Optalis Health and Rehabilitation of Grand Rapids

This citation pertains to Intake # 2977605.Based on interview, and record review, the facility failed to follow professional standards of practice to ensure safety in 1 of 3 residents (Resident #102) reviewed for safety/supervision, resulting in the lack of a comprehensive assessment for injury by a licensed nurse post-fall and the potential for injury.Findings include:Resident #102Review of a Face Sheet revealed Resident #102 was a male, with pertinent diagnoses which included right-sided hemiplegia/hemiparesis (paralysis/weakness) following a stroke, abnormal gait/mobility, depression, dementia, chronic kidney disease, and high blood pressure.Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 3/20/26, revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, indicating moderate cognitive impairment.Review of a current Care Plan for Resident #102 revealed the focus .At risk for falls due to CVA (stroke) with right sided weakness, hypertension (high blood pressure) with periods of hypotension (low…

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 # 2977605.Based on interview, and record review, the facility failed to ensure baths/showers were provided per resident preference and plan of care in 1 of 4 residents (Resident #102) reviewed for Activities of Daily Living (ADL) care, resulting in the potential for dissatisfaction with care, hygiene concerns, skin irritation, and low 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 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 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 #102In an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2990940 and 2970809. Based on interview and record review, the facility failed to maintain accurate medical records for 3 (Resident #101, #103 and #105) of 5 residents reviewed for complete and accurate medical record documentation, resulting in staff and providers mismanaging care for residents.Findings include:Resident #101Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and type 2 diabetes mellitus (chronic metabolic condition where the body develops insulin resistance and inadequate insulin production, causing high blood sugar levels.)Review of Resident #101's Treatment Administration Record (TAR) revealed, Order: Apply compression stockings early morning. one time a day for Edema (swelling). Start date: 1/22/26. Noted missing documentation to indicate if the treatment had been completed on the following dates: 4/1/26, 4/4/26, 4/6/26, 4/8/26, 4/9/26, 4/11/26, 4/14/26,…

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 a call light was within reach for 1 (Resident #110) of 3 residents reviewed for accommodation of needs, resulting in the potential for the resident to not meet their highest practicable level of well-being.Findings include:Resident #110Review of an admission Record revealed Resident #110 was a female, with pertinent diagnoses which included: other recurrent depressive disorders, muscle weakness (generalized), difficulty in walking not elsewhere classified, and cognitive communication deficit. Review of a current Care Plan for Resident #110 revealed a focus of At risk for falls due to history of falls. with revision on 11/9/25 and care planned interventions which included, Orient to surroundings and use of call light with a date initiated of 4/24/25.During an observation on 3/4/26 at 9:27 AM, Resident #110 was in her room in her bed. Resident #110's call light was not visible and was found to be hanging on the bottom of her bed frame behind the head of her bed near the floor. The call light was not…

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 #2740840. Based on interview and record review, the facility failed to ensure medical records were complete and accurate for 1 resident (Resident #101) of 5 residents reviewed for skin and wound documentation, resulting in the potential for staff and providers mismanaging the necessary care and treatments of residents. Findings include: Resident #101Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: weakness and falls. Review of Resident #101's Pressure Ulcer Care Plan revealed, .has pressure injury, with risk for delayed wound healing.Right heel.Last Revision: 11/8/25. Interventions: .Provide wound care as ordered by physician.Skin evaluations weekly.In an interview on 3/4/26 at 11:24 PM, Unit Manger (UM) P reported that she was aware of Resident #101's right heel wound and was aware of issues in December and again in January with wound dressings not getting changed and incomplete…

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 Intakes: 2663490, 2673806.Based on interview and record review, the facility failed to protect the residents' right to be free from resident to resident and staff to resident physical abuse for 3 (Resident #1, Resident #2, and Resident #9) of 8 residents reviewed for abuse, resulting in Resident #1 being struck by Resident #2 and Resident #9 being struck by a staff member.Review of Incident Summary dated 10/16/25 at 9:47 PM, revealed, .CNA (Certified Nursing Assistant) heard resident (Resident #1) yelling No, No, no stop; CNA went to source of yelling and observed (Resident #2) smack (Resident #1) on the mouth. Both residents immediately separated. (CNA U) was interviewed and stated that she was rounding on her residents and when she arrived at the room of (Resident #1), she heard her state, No, No, No. She opened the door to (Resident #1's) room and observed (Resident #2) strike her across the mouth. She immediately re-directed (Resident #2) to her room.The resident-to-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 This citation pertains to intake 2615390Based on interview and record review the facility failed to prevent misappropriation of narcotic medications for 2 (Resident #7 and Resident #8) of 2 residents reviewed for misappropriation of personal property, resulting in the potential for ineffective pain management.Findings include:Review of Incident Summary dated 8/31/2025 at 7:27 PM revealed .while processing a resident to discharge home, narcotic card count and sheet count were off by 3 cards total, effecting 2 residents. Narcotic card count sheet was changed by Agency ( Registered Nurse (RN) BBB) nurse. When further questioned as to why the card count was changed, she stated the medications were finished however she could not detail what she did with the blister packs or signed narcotic sheets.Resident #7 Review of an admission Record revealed Resident #7 was originally admitted to the facility on [DATE] for a 5-day respite stay while admitted to hospice. Review of Order Summary for Resident #7 revealed .Respite…

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 # 2673806Based on interview and record review, the facility failed to thoroughly investigate an allegation of staff-to-resident abuse for 1(Resident #9) of 8 residents reviewed for abuse, resulting in an incident of staff-to-resident physical abuse not being identified due to a lack of thorough investigation, and a potential for additional abuse to go unrecognized.Findings include:Resident # 9In an interview on 12/22/25 at 12:08pm, Resident #9 reported in mid-November, an agency nurse struck him during an argument. Resident #9 reported he was in the dining area when a nurse (Licensed Practical Nurse (LPN) SS) whom he had not previously met, approached him in the dining room but would not give him an insulin injection in the public area, despite that being his (Resident #9's) preference. Resident #9 reported LPN SS later reapproached him for the injection when the resident was in his room, they began to argue, and Resident #9 pushed LPN SS. Resident #9 reported at that time, LPN SS hit him with his hand. Resident #9 reported a member of the facility'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 follow professional standards of nursing practice for medication administration for 1 of 1 residents (Resident #11) reviewed for medication administration resulting in the not following the physician's order for administration, administering a medication late and not contacting the provider and the potential for affected resident not maintaining or achieving their highest practical physical well-being.Findings include: Resident #11:Review of an admission Record revealed Resident #11 was a female with pertinent diagnoses which included paroxysmal atrial fibrillation (irregular heartbeat), pulmonary embolism (blood clot in the lung), popliteal vein thrombosis (blood clot forms in the vein behind the knee), high blood pressure, heart failure, and low blood pressure.Review of Care Plan for Resident #11 revised on 5/28/25, revealed the focus, .The resident has altered cardiovascular status r/t (related to) chronic diastolic CHF (congestive…

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: 2611992 Based on observation, interview and record review, the facility failed to assess, monitor, document, and provide treatment per professional standards of practice for 1 resident (Resident #11) of 1 resident reviewed for quality of care, resulting in hospitalization for fecal impaction, potassium levels at a dangerous level, and implementation of treatment of weeping wounds with a potential for a decline in overall physical, mental, and psychosocial well-being. Findings include: Resident #11:Review of an admission Record revealed Resident #11 was a female with pertinent diagnoses which included iron deficiency, slow transit constipation, anxiety, mixed irritable bowel syndrome (alternating bouts of constipation and diarrhea along with abdominal pain, gas, bloating, cramping, often cycling between the two extremes), GERD (gastro-esophageal reflux disease), lymphedema (chronic swelling caused by a buildup of protein rich lymph fluid when the lymphatic system is damaged or…

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

This citation pertains to Intake: 2611992 Based on observation, interview, and record review, the facility failed to ensure appropriate external catheter care, monitoring, and cleaning for 1 (Resident #11) of 1 resident reviewed for catheter care, resulting in the potential of a urinary tract infection.Findings include: The Pure Wick at Home for females is an external catheter which sit outside the body, held in place by the anatomy of most users, and the wick is multi-layered with soft absorbent fabric designed to pull voided urine through tubing and into the connected collection canister. https://www.purewickathome.comResident #11:Review of an admission Record revealed Resident #11 was a female with pertinent diagnoses which included acute cystitis with hematuria (bladder inflammation often from a bacterial infection causing painful, frequent urination, and visible blood), overactive bladder, neuromuscular dysfunction of bladder (nerve damage causing poor bladder control, incontinence, or incomplete emptying), and carrier of carbapenem-resistant enterbacterales (CRE- an infection…

