Medilodge at the Shore

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the pharmacist sent a report for a medication recommendation/comment and/or a physician reviewed the pharmacy recommendation for 1 of 5 residents (R7) reviewed for monthly pharmacy medication regimen reviews. Findings include:A review of R7's admission Record, dated 8/14/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R7 had multiple diagnoses that included dementia, bipolar disorder, and depression. A review of R7's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 7/11/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 0 which revealed R7 was severely cognitively impaired. A review of R7's Pharmacy Medication Review Progress Note, dated 3/31/25, revealed that the line for Comment/Recommendation noted-see report was checked. This indicated that the pharmacist had made a recommendation to the…

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

Based on observation and interview, the facility failed to appropriately label medications in 1 of 2 medication carts inspected (Southwest Medication Cart).Findings include:During an inspection of the Southwest Medication Cart with Registered Nurse (RN) B on 08/12/2025 at 4:20 PM, the following observations and interview were made: - A box of Desmopressin Nasal Spray 10 mcg/ 0.1 ml (10 micrograms per 0.1 milliliters) was observed with Resident #7's name on it. However, the nasal spray container inside the box was not labeled with R7's name or any other identifying information that would indicate the spray was his if it became separated from the box. - A box of fluticasone and salmeterol was observed with Resident #32's name on it. However, the diskus inside the box was not labeled with R32's name or any other identifying information that would indicate the spray was hers if it became separated from the box. - RN B stated that the pharmacy usually labels the individual vials, inhalers, and diskus' in the boxes with the resident's name and other identifying information in case 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 ensure the medical records for 1 of 23 sample residents (R7) was complete and accurate. Findings include:A review of R7's admission Record, dated 8/14/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R7 had multiple diagnoses that included dementia, bipolar disorder, and depression. A review of R7's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 7/11/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 0 which revealed R7 was severely cognitively impaired. A review of R7's Pharmacy Medication Review Progress Note, dated 3/31/25, revealed that the line for Comment/Recommendation noted-see report was checked. This indicated that the pharmacist had made a recommendation to the physician or had noted an irregularity in R7's medication regimen. A review of R7's electronic medical record (EMR), dated 3/1/25…

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 This citation is related to intake # MI00151188 Based on interview and record review, the facility failed to follow professional standards for medication administration for one of three residents (Resident #4) reviewed for medication errors. Findings: Resident #4 (R4) Review of an admission Record revealed R4 was a [AGE] year old male, admitted to the facility on [DATE], with pertinent diagnoses of recent brain bleed requiring an extensive hospital stay and resulting in left sided weakness and paralysis, chronic kidney disease-stage 4, morbid obesity, Insulin dependent diabetes mellitus, and need for a feed tube for nutrition. Review of an Electronic Medication Administration Record (Emar) for R4, dated January 2025 revealed an order for Clonidine transdermal patch 0.1 mg (milligrams)/24 hours to be given weekly. Documentation reflects that R4 had a patch placed on 01/20/25 and on 01/29/25. There was documentation present in the electronic health record (EHR) that indicated the Clonidine patch was not available…

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 # MI00151188 Based on observation, interview, and record review, the facility failed to follow the standards of practice for two of two residents reviewed (Resident #7 and Resident #8) for tube feeding. Findings: Resident #7 (R7) Review of an admission Record revealed R7 was a [AGE] year old male, admitted to the facility on [DATE], with pertinent diagnoses of paraplegia, difficulty speaking, and protein-calorie malnutrition. During an observation on 03/19/25 at 3:10 PM, an irrigation container and syringe for R7's tube feed flushes sat on the bedside table. The plunger was inside the syringe and the syringe sat in the graduated container that contained a clear liquid. The date on the graduated container read 3/18/25. During an observation on 03/20/25 at 7:30 AM, R7's tube feed pump ran at 65 ml (milliliters) per hour. The bottle of Jevity 1.5 cal tube feed did not have the time the tube feed was initiated on 03/19/25. Review of an Electronic Medication Administration 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 MI00149340. Based on observation, interview, and record review, the facility failed to ensure that (1) Resident's needs were met timely and that (2) Call lights were within reach for two residents ( Resident #6, Resident #9) of four residents reviewed for accommodation of needs. Findings include: Resident #6 (R6): Review of an admission Record reflected R6 was a [AGE] year-old female, last admitted to the facility on [DATE], with pertinent diagnoses of Alzheimer's and rheumatoid arthritis. Review of a BIMS (Brief Interview for Mental Status) revealed R6 had severely impaired cognition. During an observation on 01/08/25 at 7:40 AM, the call light touch pad for R6 sat on the bedside table covered by a hat, out of sight and out of reach of the resident. During an observation on 01/08/25 at 9:35 AM, the call light touch pad for R6 remained on the bedside table, out of sight and out of reach of the resident, and covered by a hat. R6 sat up in bed eating breakfast. During an…

