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NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During an interview on 7/9/24 at 7:45 PM, Dietary Aide (DA) F stated, I worked in Activities for a while. The facility fired all the activities aides and kept the Activity Director. The facility had to do budget cutbacks and Activities got hit the hardest. The residents do not always have activities going on. It's sad because the residents like their activities. This citation pertains to intake: MI00142051 Based on observation, interview and record review, the facility failed to provide consistent, meaningful and person-centered activities for 6 of 18 residents (Resident #11, #12, #17, #40, #406, and #34) reviewed for activities provided by the facility, resulting in the potential for loss of interaction, joy, self-esteem, growth, sense of well-being, autonomy, connectedness, identity, creativity, independence, pleasure, and comfort. Findings include: Review of The Boredom of Solitude published 4/21/23 by Psychology Today, [NAME] Danckert Ph.D., [NAME], Ph.D, revealed .Loneliness is a complex experience, one…

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 MI00143238 and intake MI00142051 Based on observation, interview, and record review the facility failed to ensure sufficient staffing to meet the needs of 5 (Resident #2, Resident #15, Resident #17, Resident #304, and Resident #406) of 18 residents and 12 resident council meeting members reviewed for staffing, resulting in the potential for residents to not maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #2 Review of an admission Record revealed Resident #2 had pertinent diagnoses which included: acquired absence of the right leg above the knee, acquired absence of the left leg above the knee, and paraplegia. Review of a Minimum Data Set (MDS) assessment for Resident #2, with a reference date of 6/14/2024 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #2 was cognitively intact. In an interview on 7/9/24 at 7:18 PM., Resident #2 reported that it could take an hour or more for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly monitor and follow resident refrigerator protocol for 19 residents of 19 residents reviewed to ensure temperatures were within range, resulting in the potential for food born illness. Findings include: During an observation on 7/09/24 at 7:19 PM, room [ROOM NUMBER] had a personal refrigerator with no visible temperature log. Resident reported staff did not keep track of the temperature. During an observation, interview, and record review on 7/09/24 at 7:43 PM, Dietary Aide (DA) F observed checking personal refrigerator temperatures stating, The frigs (refrigerators) are checked every day either by myself or another kitchen staff that is part-time. Reviewed with DA F, June 2024's resident's personal temperature log with multiple missing documentations. Observed copy of June 2024 resident personal refrigerator temperature log with DA F. DA F stated, I'm supposed to be done with work at 7:30 PM but since the State is here, I 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.

This citation pertains to intake MI00143238 Based on observation, interview, and record review the facility failed to maintain resident dignity in 1 (Resident #15) of 9 residents review for dignity resulting in feelings of frustration and anger. Findings include: Review of an admission Record revealed Resident #15 had pertinent diagnoses which included: muscle weakness, dependence on wheelchair, morbid (severe) obesity. Review of a Minimum Data Set (MDS) assessment for Resident #15, with a reference date of 6/8/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #15 was cognitively intact. In an interview on 7/9/24 at 7:30 PM., Certified Nurse Assistant (CNA) D CNA I and CNA O reported that typical staffing is two CNAs for the B side. CNA D reported that her normal assignment was about 14 residents for the shift and that there were maybe 27 residents on B side. CNA D reported that there was not enough staff to do what the residents need us to do for them. In an interview on 7/10/24 at 10:45 AM., Resident #15 reported that she had sat 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.