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 receives necessary respiratory care and services that is in accordance with professional standards of practice for 1 (Resident #104) of 1 resident reviewed for respiratory care resulting in the potential for respiratory distress and exacerbation of respiratory conditions. Findings include: Resident #104Review of an admission Record revealed Resident #104 was originally admitted to the facility on [DATE] with pertinent diagnoses which included obstructive sleep apnea (sleep disorder characterized by repeated interruptions in breathing during sleep due to airway blockage) and chronic respiratory failure with hypoxia (inability to effectively exchange oxygen and carbon dioxide, leading to chronically low oxygen levels in the blood.)Review of Resident #104's Orders revealed, Nurse to place BIPAP(type of noninvasive ventilation that helps you breathe) at HS (night) and verify Oxygen is bled into machine. Include a Progress…

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

Based on observation and interviews, the facility failed to ensure current daily facility staffing hours were posted in a prominent location readily accessible to residents, staff, and visitors.Findings include:On 12/22/25 at 11:20 AM, staffing hours dated 12/09/25 were observed posted on a bulletin board in a glass enclosed case in the hallway directly behind the entry way and reception of the building.On 12/22/25 at 2:52 PM, staffing hours dated 12/22/25 were observed taped to the glass enclosure of the bulletin board in the hallway directly behind the entry way and reception of the building.On 12/23/25 at 11:02 AM, staffing hours dated 12/22/25 were observed taped to the glass enclosure of the bulletin board in the hallway directly behind the entry way and reception of the building.On 12/29/25 at 8:42 AM, 10:40 AM, and 11:23 AM staffing hours dated 12/22/25 were observed taped to the glass enclosure of the bulletin board in the hallway directly behind the entry way and reception of the building.In an interview on 12/29/25 at 11:24 AM Scheduler (S) K reported it was her…

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 food choices were obtained and honored for 1 (Resident #11) of 1 resident reviewed for meal services, resulting in resident dissatisfaction with their meal experience and the potential for inadequate food/fluid intake. Findings include:Resident #11: Review of an admission Record revealed Resident #11 had pertinent diagnoses which included iron deficiency, slow transit constipation, and mixed irritable bowel syndrome (alternating bouts of constipation and diarrhea along with abdominal pain, gas, bloating, cramping, often cycling between the two extremes). Review of Care Plan for Resident #11, revised on 9/23/25, revealed the focus, .The resident is at nutritional and hydration risk r/t (related to) Lymphedema (chronic swelling usually in an arm or leg from a buildup of protein-rich lymph fluid when the lymphatic system is damaged or blocked), Radiculopathy (irritation or compression of a spinal nerve root causing numbness,…

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 Certified Nursing Assistants (CNA's) yearly performance review was conducted resulting in the potential for CNA's to not be able to safely provide necessary care and services to residents, a lack of training, and the potential for unmet care needs.Findings include: On 10/23/25 at 12:48 PM, this writer requested verification of annual performance reviews for five sampled CNA files: (CNA H, M, OO, PP, and QQ). The facility was unable to provide the requested information. In an interview on 10/23/25 at 1:06 PM, Nursing Home Administrator (NHA) A reported that the facility had not completed annual performance reviews for the CNA staff.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes 2648348 and 2640731.Based on interview, and record review, the facility failed to administer the facility in a manner that ensures the highest practicable physical well-being of each resident by: 1.) ensuring that the facility had an active contract with a nursing school, 2.) maintaining and implementing policies/procedures for nurses working with nursing students, and 3.) ensure medication administration policies were based on acceptable clinical standards for resident verification, resulting in Resident #101 receiving the wrong resident medications, which were administered by a nursing school student under the supervision of an agency nurse, which lead to Resident #101 being hospitalized from [DATE]-[DATE] with diagnoses of metabolic encephalopathy (significant decline in brain function due to an underlying metabolic disturbance) and iatrogenic polypharmacy (harm caused by the administration of multiple medications). Findings include: Resident #101Review of a Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to review and update the facility assessment after changes which would require substantial modification which includes an assessment of policies and procedures, training programs, education, training and competencies of direct care staff- both employees and those who provide services under contract, and contracts/memorandums of understanding or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies resulting in the potential for unidentified resources necessary to provide care and services to the resident populationFindings include: Review of the Facility assessment dated [DATE]- 6/31/25 indicated that the facility assessment which was documented as reviewed on 6/3/25 did not include a facility nursing assistant, resident, or resident representative as part of the assessment review. The assessment did review staffing needs but had not been updated or reviewed after 6/2025. It 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.

Based on interview, and record review, the facility failed to develop, implement, and permanently maintain an in-service training program for Certified Nursing Assistants (CNA's) as determined by the yearly performance review, and ensure a total of 12 hours of yearly education, resulting in the potential for CNA's to not be able to safely provide necessary care and services to residents, a lack of training, and the potential for unmet care needs.Findings include: On 10/23/25 at 12:48 PM, this writer requested verification of annual in-service education for five sampled CNA files: (CNA H, M, OO, PP, and QQ. The facility was unable to provide the requested information. In an interview on 10/23/25 at 1:06 PM, Nursing Home Administrator (NHA) A reported that the facility had not completed annual reviews for the CNA staff, and therefore, the facility was not ensuring that the CNA's at the facility had completed the 12 hours of in-service education based on the annual performance reviews.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2602017Based on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 (Resident #504) of 3 residents reviewed for abuse resulting in an of injury of unknown origin not being reported to the state agency. Findings include: Resident #504Review of an admission Record revealed Resident #504 was originally admitted to the facility on [DATE] with pertinent diagnoses which included chronic pain and vascular dementia. Review of a Minimum Data Set (MDS) assessment for Resident #504, with a reference date of 8/25/25 indicated under Section GG: Functional abilities that Resident #504 was Dependent (01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for rolling left to right and chair/bed transfers.…

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 2602017Based on interview and record review, the facility failed to identify and thoroughly investigate an injury of unknown origin for 1 (Resident #504) of 3 residents reviewed for abuse, resulting in the potential for ongoing injuries due to an incomplete investigation of an injury of unknown origin. Findings include:Resident #504Review of an admission Record revealed Resident #504 was originally admitted to the facility on [DATE] with pertinent diagnoses which included chronic pain and vascular dementia. Review of a Minimum Data Set (MDS) assessment for Resident #504, with a reference date of 8/25/25 indicated under Section GG: Functional abilities that Resident #504 was Dependent (01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for rolling left to right and chair/bed transfers. Section J- Health Conditions: Has the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2602017Based on interview and record review the facility failed to accurately and thoroughly assess, adequately monitor and provide quality care and treatment for pressure ulcers for 1 of 3 residents (Resident #504) reviewed for wound care resulting in the potential of worsening of a pressure wound. Findings include:Resident #504Review of an admission Record revealed Resident #504 was originally admitted to the facility on [DATE] with pertinent diagnoses which included reduced mobility and type 2 diabetes (long term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident #504's Care Plan revealed, Focus: At risk for alteration in skin integrity related to: decreased mobility .Date Initiated: 05/22/2025. Interventions: Administer treatment per physician orders. Date Initiated: 05/22/2025. APM (alternating pressure mattress) to bed Date Initiated: 05/28/2025. Barrier cream to peri area/buttocks as needed. Date Initiated:…

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 1214303, 1214279, and 2588205. Based on observation, interview and record review, the facility failed to provide sufficient nursing staff for 93 of 93 residents who reside in the facility, resulting in unmet care needs, as identified by the issues ascertained during the survey that included long call light wait times, residents left in soiled briefs for extended periods of time, residents missing showers and missing other activities of daily living (ADL) care, residents missing medications, treatments, and neurological assessments after falls, nursing staff feeling frustrated, overworked, exhausted, and management staff not available to assist direct care staff with Residents' care and needs, affecting the physical, mental, and psychosocial well-being of all 93 residents residing in the facility. Findings include: In an interview on 8/12/25, Licensed Practical Nurse (LPN) CC reported that staffing at the facility had been awful for months, and had not improved since the last time…