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 is related to intake Number MI00149340. Based on observation, interview, and record review the facility failed to provide quality care to two residents (Resident#1 and Resident #6) out of 5 residents reviewed. Findings include: Resident #1 (R1): Review of an admission Record revealed R1 was a [AGE] year-old female, originally admitted to the facility on [DATE], following a 30 day inpatient hospital stay for a cerebral aneurysm with a stent placement, right sided stroke, and required intubation due to hypoxia. R1 admitted to the facility with pertinent diagnoses of left sided weakness and paralysis after a stroke in May 2024 with subsequent difficulty speaking, swallowing and impaired vision, high blood pressure, restlessness, claustrophobia, overactive bladder, broken lumbar fusion hardware (rod) in her back, use of a tube feed for nutrition (placed during recent hospitalization on 12/11/24), and muscle weakness. Review of Hospital Wound Care orders for the new tube feed site: wash with dermal…

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

This citation is related to Intake Number MI00147654 Based on observation, interview, and record review the facility failed to secure 1 of 4 unattended medication carts. Findings include: During an observation on 01/08/25 at 7:20 AM, the unattended medication cart for rooms 1-15 displayed resident information on the computer screen. Upon further observation, the unattended medication cart was unlocked. Found in the second drawer down on the left side of the medication cart were 14 different loose unidentified pills. Found in the second drawer down on the right side of the medication cart was an unsecured metal box that contained controlled substances. During an interview on 01/08/25 at 7:25 AM, License Practical Nurse (LPN) A approached the unlocked medication cart and stated you busted me, I'm sorry. During an interview on 01/08/25 at 7:35 AM, LPN B indicated that medications carts and narcotic boxes were to be locked at all times when the nurse was not at the medication cart. Review of the facility policy Medication Storage last reviewed on 01/30/24 revealed: It is the policy of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately assess/implement advanced directives (upon admission) for 2 Residents (R102 and R110) of 4 Residents reviewed for advanced directives. Findings include: R102 Review of R102's face sheet dated 9/18/24 revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: congestive heart failure, dysphagia, pharyngeal phase (swallowing problem), cognitive communication deficit, unsteady on feet, muscle weakness, Alzheimer's disease, difficulty in walking and abnormal posture. R102 was not her own responsible party. Review of R102's electronic medical record revealed no signed copy of R102's advanced directive. During an interview with the Director of Nursing on 9/17/24 at 11:40 AM, the DON said the nurses complete the advanced directives on admission. The DON said R102's son was her Durable Power of Attorney. The DON could not find any information that validated R102's son was contacted about R102'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure: 1) that a Pre-admission Screening and Resident Review (PASARR) Level I was completed timely for the annual review and 2) that the PASARR Level II was completed for 1 of 2 residents (R71) reviewed. Findings include: A review of R71's admission Record, dated 9/16/24, revealed R71 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, Resident 71's admission Record revealed multiple diagnoses that included dementia, depression, anxiety, and schizophrenia. A review of R71's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 6/7/24, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 1 which revealed R71 was severely cognitively impaired. A review of R71's [name of State] Department of Health and Human Services letter, dated 7/14//23, revealed R71 needed a PASARR II Evaluation by 7/12/24. A review of R71's electronic medical…

