Medilodge of Grand Rapids

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure wound care and compression stocking physician orders were in place for 1of 3 residents (Resident#102) reviewed for professional standards, resulting in the resident receiving care without the direction of a physician, and the potential for worsening of medical conditions. Findings include: Review of an admission Record revealed Resident #102 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: varicose veins (enlarged veins) of the bilateral (both) lower extremities with pain, chronic kidney disease (kidneys are damaged and can't filter blood the way they should), right bundle branch block (delayed electrical signal in heart's right bundle branch), and waldenstrom macroglobulinemia (cancerous changes to the white blood cells). Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 12/11/24, section M revealed the resident had no skin issues at the time 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.

This citation pertains to intake: MI00149223 Based on interview and record review, the facility failed to implement facility policy and procedure for reporting an incident of neglect (resident choking and subsequent death due to recieving wrong meal tray) to the State Agency in 1 of 1 resident (Resident #100) reviewed for neglect, resulting in the potential for continued violations going unreported or without thorough investigation. Findings include: Review of an admission Record revealed Resident #100 was a male with pertinent diagnoses which included paralysis on right dominant side, aphasia (loss of the ability to understand or express speech caused by brain damage, like with a stroke), cognitive communication deficit (progressive degenerative brain disorder resulting in difficulty with thinking and how someone uses language), dysphagia (damage to the brain responsible for production and comprehension of speech), need for assistance with personal care, intellectual disabilities, and cerebral infarction affecting right dominant side (blood flow to the brain is blocked, causing 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 Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings include: During the initial tour of the facility, starting at 9:40 AM 7/23/24, a tour of the walk in cooler found a container of breakfast sausage tightly covered with saran wrap that was warm to the touch. At this time a temperature of the sausage links was taken and found to be 109F. An interview with [NAME] QQ, at 9:55 AM on 7/23/24, found that the sausage links were pulled from the breakfast line about an hour ago and placed in the walk-in cooler. An interview with Assistant Kitchen Manager OO, at 10:08 AM on 7/23/24, found that staff log cooling on a sheet on the cabinet. A review of the Cooling Temperature Log dated 2024, found that on 5/2 and 6/11 cooling for sausage was logged. Both items were stated to start cooling at 9:00 AM and by 11:00 AM both items were logged above…

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 resident dignity and rights to privacy were honored as reported by eight of nine residents during a confidential Resident Council meeting resulting in residents feeling frustrated and disrespected. Findings include: During a confidential Resident Council meeting on 7/25/2024 at 10:00 AM, eight of nine residents reported that they feel like their rights aren't respected and there is an ongoing issue related to privacy. One resident stated that she put a sign on her door so staff must knock when they enter her room and it was torn off the door and not replaced. Another resident said that his privacy isn't respected since staff walk into his room without knocking. Five of nine residents stated that on third shift, staff are often on their phones or tablets, have earbuds on and sometimes they will have conversations on the phone while in resident rooms. Review of the Resident Council minutes dated 5/22/2024 under the clinical department revealed (2 residents names omitted) said that people come in their rooms and don't…

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 address and resolve concerns/ grievances reported in Resident Council Meetings as reported by seven of nine residents during a confidential Resident Council meeting resulting in unresolved concerns and unmet needs of residents. Findings include: During a confidential resident council meeting held on 7/25/2024 at 10:00 AM, seven of nine residents reported that concerns weren't getting resolved. They said sometimes management responds to grievances but there isn't a resolution. One resident said concerns such as showers, cold food and long call wait times have been brought up in Resident Council meetings and to various staff members and there still isn't a resolution. Another resident stated that the person in charge of grievances isn't doing a good job on follow up since they don't respond to concerns brought up. Review of the Resident Council minutes dated 1/23/2024 under the clinical department revealed (Resident name omitted) says he asks for something and is told to wait a sec (second). He says he has to keep asking as…