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 2583410 and 1214279.Based on observation, interview, and record review, the facility failed to provide respectful and dignified personal care and services for 4 (Resident #102, #103, #106, and #107) of 6 residents reviewed for dignity, resulting in unmet care needs, and feelings of diminished self-worth, sadness, and frustration. Findings include: Resident #102Review of an admission Record revealed Resident # 102 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and major depressive disorder. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 8/8/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #102 was cognitively intact. Review of Resident #102's Care Plan revealed, Focus: ADL (activities of daily living) self-care deficit related to weakness . Date Initiated: 05/04/2025. Goal: Will receive assistance necessary to meet ADL needs. Date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 1214304Based on interview and record review, the facility failed to maintain complete and accurate medical records for 4 of 9 residents (Resident #101, Resident #102, Resident #104, and Resident #108) reviewed for complete and accurate medical record documentation, resulting in the potential for staff and providers mismanaging care for residents.Findings include:Resident #101Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE] with pertinent diagnoses which included repeated falls and chronic pain. Review of Resident #101's Medication and Treatment Administration Orders for August 2025 revealed: Ketamine HCl External Cream 5 % (Ketamine HCl (Topical). Apply to Feet and legs topically three times a day for Pain. Start date 8/6/25. It was noted that there was missing documentation for administration of this treatment order on 8/13/25.GlycoLax Powder (Polyethylene Glycol 3350) (Medication used for constipation). Give 17 gram by mouth…

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 2564458Based on interview and record, review the facility failed to inform in advance and accommodate the residents' responsible party (RP) to participate in formulation of a care plans with relevant disciplines (nursing, dietary, social services, and activities) related to assessed healthcare needs for 1 (Resident #104) of 3 residents reviewed for notification for care planning resulting in ineffective communication and the potential for unmet care needs. Findings include: Resident #104Review of an admission Record revealed Resident #104 was originally admitted to the facility on [DATE] with pertinent diagnoses which included unspecified dementia, major depressive disorder, and schizoaffective disorder (a mental health condition marked by a mix of schizophrenia symptoms such as hallucinations and delusions and mood disorder symptoms such as depression and mania). Review of Resident #104's Care Plan revealed, (Resident #104) admitted to facility with Guardianship paperwork 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 to failed to ensure call lights were within reach for 1 (Resident #108) of 9 residents (reviewed for accommodation of needs, resulting in resident's inability to call for staff assistance with the potential for unmet care needs. Findings include: Resident #108Review of an admission Record revealed Resident # 108 was originally admitted to the facility on [DATE] with pertinent diagnoses which included lack of coordination, epilepsy (seizure disorder), muscle weakness, and difficulty walking. Review of a Minimum Data Set (MDS) assessment for Resident #108, with a reference date of 8/2/25 revealed Section GG: Functional abilities: Resident #108 was dependent for toileting assistance, personal hygiene and required substantial/maximum assistance with dressing. In an interview and observation on 8/14/25 at 10:26 AM, Resident #108 was sitting at the edge of his bed attempting to stand up on his own. Resident #108 was noted to be weak, and shaky as 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 Based on observation, interview, and record review, the facility failed to prevent involuntary seclusion in one of 9 residents reviewed for abuse (Resident #109), resulting in the potential for residents to not meet their highest practicable level of well-being.Findings include: Resident #109Review of an admission Record revealed Resident #109 was originally admitted to the facility on [DATE] with pertinent diagnoses which included unspecified dementia, disorientation, and cognitive communication deficit. Review of Resident #109's Care Plan revealed, Focus: (Resident #109) admitted to facility with temporary guardian. Her family member, (name redacted) was granted full guardianship on 4-14-21. Date Initiated: 08/13/2024. Interventions: Keep (Resident #109) and (Resident #109's family member) informed of changes in health and medical status for assist with continuum care planning and decision making. Date Initiated: 08/13/2024. Focus: (Resident #109) will occasionally wander into other resident's rooms, pick up…

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 appropriate Activities of Daily Living (ADL) care for 3 (Resident #102, #103 and #106) of 4 residents reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for resident's who are dependent on staff for assistance. Findings include: This citation pertains to intake 1214279. Resident #102Review of an admission Record revealed Resident # 102 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and major depressive disorder. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 8/8/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #102 was cognitively intact. Review of Resident #102's Care Plan revealed, Focus: ADL (activities of daily living) self-care deficit related to weakness . Date Initiated: 05/04/2025. Goal: Will receive assistance necessary…

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 residents received treatment in accordance with professional standards of practice for 2 (Resident #103 and Resident #108) of 9 residents reviewed for quality of care resulting in missed neurological (neuro) assessments after unwitnessed falls and missed medication doses resulting in the potential for a lack of monitoring, unnoticed adverse reactions, unnoticed injury, and the potential to negatively impact the resident's psychosocial wellbeing.Findings include: Resident #108Review of an admission Record revealed Resident # 108 was originally admitted to the facility on [DATE] with pertinent diagnoses which included lack of coordination, epilepsy (seizure disorder), muscle weakness, and difficulty walking. Review of Resident #108's Medication Administration Record (MAR) revealed, cloBAZam Oral Tablet 10 MG (Clobazam) (Anti-seizure medication) Give 1 tablet by mouth one time a day for seizures. Start date: 7/1/2025. Lacosamide Oral Tablet…

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 supervision to ensure resident safety for 2 (Resident #104 and Resident #109) of 9 residents reviewed for supervision resulting in the potential for resident-to-resident abuse. Findings include: Resident #104Review of an admission Record revealed Resident #104 was originally admitted to the facility on [DATE] with pertinent diagnoses which included unspecified dementia, major depressive disorder, and schizoaffective disorder (a mental health condition marked by a mix of schizophrenia symptoms such as hallucinations and delusions and mood disorder symptoms such as depression and mania). Review of Resident #104's Care Plan revealed, Focus: (Resident #104) is at risk for changes in mood and behavior related to alcoholic dementia with behavioral disturbance, anxiety, schizoaffective disorder .Targeted behaviors include sexually inappropriate (verbal, touching, and grabbing), Verbal (Aggressive, yelling swearing, threatening to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation contains two deficient practice statements, A & B. Deficient Practice Statement A Based on observation, interview, and record review, the facility failed to effectively implement Enhanced Barrier Precautions (EBP) per facility policy and Centers for Disease Control and Prevention (CDC) guidance, in 3 of 4 residents (Resident #2, #42, & #45) reviewed for EBP, resulting in the potential for cross-contamination and the development and spread of infection to a vulnerable population. Findings include: Resident #2 Review of an admission Record revealed Resident #2 was a female, with pertinent diagnoses which included obstructive and reflux uropathy (a blockage in the urinary tract that prevents urine from flowing properly), anemia, diabetes, heart disease, and high blood pressure. Review of a Minimum Data Set (MDS) assessment for Resident #2, with a reference date of 3/20/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated she 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 properly label, date, and store medications in 2 out of 6 medication carts resulting in the potential for decreased efficacy of medications and the exacerbation of medical conditions. Findings include: In an observation of the 400 hall medication cart on [DATE] at 8:22 AM, One bottle of a resident nitroglycerin medication was noted in the cart with a label on the bottle that stated Discard after [DATE]. Two opened insulin pens (lantus and humalog) were found without dates to indicate what day they had been opened. One lidocaine cream was noted to be opened without a resident name or open date on the package. In an interview on [DATE] at 8:30 AM, Registered Nurse (RN) SS reported that nurses were supposed to ensure that they labeled all medications when they opened them to ensure that the medications were getting disposed of when they were expired. RN SS confirmed that all medications should be labeled with a resident name as well, to…

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

Based on interview, and record review, the facility failed to ensure COVID-19 vaccinations were offered to eligible residents in 3 of 5 residents (Resident #16, #18, & #60) reviewed for COVID-19 vaccinations, resulting in the potential for development and transmission of COVID-19 within a vulnerable population. Findings include: Review of the policy/procedure Covid-19, dated 10/26/23, revealed .The facility has developed and implemented written policies and procedures that include .Covid-19 Vaccination for Residents .Residents will be screened for current suspected or confirmed cases of Covid-19, previous allergic reactions, and administration of therapeutic treatments and services to determine if they are an appropriate candidate for vaccination .Residents will be offered the Covid-19 vaccination per CDC (Centers for Disease Control and Prevention) and/or FDA (Food & Drug Administration) guidelines unless such immunization is medically contraindicated, they have already been immunized during the time period, or they refuse to receive the vaccine .The resident's medical record will…