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 follow the care plan for 1 Resident (R465) for assistance with eating. Findings included: Review of R465's face sheet dated 9/17/24 revealed he was an [AGE] year-old male admitted to the facility on [DATE] and diagnoses included kidney failure, dementia, macular degeneration (visual problem), dysphagia (swallowing problem) and cognitive communication deficit. R465 was not his own responsible party. Review of R465's activities of daily living care plan dated 9/11/24 revealed that he required assistance of one person for eating. R465 was observed on 9/17/24 at 12:05 PM eating lunch. No staff in room, resident was requesting cold water but did not know how to put on the call light. CNA L came in the room at 12:10 PM and left again attempting to get R465 thickened cold water. R465 still had his meal tray in front of him when CNA L left the room. R465 was observed up in his wheelchair in his room on 4/18/24 at 8:08 AM eating breakfast. No staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to adequately assess one resident (R465) for hydration and food intake of 1 Resident reviewed for nutrition. Findings included: Review of R465's face sheet dated 9/17/24 revealed he was an [AGE] year-old male admitted to the facility on [DATE] and diagnoses included kidney failure, dementia, macular degeneration (visual problem), dysphagia (swallowing problem) and cognitive communication deficit. R465 was not his own responsible party. Review of R465's activities of daily living care plan dated 9/11/24 revealed that he required assistance of one person for eating. R465 was observed in bed awake on 9/16/24 at 9:23 AM. R465 wanted water but did not know how to use his call light. R465 did not have any drinks in his room. Resident was assisted by the Surveyor to put his light on as staff were not in the room. Certified Nurse Aide (CNA) L responded. R465 told CNA L he wanted cold water. CNA L returned to the room without any drinks. CNA L said…

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, interviews and record review, the facility failed to follow up on dialysis concerns for 1 Resident (R26) of 2 Residents reviewed for dialysis. Findings included: Review of R26's face sheet dated 9/17/24 revealed that she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: end stage renal disease, diabetes mellitus 2, congestive heart failure, bipolar disorder, epilepsy and major depressive disorder. R26 was her own responsible party. Review of R26's hemodialysis communication record dated 9/7/24 revealed a handwritten note in the section to be completed by dialysis center. c/o (complained of) intradialytic cramping. The section to be completed by facility upon return from dialysis was not completed. Review of R26's hemodialysis communication record dated 8/30/24 revealed a handwritten note, please put cream on full length of graft, Calcitriol 25 mg (medication to treat low calcium) and Novasource (renal nutritional supplement). Cramping end of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the pharmacist reported identified irregularities to the physician for 1 of 5 residents (R80) reviewed for monthly pharmacist Medication Regimen Reviews, resulting in the potential for the physician not being aware of drug irregularities. Findings include: A review of R80's admission Record, dated 9/18/24, revealed R80 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, Resident 80's admission Record revealed multiple diagnoses that included chronic kidney disease, diabetes, visual hallucinations, and bipolar disease. A review of R80's Pharmacy Medication Review Progress Notes, dated 10/1/23 to 9/18/24, revealed the following entries: - 2/29/24- Comment/Recommendation noted- see report. - 3/22/24- chart reviewed, one note to MD (physician). A review of R80's electronic medical record, dated 2/22/24 to 9/18/24, failed to reveal any reports and/or notes to the physician that detailed the recommendations and/or…

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 adhere to the physicians ordered time frame for administration of a controlled substance (Oxycodone) when administered five hours early to one Resident (R63) of five residents reviewed for administration of controlled substances. Findings: Review of the Electronic Medical Record (EMR) revealed R63 initially admitted to the facility 5/16/23 with pertinent diagnoses that included chronic respiratory failure with hypoxia, asthma, and dementia. Review of the EMR Physicians Orders for R63 revealed an order entered 8/13/24 at 6:13 PM for Oxycontin Oral Tablet ER (extended release) 12-hour 30 milligram (mg) to be administered every 12 hours. Review of the facility document titled Controlled Substance Record for R63 for oxycontin ER 30mg reflected the medication was administered to the Resident at 12:00 AM on 9/15/24. The document reflected that the next dose was administered at 7:00 AM on 9/15/24, five hours before the Resident was due for the next dose. Review of the manufacturer's package insert for Oxycontin revealed this…

