weight Policy' undated, revealed each individual's weight will be determined and documented upon admission to the facility. Procedure: 1.) Nursing will be responsible for the initial determination of each individual's weight. Subsequent measurements for weight will be documented on the appropriate designated form or tracker in the computer database. Weight will be documented on the individual assessment instrument (MDS for nursing facilities), and in the medical nutrition therapy (MNT) assessment. Weight will be obtained weekly for 4 weeks after admission. Subsequent weights will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed follow physician's orders for enteral feeding for one resident (Resident #83) of one resident reviewed for enteral feeding, resulting in the resident not receiving the ordered amount of enteral feeding. Findings Include: Resident #83 (R83): Resident #83 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include, aphasia, dysphagia and history of a transient ischemic attack. On 09/30/24 at 10:04 AM, R83 was observed in bed, well dressed, groomed and free of any odors. Observation revealed that R83 had their enteral feeding infusing, the rate of the infusion on the pump was set at 70 ml/hr, the bottle of Glucerna was dated 09/30/24, dated for a start time of 09/29/24 at 11:00 pm. On 10/01/24 at 09:30 AM, observation revealed that R83 had their tube feeding infusing at 70ml/hr. The bottle of Glucerna was dated 10/01/24 and was dated for a start time of 09/30/24 at 11:00 pm. On 10/01/24 at 02:19 PM, record review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide medications as ordered for one resident (Resident #113) of one resident reviewed for pain management, resulting in Resident #113 experiencing pain and calling 911 and leaving the facility. Findings Include: Resident #113: A record review of the electronic medical record indicated Resident #113 was admitted to the facility on [DATE] at 9:50 PM with diagnoses: recent left knee joint replacement, pain, arthritis, anxiety, hypothyroidism, atrial fibrillation, asthma, claustrophobia, anemia, and essential tremor. The resident discharged back to the hospital a few hours later on 7/30/2024 at approximately 1:23 AM. A record review of the progress notes for Resident #113 revealed the following: 7/30/2024 at 1:23 AM, a Skilled Charting note, Guest alert and oriented and ale to make needs known, guest called 911 to be took back to the hospital because she didn't get her pain medication when she asked. When I tried to explain to her what was going on 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.

Based on observation, interview, and record review, the facility failed to ensure clinical staff posting of licensed and un-licensed staff levels were posted in a visible area for residents and visitors to review, resulting in the inability for residents and visitors to know what clinical staff were working on those days. Findings include: According to the State Operations Manual (SOM) reflected The facility must post the total number and actual hours worked by licensed and un-licensed nursing staff directly responsible for the resident care per shift to include registered nurses Licensed Practical Nurses and Certified Nursing Aides. The SOM guides that the facility must Ensure staffing information is posted in a prominent place readily accessible to residents and visitors Observation on 9/30/2024 at 8:47 AM upon entrance to the facility in the front lobby there was no identified clinical staff level posting visible upon looking around entry. Observation on 9/30/2024 at 10:07 AM review of 100 hall and 600 hall reviewed for clinical nursing staffing hours to be posted for resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to care plan an antipsychotic injectable medication (Invega) and to ensure community mental health services coordination of care for one resident (Resident #467) out of one resident reviewed for community mental health services, resulting in feelings of worry and concern with the likelihood of an overall decrease in psychosocial well-being. Findings include: Resident #467: On 10/01/24, at 8:48 AM, Resident #467 was resting in their bed. They voiced a concern about going home and that they needed to talk to their HOPE case manager because they were discharging in a few days. The resident repeated their concern twice and offered the name of their case manager. On 10/01/24, at 2:30 PM, a record review of Resident #467's electronic medical record revealed an admission on [DATE] with diagnoses that included schizoaffective disorder, bipolar disorder and anxiety. Resident #467 required assistance with Activities of Daily Living and had intact…