Based on interview and record review the facility failed to provide an environment free from psychosocial abuse in 2 (Resident #2 and Resident #36) of 2 residents reviewed for abuse resulting in feelings of frustration, mental anguish, and a loss of autonomy (freedom from external control or influence). Findings include: Resident #2 Review of an admission Record revealed Resident #2 had pertinent diagnoses which included: acquired absence of the right leg above the knee, acquired absence of the left leg above the knee, and paraplegia. Review of a Minimum Data Set (MDS) assessment for Resident #2, with a reference date of 6/14/2024 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #2 was cognitively intact. In an interview on 7/9/24 at 7:18 PM., Resident #2 stated .I can't go out the side door or the front door and there is a tracker on my power wheelchair .I was forced to quit (smoking) because I can't leave the property . In an interview on 7/10/24 at 9:57 AM., Resident #2 stated .I am on house arrest . when asked by this surveyor when he…

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 #MI00145579. Based on interview, and record review, the facility failed to prevent the misappropriation of resident medications in 1 of 3 residents (Resident #36) reviewed for abuse, resulting in loss of resident's diabetes medication, a delay in treatment of diabetes, and the potential for the resident to not reach their highest practical well-being. Findings include: Resident #36 Review of an admission Record revealed Resident #36 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: type 2 diabetes (problem in the way the body regulates and uses sugar). Review of a Minimum Data Set (MDS) assessment for Resident #36, with a reference date of 3/14/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #15 was cognitively intact. Review of a Facility Reported Incident dated 5/9/24 at 5:53 PM revealed, .potential missing medication, Ozempic (improves blood sugar)…

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 revise person centered care plans in 1 (Resident #2) of 18 reviewed for care plan revision resulting in the potential for implementation of inaccurate care interventions. Findings include: Resident #2 Review of an admission Record revealed Resident #2 had pertinent diagnoses which included: acquired absence of the right leg above the knee, acquired absence of the left leg above the knee, and paraplegia. Review of a Minimum Data Set (MDS) assessment for Resident #2, with a reference date of 6/14/2024 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #2 was cognitively intact. In an interview on 7/9/24 at 7:18 PM., Resident #2 stated .I can't go out the side door or the front door and there is a tracker on my power wheelchair .I was forced to quit (smoking) because I can't leave the property . In an interview on 7/11/24 at 10:29 AM., Social Services Advocate (SSA) C reported that NHA A had to take away Resident #2's ability to go outside. SSA C reported that Resident #2 used to go…

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 resident was consistently provided with showers/bathing for 2 of 7 residents (Resident #27 and Resident #406) reviewed for activities of daily living, resulting in unmet personal hygiene needs with the potential for isolation, psychosocial harm, skin breakdown, harboring infection, and decreased self-esteem. Findings include: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 50742-50744). Elsevier Health Sciences. Kindle Edition.Personal hygiene affects patient's comfort, safety, and well-being. Hygiene care included cleaning and grooming activities that maintain personal body cleanliness and appearance. Personal hygiene activities which as taking a bath or shower and brushing and flossing the teeth also promote comfort and relaxation foster a positive self-image, promote healthy skin, and help prevent infection and disease . Resident #27: Review of 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 interview and record review, the facility failed to maintain sufficient urine incontinence care in 1 resident (Resident #304) of 1 resident reviewed for incontinence care resulting in the potential for skin breakdown. Findings include: Resident #304 (R304) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R304 admitted to the facility on [DATE] with diagnoses of anxiety, depression, and dementia. Brief Interview for Mental Status (BIMS) reflected a score of 14 out of 15 which indicated R304 was cognitively intact (13 to 15 cognitively intact). During an interview on 7/09/2024 at 8:17 PM, R304 stated that she was left in urine for about an hour that day. She was teary eyed while talking about it and said it didn't make her feel good. R304 said that she asked to get up several times and it took them about an hour to get to her up. R304 stated that she knows lying in urine isn't good for her skin and she was worried about developing pressure ulcers on her bottom. 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.