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 medical record for 3 of 23 sampled residents (R71, R102, and R415), resulting in the potential for providers not having an accurate and complete picture of the resident's stay at the facility. Findings include: Resident #71 A review of R71's admission Record, dated 9/16/24, revealed R71 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, Resident 71's admission Record revealed multiple diagnoses that included dementia, depression, anxiety, and schizophrenia. R71's admission Record also revealed R71 was receiving hospice services. A review of R71's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 6/7/24, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 1 which revealed R71 was severely cognitively impaired. A review of R71's Hospice Consent Form, dated 4/2/24, revealed R71 began to receive hospice services…

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 Enhanced Barrier Precautions (EBP) were implemented for one resident (R5) of 23 residents reviewed for infection control practices. Findings include: R5 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R5 admitted to the facility on [DATE] with a readmission date of 9/1/24 with diagnosis of (but not limited to) sepsis, diabetes and a right femur fracture. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which represented R5 was cognitively intact. R5 required extensive staff assistance of 1-2 with all activities of daily living. During an observation on 9/18/24 at approximately 9:15 AM, R5 had a stop sign posted on her door that indicated providers and staff must wear gloves and gowns for the following high-contact resident care activity, Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use:…

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 immunizations were offered and provided to one resident (R29) of 5 residents reviewed for immunizations. Findings include: R29 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R29 admitted to the facility on [DATE] with diagnosis of (but not limited to) diabetes, heart failure and chronic obstructive pulmonary disease. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which represented R29 was cognitively intact. The facility provided a copy of the Pneumococcal Vaccine (Series) policy dated 3/1/22 last revised on 10/30/23 for review. The policy reflected adults ages 19-64 who had diagnosis of (but not limited to) diabetes, heart failure or chronic obstructive pulmonary disease should be offered the pneumococcal vaccine upon admission to the facility. The policy reflected, 10. For adults 19-[AGE] years old who have only received PPSV23: Give 1 dose of PCV15 or PCV20. During an interview and 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: MI00144606 Based on interview and record review, the facility failed to 1.) assess and monitor pressure injuries/wounds, 2.) ensure pressure injury/wound assessments were complete, accurate, and documented in the resident record, 3.) notify the provider and the DPOA (Durable Power of Attorney) of new and deteriorating pressure injuries/wounds, and 4.) provide ordered wound treatments and ensure treatments were in place for pressure injuries/wounds for 1 of 3 residents (Resident #2) reviewed for alterations in skin integrity/pressure ulcers, resulting in incomplete and inaccurate wound assessment and a delay in wound treatment. Findings: Resident #2 (R2) Review of an admission Record revealed R2 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: stroke with Review of R2's hospital documentation Wounds-Active Wounds Moisture Associated Skin Damage Gluteal dated 4/10/24 and Toe Right Anterior dated 4/13/24 .Unclear wound on his…

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

This citation pertains to intake M100139912. Based on interview and record review, the facility failed to have a system in place to ensure routine monitoring of patient care equipment for safe and functional condition with the potential to affect the safety of all residents residing in the facility. Findings include: In an interview on 4/16/24 at 10:00 AM, the Director of Nursing (DON) reported they do not have a log of resident care equipment being monitored. The mechanical lifts get checked once or twice a year by the company, but the maintenance department does not have a log of patient care equipment being routinely monitored for function and safety including but not limited to wheelchairs, shower chairs, mechanical lifts, bed rails. They do have an electronic communication program in place to communicate to the maintenance department for equipment that needs to be fixed, but no formal system for preventative maintenance and monitoring of patient care equipment. Review of a policy titled Preventative Maintenance Program last revised 3/12/22 revealed A Preventative Maintenance…

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

This citation pertains to MI00140080 Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed to ensure proper hand hygiene was performed 1). During tray meal pass on the Northwest Hall 2). during incontinence care for 1 resident (R11), resulting in the potential of cross-contamination and the spread of illness and disease. Findings include: Review of a policy titled Hand Hygiene last revised 12/13/23 revealed: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Alcohol-based hand rub is not allowed to be used in the kitchen or other food preparation areas. Review of the Hand Hygiene Table included with the Hand Hygiene policy revealed when and how hands should be washed including: Between resident contacts; and After handling contaminated objects . Either Soap and Water or Alcohol Based Hand Rub (ABHR is preferred) During a meal pass observation of the Northwest…