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 access to bath linens and maintain sanitary conditions for 2 (Resident #13 and Resident #18) of 14 residents sampled for home-like environment, and 7 of 9 residents during a confidential interview, resulting in feelings of frustration, potential delay in care due to limited supplies, and unsanitary conditions. Findings include: Resident #13 Review of an admission Record revealed Resident #13, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: multiple sclerosis (chronic disease that affect the central nervous system causing weakness, loss of coordination, numbness, pain), need for assistance with personal care, and generalized anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #13, with a reference date of 6/22/24 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #13 was cognitively intact. Section GG of the MDS revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide routine showers for 4 (Resident #11, Resident #13, Resident #22, and Resident #35) of 6 residents reviewed for showers, and 7 of 9 residents who attended a confidential meeting, resulting in feelings of frustration, disappointment, and embarrassment about their personal appearance and overall, body cleanliness. Findings include: Review of Fundamentals of Nursing-E-Book (kindle Locations 50742-50744), [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME] Elsevier, Health Services. Kindle Edition revealed: Personal hygiene affects patients' comfort, safety, and well-being. Hygiene care includes cleaning and grooming activities that maintain personal body cleanliness and appearance. Personal hygiene activities such as taking a bath or shower . also promote comfort and relaxation, foster a positive self-image, promote healthy skin, and help prevent infection and disease. Resident #11 Review of an admission 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 provide adequate staff to meet resident needs for 6 (Resident #11, Resident #13, Resident #18, Resident #22, Resident #35 and Resident #12) of 14 residents sampled for sufficient staffing, and 7 of 9 resident who attended a confidential meeting. This deficient practice resulted in long call light wait times, lack of routine showers for dependent residents, limited resident supervision, staff burnout, and the potential for a decline in resident quality of life and/or quality of care. Findings include: Resident #11 Review of an admission Record revealed Resident #11, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: multiple sclerosis (chronic disease that affect the central nervous system causing weakness, loss of coordination, numbness, pain), paraplegia (paralysis of the lower body), and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #11, with a reference date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide food at a palatable temperature to 9 of 9 residents interviewed during resident council and 2 of 2 resident (Resident #15 and Resident #27) reviewed for food palatability, resulting in the potential for decreased food consumption and potential nutritional decline. Findings include: During a tour of lunch service, at 11:38 AM on 7/23/24, an interview with [NAME] QQ found that hot food on the steam table should be around 165F to stay hot for residents. At 11:48 AM on 7/23/24, a test stray of the regular meal was plated for the surveyor and placed on the health center one cart. At 11:52 on 7/23/24, the cart and test tray made it to the floor of Health Center one. At 12:07 PM on 7/23/24, all trays were passed from the health center one cart and the surveyor brought the test tray back to the conference room. At this time the following temperatures were found, Pasta/Meat was 122F and the peas were 121F. A revisit to the kitchen, at 8:03…

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 consistently provide a nourishing nighttime snack to eight of nine residents who attended a confidential Resident Council meeting resulted in the potential for residents to have more than 14 hours between a substantial evening meal and breakfast the following day, decreased oral intake, and the potential for weight loss. Findings include: During a confidential resident council meeting held on 7/25/2024 at 10:00 AM, eight of nine residents reported that they don't get snacks at bedtime and if they ask for it, they are often given only one choice. One resident stated that there weren't any healthy choices, the snacks are salty and not diabetic friendly and there weren't choices in what they get at night. Another resident said that she thinks staff is eating resident snacks. Review of the document Mealtimes revealed that breakfast is served 7:30-8:30 AM and dinner is from 5:30-6:30 PM. The time from the end of dinner to breakfast the next morning is approximately 13- 14 hours. Review of the Resident Council minutes dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate advanced directive information was in place for 1 of 3 (Resident #21) residents reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers. Findings include: Resident #21 Review of an admission Record revealed Resident #21 was originally admitted to the facility on [DATE] with pertinent diagnoses which included adult failure to thrive. Review of Resident #21's Code Status (a medical team that indicates what to do if resident experiences cardiac or respiratory arrest) in the electronic health record (EHR) revealed that resident was listed as full resuscitation. Review of Resident #21's Advance Directive dated [DATE] which was signed by Resident #21's guardian, indicated that Resident #21's end of life preference were for no 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 interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) evaluation was completed for 1 (Resident #20) of 2 residents reviewed for PASARR Screening, resulting in the potential for unmet mental health and psychiatric care needs. Findings include: Resident #20 Review of an admission Record revealed Resident #20 was originally admitted to the facility on [DATE] with pertinent diagnoses which included schizoaffective disorder, depressive type, major depressive disorder, and anxiety disorder, and suicidal ideations. Review of Resident #20s Preadmission Screening (PAS) Annual Resident Review (ARR) Level I Screening dated 3/26/24 indicated the following: Questions 1-4 in section II were marked Yes: 1. Resident #20 had a current diagnosis of mental illness. 2. Resident #20 had received treatment for mental illness. 3. Resident #20 had routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days. 4.…

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 #27(R27) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R27 admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Type 2 diabetes, and depression. Brief Interview for Mental Status (BIMS) reflected a score of 10 out of 15 which indicated R27 was cognitively impaired (8-12 moderately impaired). During an interview on 7/24/2024 at 8:36 AM, R27 stated that he goes to dialysis 3 days a week and he thinks it is going okay. Review of R27's physician orders revealed the following orders related to his dialysis: hemodialysis 3 days a week on Mondays, Wednesdays, and Fridays, also orders state AV (atrioventricular) shunt site-monitor every shift for signs and symptoms of infection/bleeding, AV shunt site upper arm. Monitor for thrill and bruit every shift, call provider if absent. Review of R27's care plan revealed that there wasn't a nursing care plan for his dialysis status. During an interview on 7/24/2024 at 2:01 PM, Registered Dietitian (RD) W and RD X…