Based on observation, interview, and record review, the facility failed to maintain a BiPAP after resident use for infection control for 1 (Resident #13) of 1 resident, resulting in the potential for cross-contamination of respiratory equipment, transmission of disease, and growth of infectious microorganisms. Findings include: Review of an admission Record revealed Resident #13 was a female with pertinent diagnoses which included heart failure, pulmonary hypertension, insomnia, obstructive sleep apnea, and asthma. Review of current Care Plan for Resident #13 revised on 2/29/24, revealed, the focus, .I have a sleep disturbance r/t (related to) obstructive sleep apnea that requires me to use CPAP Unit. Please remind me that I am to wear this at night and during naps with the intervention .Clean CPAP equipment, tubing, filters, bags and masks per facility protocol .Clean or replace filters per Manufacture recommendations once a week . Review of Orders dated 3/21/24, revealed, .CPAP Mask: Wash with mild soap and warm water. Rinse thoroughly and let air dry .every day shift .Do not 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 observation, interview, and record review the facility failed to identify post traumatic stress disorder (PTSD) triggers and develop individualized care plan interventions to mitigate triggers for 1 (Resident #65) of 24 residents reviewed for trauma informed care, resulting in the potential of re-traumatization due to staff not being informed and knowledgeable of the resident's past trauma. Findings include: Review of an admission Record revealed Resident #406 was a female with pertinent diagnoses which included spinal stenosis (space inside the bones of the spine get too small), wedge compression fracture of fifth lumbar vertebra (spinal compression fracture that occurs when the front of a vertebra collpases, but the back does not), wedge compression fracture of first lumbar vertebra, fusion of spine (surgical procedure that permanently joins two or more vertebra together so there is no movement between them), muscle weakness, difficulty in walking, unsteadiness on feet, and lack of coordination. In 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.

Based on interview and record review the facility failed to ensure the nursing staff was evaluated for appropriate competencies and skill sets resulting in the potential for residents of the facility to be unable to maintain the highest practicable physical, mental, and psychosocial well-being and the potential for decreased resident safety for all residents who resided in the facility. Findings include: In an interview on 7/12/24 at 10:41 AM., Director of Nursing (DON) B reported that she had provided a competency fair for nursing employees last month and that it was poorly attended. DON B reported that she did not make the competency fair attendance mandatory. DON B reported that a staff development role did not exist, and the responsibilities of that role fell to the director of nursing. Review of untitled spreadsheet document on 7/17/24 provided by DON B revealed columns that included employee names, position, department date, hire date, initial competency, annual competency 2023 and annual competency 2024. The untiled document included a total of 50 employee names, all from 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 facilitate appropriate mental health treatment and services for 1 (Resident #406) of 1 resident reviewed for mental health services, resulting Resident #406 being sent to a psychiatric hospital for hospitalization causing psychosocial distress and fear. Findings include: According to, National Alliance on Mental Illness (NAMI) Post-traumatic stress disorder (PTSD) is an anxiety disorder that can occur after someone experiences a traumatic event that caused intense fear, helplessness, or horror. PTSD can result from personally experienced traumas (e.g., rape, war, natural disasters, abuse, serious accidents, and captivity) or from the witnessing or learning of a violent or tragic event .While it is common to experience a brief state of anxiety or depression after such occurrences, people with PTSD continually re-experience the traumatic event; avoid individuals, thoughts, or situations associated with the event; and have symptoms of excessive emotions.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that follow up with pharmacy recommendations occurred for 1 resident (Resident #22) of 5 residents reviewed for medications resulting in the potential for medication side effects and/or unnecessary medications for residents. Findings include: Resident #22 (R22) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R22 admitted to the facility on [DATE] with diagnoses of type 2 diabetes, bipolar disorder, anxiety and depression. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R22 was cognitively intact (13 to 15 cognitively intact). Review of the Pharmacy to Physician Monthly Medication Regimen Review communication dated 1/29/2024 revealed the following recommendation: D/C (discontinue) the following PRN (as needed) orders. Meclizine 25 mg (milligrams) q8hr (every 8 hours) prn for dizziness and dicyclomine 20 mg q8hr prn for cramping {both have high antichol loads (anticholinergic,…

