Optalis Health & Rehabilitation at Kent-Crossing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2731057.Based on observation, interview, and record review, the facility failed to maintain a clean and comfortable environment for 3 residents (R8, R108, and R12) of 4 residents reviewed for a sale/clean/comfortable homelike environment, resulting in unclean/unkempt resident rooms and the potential for cross contamination, bacterial harborage, and the potential for a reasonable person to experience feelings of embarrassment, shame, and/or loss of self -esteem. Findings include:R8According to R8's Minimum Data Set (MDS) dated [DATE], indicated R8 was cognitively intact with a BIMS of 13/15. Section GG-Functional Status indicated the resident was dependent on staff for transfers and did not stand or walk during this time of assessment. During an observation on 3/17/26 at 11:25 AM, there was a dresser behind R8's bed that had dust and debris under a bottle of stoma powder lying on its side, a jar of chicken bouillon, various wound and ostomy supplies, and a pair of scissors 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 incident is linked to intake 2612225.Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff for 1 resident (R14) of 3 reviewed for abuse, resulting in facility staff verbally assaulting R14 resulting in feelings of frustration, mental anguish, and a loss of autonomy (freedom from external control or influence). Findings include:According to the Minimum Data Set (MDS) dated [DATE], R14 was cognitively intact as evidence of a score of 15/15 on her Brief Interview Mental Score (BIMS) with a preferred language of Kinyardwanda and needed an interpreter to communicate with doctor or health care staff. R14 was independent with her ADLs (activities of daily living) and had diagnoses that included anemia, diabetes, PTSD (post-traumatic stress disorder), and cirrhosis of liver. Review of R14's Care Plan dated 11/25/25, Communication concerns, Cognitive deficits, Language barrier.speaks Kinyarwanda. The goal for R14 was to continue to communicate…

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 #2608884Based on interview and record review, the facility failed to safeguard credit card numbers for 1 resident (Resident #127) of 3 residents reviewed for abuse, resulting in a staff member making an unauthorized purchase using a resident's credit card.Findings include:Review of an admission Record revealed Resident #127 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: frontotemporal neurocognitive disorder (early onset decline in cognitive function). Review of a Facility Reported Incident (FRI) dated 8/13/25 at 11:08 AM regarding misappropriation for Resident #127 revealed, On 8.13.25 at approximately 10:30am, business office manager (BOM O) was on the phone with the resident's brother (Family Member (FM) SS) who handles the resident's financial transactions for billing. He stated he had had to block his old card and that was why a patient bill amount had been rejected and so he needed to establish a new card. (BOM O) asked him how…

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 not prescribed PRN (as needed) psychotropic medications for greater than 14 days for 1 resident (Resident #18) of 5 residents reviewed for unnecessary medications, resulting in lack of monitoring and medical necessity documented to extend use of PRN anti-anxiety medication.Findings include: Resident #18Review of an admission Record revealed Resident #18 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia with psychotic disturbance. (anxiety was not noted in diagnoses)During an observation on 03/18/2026 at 4:34 PM Resident #18 was independently walking in the hallway near the nurse's station.Review of Resident #18's IDT (Interdisciplinary Team) Progress Note dated 2/8/26 revealed, .review of unwitnessed fall.Resident has diagnosis of dementia and prefers to walk independently on the unit, with occasions of restlessness and is receiving hospice services. Intervention for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes 2612225.Based on interview and record review the facility failed to ensure facility staff implemented the abuse policy in 1 of 1 residents (R108) reviewed for abuse, resulting in a delay in reporting of staff to resident verbal abuse to the state agency. Findings include: R108According to the Minimum Data Set (MDS) dated [DATE], R14 was cognitively intact as evidence of a score of 15/15 on her Brief Interview Mental Score (BIMS) with a preferred language of Kinyardwanda and needed an interpreter to communicate with doctor or health care staff. R14 was independent with her ADLs (activities of daily living) and had diagnoses that included anemia, diabetes, PTSD (post-traumatic stress disorder), and cirrhosis of liver.Review of R14's Care Plan dated 11/25/25, Communication concerns, Cognitive deficits, Language barrier.speaks Kinyarwanda. The goal for R14 was to continue to communicate at present level with optimal understanding. Interventions to meet the resident's goals included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete a significant change Minimum Data Set (MDS) assessment for a resident admitted to hospice, in 1 resident (Resident #18) of 23 residents sampled for MDS accuracy, resulting in the potential for unassessed physical, mental, emotional, and psychosocial needs. Findings include:Review of an admission Record revealed Resident #18 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia.Review of Resident #18's Hospice Election Contract revealed, .services to begin on 12/31/25.Review of Resident #18's Care Plan revealed, Hospice/Palliative Care: Resident was admitted under (name omitted) hospice care r/t (related to) dementia. Date initiated: 12/31/25.Review of a Minimum Data Set (MDS) assessment for Resident #18, with a reference date of 12/17/25 revealed that the resident was not receiving hospice services while in the facility during the 7-day look back period. There was no Significant…