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 residents received care in accordance with professional standards in 1 (Resident #35) of 1 residents reviewed for quality of care, resulting in Resident #35 having dysuria (pain with urination) for approximately 2 weeks, due to the facility mishandling the lab specimen resulting in a significant delay in the treatment of vulvovaginits (infection or inflammation of the vagina or vulva) and the potential for a decline in overall physical, mental and psychosocial well being. Findings include: Resident #35 Review of an admission Record revealed Resident #35 was originally admitted to the facility on [DATE] with pertinent diagnoses which included adult failure to thrive. Review of a Minimum Data Set (MDS) assessment for Resident #35, with a reference date of 6/14/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #35 was cognitively intact. Review of Resident #35's Orders revealed, . UA (urinalysis)…

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 observations, interviews, and record review, the facility failed to reassess resident's preference for use of therapy-recommended positioning device for 1 (Resident #12) of 2 residents reviewed for positioning, resulting in the potential for decreased range of motion and related complications, skin breakdown, worsening of contractures (hardening of the muscles, tendons, and other tissues) and pain. Findings include: Resident #12 Review of an admission Record revealed Resident #12 was a female, with pertinent diagnoses which included: stiffness of right wrist, stiffness of left wrist, stiffness of right hand, stiffness of left hand, and acquired absence (amputation) of right toe. Review of a Minimum Data Set (MDS) assessment for Resident #12, with a reference date of 6/11/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #12 was cognitively intact. During an observation and interview on 7/23/24 at 10:19 AM, Resident #12 was in her room and was seated in her wheelchair. This surveyor noted…

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 supra-pubic catheter care for 1of 2 residents (Resident #22) reviewed for catheter care, resulting in the potential for urinary tract infection and complications related to occlusion of catheter tubing. Findings include: Review of an admission Record revealed Resident #22, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: tubulo-interstitial nephritis (inflammation of an area of the kidney), obstructive uropathy (condition that inhibits normal urine flow), unspecified hydronephrosis (excessive fluid in a kidney) and artificial openings of the urinary tract. Review of a Minimum Data Set (MDS) assessment for Resident #22, with a reference date of 5/23/24 revealed Section H of the MDS revealed Resident #22 had an indwelling urinary catheter. Review of a Care Plan for Resident #22, with a reference date of 12/18/23, revealed a focus/goal/interventions of: Focus: Resident has a need…

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 adequate care for residents who received enteral nutrition (tube feeding) in 1 (Resident #21) of 2 residents reviewed for tube feeding, resulting in the potential for aspiration pneumonia and spoiled tube feeding. Findings include: Resident #21 Review of an admission Record revealed Resident #21 was originally admitted to the facility on [DATE] with pertinent diagnoses which included adult failure to thrive. Review of Resident #21's Orders revealed, Enteral Feed Order every shift related to dysphagia (difficulty swallowing) following cerebral infarction (stroke). Jevity (enteral feeding formula) 1.5 at 50 ml/hr continuous. Start date: 5/8/24. Review of Resident #21's Orders revealed, Head of bed elevated 30-45 degrees. Start date: 5/9/24. During an observation on 7/23/24 at 11:08 AM, Resident # 21 was lying in bed. It was noted that Resident #21's bed was not elevated to 30-45 degrees. Resident #21's tube feed was running at 50…

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 obtain physician orders for use of oxygen for 1 of 1 resident (Resident #20) reviewed for respiratory care resulting in the potential for improper use, inaccurate settings, irregular cleaning, and respiratory infection. Findings include: Review of an admission Record revealed Resident #20 was originally admitted to the facility on [DATE] with pertinent diagnoses which included weakness. Review of Resident #20's Orders did not reveal orders for oxygen administration. Review of Resident #20's Care Plan did not reveal a care plan focus area related to oxygen use. During an observation on 7/23/24 at 12:55 PM, Resident #20 was in lying in her bed. Resident #20 was receiving oxygen via nasal cannula. The oxygen concentrator was noted to be running at 3 liters/minute. During an observation on 7/24/24 at 12:05 PM, Resident #20 was in lying in her bed. Resident #20 was receiving oxygen via nasal cannula. The oxygen concentrator was noted to be…

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

Based on interview and record review, the facility failed to ensure physician ordered laboratory diagnostic services were obtained and completed in a timely manner in 1 (Resident #35) of 1 residents reviewed for laboratory services, resulting in delayed treatment/intervention related to lab results, increased pain/discomfort, and impaired coordination of care. Findings include: Review of Resident #35's Orders revealed, . UA (urinalysis) w/reflex to C&S (culture and sensitivity) if appropriate. Start date: 7/12/24 . Review of Resident #35's electronic health record (EHR) did not reveal any notes related to the delayed results of Resident #35's urinalysis that was ordered on 7/12/24. During an interview on 7/23/24 at 1:18 PM, Resident #35 reported that she had been experiencing pain with urination for over two weeks. Resident #35 reported that the facility had taken a urine sample to check for a urinary tract infection on 7/12/24, but the facility did not get results from that urine sample. Resident #35 reported that she had learned on 7/19/24 that the facility never received the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control practices to provide sanitary conditions for resident shared equipment, and implement Enhanced Barrier Precautions (EBP) for a residents with an MDRO (multi drug resistant organism) during care for 3 of 4 residents (Resident #103, #104, & #107) reviewed for infection control, urinary catheter care, wound dressing changes, resulting in the potential for the spread of infection, cross-contamination, and disease transmission for residents residing in the facility. Findings include: Resident #103 Review of an admission Record revealed Resident #103, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: history of stroke. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 3/21/24 revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #103 was mildly cognitively impaired. Review of Resident #103's Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to respect residents private space for 3 of 6 residents (Resident #103, #107 & #111) reviewed for privacy/dignity,resulting in feelings of embarrassment and the potential for resulting in negative psychosocial outcomes. Findings include: Resident #103 Review of an admission Record revealed Resident #103, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: history of stroke. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 3/21/24 revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #103 was mildly cognitively impaired. In an observation on 4/18/24 at 11:00 AM., Certified Nurse Aide (CNA) U performed catheter care and pericare for Resident #103. During Resident #103's catheter care a staff (Lead CNA K) knocked once on the door, opened it quickly and wide open and said to CNA U there is (restaurant name omitted) lunch for us .…