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 obtain consent for antipsychotic usage for one resident (Resident #53), resulting in Resident #53 being administered an antipsychotic medication without the appropriate consent and risk-versus-benefit analysis of the medication explained to the resident or the resident's responsible party and the increased likelihood for serious side effects and adverse reactions. Findings include: Record review of the facility 'Use of Psychotherapeutic medications' dated 6/23/2019 revealed a resident will not receive psychotherapeutic medications unless such a medication is needed to treat a specific condition as diagnosis and documented . Assessment and documentation: ii.) Informed consent from the resident and/or responsible party along with education regarding potential side-effects. Record review of the 'Nursing 2017 Drug Handbook' Wolters Kluwer 2017 page 156, Abilify antipsychotic medication adverse reactions included: increased suicide risk, neuroleptic malignant syndrome, seizures, hostility, tardive dyskinesia Resident #53:…

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 8 of 19 medication punch cards in the 100 Hall Controlled/Narcotic substance medication cabinet were free of puncture holes, resulting in the likelihood for misappropriation of medication by one narcotic punch card to have 2 tablets with taped over punch holes noted upon inspection and the likelihood of cross contamination and ineffective medications. Findings include: Record review of the facility 'Controlled Substances' 2001 MED-Pass, Inc. (revised December 2012 policy dated) revealed the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Policy Interpretation and Implementation: #8.) Unless otherwise instructed by the Director of Nursing Services, when a resident refuses a non-unit dose medication (or it is not given), or a resident receives partial tablets or single dose ampoules (or it is not given), the medication shall be destroyed and may not be returned to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that narcotic medications were accurately documented according to professional standards of practice for one resident (Resident #901). Findings include: Resident #901 (R901): On 7/1/24 at 11:40 AM, R901 was observed lying in bed. R901 was asked about care at the facility. R901 explained they did not think they were getting their Norco (a narcotic pain medication) correctly. Review of the clinical record revealed R901 was admitted into the facility on 3/2/23 with diagnoses that included: peripheral vascular disease, polyneuropathy (damage to multiple nerves) and anxiety disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R901 was cognitively intact. Review of R901's July 2024 Medication Administration Record (MAR) revealed a physician order for, HYDROcodone-Acetaminophen (Norco) Oral Tablet 5-325 MG (milligrams) . Give 1 tablet by mouth every 6 hours for CHRONIC PAIN with a start date of 3/3/23. The times of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Numbers MI00123400 and MI00124171. Based on observation, interview and record review, the facility failed to provide timely assistance with Activities of Daily Living (ADL) that included oral, nail and incontinence care and bathing activities for six residents (Resident #6, Resident #14, Resident #29, Resident #35, Resident #130, and Resident #191) of seven residents reviewed for ADL care, resulting in unmet care needs, poor hygiene and the potential for infection, skin irritation, body odor, embarrassment, diminished feelings of self-worth and loss of dignity. Findings include: Resident #6: A review of Resident #6's medical record revealed an admission into the facility on 5/26/23 with diagnoses that included non-Hodgkin lymphoma, chronic obstructive pulmonary disease, pressure ulcer of left heel and sacral region, pain, heart failure, diabetes, dementia, and depression. A review of the Minimum Data Set (MDS) assessment, dated 6/1/23, revealed the Resident had a Brief Interview…

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 MI00123400 and MI00124171. Based on observation, interview, and record review the facility failed to ensure there was adequate staff to meets the needs of the residents, resulting in resident verbalizations of waiting long periods of time for call lights to be answered, receive assistance with Activities of Daily Living (ADL): bathing, nail care, toileting and incontinence care, and the timely administration of medications timely as ordered for eight residents (Residents #6, #11, #35, #39, #72, #184, #185, and #187), and a Confidential Group of residents from twenty residents reviewed for activities of daily living care, resulting in resident dissatisfaction, frustration and unmet care needs. Findings Include: FACILITY Sufficient and Competent Nurse Staffing During a review of the posted staffing sheets and staffing schedules indicated the resident census at the facility had progressively increased consistently from August of last year 2022, from 40's to 60's to 80's.…