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 significant change Preadmission Screening and Resident Review (PASARR) Level 1 screening was submitted and a Level II PASARR evaluation was completed for 1 (Resident #15) of 1 resident reviewed for PASARR Screening, resulting in the potential for unmet mental health and inappropriate placement in the skilled nursing facility. Findings include:Resident #15Review of an admission Record revealed Resident #15 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: schizoaffective disorder, bipolar type (chronic mental health condition combining hallucinations, delusions, disorganized speech with severe mood swing, specifically mania and often depression).Review of a Minimum Data Set (MDS) assessment for Resident #15 with a reference date of 2/10/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 14/15, which indicated the resident was cognitively intact. Section N of the MDS revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2731057.Based on observation, interview, and record review, the facility failed to ensure adequate labeling, dating/timing, and maintain cleanliness of enteral feeding equipment for 2 residents (R108 and R8) of 2 residents reviewed for enteral feeding, resulting in the potential for spoiled enteral feeding supplement and infections. Findings include:R108According to R108's Minimum Data Set (MDS) dated [DATE], indicated R108 was unable to complete the BIMS (Brief Interview Mental Status) and was severely cognitively impaired with a score of 00/15. Section K-Swallowing/Nutritional Status revealed nutritional approaches included R108 had a feeding tube. Diagnoses included cerebrovascular accident (CVA/stroke) and calorie-deficient malnutrition.Review of R108's Order Summary, dated 2/6/26, revealed, Enteral Feed.OFF 9:00 AM.Review of R108's Care Plan, dated 2/5/26, included a focus of Need for Feeding Tube, indicating the resident had a resident-specific treatment plan for enteral…

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 2802001, 2802220, 2798542, & 2737401. Based on interview and record review, the facility failed to identify incorrect medication orders during the monthly medication regimen review for 1 of 6 residents (Resident #39), reviewed for medication regimen reviews, resulting in the unnecessary administration of an antipsychotic medication and the potential for worsening medical conditions. Findings include:Resident #39 Review of an admission Record revealed Resident #39 was originally admitted to the facility on [DATE] with pertinent diagnoses which included paranoid schizophrenia (chronic and serious mental health condition that can significantly affect how a person thinks, feels, and behaves) and cognitive communication deficit. Review of Resident #39's Medication Regimen Review dated 1/30/26 and completed by Consulting Pharmacist (CP) AAA revealed, Based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it is my…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide requested immunizations to 2 of 5 residents (R12 and R108) reviewed for immunizations, resulting in the potential for acquiring, transmitting, or experiencing complications from communicable diseases. Findings include:R12According to the Minimum Data Set (MDS) dated [DATE] revealed R12 was cognitively intact per his BIMS (Brief Interview Mental Status) of 15/15. R12 diagnoses included debility-cardiorespiratory conditions including congestive heart failure. Section O-Special Treatments, Procedures, and Programs revealed R12's pneumococcal vaccination was up to date.Review of R12's Immunizations, date not listed, indicated the vaccine was refused.Review of R12's Order Summary did not have an order for administration of the pneumococcal vaccine.During an interview and record review, on 3/19/26 at 1:05 PM, Regional Infection Control Preventionist (ICP AA) and Director of Nursing (DON) B stated while looking through resident medical charts, I am…