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 #MI00152454 Based on observation, interview and record review, the facility failed to ensure a functioning call light was in place for 4 residents (Resident #85, #63, #57 & #337) of 18 residents reviewed for supervision, and have a fully operational call system in place for all 89 residents residing in the facility resulting in the potential for unmet needs, harm or serious injury. Findings include: Resident #85 Review of a Minimum Data Set (MDS) assessment for Resident #85, with a reference date of 3/3/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #85 was cognitively intact. In an interview on 05/05/25 at 10:32 AM, Resident #187 reported that he had been waiting for staff to answer his call light for about 2 hours. Observed Resident #187's call light lit up on the wall in the room, but the light in the hall was not on. Reported to Licensed Practical Nurse (LPN) FF who said that he would tell the…

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

Based on interview, and record review, the facility failed to implement an effective training program in regard to infection prevention and control and Enhanced Barrier Precautions (EBP) in 4 of 5 staff members reviewed for infection control/EBP education, resulting in the potential for cross-contamination and the spread of infection to a vulnerable population. Findings include: On 5/7/25 at 3:53 PM, requested information from Infection Preventionist C to verify that Agency Registered Nurse (RN) QQ and Agency RN UU completed education in regard to EBP prior to working a shift at the facility. In an interview and record review on 5/8/25 at 10:43 AM, Infection Preventionist C reported there is a binder of information at the front entrance to the facility that Agency staff are required to review prior to the start of their shift. Infection Preventionist C reported this was not something that previously required signatures for verification of completion, but that process will be implemented going forward. Infection Preventionist C reported the staffing agency informs the Agency nursing…

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 were cared for with dignity and respect for 3 (Resident #14, #16 and #61) of 5 residents reviewed for dignity, resulting in the potential for feelings of embarrassment, frustration, depression, and loss of self-worth and an overall deterioration of psychological well-being. 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 major depressive disorder and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #14, with a reference date of 3/13/25 revealed a Brief Interview for Mental Status (BIMS) score of 10/15 which indicated Resident #14 was moderately cognitively impaired. 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 with late onset. Review of a Minimum Data Set…

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 obtain psychotropic medication consent prior to administration of psychotropic medication per facility policy for 1 resident (Resident #15) of 5 residents reviewed for unnecessary medications, resulting in the resident and/or representative not being fully informed and the potential for resident decision makers not having an accurate picture of resident condition. Findings include: Review of an admission Record revealed Resident #15 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia, depression and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #15, with a reference date of 3/3/2025 revealed a Brief Interview for Mental Status (BIMS) score of 00, out of a total possible score of 15, which indicated Resident #15 was cognitively severely impaired. In an interview on 5/07/25 at 07:33 AM, Certified Nursing Assistant (CNA) O reported that Resident #15 was not able to clearly verbalize her…

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 #MI00152454 Based on interview and record review the facility failed to notify a resident durable power of attorney(DPOA)/emergency contact of a fall and transfer to hospital for 1 (Resident #337) of 2 residents reviewed for notification, resulting in the potential for a delay in required medical treatment. Findings include: Review of an admission Record revealed Resident #337 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness on one side). Review of Resident #337's Progress Note dated 4/21/25 and documented by Licensed Practical Nurse (LPN) P revealed, Resident found laying (sic) in prone position next to bed started neuros (neurological assessments), vitals (vital signs) slightly elevated, no c/o (complaint of) pain, large bruise on right knee, bump and bruise on left side of forehead, contact on-call…

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 issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for non-covered services in 1 resident (Resident #188) of 3 residents reviewed for timely provision of notifications, resulting in the potential for unforeseen financial obligation and hardship. Findings include: Review of Resident #188's SNF Beneficiary Notification Review worksheet completed by the facility indicated after her last covered day (9/17/24), the resident paid privately from 9/18/24 to 9/23/24. The supporting documentation included a Beneficiary Notification dated and signed on 9/17/24, and indicated the resident's last covered day would be 9/17/24. There was no Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) included with the supporting documentation provided by the facility. Review of Resident #188's Progress Note dated 9/17/2024 at 08:31 AM revealed, .Spoke with (Resident #188) regarding her request to be discharged from therapy services and to end her skilled stay. Pt (patient) reporting she is not feeling well enough to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure proper discharge notifications were completed in 2 residents (Resident #85 & #337) of 2 residents reviewed for discharge process, resulting in the State Long-Term Care (LTC) Ombudsman not receiving notification of Resident #85's discharge to the hospital and DPOA (Durable Power of Attorney) not receiving written notice of bed hold for Resident #337. Findings include: In an email correspondence on 5/1/25 at 10:04 AM, LTC Ombudsman reported that the facility had not been sending notifications for emergency/hospital transfer and discharge notifications. In an interview on 05/07/25 at 10:44 AM, Nursing Home Administrator (NHA) A reported that to her knowledge, notices to the ombudsman regarding discharges were being done at the corporate level. NHA A provided 4 log sheets for January, February, March and April of 2025. NHA A reported that she did not know why Resident #85 was not listed on the April 2025 log of discharges. NHA A was not able to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement care plan interventions for 1 (Resident #5) of 18 Residents reviewed for care planning, resulting in a potential for unmet care needs. Findings include: Review of an admission Record revealed Resident #5 was originally admitted to the facility on [DATE] with pertinent diagnoses which included weakness and need for assistance with personal care. Review of Resident #5's Care Plan revealed, (Resident #5) is at risk fort risk for falls due to side effects of medication, behaviors, debility, poor PO (by mouth) intake, history of ataxia (lack of muscle coordination), impaired safety awareness, visual impairment, osteoporosis (skeletal disorder).Date Initiated: 08/13/2024. Interventions: Call light within reach. Date Initiated: 08/13/2024 .Fall mat next bed. Date Initiated: 08/13/2024 . In an observation on 5/5/25 at 4:12 PM, Resident #5's was noted to be lying in bed. It was noted that there was no fall mat next to Resident #5's bed.…

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 received the necessary care and services, consistent with professional standards of practice to prevent and promote healing of pressure ulcers in 1 resident (Resident #45) of 3 residents reviewed for pressure ulcers, resulting in the development of an unstageable pressure injury to the right heel, and the potential for additional new, worsening and/or reoccurrence of pressure injuries due to the resident's bed being too short and his feet pressing against the footboard for extended periods. Findings include: Resident #45 Review of an admission Record revealed Resident #45 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: unstageable pressure ulcer left heel. Review of Resident #45's most recent Braden Scale for Predicting Pressure Sore Risk dated 12/5/24 indicated that the resident was 14, at a moderate risk. During an observation and interview on 05/05/25 at 09:56 AM Resident #45…

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 implement care planned interventions for bed mobility to to prevent a fall in 1 of 4 residents (Resident #45) reviewed for falls, resulting in a fall with injury. Findings include: Resident #45 Review of an admission Record revealed Resident #45 was a male, with pertinent diagnoses which included: muscle weakness and repeated falls. Review of an Incident Report for Resident #45 dated 4/26/25 at 8:20 PM revealed, .Nursing Description: CNA (certified nurse aide) reported to RN (registered nurse) that resident was on the floor. RN entered resident room to find (Resident #45) on the floor next to his bed, his position was partially underneath bed #1, his head and shoulders were under the head of the bed side and his BLE's (bilateral (both) lower extremities) were positioned diagonally with bilateral feet on the foot of bed side between bed #1 and bed #2. Resident was found face down .RN then rolled resident over on his back and found resident to have…

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 ensure post dialysis assessment and monitoring for 1 (Resident #42) of 1 resident reviewed for dialysis care, resulting in the potential for the resident to not meet his highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an admission Record revealed Resident #42 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: chronic kidney disease and dependence on renal dialysis. Review of Resident #42's Care Plan revealed, The resident needs dialysis: Hemodialysis r/t (related to) ESRD (end stage renal disease) and Renal Osteodystrophy (weakening of bones). Date Initiated: 11/21/2024. Revision on: 04/17/2025. Interventions: Do not draw blood or take B/P in arm with graft. Date Initiated: 11/21/2024 . Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of infection to access site: Redness, Swelling, warmth or drainage. Date Initiated: 11/21/2024.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a prompt response to the registered pharmacist's monthly medication regimen review (MRR) recommendations for 3 (Resident #40, #15, #35) of 5 residents reviewed for unnecessary medications, resulting in the registered pharmacist's recommendations not being addressed in a timely fashion and the potential for negative medication side effects as a result of unaddressed recommendations. Findings include: Resident #40 Review of an admission Record revealed Resident #40 was a female, with pertinent diagnoses which included: dysphagia, oral phase (swallowing difficulty) and unspecified dementia, unspecified severity, with other behavioral disturbance. Review of a Minimum Data Set (MDS) assessment for Resident #40, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 2, out of a total possible score of 15, which indicated Resident #40 was severely cognitively impaired. Nystatin-Triamcinolone cream Review of 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 to ensure residents were screened for eligibility to receive pneumococcal vaccinations and receive the vaccination if eligible in 1 of 5 residents (Resident #60) reviewed for vaccinations, resulting in the potential of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia. Findings include: Review of the policy/procedure Vaccination - Pneumococcal Vaccine, dated 11/22/24, revealed .Residents will be offered a pneumococcal vaccine unless it is medically contraindicated, or the resident is up to date on their pneumococcal vaccinations .The type of pneumococcal vaccine .offered will depend upon the recipient's age and susceptibility to pneumonia and previous pneumococcal vaccinations given in accordance with current CDC (Centers for Disease Control and Prevention) guidelines and recommendations .A pneumococcal vaccination is recommended for all adults 50 years and older and based on the following recommendations .For adults 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.