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 secure storage, accountability, and reconciliation of the controlled substance Ativan in the medication refrigerator of the South Medication Room, for one of two medication storage rooms reviewed for medication storage and labeling task, resulting in the potential for narcotic diversion. Findings include: On 8/18/23 at 9:00 AM, an observation was made with Unit Manager, Nurse H of the South Medication Room. The medication room had a secure lock leading into the medication room from the hallway. An observation was made of the medication refrigerator that did not have a lock on the door. Inside the refrigerator was a removable box with the controlled substance Ativan that included three vials of 2 mg(milligrams)/ml (milliliter) and oral Ativan 2 mg/ml, 30 ml. The box had a green plastic tag on the box. The Unit Manager was asked about the process when the Ativan was taken out. The Unit Manager reported that the green tag would be taken off and replaced with a red tag that were located inside the box with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure that medical supplies were stored in sanitary conditions and expired supplies were disposed of properly for one of two medication rooms, one emergency crash cart and three clean utility/supply rooms reviewed for medication and medical supply storage, resulting in the potential for medical procedures to be performed with expired medical equipment and decreased efficacy. Findings include: On [DATE] at 9:00 AM, medication and medical supplies were reviewed with Unit Manager, Nurse H of the South Medication room. An observation was made of multiple green top vacutainers for blood draws expired on [DATE], red vacutainers expired on [DATE], vacutainer blood collection sets that expired [DATE]. The Unit Manager was asked if there were more collection sets and she responded that there was only the two and both were expired. An observation was made of two blood draw kits, and both were expired. The Unit Manager stated, We don't draw blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests in the kitchen, satellite kitchen and Resident #28's room, potentially effecting all residents in the building. Findings Include: FACILITY Kitchen On 8/02/23 at 9:00 AM, during an initial tour of the main kitchen with Chef Manager N and Corporate Dietary Manager O, several small flies/drain flies were observed in the kitchen flying around. On 8/2/2023 at 9:40 AM during a tour of the satellite kitchen used for meal serving to the 200-500 halls, observed to have several small flies/drain flies crawling on a large container of honey. Requested pest management logs. Corporate Dietary Manager O said pest management handled by Facilities Manager P. She said the pest control company came to the facility monthly. On 8/2/2023 at 3:00 PM, reviewed the facilities Pest management log book/Pest Service Sighting log. Per documentation sheets in the book the last…

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 MI00123400 and MI00124171. Based on observation, interview and record review, the facility failed to ensure that one resident was treated in a dignified manner for Resident #65, of two residents reviewed for dignity, resulting in Resident #65 having soiled briefs left on a clean bed and thrown on the floor. Findings Include, On 08/03/23 at 1:55 PM, during a tour of the facility a bag with soiled linen was observed on the floor in room [ROOM NUMBER]. A hospice aid entered the room and said she was there to see a resident in room [ROOM NUMBER]. She had not yet been in the room. Upon walking up and down the 300 hallway, no facility staff were observed. Resident #65: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #65 was admitted to the facility on [DATE] with diagnoses: Anxiety, weakness, groin abscess, hypertension, polyneuropathy, and peripheral vascular disease. The MDS assessment dated [DATE] revealed the resident had full…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to review and revise care plans with resident changes to ensure that interventions necessary for care and services were provided for two residents (Resident #50, Resident #72) of twenty residents reviewed, resulting in the potential for unmet care needs. Findings Include: Resident #72: Pressure Ulcer/Injury A record review of the Face sheet and Minimum Data Set assessment indicated Resident #72 was admitted to the facility on [DATE] with diagnoses: recent history of a stroke, left-sided weakness diabetes, acute respiratory failure, hypertension, heart failure, and weakness. On 8/1/2023 the resident was identified to have a pressure ulcer on the right heel unstageable. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 14/15 and the resident needed extensive 1-person assistance with bed mobility, dressing, toileting and hygiene and total 2-person…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prevent a facility-acquired pressure ulcer for one resident (Resident # 72) and ensure appropriate interventions were in place and enacted for one resident (Resident#72) of two residents reviewed for pressure ulcers, resulting in Resident #72 developing a facility-acquired pressure ulcer that changed from a blister to black necrotic tissue. Findings Include: Resident #72: Pressure Ulcer/Injury A record review of the Face sheet and Minimum Data Set assessment indicated Resident #72 was admitted to the facility on [DATE] with diagnoses: recent history of a stroke, left-sided weakness diabetes, acute respiratory failure, hypertension, heart failure, and weakness. On 8/1/2023 the resident was identified to have a pressure ulcer on the right heel unstageable. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 14/15 and the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that Restorative Nursing services were provided to one resident (Resident #11) of 2 residents reviewed for range of motion and restorative services, resulting in a potential for Resident #11 to have a decline in range of motion and mobility Findings Include: Resident #11: Rehab and Restorative A record review of the Face Sheet and Minimum Data Set (MDS) assessment for Resident #11 indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, fibromyalgia, gout, weakness, asthma, heart disease, hypothyroidism, hypertension, depression, anxiety, peripheral vascular disease, history of falls. The MDS assessment dated [DATE] indicated the resident had full cognitive abilities with a Brief Interview for Mental Status Score (BIMS) of 14/15 and needed extensive 2-person assistance with bed mobility and total 2-person assistance with transfers and needed 1-person assistance with all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide necessary management and care of an indwelling urinary catheter for two residents (Resident #49, and Resident #60) and assessment and management of care for one resident (Resident #227) who performed straight catheterization herself of three residents reviewed for urinary catheters, resulting in the potential for complications including infection and a decline in condition. Findings Include: Resident #49: Urinary Catheter or UTI On 8/03/23 at 2:56 PM during a tour of the facility Resident #49 was observed lying in bed in her room. The room smelled strongly of urine. She was observed to have a Foley catheter; the catheter had sediment in the tubing. The resident said she'd had the catheter during her stay at the facility. A record review of the Face sheet and Minimum Data Set assessment (MDS) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: right hip fracture, history of left hip…