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

Based on interview and record review the facility failed to ensure residents' personal funds held by the facility were accessible to residents for 40 residents in the facility, including 3 (Residents #110, 104, and 114) out of the total facility census of 111 resulting in frustration and being upset without access to their money and the inability to make personal purchases.Findings include:Resident #110:During an interview on 8/6/25 at 9:48 AM, Resident #110 was visibly frustrated and upset as he reported he hasn't had access to his personal funds (money) held by the facility since the new company took over (The new ownership took over the facility on 7/1/25). Resident #110 reported that when he tried to access his money since the ownership switched, he was unable to receive his money. Resident #110 reported he wanted his money and didn't like knowing someone else had it and he couldn't access it.During an interview on 8/6/25 at 10:10 AM, Administrator in Training C confirmed residents didn't currently have access to their facility held money and the new company took over the…

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

This citation pertains to intake # 1214940 & 2567893.Based on interview, and record review, the facility failed to protect the residents' right to be free from sexual and verbal abuse by a resident in 5 of 6 residents (Resident #101, #102, #104, #103 & #105) reviewed for abuse prevention, resulting in multiple instances of resident-to-resident sexual abuse, verbal abuse, and the potential for emotional distress.Findings include:In an interview on 8/5/23 at 10:53 AM, Confidential Informant (CI) GG reported there was an incident involving potential resident-to-resident sexual abuse at the facility in July where a male resident (Resident #104) kissed two female residents (Resident #101 & #102) who were unable to consent due to cognitive impairment. Resident #101 Review of an admission Record revealed Resident #101 was a female, with pertinent diagnoses which included schizoaffective disorder, depressive type, dementia, and insomnia. Noted Resident #101 was not her own responsible party. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 6/17/25,…

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

This citation pertains to intake # 1214940 & 2567893.Based on interview, and record review, the facility failed to report allegations of resident-to-resident sexual and verbal abuse to the State Agency in a timely manner in 5 of 6 residents (Resident #101, #102, #104, #103, & #105) reviewed for abuse prevention and reporting, resulting in the potential for incomplete investigations, and further instances of abuse to go unreported.Findings include:In an interview on 8/5/23 at 10:53 AM, Confidential Informant (CI) GG reported there was an incident involving potential resident-to-resident sexual abuse at the facility in July where a male resident (Resident #104) kissed two female residents (Resident #101 & #102) who were unable to consent due to cognitive impairment. CI GG reported Administrator A was notified of the abuse allegations but did not report the allegations to the State Agency. CI GG reported Resident #104 made inappropriate sexual statements to another resident (Resident #103) and Administrator A did not report the additional allegation to the State Agency. CI GG reported…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes #1214940, 2568025, 2569731, and 2583148.Based on interview and record review the facility failed to ensure sufficient staffing to meet resident care needs for 7 (Residents #103, 105, 110, 111, 112, 106, and 109) of 14 residents reviewed for staffing, resulting in feelings of staff not knowing their needs, medications being administered late, extended call light wait times, and negative resident emotions. Findings include:Resident #103: During an interview on 8/6/25 at 8:54 AM, Resident #103 reported her experience living at the facility with staffing levels was “not good”. Resident #103 stated, “They (the facility staff) don’t respond to your call light timely” and reported there isn’t enough help from the staff. Resident #103 felt the staff numbers working each day were lower and worse than they were before the switch of the company/ownership last month (7/1/25; the facility switched ownership). Resident #103 reported the facility now had lots of agency staff, but the agency…