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: MI00143109 Based on observation, interview, and record review, the facility failed to accommodate a resident's right to make choices that were consistent with their plan of care for 3 of 7 residents (Residents #107, #104 & #111) reviewed for resident choices and preferences, resulting in the potential for residents not meeting their highest practicable level of well-being. Findings include: Resident #107 Review of an admission Record revealed Resident #107, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: lumbar fracture (lower back). Review of a Minimum Data Set (MDS) assessment for Resident #107, with a reference date of 2/15/24 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #107 was cognitively intact. Further review of Resident #107's MDS-section Section GG - Functional Abilities and Goals revealed Resident #107 was coded as a #1 indicating 01. Dependent - Helper does ALL of the effort.…

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: # MI00142857 Based on interview, and record review, the facility failed to prevent misappropriation of a residents' narcotic (controlled substances) medications for 1 of 5 residents (Resident #102) reviewed for misappropriation of property resulting in missing pain medication, and the potential for uncontrolled pain and discomfort. Findings include: Review of a Facility Reported Incident (FRI) investigation dated 2/15/24 revealed: Incident Summary On 1-31-24 at 1830 the narcotic count sheet for Oxycodone IR 15 mg had a change made to count from 19 to 14 tabs. 2 nurses signatures were present indicating 4 tabs were wasted Licensed Practical Nurse (LPN Z) stated that while dispensing medications she noted that the blister pack had torn open and 4 pills were loose in the pack. She (LPN Z) stated she removed the 4 pills from the package and placed them in a medication cup to destroy with another nurse so they would not get lost. (LPN Z) stated she was busy so she locked them in 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.

This citation pertains to intakes: #MI00143109 & MI00143578. Based on observation, interview and record review, the facility failed to provide palatable food for 3 of 5 residents (Resident's #102, #104 & #111) reviewed for food palatability, resulting in residents being dissatisfied with the quality, portion size, taste and temperature of their food and the potential weight loss. Findings include: During an observation/interview on 4/16/24 at 1:10 PM., noted the lunch carts in the 3 dining rooms. It was noted that many of the meal trays were observed to have approximately 50%-75% of the meal still on the plates. Certified Nurse Aide (CNA) U reported there have been a lot of issues with the kitchen and the staffing turnover in the dietary department. CNA U reported the residents complain about the food a lot, and don't eat some of the food items served. CNA U reported the residents complain that it is always the same thing, cold, and does not look or taste good. CNA U reported there was an alternative menu, but residents refuse to eat the same thing on that menu too, hamburgers,…

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: #MI00143109 & MI00143578. Based on observation, interview, and record review the facility failed to maintain a safe, functional, and sanitary environment by not properly cleaning resident rooms, common areas, and commonly touched items for 2 residents (Resident #102 & #104) of 7 reviewed for homelike environment, resulting in strong odors in the facility, and an increased potential of infection, affecting residents in the facility. Findings include: Review of Resident Council Minutes from 1/3/24 through 3/19/24 revealed: Resident concerns (all resident names omitted) were as follows: 1/3/24: (residents) said that the dining tables are very dirty & its non-appetizing to eat at dirty tables. (resident) said he's noticed that the tables aren't routinely wiped down after each meal .housekeeping .(resident) mentions that her bed doesn't get cleaned under .Resident Council Minutes dated 2/20/24 Housekeeping: (resident same as 1/3/24) has asked month after month for her floor under her bed to be cleaned. She took me (activity staff) to her room to show me…