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 label, date, and store medications in 1 out of 2 medications rooms and 2 of 2 medication carts, resulting in the potential for decreased efficacy of medications and the potential for the compromise of medications and/or the misappropriation of medication. Findings include: In an interview on 07/17/24 at 10:01 AM, Unit Manager (UM) W reported that the medication refrigerator temperatures are supposed to be monitored and recorded every shift, at approximately 4:00 AM and 4:00 PM. During a Medication Storage observation and interview on 07/17/24 at 10:21 AM, UM G reported that the night shift nurse is responsible for monitoring the refrigerator temperatures. Review of the the B hall medication room revealed a refrigerator with multiple resident medications and vaccinations. Subsequent review of the refrigerator temperature log for the B hall revealed, multiple missing temperature records for day time monitoring and almost no monitoring at night. UM G reported that she recently moved the binder with 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 residents who were eligible for recommended vaccines were offered vaccinations in a timely manner for 2 residents (Resident #6 & #27) out of 5 residents reviewed for immunizations resulting in the potential for developing vaccine preventable disease. Findings include: In an interview on 07/09/24 at 08:44 PM, Nursing Home Administrator (NHA) A reported that Regional Clinical Director/Infection Preventionist (IP) KK is currently the only person that holds the Infection Preventionist Certification, and she oversees Director of Nursing (DON) B's implementation of the program. In an interview on 07/10/24 at 03:22 PM, ICP KK reported that she had not yet familiarized herself with how the previous Infection Preventionist tracked resident vaccinations. Resident #6 Review of an admission Record revealed Resident #6 was originally admitted to the facility on [DATE]. Review of Resident #6's Immunizations Record revealed, Influenza doses were received…