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 # 2568025.Based on interview, and record review, the facility failed to notify family of a change in resident condition requiring hospitalization in 1 of 3 residents (Resident #107) reviewed for notification of changes, resulting in family being unaware of a resident's decline with resulting hospitalization and the potential for emotional distress.Findings include:In an interview on 8/5/25 at 3:08 PM, Family Member Z reported Resident #107 was sent to the hospital on 7/18/25 due to difficulty breathing. Family Member Z reported she was the one to receive phone calls/notifications when changes occurred, but that day no one from the facility contacted her to inform her of Resident #107's change in condition or hospital transfer. Family Member Z reported she first became aware of Resident #107's condition when the hospital Social Worker called her to inform her that Resident #107 was unresponsive. Family Member Z stated .I never got a chance to speak to her (Resident #107) again .Resident #107Review of an admission Record revealed Resident #107 was 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 #2574473Based on observation, interview, and record review, the facility failed to provide timely and consistent ADL (activities of daily living) care to 1 resident (Resident #109) of 3 reviewed for ADL care, resulting the resident experiencing back pain from remaining in bed, missing showers, feelings of frustration, and embarrassment.Findings include:Resident #109Review of an admission Record revealed Resident #109 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: fracture of shaft of humerus (upper arm), left arm, fracture of fifth lumbar vertebra (lower spine), unspecified fall and encephalopathy (condition in which functioning of the brain is affected by an agent or condition).Review of a Minimum Data Set (MDS) assessment for Resident #109 with a reference date of 7/15/25, revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #109 was moderately cognitively impaired. Section F revealed 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.

Based on interview and record review, the facility failed to employ an Activity Director who possessed the required qualifications resulting in the potential for unmet psychosocial needs, feelings of boredom and a lack of person-centered activities. This citation has the potential to impact all 126 residents within the facility. Findings include: Review of certification standards of the National Certification Council for Activity Professionals revealed ADC (Activity Director Certified) Certification ensures an individual has the knowledge and skills to lead and direct an activities and life enrichment department. ADC Certification validates the competencies necessary to be an Activity Director including leadership, management, advocacy, care planning and documentation. Review of a Activities Director Job Description provided by the facility revealed: Education, Training, and Experience: .eligible for certification as a therapeutic recreation specialist or activities professional qualified Occupational Therapist .has completed a training course approved by the state . In 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.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food in the kitchen. Findings include: An initial kitchen/food service tour was conducted on 1/27/25 beginning at 9:46 AM with Food Service Director (FSD) II. The following observations/interviews were completed: At 9:50 AM in the freezer, it was noted that cases of hamburger patties, Salisbury steaks, and egg patties were opened but were not securely closed (to prevent contamination). FSD II reported the food products should have been securely closed after opening. There was a frozen pickle slice on the floor of the freezer, and it was noted that there was a buildup of dirt, grime, and debris underneath the food storage racks and in the corners of the floor. There was a plastic cover over the sprinkler head in the ceiling that was broken in half, part of which was on the freezer floor in the corner underneath a storage rack.…

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 DPS B Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Findings include: During an observation of the kitchen, at 10:32 AM on 1/28/25, it was observed that a water line was found coming out from behind the two-door reach in cooler where an ice machine used to be located. An interview with Maintenance Director (MD) I, at 10:42 AM on 1/28/25, in the kitchen, found that he was unaware of the water line. When asked about how the facility handles flushing stagnant water lines. MD I stated that he goes to vacant rooms to flush them once a month. When asked about minimal use or unused fixtures in the facility, MD I stated his 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 This citation pertains to Intake MI00147770 Based on observation, interview and record review, the facility failed to maintain the dignity of 4 (Resident #26, Resident #55, Resident #57 and Resident #112) of 25 residents reviewed for dignity, and 3 of 6 residents who attended a confidential meeting, resulting in feelings of decreased self-worth, frustration, and residents receiving assistance with eating in a disrespectful manner. Findings include: Review of a Dignity and Respect facility policy, with a reference date of 7/11/18, revealed: The staff shall display respect for Resident's when speaking with, caring or (sic), or talking about them. Resident #26 Review of an admission Record revealed Resident #26, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: major depressive disorder (persistent depressed mood causing significant impairment in daily life) and generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities). Review of a Minimum…