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 assessment was completed for self-administration of nebulizer breathing treatments and that the nebulizer equipment was stored per facility policy for one resident (Resident #50) of three residents reviewed for respiratory care, resulting in the potential for adverse effects, inadequate administration of medication, exacerbation of symptoms and infection. Resident #50: A review of Resident #50's medical record revealed an admission into the facility on 9/11/21 and re-admission on [DATE] with diagnoses that included chronic obstructive pulmonary disease, dementia, paranoid schizophrenia, age-related cognitive decline, pneumonia, mood disorder, depression, and heart disease. A review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 12/15 that indicated moderately impaired cognition and the Resident needed limited assistance with activities of daily living. On 8/2/23 at 11:11…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that dialysis communication forms were complete and included accurate weight assessment for one resident (Resident #129) of two residents reviewed for Dialysis care, resulting in the potential for a decline in condition and the inability for a prompt response to care needs. Findings Include: Resident #129: Dialysis On 8/03/23 at 3:35 PM , Resident #129 was observed sitting in a wheelchair in her room. She said she had nausea; and stated, It happens sometimes. She said she had recent abdominal surgery. Resident #129 said she went to dialysis 3 days a week/Monday, Wednesday, Friday. She pointed to a dialysis fistula in her left arm. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #129 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: recent surgery intestinal obstruction with surgical repair, end stage renal disease, renal dialysis services, GERD, polycystic kidney disease,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent significant medication errors and accurate documentation of medication administration for three residents (Resident #39, Resident #65 and Resident #178 ) of eight residents reviewed for medication errors, resulting in medications being administered to the residents hours after they were due, leading to resident frustration and anger with the potential for mistreatment of the resident's medical conditions, side effects, adverse effects and a decline in condition. Findings Include: Resident #39: Antibiotic Use A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #39 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: right foot infection, diabetes. Atrial fibrillation, hypertension, hypothyroidism, GERD, heart failure, history of kidney failure, weakness, neuropathy. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview…

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 handwashing and Personal Protective Equipment were used for two residents (Resident #21, Resident #39) of nine residents sampled for medication administration, resulting in the likelihood for cross contamination, prolonged resident illness, antibiotic usage with possible hospitalization. Findings include: Record review of the facility 'Standard Infection Control' section 3.1 policy dated 8/2021 recommended the use of standard precautions during all patient care procedures . Record review of the facility 'Handwashing and Hand Hygiene' policy dated 4/29/2020 revealed to ensure appropriate hand hygiene which is essential in reducing the risk of transmission of infectious agents. To protect our residents, visitors and staff, each facility will promote hand hygiene practices during all care activities and working in locations within the facility. Conditions which may require hand hygiene include but not limited to: Before and After applying gloves, before and after eating, after using the restroom,…

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.