This citation pertains to Intake: MI00150382 Based on observation, interview, and record review, the facility failed to provide an environment that promoted resident dignity in 1 (Resident #108) of 10 residents reviewed for dignity, resulting in the potential of feelings of frustration, embarrassment, and loss of self-worth, and a negative psychosocial outcome for the residents impacting their quality of life. Findings include: According to Your Rights and Protections as a Nursing Home Resident revealed, .At a minimum, Federal law specifies that nursing homes must protect and promote the following rights of each resident. You have the right to .Be Treated with Respect: You have the right to be treated with dignity and respect, as well as make your own schedule and participate in the activities you choose . https://downloads.cms.gov/medicare/your_resident_rights_and_protections_section.pdf Resident #108: Review of an admission Record revealed Resident #108 was a female with pertinent diagnoses which included right artificial hip joint, joint replacement surgery, muscle weakness,…

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 resolve resident concerns for 1 (Resident #107) of 1 sampled resident reviewed for resolution of concerns resulting in feelings of frustration and a potential decline in psychosocial and mental well-being. Findings include: Review of admission Record revealed Resident #107 was originally admitted to the facility on [DATE] with pertinent diagnoses which included depression. Review of Resident #107's Care Conference Note dated 1/16/25 revealed, .Conference Summary: . Blood draws no results given to resident, UA (urinalysis) not having results. Discussed outside medication being delivered to the facility. Unit Manager will research the appropriateness of these medication (sic). Ears plugged up. This problem still exists. Unit Manager to resolve. Resident stated her spasm has been awful from the UTI (urinary tract infection). Discussed flushing of catheter. Tooth issues. (Dental Provider) does extractions. Dr to review medication and medical diagnosis.…

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 MI00150229. Based on interview and record review, the facility failed to implement its policy and procedures on abuse and neglect by staff not reporting an allegation of abuse immediately to the abuse coordinator for 1 residents (Resident #105) of 5 residents reviewed, resulting in the potential for ongoing mistreatment, abuse or neglect. Findings include: Resident #104 Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 12/18/24 revealed Resident #104 was originally admitted to the facility on [DATE] with pertinent diagnoses included psychotic disorder. Resident #105 Review of admission Record revealed Resident #105 was originally admitted to the facility on [DATE] with pertinent diagnoses which included adult failure to thrive. Review of an Incident Report dated 1/11/25 revealed, Incident Summary: (Resident #104) was seen touching (Resident #105) breast on top of her gown in her bed. (Resident #105) was calling out for help several times,…

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 MI00150232, MI00150229, MI00150376. Based on observation, interview, and record review, the facility failed to thoroughly investigate allegations of abuse and neglect in 4 (Resident #103, #104, #105, and #107 ) of 5 residents reviewed for abuse and neglect resulting in incomplete abuse investigations and the potential for future mistreatment and/or abuse. Findings include: Resident #103 Review of admission Record revealed Resident #103 was originally admitted to the facility on [DATE] with pertinent diagnoses which included history of falling. Review of anIncident Report submitted by Nursing Home Administrator (NHA) A dated 1/12/25 revealed, . Details: (Resident #103) was seen in the bathroom laying on his back with an abrasion on his forehead, he was able to tell staff that he didn't hit his head, but he had a change in condition and staff notified on-call physician and an order was to send to local hospital. (Resident #103) returned with a hemorrhage. A full investigation will…

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 prevent the further development of pressure ulcers for 1 (Resident #109) of 1 sampled resident reviewed for pressure ulcers, resulting in the development of 1 facility acquired pressure ulcer. Findings include: Resident #109: Review of an admission Record revealed Resident #109 was a male with pertinent diagnoses which included mild cognitive impairment, Alzheimer's disease, weakness, restlessness and agitation, dementia, and pain. Review of current Care Plan for Resident #109, revised on 01/22/2025, revealed the focus, .Actual Pressure Injury Formation Related to decreased mobility, friction, prediabetes, overall decline with hospice care in place. Left heel St (stage) III, resolved 1/21/25 per wound care consult. Risk continues for maintaining resolved wound status secondary to progressing comorbidities, friction and shearing r/t resident rubbing heels on mattress with removal of foam heel boots. Debility and generalized weakness with decreased physical mobility and overall decline with hospice care in place…

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 # MI00147580. Based on interview, and record review, the facility failed to ensure it was administered in a manner that maintains the safety and care of residents, so residents may reach their highest practicable physical, mental, and psychosocial well-being, for all 92 residents who reside at the facility, resulting in quality care not being provided to residents, insufficient management of facility staffing, and a lack of follow-up in regard to concerns voiced by staff. For additional information see citations F600 and F725. Findings include: Review of the policy/procedure Staffing, dated 11/3/23, revealed .The facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for the residents in accordance with the residents plan of care .Licensed nurses and nursing assistants are available 24 hours a day, 7 days a week to provide direct resident care services .Staffing numbers and the skill requirements of direct care staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake # MI00147580, MI00147814, MI00147822, & MI00147838. Based on interview, and record review, the facility failed to report allegations of abuse and neglect to the State Agency in a timely manner in 11 of 15 residents (Resident #103, #104, #113, #120, #124, #125, #126, #105, #106, #108, & #109) reviewed for abuse and neglect, resulting in the potential for additional allegations of abuse and neglect to go unreported and delayed investigation. Findings include: In an interview on 1/6/25 at 3:48 PM, Licensed Practical Nurse (LPN) QQ reported staffing was a major issue in September/October 2024 after the change in facility ownership. LPN QQ reported at times they were the only nurse on the 300/400 Hall, or there was no oncoming nurse at the end of their shift. LPN QQ reported on 10/18/24 the Agency nurse scheduled to relieve them at 6:30 PM on the 300 Hall did not show up for the shift. LPN QQ reported that evening there was only one nurse on the 400 Hall, and no nurse on the 300 Hall.…

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 # MI00146268, MI00147061, MI00147580, MI00147744, MI00147821, MI00148620, & MI00148986. Based on interview, and record review, the facility failed to provide sufficient staff to meet resident needs in 9 of 11 residents (Resident #101, #107, #104, #103, #113, #120, #124, #125, & #126) reviewed for sufficient staffing, resulting in missed showers/baths, a lack of supervision of residents at risk for falls and elopement, long call light wait times, rushed staff, and missed medications. For additional information see citations F600, F677, F689, and F760. Findings include: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 1589-1592). Elsevier Health Sciences. Kindle Edition.Time management, therapeutic communication, patient education, and compassionate implementation of bedside skills are just a few of the essential skills you need. It is important for your patients to leave the health 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.