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 individualized activities for 4 of 6 Residents (Resident #26, Resident #39, Resident #42 and Resident #55) reviewed for activities, resulting in feelings of boredom, and a potential for a decline in physical, mental and psychosocial well-being. Findings include: Review of Revolutionizing the Experience of Home by Bringing Well-Being to Life: The [NAME] Alternative Domains of Well-Being, Copyright 2012, Rev. 2020, revealed The [NAME] Alternative defined one domain of wellness as Connectedness- the state of being connected; alive .engaged, involved . Without meaningful interactions the individual can become disconnected .develop loneliness, helplessness, and boredom. Review of Participating in Activities You Enjoy as You Age, published by the National Institute on Aging, 3/28/22, revealed: Research has shown that older adults with an active lifestyle: .may lower risk for developing some health problems, including dementia, heart…

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 weight measurements; follow-up of residents at risk for altered nutrition status; and on-going nutritional assessment for 4 (Residents #59, #89, #111, and #121) of 5 residents reviewed for nutritional care and services, resulting in missed re-weights (Resident #59), incomplete nutrition status monitoring of a tube fed resident with a stage IV pressure ulcer (Resident #111), inconsistent weight measurements for a newly admitted resident (Resident #121), missed nutritional assessments (Resident #89, #111) and the potential for unidentified weight loss, nutritional status decline, and unmet nutritional needs for all residents. Findings include: Review of the policy Nutrition Monitoring & Management Program Adopted 7/11/2018 revealed, POLICY: It is the policy of this facility to ensure that all residents maintain acceptable parameters of nutritional status, such as body weight and protein levels; unless the resident's clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living, affecting residents in following areas: Findings Include: During a tour of the facility, at 1:18 PM on 1/28/25, a review of empty resident room [ROOM NUMBER] found an accumulation of dust, dirt, sand, and dead ants under the register on the far side of the room. During a tour of the 600 hall spa room, by resident room [ROOM NUMBER], at 1:21 PM on 1/28/25, it was observed that the spa room was hot and humid upon entering the room. A temperature of the wall with an infra-red thermometer found it to be 82F with moisture dripping down the windowsills. Aluminum window frame was observed with black spots and accumulation of black debris. Black debris was able to be wiped away from the window frame with a paper towel. Further review…

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 (Resident #27) of 5 residents reviewed for accommodation of needs, resulting in the inability to call for staff assistance, and potential unmet care needs. Findings include: Resident #27 Review of admission Record revealed Resident #27 was originally admitted to the facility on [DATE] with pertinent diagnosis which included unsteadiness of feet. Review of Resident #27's Care Plan revealed, (Resident #27) has communication and/or comprehension concern r/t ( related to) Hearing deficit, deconditioning, diagnosis of Dementia. Date Initiated: 11/12/2024 .Interventions: Ensure/provide a safe environment: call light in reach . Date initiated: 11/12/2024 . During an observation on 1/27/25 at 9:52 AM, Resident #27 was lying in his bed. It was noted that Resident #27's touch pad call light was lying on the floor behind Resident #27's bed and out of his reach. Resident #27 reported that he would use his 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.