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 MI00139838 and MI00139892. Based on interview and record review, the facility failed to provide sufficient nursing staff to meet the needs of 12 of 12 residents in the Pinewood unit on the evening of 11/27/2023 and early morning of 11/28/2023, resulting in 12 residents on Pinewood not being checked and changed every two hours, delayed care, and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: In an interview on 12/13/2023 at 9:40 AM, Certified Nursing Assistant (CNA) M reported there was a night a few weeks ago there were only two aides working, CNA T and CNA N, and the residents on Pinewood were neglected all night. CNA M reported all the residents on Pinewood the following morning were wet and raw. CNA M reported CNA T and CNA N did not perform check and changes on Pinewood that evening. In an interview on 12/13/2023 at 12:45 PM, Scheduler CC reported 11/27/2023 was the evening the facility was short staffed and CNA M complained Pinewood residents did not receive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 1) ensure proper hand hygiene, glove use, and handling of soiled linens during incontinence care and 2) ensure proper cleaning of shared medical equipment in between resident use for 2 residents (Resident #103 and #105) of 3 residents reviewed for infection control, resulting in the potential for cross-contamination, disease exposure, and the development and spread of infection to a vulnerable population. Findings include: Resident #103 Review of an admission Record revealed Resident #103 admitted to the facility on [DATE] with pertinent diagnoses which included congestive heart failure, cerebral infarction, and dementia. In an observation and interview on 12/12/2023 at 12:12 PM in Resident #103's room, Non-certified Aide O entered the room without performing hand hygiene and donned gloves prior to performing incontinence care. Non-certified Aide O removed Resident #103's brief and cleaned a large amount of stool from resident's perineum…

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 MI00140929. Based on interview and record review, the facility failed to ensure one staff (Former Kitchen Worker LL) received a timely background check and fingerprinting, resulting in the potential for abuse and neglect for all residents. Findings include: In an interview on 12/7/2023 at 3:52 PM, Dietary Aide GG reported the facility hired a kitchen worker with a history of criminal sexual conduct without performing finger printing and later fired the employee after finger printing was completed. Dietary Aide GG reported she was concerned for the safety of residents. In an interview on 12/11/2023 at 10:05 AM, Human Resources (HR) staff EE reported he was responsible for completing background checks and fingerprinting at the facility. HR staff EE reported ideally background checks and fingerprinting are completed before hire. HR staff EE reported Former Kitchen Worker LL was hired on 9/7/2023 and missed several appointments for fingerprinting. HR staff EE reported Former Kitchen Worker LL was terminated on 10/16/2023 after fingerprinting returned and he was…

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 MI00139838. Based on interview and record review, the facility failed to notify the emergency contact of the transfer of 1 resident (Resident #101) out of 6 residents reviewed for notification of changes, resulting in family not being aware that Resident #101 had transferred to the local hospital. Findings include: Review of an admission Record revealed Resident #101 admitted to the facility on [DATE] with pertinent diagnoses which included acute pancreatitis with infected necrosis and diabetes mellitus. Further review revealed Family Member Y was listed as Resident #101's Emergency Contact #1. In a telephone interview on 12/12/2023 at 10:10 AM, Family Member Y reported he was not contacted by the facility when Resident #101 was sent to the hospital. Review of Resident #101's electronic medical record Progress Notes, Orders-Administration Note, dated 9/29/2023 at 4:02 PM, revealed Resident #101 was sent to the local hospital emergency department to verify placement of his drain.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to update a care plan to reflect current interventions for 1 resident, (Resident #109) of 13 residents reviewed for accuracy of care plans, resulting in the potential for staff to provide care that is inconsistent with the needs of the resident. Findings include: Review of an admission Record revealed Resident #109 admitted to the facility on [DATE] with pertinent diagnoses which included cerebral infarction, right sided weakness, and anemia. Review of a Minimum Data Set (MDS) assessment for Resident #109, with a reference date of 9/25/2023 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #109 was cognitively intact. Further review of same MDS assessment revealed Resident #109 required assistance with bed mobility. Review of a current risk for impaired skin integrity Care Plan intervention for Resident #109 on 12/13/2023 at 8:10 AM, with a revision date 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 MI00139838. Based on interview and record review, the facility failed to ensure accurate admission orders were written for one resident (Resident #101) of 13 residents reviewed for accuracy of physician's orders, resulting in the delay of treatment and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an admission Record revealed Resident #101 admitted to the facility on [DATE] with pertinent diagnoses which included acute pancreatitis with infected necrosis and diabetes mellitus. Review of local hospital documentation dated 9/20/2023 revealed Resident #101 was discharged from the local hospital to the facility on 9/20/2023 with physicians orders for blood glucose testing 3 times a day, amoxicillin-clavulanate 875-125 mg (antibiotic) twice a day, insulin lispro (short acting insulin) with meals, blood glucose checks three times a day, and orders to clean drain site with soap and water,…