This citation pertains to Intake # MI00147061. Based on observation, interview, and record review, the facility failed to ensure effective hand hygiene and glove use during incontinence care in 1 of 4 residents (Resident #101) reviewed for infection control during incontinence care, resulting in the potential for cross-contamination and the development and spread of infection and disease. Findings include: Resident #101 Review of an admission Record revealed Resident #101 was a female, with pertinent diagnoses which included bladder dysfunction, depression, anxiety, and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 12/13/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated she was cognitively intact. In an observation and interview on 1/2/25 at 1:47 PM, Resident #101 was noted in bed in her room. Resident #101 reported she had an indwelling catheter and has had issues with frequent Urinary Tract Infections (UTIs) while at the facility. Observed Certified…

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 MI00148620 Based on observation, interview and record review, the facility failed to provide an environment that promoted a dignified dining experience for 1 (Resident #115) of 3 residents reviewed for dignity and respect, resulting in the potential for feelings of frustration, depression, loss of self-worth, and an overall deterioration of psychological well-being. Findings include: Resident #115 Review of an admission Record revealed Resident #115 was a female, with pertinent diagnoses which included: Alzheimer's disease (a form of dementia) with late onset, and major depressive disorder. Review of a Minimum Data Set (MDS) assessment for Resident #115, with a reference date of 11/15/24 revealed the Staff Assessment for Mental Status Cognitive Skills for Daily Decision Making indicated Resident #115 was Severely impaired. Further review of said MDS revealed Resident #115 required substantial/maximal assistance for eating. Review of Resident #115's current Care Plan revealed the focus of, (Resident #115) has an ADL (activities of daily living) Self…

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 # MI00149269, MI00149295, & MI00149428. Based on interview, and record review, the facility failed to prevent the misappropriation of resident medications in 3 of 15 residents (Resident #116, #118, & #119) reviewed for misappropriation of property, resulting in the unauthorized use of a resident's personal property, and the potential for missed medications and uncontrolled anxiety. Findings include: Review of the policy/procedure Controlled Medication Guidelines, dated 3/20/24, revealed .When the licensed nurse removes the controlled medication from the package, they will document the quantity removed and the quantity left on the Controlled Drug Receipt/Record/Disposition Form .After administration of the controlled medication the licensed nurse will document the administration on the medication administration record . Resident #116 Review of an admission Record revealed Resident #116 was a male, with pertinent diagnoses which included lung cancer, heart failure, and obstructive…

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/or implement a person centered, comprehensive care plans for 2 residents (Resident #120 and #200) of 4 residents reviewed for care planning, resulting in Resident #120 not receiving adequate supervision to prevent resident to resident abuse, and the potential for residents to not meet their highest practicable level of physical and psychosocial wellbeing. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.16, Chapter 4: Care Area Assessment (CAA) Process and Care Planning, revealed .the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident 's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent 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 This citation pertains to Intake # MI00147061, MI00149269, MI00149295, & MI00149428. Based on interview, and record review, the facility failed to follow professional standards of practice for medication administration in 3 of 14 residents (Resident #101, #116, & #118) reviewed for medication administration, resulting in missed thyroid medication, inaccurate documentation of medication administration, and medications administered without a valid physician order. Findings include: The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 20717-20719). Elsevier Health Sciences. Kindle Edition. Resident #101 Review of an admission Record revealed Resident #101 was a female, with pertinent…

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 # MI00147061, MI00147744, & MI00148986. Based on observation, interview, and record review, the facility failed to ensure baths/showers and hygiene care were provided per resident preference and plan of care in 3 of 5 residents (Resident #101, #104, & #113) reviewed for Activities of Daily Living (ADL) care, resulting in the potential for dissatisfaction with care, hygiene concerns, skin irritation, and low 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 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 and brushing and flossing the teeth also promote comfort and relaxation, foster a positive self-image, promote healthy…

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 # MI00147580. Based on interview, and record review, the facility failed to assess the resident and implement immediate interventions to ensure safety after an attempted elopement in 1 of 6 residents (Resident #103) reviewed for safety/supervision, resulting in the potential for additional elopement attempts and serious injury. Findings include: Review of the policy/procedure Elopement, dated 8/2022, revealed .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions…

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 # MI00147061 & MI00147821. Based on observation, interview, and record review, the facility failed to provide appropriate incontinence and catheter care in 2 of 4 residents (Resident #101 & #107) reviewed for incontinence/catheter care, resulting in cross-contamination, missed episodes of nephrostomy (a tube that drains urine from the kidney) care, and the potential for catheter related complications including the development of urinary tract infections. Findings include: Review of the policy/procedure Incontinence Care, dated 4/22/24, revealed .POLICY OVERVIEW: To provide guidelines for cleansing the perineum and buttocks after an incontinence episode or with daily care .GUIDELINES .Perform hand hygiene and don gloves (and other PPE (Personal Protective Equipment) as needed) .Position the resident on their back with their knees flexed and feet flat on the bed .If the resident is unable to maintain this position, assist to a side lying position .If feces are present, remove with toilet paper or disposable wipe by wiping from the front of the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain a complete and accurate medical record related to Advance Directives / Code Status for 1 (Resident #111) of 1 sampled resident reviewed for Advance Directives / Code Status, resulting in an incongruent reflection of the resident records and the potential for the resident's care wishes not being honored as desired. Findings include: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing.High-quality documentation is necessary to enhance efficient, individualized patient care. Quality documentation has five important characteristics: it is factual, accurate, complete, current, and organized . Accessed from: Kindle Locations 24106-24108). Elsevier Health Sciences. Kindle Edition. Resident #111 Review of an admission Record revealed Resident #111 was a male. Review of Resident #111's DO-NOT-RESUSCITATE ORDER signed by Resident #111's Responsible Party (Family Member FM TT), 2 physicians…

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 # MI00147744 & MI00148620. Based on observation, interview, and record review, the facility failed to ensure a sanitary and comfortable environment in 2 of 5 residents (Resident #103 & #104) reviewed for a clean/homelike environment, resulting in noxious odors and the potential for decreased satisfaction with the living environment. Findings include: Resident #103 Review of an admission Record revealed Resident #103 was a male, with pertinent diagnoses which included stroke, muscle weakness, anxiety, and depression. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 10/16/24, revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated moderate cognitive impairment. In an observation on 1/6/25 at 3:09 PM, noted a strong urine smell in Resident #103's bathroom. Observed that Resident #103's toilet seat was up, and the toilet bowl was unflushed with yellow urine and toilet paper visible in the bowl. Noted a splattered brown substance on the back surface 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.

Based on observation, interview, and record review, the facility failed to: 1.) properly label, date, and discard opened food products; 2.) securely cover opened food products before storage; 3.) clean food and non-food contact surfaces; 4.) thoroughly clean pans and cups before storage; and 5.) remove and discard rotten food items from among fresh items. These conditions resulted in an increased risk of food borne illness that affected all residents who consume food from the kitchen. Findings include: On 3/19/24 beginning at 9:16 AM, an initial tour of the kitchen/food service was conducted with Assistant Food Service Director (AFSD) EE and Food Service Director (FSD) FF. The following observations/interviews occurred during this initial tour: At 9:20 AM in the reach-in cooler at the end of the cook's preparation area, noted 4 opened containers of vanilla nutrition supplement drink (name omitted). Two (2) of the opened containers were labeled with an opened date of 3/9/24 and a discard date of 3/12/24 and 2 of the containers were opened but not labeled. There was an opened, half…

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 faciled to 1) discard expired medication and COVID-19 antigen test kits, 2) secure resident medications, and 3) separate medications stored in medication carts by route of administration, resulting in unsecured medication and the potential for cross contamination, decreased efficacy of medications, and the exacerbation of resident medical conditions. Findings include: In an observation and interview on [DATE] at 8:40 AM on the rehab unit, a fluticasone/salmeterol (Advair, an inhaler used to prevent symptoms of asthma and chronic obstructive pulmonary disorder) inhaler dated opened on [DATE] was found in the medication cart. Licensed Practical Nurse (LPN) P reported this inhaler was expired and should have been discarded 30 days after it was opened. Review of facility pharmacy tool Storage and Stability of Selected Medications on [DATE] at 8:42 AM revealed fluticasone/salmeterol (Advair) inhalers expire 30 days after being opened. In an observation…