This citation pertains to Intake # MI00149017. Based on interview, and record review, the facility failed to report allegations of abuse to the State Agency in a timely manner in 2 of 2 residents (Resident #115 & #127) reviewed for abuse and reporting, resulting in the potential for additional allegations of abuse and to go unreported and delayed investigation. Findings include: Review of the policy/procedure Abuse and Neglect, dated 3/24/23, revealed .Abuse (is) defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .All allegations of abuse will be reported to the appropriate State Agencies immediately after the initial allegation is received . Resident #115 Review of an admission Record revealed Resident #115 was a female, with pertinent diagnoses which included adjustment disorder with mixed anxiety and depressed mood. Review of a Minimum Data Set (MDS) assessment for Resident #115, with a reference date of 11/4/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, out…

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, observation and record review, the facility failed to complete Minimum Data Set (MDS) assessments that accurately reflect resident status in 1 of 25 residents (Resident #121), resulting in an inaccurate reflection of resident status and the potential for physical complications due to unidentified needs. Findings include: Resident #121 Review of an admission Record revealed Resident #121 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: heart attack and tracheostomy (a surgical procedure that creates an opening in the front of the neck to provide airway and allow breathing) care. Review of a MDS assessment for Resident #121, with a reference date of 12/18/24 revealed the resident did not receive tracheostomy services while a resident. Review of Resident #121's Physician Orders revealed, Change all trach related supplies: nebulizer tubing, corrugated tubing, trach mask, overflow container, suction parts, etc. On Sunday night shift every week as needed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) evaluation was completed for 1 (Resident #55) of 4 residents reviewed for PASARR Screening, resulting in the potential for unmet mental health and psychiatric care needs. Findings include: Resident #55 Review of admission Record revealed Resident # 55 was originally admitted to the facility on [DATE] with pertinent diagnoses which included psychotic disorder with delusions. Review of Resident #55s Preadmission Screening (PAS) Annual Resident Review (ARR) Level I Screening dated 2/5/24 indicated the following: Questions 1-4 in section II were marked Yes: 1. Resident #55 had a current diagnosis of mental illness and dementia. 2. Resident #55 had received treatment for mental illness. 3. Resident #55 had routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days. 4. There is presenting evidence of mental illness or dementia, including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans in 3 of 25 residents (Resident #73, #97, & #27) reviewed for comprehensive care plans, resulting in the potential for unmet medical, physical, mental, and psychosocial needs. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.19.1, Chapter 4: Care Area Assessment (CAA) Process and Care Planning, dated October 2024, 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 each resident's written plan of care . According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME];…

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 practice for wound care and documentation of meal intake in 3 of 25 residents (Resident #230, #27, & #89) reviewed for professional standards, resulting in missed wound treatments and inaccurate documentation. 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. A health care provider's order for changing a dressing indicates the dressing type, the frequency of changing, and any solutions or ointments to be applied to the wound. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME].…

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 properly assess a resident after a fall in 1 (Resident #48) of 25 residents reviewed for quality of care, resulting in a potential for unidentified injuries after a fall. Findings include: Review of an admission Record revealed Resident #48 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unsteadiness on feet. Review of a Minimum Data Set (MDS) assessment for Resident #48, with a reference date of 11/19/24 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #48 was cognitively intact. Section J revealed Resident #48 experienced almost constant pain and two or more falls during the assessment period. Review of a Care Plan for Resident # 48, with a reference date of 1/15/25, revealed a focus/goal/interventions of: (Resident #48) is at risk for falls .Goal: (Resident #48) will remain free from fall related injury .Interventions: .anti roll backs to wheelchair .gripper socks…

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 a resident who was a trauma survivor received care and services that addressed their psychosocial needs for 1 (Resident #39) of 25 residents reviewed for trauma-informed care, resulting in a potential for Resident #39 to experience re-traumatization. Findings include: Review of Trauma-Informed Therapy Explained, 2/16/24, PositivePsychology.com, revealed: Trauma-Informed care, a vital approach in mental health, acknowledges trauma's impact and aims to establish a safe, healing environment .trauma informed care involves being mindful of potential triggers to prevent re-traumatization . Resident #39 Review of an admission Record revealed Resident #39 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: major depressive disorder (persistent sad or depressed mood that impacts daily life) anxiety disorder, and dementia (general term for loss of memory, language, problem solving or other abilities that are…