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 MI00139838. Based on interview and record review, the facility failed to 1) provide drain care, 2) administer medications, and 3) perform blood glucose monitoring according to physician's orders for 1 resident (Resident #101) of 4 residents reviewed for quality of care, resulting in lack of treatment, monitoring, and care and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an admission Record revealed Resident #101 admitted to the facility on [DATE] with pertinent diagnoses which included acute pancreatitis with infected necrosis and diabetes mellitus. Review of local hospital documentation dated 9/20/2023 revealed Resident #101 was discharged from the local hospital to the facility on 9/20/2023 with physicians orders for blood glucose testing 3 times a day, amoxicillin-clavulanate 875-125 mg (antibiotic) twice a day, insulin lispro (short acting insulin) with meals, insulin glargine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to 1) implement preventative pressure ulcer interventions consistent with professional standards of practice and 2) perform a skin assessment upon readmission from the local hospital for 1 resident (Resident #103) of 3 residents reviewed for pressure ulcer prevention and treatment, resulting in the potential for skin breakdown and overall deterioration in health status. Findings include: Review of an admission Record revealed Resident #103 admitted to the facility on [DATE] with pertinent diagnoses which included congestive heart failure, cerebral infarction, and dementia. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 9/21/2023 revealed a Brief Interview for Mental Status (BIMS) score of 4, out of a total possible score of 15, which indicated Resident #103 was severely cognitively impaired. Further review of same MDS assessment revealed Resident #103 required assistance with bed mobility. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain an accurate health record for 1 resident (Resident #101) of 13 residents reviewed for accuracy of medical records, resulting in unclear documentation and the potential for miscommunication and an unclear picture of the resident's health care status. Findings include: Review of an admission Record revealed Resident #101 admitted to the facility on [DATE] with pertinent diagnoses which included acute pancreatitis with infected necrosis and diabetes mellitus. Review of Resident #101's September 2023 Medication Administration Record (MAR) revealed an order to inject Humalog (short acting insulin) 3 times a day per sliding scale and notify the physician if the blood glucose level was over 500. Review of Resident #101's blood sugar documentation revealed a blood sugar level of 520 at 4:05 PM on 9/26/2023, measured by Registered Nurse (RN) D. Review of Resident #101's electronic medical record and progress notes dated 9/26/2023 did not reveal…

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 datemarking and discarding of potentially hazardous foods. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 49 residents who consume food from the kitchen. Findings Include: 1. During a tour of the kitchen, starting at 7:34 AM on 6/12/23, it was observed that some items were not dated or were held in the walk-in cooler past their discard dates. These items were a pan of lasagna dated 6/1 to 6/7, a large bowl of lasagna sauce dated 6/1 to 6/7, a container of hot dogs not dated, a container of chicken salad not dated, and a tray of 21 nutritional shakes not dated. A review of the manufacture directions on the shakes state the shakes can be held for up to 14 days from thaw. An interview with Dietary Manager SS, at 8:27 AM on 6/12/23, found that the nutritional shakes are normally tracked with a label on the tray, but one was not there. At this time, a further review of the walk-in cooler found a box of peeled and sliced…

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 #'s MI00136297, MI00135104, MI00135459, and MI00137661. Based on observation, interview and record review, the facility failed to ensure assistance with Activities for Daily Living (ADL) care (showers, incontinence care, eating) was consistently provided for 4 residents (Resident #14, #16, #27 and #44) of 9 residents reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for residents who are dependent on staff for assistance. Findings include: Resident #14 Review of an admission Record revealed Resident #14 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: spastic quadriplegic cerebral palsy (paralysis of both arms and both legs, with muscle stiffness). Review of a Minimum Data Set (MDS) assessment for Resident #14, with a reference date of 5/22/23 revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated Resident #14 was cognitively impaired. 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 observation, interview, and record review, the facility failed to 1) secure resident medications and 2) discard expired medication, resulting in unsecured medication and the potential for decreased efficacy of medications and the exacerbation of resident medical conditions. Findings include: Unsecured Medication In an observation on [DATE] at 9:03 AM, Registered Nurse (RN) I left the Birchwood Hall medication cart unlocked and unsecured for approximately two minutes while she walked out of sight of the cart. In an observation on [DATE] at 9:22 AM, RN I left the Birchwood Hall medication cart unlocked and unsecured for approximately 10 minutes while passing medication in a resident room, out of sight of the cart. In an interview on [DATE] at 9:35 AM, RN I reported the medication cart should be locked any time she steps away from the cart. Medication Storage In an observation and interview on [DATE] at 8:21 AM during a tour of the Ridgewood Hall medication cart, a bottle of 500 mg oyster shell calcium was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 1) ensure appropriate hand hygiene and glove use during incontinence care for 3 residents (Resident #21, #20, and #2) of 6 residents reviewed for incontinence care, 2) ensure appropriate infection control during tube feeding for 1 resident (Resident #43) of 1 resident reviewed for tube feeding, and 3) ensure appropriate hand hygiene during medication administration, resulting in the increased potential for the development and transmission of communicable diseases and infection in a vulnerable population. Findings include: Resident #21 Review of a Minimum Data Set (MDS) assessment for Resident #21, with a reference date of 5/22/2023 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated Resident #21 was moderately cognitively impaired. Further review of same MDS assessment revealed Resident #21 required assistance with toilet use and personal hygiene. In an observation 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 activities of daily living (ADL) cares were provided per resident preference for 1 (Residents #6) of 19 residents reviewed for resident preferences, resulting in the potential for overall decline in sense of physical, mental, and psychosocial well-being. Findings include: Review of an admission Record revealed Resident #6 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #6, with a reference date of 3/31/23 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated Resident #6 was cognitively impaired. Review of the Functional Status revealed that Resident #6 required extensive assistance of 2 people with bed mobility. Review of Preferences for customary routine and activities indicated that choosing between bed bath or shower was somewhat important to Resident #6. Review of Resident #6's Care Plan revealed, .needs…