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 they consistently educated, offered and administered COVID-19 vaccines or maintain valid declination in the medical record for 1 resident (Resident #27) of 5 residents reviewed for vaccinations, and failed to educate, offer and track COVID-19 vaccine status staff for facility staff, resulting in the lack of vaccine tracking, the residents right to choose and receive vaccine treatment options, and the right to an informed consent. Findings include: In an interview on 07/09/24 at 08:44 PM, Nursing Home Administrator (NHA) A reported that Regional Clinical Director/Infection Preventionist (ICP) KK is currently the only person that holds the Infection Preventionist Certification, and she oversees Director of Nursing (DON) B implementation of the program. In an interview on 07/10/24 at 03:22 PM, ICP KK reported that she had not yet familiarized herself with how the previous Infection Preventionist tracked resident vaccinations. Resident #27 Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to make sure residents had an operable call light within reach in 1 of 18 residents (Resident #5) reviewed for call lights, resulting in the potential for delayed emergency response and negative resident outcomes. Findings include: Resident #5 (R5) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R5 admitted to the facility on [DATE] with diagnoses of vascular dementia and dysphagia. Brief Interview for Mental Status (BIMS) reflected a score of 00 out of 15 which indicated R5 was severely cognitively impaired (00 to 07 is severe cognitive impairment). She was under Hospice care. During an interview on [DATE] at 8:53 PM, R5 was observed to be lying in bed and had emesis on her right arm, on her bed, on the floor and on her fall mat. R5 was pleasantly confused and surveyor asked her to press her call light. R5 pressed call light and it wasn't working. Then, surveyor pressed call light too and observed it wasn'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00142938. Based on observation, interview and record review, the facility failed to provide care to prevent the development, consistent with professional standards of practice in 1 of 3 residents (Resident #405) reviewed for pressure injuries, resulting in the development of pressure ulcers on bilateral heels, and the potential for infection and overall deterioration in health status for all residents at risk for deterioration in skin integrity. Findings include: Resident #405 Review of an admission Record revealed Resident #405 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: weakness, difficulty walking and prediabetes (higher than normal blood sugar levels). Review of a Minimum Data Set (MDS) assessment for Resident #405, with a reference date of 2/8/24 revealed that the resident was at risk for pressure ulcers, and had zero unhealed ulcers. Review of Resident #405's Hospital Records indicated that the resident had admitted 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 This citation pertains to intake number MI00137705, MI00138640, and MI00140035. Based on interview and record review, the facility failed to ensure adequate staff to meet resident needs for 2 residents (Resident #1 and #3) of 5 residents reviewed for staffing, resulting in unmet resident needs and the potential for all residents to be affected. For additional information see citations F550 and F677. Findings include: Resident #1 Review of an admission Record revealed Resident #1 admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness, cellulitis, and obesity. Review of a Minimum Data Set (MDS) assessment for Resident #1, with a reference date of 11/23/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #1 was cognitively intact. Further review of the same MDS assessment revealed Resident #1 required assistance with toileting and bathing. Review of a current activities of daily living Care Plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00137705. Based on interview and record review, the facility failed to promote dignity in 2 residents (Resident #1 and #3) of 4 residents reviewed for dignity and respect, resulting in feelings of diminished self-worth and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #1 Review of an admission Record revealed Resident #1 admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness, cellulitis, and obesity. Review of a Minimum Data Set (MDS) assessment for Resident #1, with a reference date of 11/23/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #1 was cognitively intact. Further review of the same MDS assessment revealed Resident #1 required assistance with toileting and bathing. Review of a current activities of daily living Care Plan intervention for Resident #1, with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed ensure staff followed the standard of care for documentation and 1) accurately document physician's orders, 2) document vital signs in the medical record, and 3) document medication at the time given for 1 resident (Resident #9) of 9 residents reviewed for accuracy of physician's orders and accuracy of the medical record, resulting in the potential for residents to receive inappropriate care, lack of communication among care providers, 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 #9 admitted to the facility on [DATE] with pertinent diagnoses which included chronic obstructive pulmonary disorder and intellectual disabilities. Physician's orders/Documentation of vital signs Review of Resident #9's Practitioner Progress Note, dated [DATE] at 10:58 AM, revealed Resident had returned from the local emergency department 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 This citation pertains to MI00140335. Based on interview and record review, the facility failed to provide a means of communication for a resident who's first language was not English in 1 of 3 residents (Resident #7) reviewed for effective communication, resulting in frustration and the inability to communicate resident needs. Findings include: Review of an admission Record revealed Resident #7 admitted to the facility on [DATE] with pertinent diagnoses which included the need for left shoulder orthopedic aftercare and chronic lymphocytic leukemia. Review of Resident #7's admission Assessment, dated 10/6/2023, revealed Resident #7's preferred language was Spanish and she preferred an interpreter to communicate with health care staff. In a telephone interview on 2/13/2024 at 12:33 PM, Family Member DD reported Resident #7 was unable to communicate well in English and the facility did not use translation services when speaking to Resident #7 and did not explain how translation services could be accessed. In 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 pertains to intake MI00142222. Based on interview and record review, the facility failed to provide routine showers to dependent residents for 2 of 5 residents (Resident #3 and #9) reviewed for activities of daily living, resulting in residents feeling dirty and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #3 Review of an admission Record revealed Resident #3 admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #3, with a reference date of 11/16/2023 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #3 was cognitively intact. Further review of the same MDS assessment revealed Resident #3 required assistance with bathing. Review of a current activities of daily living Care Plan intervention…

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 MI00138561 and MI00139920. Based on interview and record review, the facility failed to ensure the safety and prevent elopement of 2 of 6 residents (Resident #4 and #6) reviewed for accidents and hazards, resulting in the elopement of Resident #4 and Resident #6 and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #4 Review of an admission Record revealed Resident #4 admitted to the facility on [DATE] with pertinent diagnoses which included schizoaffective disorder, altered mental status, and mild cognitive impairment. Review of Resident #4's Elopement Risk Assessment, dated 5/16/2023, revealed Resident #4 was identified as being at risk for elopement. Review of a Facility Related Incident investigation report, submitted 7/18/2023 at 4:11 PM, revealed Resident #4 eloped from the facility on 7/11/2023 at approximately 6:35 PM when she exited the building after Registered Nurse (RN) W…