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 respond to weight gain for one resident, Resident #88 (R88) reviewed for weight changes. This deficient practice resulted in a 17.3% (64 lbs.) weight/fluid gain in 30 days for R88 with the potential for decline in health status and comprised respiratory functioning. Findings include: The facility provided the policy/procedure for Weight Monitoring dated 10/30/2020 and revised on 1/1/2022 for review. The policy reflected, If clinically indicated - monitor weight daily .6. Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% change in weight in 1 month (30 days) . R88 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R88 admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of (but not limited to) congestive heart failure, chronic kidney disease, and respiratory failure with a tracheostomy.…

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 staff failed to conduct a count on the controlled substance before taking possession of the keys to the medication cart for 2 of 4 medication carts. This deficient practice resulted in the potential for misappropriation and diversion of resident medications. Findings included: The facility provided a copy of the policy/procedure for Controlled Substance Administration & Accountability dated 10/30/2020, last revised on 1/1/2022 for review. The policy reflected, 8. The Charge Nurse on duty will maintain the keys to controlled substance containers. The keys to this container should not be shared with other staff, including licensed staff without first conducting a complete controlled substance count . During an observation and interview on 9/14/23 at approximately 11:05 AM, Nurse K was asked if she was the Charge Nurse for the Southwest Unit and had possession of the keys to the medication cart and Nurse K stated, Yes, I took over at about 10:30 (AM). When asked if she counted with the outgoing nurse, Nurse K stated no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to secure medications for 1 of 4 medication carts (Southwest Unit) and medications for Resident #57 (R57), reviewed for medication storage. This deficient practice resulted in the potential for loss or diversion to occur. Findings include: The facility provided a copy of the policy/procedure for Medication Storage dated 10/30/2020, last revised on 1/1/2022 for review. The policy reflected, All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls . R57 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R57 admitted to the facility on [DATE] with diagnosis of (but not limited to) femur fracture, sepsis, and diabetes. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which represented R57 was cognitively intact. During an observation on 9/12/23 at 12:00 PM, and 9/13/23 at 9:00 AM,…

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

Based on observation and interview, the facility failed to ensure equipment and physical facilities were maintained in proper working order, potentially affecting all residents that receive food and beverages from the dining rooms and kitchen. During a follow up kitchen tour on 09/13/23 at 11:02 AM with Dietary Manager (DM) R the following concerns were observed: 1.) The first basin of the 3-Compartment Sink was observed to not be functioning due to the drain lines being disconnected from the sink's basin. DM R stated our garbage disposal broke, and it was removed. 2.) The floor drain beneath the 3-Compartment Sink was observed not draining properly. As the water from the sink's basin was released it would back up in the drain and flow onto the flooring. 3.) The faucet on the 2-Compartment Sink had the handles turned to an off position, however, hot water was streaming continuously from the faucet. Review of the FDA 2017 Food Code Section, 5-205.15 System Maintained in Good Repair Reflected the following, A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; P and (B)…

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 and document care and failed to implement the plan of care for one dependent Resident #82 (R82), resulting in scheduled personal hygiene not being performed and the potential for all facility residents to not be offered planned hygiene care and the potential for loss of self-worth. Findings: Review of the Electronic Medical Record (EMR) revealed R82 originally admitted to the facility 5/6/22 and has pertinent diagnoses that include Morbid Obesity, Cognitive Communication Deficit, and Hemiplegia/Hemiparesis (weakness or paralysis of one side of the body). The Minimum Data Set (MDS) dated [DATE] reflected R82 is severely cognitively impaired, is incontinent of bowel and bladder, and is totally dependent on two staff for hygiene and bathing. Review of the Care Plan reflected R82 requires the assistance of two staff for Bathing/Showering initiated 5/10/22 and is without revision. Review of the previous 30 days of the Task: ADL (activities of daily…

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.