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 update advance directive status in the electronic health record of one resident (Resident #33) of 3 residents reviewed for advance directives, resulting in the potential for end of life choices not being honored. Findings include: Resident #33 Review of an admission Record revealed Resident #33 admitted to the facility on [DATE] with pertinent diagnoses which included cognitive deficit following stroke and vascular dementia. Further review revealed the resident to be full code status. Review of a Minimum Data Set (MDS) assessment for Resident #33, with a reference date of 5/7/2023 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #33 was severely cognitively impaired. Review of Resident #33's active Physician's Orders on 6/12/2023 at 3:02 PM revealed Resident #33 was full code. Review of Resident #33's Limited Treatment Worksheet, dated 1/21/2021, revealed Resident #33's legal…

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 privacy for 1 resident (Resident #44) of 1 resident reviewed for privacy during bathing care, resulting in frustration and dissatisfaction with care. Resident #44 Review of an admission Record revealed Resident #44, was originally admitted to the facility on [DATE] with pertinent diagnoses which included post-traumatic stress disorder (PTSD), depression, and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #44, with a reference date of 3/23/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #44 was cognitively intact. In a care observation on 6/14/23 at 10:40 AM, Certified Nursing Assistant (CNA) D and CNA K were assisting Resident #44 with a bed bath. As CNA D and CNA K started bed bath care on Resident #44, it was noted that the window blinds in Resident #44's room were completely open. A sidewalk was approximately 10 feet from window with view of 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 interview and record review, the facility failed to develop and implement a comprehensive, person-centered diabetic care plan for 1 Resident (Resident #4) of 1 Resident reviewed for care planning, resulting in a potential for unmet care needs. Resident #4 Review of Resident #4's admission Record revealed Resident #4, was originally admitted to the facility on [DATE] with pertinent diagnoses which included type 2 diabetes and cognitive communication deficit. Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 2/10/23 revealed a Brief Interview for Mental Status (BIMS) score of 2/15 which indicated Resident #4 was severely cognitively impaired. Review of Resident #4's Care Plan did not reveal a care plan focus for Resident #4's diagnosis of diabetes. During an interview on 6/14/23 at 4:24 PM, Director of Nursing (DON) B' reported that she was unable to find any goals or interventions in Resident #4's care plan related to Resident #4's diabetes diagnosis. DON B reported…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow professional standards for medication administration for 2 (Resident #16, Resident #20) out of 7 residents reviewed for medication administration, from a total sample of 19 residents, resulting in the potential for worsening of health conditions and mismanagement of medications. Findings Include: Resident #16 Review of an admission Record revealed Resident #16 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Alzheimer's disease. Review of a Minimum Data Set (MDS) assessment for Resident #16, with a reference date of 6/6/23 revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #16 was cognitively impaired. During an observation on 06/13/23 at 01:51 PM in Resident #16's room, CNA D assisted Resident #16 with her pants and to change her incontinence brief. During the incontinence care, CNA D found oral medication on the bed underneath Resident #16. There…

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 #MI00137590. Based on observation, interview and record review the facility failed to ensure residents received care in accordance with treatment orders for non-pressure wounds for 1 of 19 residents (Resident #20) reviewed for quality of care, resulting in the potential for infection and the worsening of medical conditions. Resident #20 Review of an admission Record revealed Resident #20 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Bullous Pemphigoid (skin blistering condition). Review of a Minimum Data Set (MDS) assessment for Resident #20, with a reference date of 3/14/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #20 was cognitively intact. Review of Resident #20's Care Plan revealed, .potential impairment to skin integrity related to Bullous Pemphigoid. Open blisters on right upper dorsal thigh and right interior thigh. Revision: 5/5/23. Interventions: Keep skin clean and dry…

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 #'s MI00136297 and MI00137590. Based on observation, interviews, and record review, the facility failed to ensure interventions were in place to prevent the development or worsening of pressure ulcers for 3 residents (Resident #14, #20 and #6), of 6 residents reviewed for pressure ulcers, resulting in the potential for development of avoidable and/or worsening pressure ulcers. Findings include: Resident #14 Review of an admission Record revealed Resident #14 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: spastic quadriplegic cerebral palsy (paralysis of both arms and both legs, with muscle stiffness). Review of a Minimum Data Set (MDS) assessment for Resident #14, with a reference date of 5/22/23 revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated Resident #14 was cognitively impaired. Review of the Functional Status revealed that Resident #14 required extensive assistance of 2 people for bed mobility,…