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 to failed to ensure call lights were in reach for 4 (Resident #53, Resident #357, Resident #358, Resident #359) of 17 residents reviewed for call light placement, resulting in the potential for resident needs not being met. Findings include: Resident #53 Review of an admission Record revealed Resident #53, was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness, difficulty in walking, and unsteadiness on feet. Review of a Minimum Data Set (MDS) assessment for Resident #53, with a reference date of 4/3/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #53 was cognitively intact. Review of Resident #53's Care Plan revealed, .I am at increased risk for falls r/t (related to) hypoxia (Low oxygen) and weakness, obesity, and O2 use via NC (Nasal cannula), chronic pain, and opioid use. Date initiated 3/29/23. Interventions: Be sure my call light is within…

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 MI00128627 and MI00135835. Based on observation, interview, and record review, the facility failed to provide palatable food products for 4 residents (Resident #40, #19, #21, and #49) of 4 residents reviewed for palatability, resulting in dissatisfaction with meals, decreased food acceptance, the potential for nutritional decline, and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #40 Review of an admission Record revealed Resident #40 admitted to the facility on [DATE] with pertinent diagnoses which included protein-calorie malnutrition and chronic kidney disease. Review of a Minimum Data Set (MDS) assessment for Resident #40, with a reference date of 5/18/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #40 was cognitively intact. In an interview on 6/5/2023 at 1:55 PM, Resident #40 reported she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY R38 According to the Minimum Data Set (MDS) 3/23/2023, R38 scored 5/15 (cognitively impaired) on his BIMS (Brief Interview Mental Status), required extensive assistance of one-person physical assistance to move/change position in bed, with diagnoses that included dementia, manic depression, and Parkinson's disease. Observed on 6/05/23 at 10:48 AM, R38 had a transmission-based precautions isolation cart outside of his room containing PPE (personal protection equipment). There was no transmission-based precautions signage on the resident's door indicating the type of precaution or what PPE was required to enter the room. Review of R38's Change in Condition 6/3/2023 (Saturday), reported the resident had signs/symptoms of a respiratory infection that was identified with a dry and nagging cough with almost lost of voice. R38 was reported to have been placed in isolation. Review of R38's Order Summary did not have an order for Transmission-Based Precautions. Review of R38's Care Plan did not have a focus for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were assessed for self-administration of medications for 1 (Resident #53) of 1 residents reviewed for self administration of medication, resulting in unsupervised administration of medications and the potential for mismanagement of medication and potential for adverse side effects. Findings include: Review of an admission Record revealed Resident #53, was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness, difficulty in walking, and unsteadiness on feet. Review of a Minimum Data Set (MDS) assessment for Resident #53, with a reference date of 4/3/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #53 was cognitively intact. During an observation and interview on 6/5/23 at 10:03 AM in Resident #53's room, a medication cup containing approximately 7 pills was observed on Resident #53's tray table. Resident #53 reported that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident choices were provided during preparation of medication for 1 (Resident #53) of 1 residents, from a total sample of 17 reviewed for resident choices resulting in dissatisfaction in care. Findings include: Review of an admission Record revealed Resident #53, was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness, difficulty in walking, and unsteadiness on feet. Review of a Minimum Data Set (MDS) assessment for Resident #53, with a reference date of 4/3/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #53 was cognitively intact. During an interview on 6/7/23 at 9:34 AM, Resident #53 reported that he was concerned with the way that two nurses were administering his methadone medication. Resident #53 reported that he (Resident #53) preferred for the nurses to bring the bottle to his room and open the sealed bottle in front of him,…

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 prompt resolution of grievances for 1 resident (Resident #46) of 17 residents, reviewed for resolution of grievances, resulting in delayed resolution of resident's complaint/grievance and resident frustration. Findings include: Resident #46 Review of an admission Record revealed Resident #46 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #46, with a reference date of 4/6/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #46 was cognitively intact. In an interview on 06/05/23 at 01:33 PM, Resident #46 reported that he was scheduled to discharge home that day, and was frustrated due to an unresolved issue with the facility. Resident #46 reported that about 7 months ago the facility told him that they were not able to get the incontinence pads that he had been using and stated, .they told me if I bought…