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 COVID-19 immunizations were offered to 6 of 6 residents (Resident #58, #46, #32, #52, #10 and #38) reviewed for COVID-19 immunizations, resulting in an increased risk for infection, and the potential spread of COVID-19 infection to other residents, staff, and visitors. Findings include: Resident #58 Review of an admission Record revealed Resident #58 was originally admitted to the facility on [DATE] with pertinent diagnoses which included personal history of Covid-19. Review of Resident #58's Immunization Record revealed that Resident #58 had last received a Covid-19 vaccination on 8/9/22. Resident #46 Review of an admission Record revealed Resident #46 was originally admitted to the facility on [DATE] with pertinent diagnoses which included personal history of Covid-19. Review of Resident #46's Immunization Record revealed that Resident #46 had last received a Covid-19 vaccination on 2/2/21. Resident #32 Review of an admission Record 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 interview and record review, the facility failed to ensure residents are treated with dignity and respond to resident call lights timely in 3 of 3 residents (Residents # 23, #26 and #38) reviewed for dignity, resulting in episodes of incontinence and feelings of frustration and loss of self-worth with the potential for overall deterioration of psychological well-being. Findings include: Resident #23 Review of an admission Record revealed Resident #23 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #23, with a reference date of 2/21/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #23 was cognitively intact. Review of Resident #23's Care Plan revealed, (Resident #23) has an ADL (activities of daily living) self care deficit. Date initiated: 5/4/22. Interventions: .Toileting: incontinent change brief as needed. Date initiated: 5/6/22 . During…

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 call lights were in reach for 1 of 19 residents (Resident #5) reviewed for accommodation of needs, resulting in the inability to call for staff assistance and the potential for unmet care needs. Findings include: Review of an admission Record revealed Resident #5 was originally admitted to the facility on [DATE] with pertinent diagnoses which included weakness and need for assistance with personal care. Review of Resident #5's Care Plan revealed, (Resident #5) is at risk for falls r/t medication side effects, behavior disturbances, debility (physical weakness), poor PO (by mouth) intake, and dementia. Date initiated: 11/9/2016 . Interventions: . Keep call light within reach. Date initiated: 3/15/2022 During an observation on 3/19/24 at 9:51 AM, Resident #5 was observed lying in her bed. Resident #5's touch pad call light was noted lying underneath Resident #5's bed and out of her reach. During an observation on 3/20/24 at 12:12 PM,…

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 accurately complete a Minimum Data Set (MDS) assessment for 1 (Resident #28) of 19 sampled residents reviewed for MDS accuracy, resulting in an inaccurate reflection of the resident's health status. Findings include: Review of an admission Record revealed Resident #28 was a female, with pertinent diagnoses which included: unspecified dementia, unspecified severity, without behavioral. Review of Resident #28's Minimum Data Set (MDS) assessment submission history revealed a Comprehensive Assessment was completed with a reference date of 11/22/23 and a Quarterly Assessment was completed with a reference date of 2/21/24 for Resident #28. Review of Resident #28's MDS Quarterly Assessment with a reference date of 2/21/24 revealed, .Section J - Health Conditions .J1800. Any Falls Since Admission/Entry or Reentry or Prior Assessment .whichever is more recent Has the resident had any falls admission/entry or reentry or the prior assessment . The response was coded as 0, No (to indicate that resident had not fallen since the last…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement consistent pressure ulcer interventions, monitoring, and treatments consistent with physician orders and professional standards of care for 1 of 3 residents (Resident #32) reviewed for pressure injuries, resulting in the potential for worsening of facility acquired pressure ulcers and further skin breakdown. Findings include: Resident #32 Review of an admission Record revealed Resident #32 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #32, with a reference date of 1/16/24 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #13 was cognitively intact. Review of Resident #32's Braden (assessment tool used to determine level of risk for developing pressure wounds) dated 1/2/24 indicated 13, at moderate risk. During an observation and interview on 03/19/24 at 12:29 PM Resident #32 was sitting in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that liquids were served according to Physician's Orders for 1 resident (Resident #35), of 3 residents reviewed for nutrition services, resulting in Resident #35 being served un-thickened (thin) liquid and liquid with a straw and the potential for Resident #35 to aspirate (accidentally breathe liquid into the lungs potentially resulting in aspiration pneumonia). Findings include: Dysphagia refers to difficulty swallowing. The causes and complications of dysphagia vary. Complications include aspiration pneumonia, dehydration, decreased nutritional status, and weight loss. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing- E-Book (Kindle Locations 64741-64743). Elsevier Health Sciences. Kindle Edition. Review of an admission Record revealed Resident #35 admitted to the facility on [DATE] with pertinent diagnoses which included pneumonia, chronic obstructive pulmonary disorder, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were screened for eligibility to receive pneumococcal vaccinations and receive vaccination if eligible for 2 (Resident #32 and #10) of 5 residents reviewed for vaccinations, resulting in the potential of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia. Findings include: Resident #32 Review of an admission Record revealed Resident #32 was originally admitted to the facility on [DATE] with pertinent diagnoses which included acute respiratory failure with hypoxia (low levels of oxygen in body tissues). Review of Resident # 32's Immunization Record revealed that Resident #32's had last received a Pneumovax vaccination on 2/4/2014. This was documented as a historical vaccination which indicated that Resident #32 did not receive the vaccination at the facility. During an interview on 3/20/24 at 1:30 PM, Director of Nursing/ Infection Preventionist (DON-IP) B reported that Resident #32 had last 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 This citation pertains to Intake # MI00141034. Based on interview, and record review, the facility failed to honor an advance directive and the resident's right to refuse treatment in 1 of 5 residents (Resident #108) reviewed for code status/Cardiopulmonary Resuscitation (CPR), resulting in CPR being performed on a resident with a status of Do Not Resuscitate (DNR). Findings include: Review of an admission Record revealed Resident #108 was a male, with pertinent diagnoses which included stroke, respiratory failure, atrial fibrillation (an irregular heart rate that results in poor blood flow), anemia, and high blood pressure. Review of a Minimum Data Set (MDS) assessment for Resident #108, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated moderate cognitive impairment. Review of a DO-NOT-RESUSCITATE ORDER form for Resident #108, dated [DATE], revealed .I have discussed my health status with my physician named…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake numbers MI00137970 and MI00138542. Based on observation, interview, and record review, the facility failed to implement timely infection control techniques including: 1. Application of antiparasitic cream for all unit residents when several residents became symptomatic 2. Deep cleaning of common areas of the unit because infected residents were unable to abide by contact precautions 3. Effective use of Personal Protective Equipment during a scabies outbreak in 4 of 4 Residents (Resident #102, Resident #106, Resident #103 and Resident #101) reviewed for infection control, resulting in an outbreak, and spread of scabies for all four residents and the potential spread to all 21 residents within the memory care unit. Findings include: Review of Centers for Disease Control and Prevention (CDC), Resources for Health Professionals, Parasites and Scabies, (cdc.gov), 2023, the section labeled Control revealed A scabies outbreak suggests that transmission has been occurring within 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. Serve resident meals in a timely manner and per facility scheduled times and 2. Serve 2 of 2 residents (Resident #7 and #30) their meal timley, resulting in delayed meal service and the potential for resident dissatisfaction with the dining experience. Findings include: Review of a document submitted to State Agency (SA) titled Lodge Meal Times revealed, Breakfast 6:30am - 8:45am Lunch 11:30am-12:30pm Dinner 5:00-6:00pm During an observation/interview on 2/13/23 at 10:24 AM on the 300 Hall, noted breakfast meal trays were being served to the residents who were dining in their rooms. Certified Nurse Aide (CNA) X reported breakfast should be served beginning at 6:30 AM but it was late because there had been a lot of resident call lights going off that morning. CNA X reported that room tray meal delivery was a process even without having to answer multiple call lights because the CNAs were responsible for retrieving resident beverages,…

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 #MI00131204. Based on observation, interview, and record review the facility failed to: 1. Properly store raw animal product to minimize contamination; 2. Clean food and non-food contact surfaces to sight and touch; 3. Properly date mark potentially hazardous foods; and 4. Ensure proper installation of an air gap on an ice machine. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 85 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the facility, starting at 9:08 AM on 2/13/23, observation of the main walk-in cooler found a box of raw salmon stored on the second to top shelf over ready to eat slices of ham on a sheet tray. When asked if this is where raw animal product gets stored in the walk-in cooler, Food Service Director (FSD) KK removed the raw salmon from the second to top shelf and made room on the bottom shelf of the wire rack. Further review of an expediting cart, in the walk-in cooler, found raw ground beef, thawing on a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00133647. Based on observation, interview and record review the facility failed to provide food at a palatable temperature for 2 of 16 residents (Resident #79 and #30) reviewed for food palatability, resulting in the potential for decreased food consumption and nutritional decline for all residents who consume food orally. Findings include: During an interview with Food Service Director (FSD) KK at 9:15 AM on 2/13/23, it was found that lunch service starts at 11:15 AM. When asked how meal service has been going, FSD KK stated that they are working on changing the dining experience to focus on a more resident centered restaurant style dining. FSD KK went on to state that himself and Assistant Food Service Director (AFSD) II are newer to the roles and have been working on improving the dining experience. Previously the facility had multiple serving sites, and now that we are serving everything out of the main kitchen, we are working on fine tuning that process. The facility has…