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 range of motion services for 1 resident (Resident #12) of 2 residents reviewed for limited range of motion, resulting in the potential for decreased range of motion and residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #12 Review of an admission Record revealed Resident #12 admitted to the facility on [DATE] with pertinent diagnoses which included multiple sclerosis and paraplegia (paralysis of the legs). Review of a Minimum Data Set (MDS) assessment for Resident #12, with a reference date of 3/28/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #12 was cognitively intact. Further review of same MDS assessment revealed Resident #12 required assistance with bed mobility. Review of a current activities of daily living Care Plan intervention for Resident #12, with a revision date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate safety measures to ensure resident safety in 2 residents (R150 and R151) of 19 residents reviewed for accidents and hazards, resulting in the potential for accidents and/or injuries. Findings include: R150 According R150's admission Record she had admitted to the facility on [DATE] and did not have a Minimum Data Set evaluation completed. During observations and interviews R150 was able to communicate with clear speech and understanding. During an observation and interview on 6/14/2023 at 11:10 AM, R150 was in her bathroom sitting in a wheelchair. Resident stated, I am waiting for someone to help me on the toilet. I have to use the bathroom. I just got done with therapy. They left me here. A staff person said they would come help me to the toilet, but no one has come back. R150 initiated her bathroom call light at 11:12 AM. Licensed Practical Nurse (LPN) G was in the common area with view of the call light over R150'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 observation, interview and record review, the facility failed to provide supplemental oxygen therapy according to physician's orders, the plan of care and professional standards for 1 resident (Resident #6) of 1 resident reviewed for oxygen use, resulting in the potential for hypoxemia (low oxygen in the blood). Findings include: Review of an admission Record revealed Resident #6 was originally admitted to the facility on [DATE] with pertinent diagnoses: asthma, heart failure, and sleep apnea (stop breathing during sleep). Review of a Minimum Data Set (MDS) assessment for Resident #6, with a reference date of 3/31/23 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated Resident #6 was cognitively impaired. Review of Special Treatments indicated the resident used Oxygen. During an observation on 06/12/23 at 02:50 PM, Resident #6 was in bed with the HOB (head of bed) 90 degrees and oxygen running via nasal cannula (delivers oxygen through…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a trauma informed care plan for 1 (Resident #44) of 1 resident reviewed for trauma informed care, resulting in the potential for exposure to trauma triggers and re-traumatization. Findings include: Resident #44 Review of an admission Record revealed Resident #44, was originally admitted to the facility on [DATE] with pertinent diagnoses which included post- traumatic stress disorder (PTSD), depression, and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #44, with a reference date of 3/23/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #44 was cognitively intact. Review of Resident #44's Care Plan did not reveal a focused care plan goal that addressed Resident #44's PTSD diagnosis. Review of Resident #44's Initial Social Services History Assessment revealed, . Section H. Trauma Informed Care. 1. Does resident have a diagnosis of Post-Traumatic Stress…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an as needed psychotropic medication was not prescribed for longer than 14 days for one resident (R5) of three residents reviewed for unnecessary medications, resulting in the potential for unnecessary psychotropic medications ad adverse reactions. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R5 scored 5/15 (severely cognitively impaired) on his BIMS (Brief Interview Mental Status). Section N: Medications reported R5 received antipsychotics were received on a routine basis with diagnoses that included generalized anxiety disorder. Review of R5's Order Summary reported on 5/19/2023 Lorazepam tablet 0.5 mg give 1 tablet by mouth every 8 hours as needed for gad (generalize anxiety disorder). It was noted 6/2/2023 was 14-days from order date with no new orders for the PRN Lorazepam 0.5 mg tablet. Review of R5's Medication Administration Record/Treatment Administration Record (MAR TAR) June 1, 2023 - June 30, 2023, reported…

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 a significant medication error in 1 (Resident #4) of 5 residents reviewed for medication errors, resulting in Resident #4 receiving insulin (medication that controls blood sugar levels) at a greater frequency than ordered. Findings include: Resident #4 Review of Resident #4's admission Record revealed Resident #4, was originally admitted to the facility on [DATE] with pertinent diagnoses which included type 2 diabetes and cognitive communication deficit. Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 2/10/23 revealed a Brief Interview for Mental Status (BIMS) score of 2/15 which indicated Resident #4 was severely cognitively impaired. Review of Resident #4's admission Record indicated that Resident #4 was admitted to the hospital on [DATE] and discharged on 4/5/23. Review of Resident #4's Hospital Record revealed, Trulicity (Insulin) 0.75 MG/0.5 ML Injection. Inject 0.75 mg under the skin every Saturday.…

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 accurate medical records for 2 out of 19 residents (Resident #14 and #16) reviewed for medical records, resulting in inaccurate medical records and the potential for facility staff and providers to have inaccurate information related to the resident's nutritional status. Findings include: Resident #14 Review of an admission Record revealed Resident #14 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: spastic quadriplegic cerebral palsy (paralysis of both arms and both legs, with muscle stiffness). Review of a Minimum Data Set (MDS) assessment for Resident #14, with a reference date of 5/22/23 revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated Resident #14 was cognitively impaired. Review of the Functional Status revealed that Resident #14 required extensive assistance of 1 person for eating. During an observation on 06/13/23 at 09:06 AM, Resident #14 was in a…

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