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) apply barrier cream during incontinence care for 1 resident (Resident #11) of 1 resident reviewed for incontinence care and 2) provide a physician's order for oxygen therapy for 1 resident (Resident #2) of 3 residents reviewed for respiratory care, resulting in the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #11 Review of an admission Record revealed Resident #11 admitted to the facility on [DATE] with pertinent diagnoses which included cerebral infarction (stroke) and cognitive communication deficit. Review of a Minimum Data Set (MDS) assessment for Resident #11, with a reference date of 4/27/2023 revealed a Brief Interview for Mental Status (BIMS) score of 2, out of a total possible score of 15, which indicated Resident #11 was severely cognitively impaired. Further review of same MDS assessment revealed Resident #11 required assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure showers and hygiene care were provided per resident preference and plan of care for 2 (Resident #358 and Resident #41) of 5 resident reviewed for Activities of Daily Living (ADL) care, resulting in inadequate personal hygiene, missed showers, and dissatisfaction with care and hygiene concerns. Findings Include: Resident #41 Review of an admission Record revealed Resident #41, was originally admitted to the facility on [DATE] with pertinent diagnoses which included major depressive disorder and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #41, with a reference date of 4/13/ 23 revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #41 was moderately cognitively impaired. During an observation and interview on 6/5/23 at 12:43 PM, Resident #41 Reported that she had not had a shower since she was placed in isolation precautions approximately a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1.) ensure residents received recommended services following occupational therapy discharged , and 2.) thoroughly assess and provide consistent treatment of a skin condition, for 2 (Resident #21 and #53) of 17 residents, reviewed for quality of care, resulting in Resident #21 not meeting his highest practicable physical and psychosocial well-being due to being unable to propel wheelchair, and inadequate treatment of dry itchy skin for Resident #53. 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: polyosteoarthritis (joint pain and stiffness), bilateral artificial knee joints, and dislocation of left shoulder. Review of a Minimum Data Set (MDS) assessment for Resident #21, with a reference date of 4/27/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which…

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 implement fall prevention interventions for 2 (Resident #358 and #32) of 2 residents reviewed for falls, resulting in inadequate fall prevention interventions and potential for further falls and major injury. Findings include: Resident #358 Review of an admission Record revealed Resident #358, was originally admitted to the facility on [DATE] with pertinent diagnoses which included weakness, muscle weakness,difficulty in walking, and unsteadiness on feet. Review of a Minimum Data Set (MDS) assessment for Resident #358, with a reference date of 6/6/23 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #358 was cognitively intact. Review of Resident #358's Care Plan revealed, .I am at increased risk for falls r/t (related to) psychoactive medication use, weakness, COPD (Chronic Obstructive Pulmonary Disease), Hx (history) of falls with fracture, mental illness, incontinence (inability to control the…

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

Based on observation, interview, and record review, the facility failed to maintain a oxygen delivery equipment for infection control for 1 of 3 residents (R2) reviewed for respiratory care, resulting in the potential for infections and unmet medical needs. Findings include: R2 According to the Minimum Data Set (MDS) 3/16/2023, R2 scored 1/15 (severely cognitively impaired) on his BIMS (Brief Interview Mental Status) required supervision to position/turn in bed with no impairments in his arms or legs. Diagnoses included non-traumatic brain dysfunction. During an observation on 6/6/2023 at 9:55 AM, R2 was in his bed wearing oxygen running at 2 LPM (liters per minute) connected to an oxygen concentrator (produces oxygen). The oxygen was administered via a nasal cannula (NC) connected tubing that was not labeled or dated. There was a clear plastic bag on the side of the concentrator that was not labeled or dated. During an observation on 6/6/2023 at 11:50 AM, R2 was in his bed not wearing oxygen. His oxygen tubing and nasal cannula was neatly coiled in a clear plastic bag hanging 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.