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 Intakes: MI00133647 and MI00131204 Based on observation and interview, the facility failed to effectively clean and maintain the physical plant resulting in the increased likelihood for cross-contamination, bacterial harborage, and possible decrease in the satisfaction of environment for residents of the facility. Findings include: An initial environmental tour of the facility revealed the following observations: During an observation on 2/13/23 at 9:32 AM in room [ROOM NUMBER], noted several large scrapes/gouges in the wall at the head of the resident bed such that paint was removed and drywall was exposed. During an observation on 2/13/23 at 9:48 AM in room [ROOM NUMBER], noted several large scrapes/gouges in the wall at the head of the resident bed such that paint was removed and drywall was exposed. There was a dried red stain and piece of debris on the privacy curtain between the two resident beds. During an observation on 02/13/23 at 10:18 AM in room [ROOM NUMBER], noted several…

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 timely care and services to promote dignity in 1 of 5 residents (Resident #30) reviewed for dignity/respect, resulting in long call light wait times, episodes of incontinence and feelings of embarrassment, and the potential for feelings of diminished self-worth, sadness, and frustration. Findings include: Review of a facility policy with a revision date of 10/2022 revealed: POLICY: Promoting and Maintaining Resident Dignity Policy It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident ' s quality of life by recognizing each resident ' s individuality . Resident #30 Review of an admission Record revealed Resident #30, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: type 2 diabetes. Review of a Minimum Data Set (MDS)…

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 and assistance were provided per resident preference for 1 (Resident #1) of 28 sampled residents reviewed for resident preferences, resulting in the potential for dissatisfaction with care and an overall decline in sense of physical, mental, and psychosocial well-being. Findings include: Review of a facility Policy dated 5/2022 revealed: Activities of Daily Living Policy: .The facility will, based on the resident ' s comprehensive assessment and consistent with the resident ' s needs and choices, ensure a resident ' s abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: .1. Bathing, dressing, grooming and oral care; .2. Transfer and ambulation; .3. Toileting; .4. Eating to include meals and snacks; and .5. Using speech, language or other functional communication systems Policy Explanation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were free from physical restraints imposed for the purpose of convenience in 1 of 1 resident (Resident #81) reviewed for restraints, resulting in the restriction of mobility and a potential for decline in physical functioning, psychosocial wellbeing, and the development of skin breakdown. Findings include: A review of a Face Sheet revealed Resident #81 was admitted to the facility on [DATE] with pertinent diagnoses that included: unspecified dementia, major depressive disorder, and urge incontinence. A review of Resident #81's Minimum data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 99 which indicated Resident #81 was unable to complete the assessment due to severe cognitive impairment. Resident #81 scored a 1 (supervision) for walking in her room and in corridors. Resident #81 scored 0, (steady at all times) for moving from seated to standing position, walking, turning…

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 a resident or resident representative was notified in writing of a transfer to an acute care hospital in 1 of 1 resident (Resident #73) reviewed for transfer notices. Findings include: Review of a Progress Note dated 2/9/2023 at 10:37 a.m. revealed Resident #73 had Noted SOB (shortness of breath) this AM with oxygen saturation at room air at 60-64% with oxygen applied by mask with oxygen went up to 88%-90% with shallow breathing at 25 per minute. Noted crackles and wet cough. NP (Nurse Practitioner) notified , and POA (Power of Attorney) notified and wanted resident to be sent to hospital for evaluation and tx. Ambulance pick up resident at 9:30am . In an interview on 02/15/23 at 02:00 PM, License Practical Nurse (LPN) N reported that the family was called and they said to send her out. LPN N stated, I only called the family about going to the hospital, but did not notify in writing. I just forgot. Nurses are supposed to do it.

Based on interview and record review, the facility failed to ensure a resident or resident representative was notified in writing of a transfer to an acute care hospital in 1 of 1 resident (Resident #73) reviewed for transfer notices. Findings include: Review of a Progress Note dated 2/9/2023 at 10:37 a.m. revealed Resident #73 had Noted SOB (shortness of breath) this AM with oxygen saturation at room air at 60-64% with oxygen applied by mask with oxygen went up to 88%-90% with shallow breathing at 25 per minute. Noted crackles and wet cough. NP (Nurse Practitioner) notified , and POA (Power of Attorney) notified and wanted resident to be sent to hospital for evaluation and tx. Ambulance pick up resident at 9:30am . In an interview on 02/15/23 at 02:00 PM, License Practical Nurse (LPN) N stated, I only called the family about (Resident #73) going to the hospital. I did not do a bed hold. Nurses are supposed to do it.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake #MI00134395 Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 24 residents (Resident #79 ) reviewed for care planning, resulting in unmet incontinence care needs contributing to the worsening of a pressure ulcer for Resident #79. Findings include: Resident #79 Review of an admission Record revealed Resident #79 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Pressure ulcer of sacral (tail bone) region, Stage 3. Review of a Minimum Data Set (MDS) assessment for Resident #79, with a reference date of 12/15/22 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #79 was cognitively intact. Review of the Functional Status revealed that Resident #79 was completely dependent on 2 staff members for toileting. Review of Resident #79's Care Plan revealed, .FOCUS: Foley Catheter…

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 services according to professional standards of practice for 1 (Resident #7) of 24 residents reviewed for provision of professional services, when licensed nursing staff failed to follow the physician orders for nutritional supplements, resulting in the potential for malnutrition. Findings include: Resident #7 Review of an admission Record revealed Resident #7 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: anorexia (eating disorder). Review of Resident #7's Care Plan revealed, .at increased nutritional risk r/t (related to) dx (diagnosis) dementia .anorexia, hx/o (history of) poor PO intake .is now on hospice services. Date Initiated: 10/29/2016. Revision on: 08/01/2022. INTERVENTIONS: Med Pass 2.0 (protein and calorie supplement) 120 cc (4 ounce) four times a day .Diet: Regular .Encourage fluids throughout the day .Invite (Resident #7) to activities that promote additional intake .Offer…

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 #MI00131204. Based on observation, interview, and record review, the facility failed to maintatin professional standards of care and provide adequate incontinence care in 1 of 3 residents (Resident #79) reviewed for bowel and bladder incontinence, resulting in an increased risk for UTI (urinary tract infection) and the potential for skin breakdown. Findings include: Review of an admission Record revealed Resident #79 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Pressure ulcer of sacral (tail bone) region, Stage 3. Review of a Minimum Data Set (MDS) assessment for Resident #79, with a reference date of 12/15/22 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #79 was cognitively intact. Review of the Functional Status revealed that Resident #79 was completely dependent on 2 staff members for toileting. Review of Resident #79's Care Plan revealed, .FOCUS:…

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 timely and consistent nutrition/hydration and weight status follow-up of a resident deemed at Nutrition Risk in 1 (Resident #1) of 3 residents reviewed for nutritional care and services, resulting in inadequate monitoring and reassessment of a resident following a documented significant weight loss. Findings include: Review of a Face Sheet revealed Resident #1 was a female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: anemia and dysphagia (swallowing difficulty). Review of Resident #1's current Care Plan revealed a focus of (Resident #1) is at increased nutritional risk r/t (related to) diagnoses: fall w fracture/rt (right) hip incision, anxiety/depression, diverticulitis w/ (with) colostomy, GERD (gastro-esophageal reflux disease) with pertinent interventions which included .Monitor/document/report to MD (medical doctor) PRN (as needed) s/sx (signs/symptoms) of dysphagia .Monitor/report/report to MD…

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

Based on observation and interview the facility failed to discard expired tube feeding supplements. These conditions resulted in an increased risk for contaminated foods and an increased risk of food borne illness for individuals who are prescribed these specific supplements. Findings include: During a tour of the facilities central supply storage room, at 3:00 PM on 2/13/23, it was observed that the following tube feeding supplements were found stored passed their use by date: three full boxes of Glucerna with a use by date of 1NOV2021, one box of Glucerna with a use by date of 1MAY2022, and two boxes of Osmolite with a use by date of 1FEB2023. At this time Plant Operations Manager J removed the product from Central Supply storage. During an interview with ADON (Assistant Director of Nursing) C, at 3:10 PM on 2/13/23, found that no residents are currently on any of the tube feeding supplements in question.