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 interviews and record review, the facility failed to facilitate outside dental services in a timely manner for 1 of 1 residents (Resident #55) reviewed for dental care, resulting in Resident #55 having prolonged poor condition of teeth, and the potential for a life threatening infection. Findings include: Resident #55 Review of admission Record revealed Resident # 55 was originally admitted to the facility on [DATE] with pertinent diagnoses which included huntington's disease (a condition which causes nerve cells in the brain to break down over time). Review of a Minimum Data Set (MDS) assessment for Resident #55, with a reference date of 11/27/24 revealed a Brief Interview for Mental Status (BIMS) score of 99/15 which indicated Resident #55 was severely cognitively impaired. Review of Resident #55's Medical Practitioner Progress Note dated 6/6/24 and documented by Nurse Practitioner (NP) ZZ revealed, .(Resident #55) recently missed appointment with (local facility dental service provider) because 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 interview and record review, the facility failed to provide written notification of the facility bed hold policy upon discharge to an acute care hospital for 2 (Resident #102 and #103) of 3 residents reviewed for emergency hospital transfer resulting in the potential for unanticipated expense or the loss of desired room placement in the facility. Findings include: Resident #102 Review of an admission Record revealed Resident #102 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness. Review of Resident #102's Acute Care Transfer note dated 10/18/24 revealed, (Resident #102) transferred to hospital .Statement that Bed Hold Policy & Facility Initiated Transfer for Nursing Home forms Provided? Medication list and facesheet sent with (Resident #102) . It was noted that there was no documentation noted to indicate written notification of the facility bed hold policy was provided upon discharge. Resident #103 Review of an admission Record revealed 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: MI00147492 Based on interview and record review, the facility failed to address an acute change of condition and notify the physician of symptoms of increased lethargy (abnormal drowsiness), right upper extremity weakness, asymmetry (unequal) on the right side of face, decreased grip strength, increased pain, warmth, and swelling in the right knee in 1 (Resident #101) of 3 residents reviewed for quality of care, resulting in the delay of treatment and interventions in the diagnosis of subacute cerebral vascular accident (CVA) (Stroke) and acute RLE (right lower extremity) DVT (deep vein thrombosis). Findings include: According to the Mayo Foundation for Medical Education and Research, It should be noted when signs and symptoms of a stroke begin, because the length of time they have been present may guide treatment decisions. Seek immediate medical attention if you notice any signs or symptoms of a stroke, even if they seem to fluctuate or disappear. Call 911 or your local…

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 safety with eating assistance for 1 (Resident #101) of 4 residents reviewed for accidents/hazards resulting in the potential for accidents and serious injury. Findings include: Resident #101 Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE] with pertinent diagnoses which included aphasia (language disorder that affects a person's ability to communicate) following cerebral infarction (stroke) and dysphasia (difficulty swallowing). Review of Resident #101's Orders revealed, Regular Diet: Dysphagia/pureed/NDD1 (National Dysphagia 1 Diet) texture, regular fluid, thin consistency, 1:1: assist, 1 tsp at a time. Order start date: 10/21/24 . Review of Resident #101's Kardex (care plan orders for Certified Nursing Assistants) revealed, Foods/Fluids: .Ensure (Resident #101's) HOB (head of bed) is elevated at 90 degrees for all meals. Pureed diet, all thin liquids given with spoon.…

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 #MI00146336. Based on interview, and record review, the facility failed to provide adequate supervision to prevent elopement and respond appropriately to the alarm system in 1 of 3 residents (Resident #103) reviewed for wandering/elopement, resulting in Resident #103 exiting the facility unbeknownst to staff and the potential for injury. Findings include: Review of the policy/procedure Elopement, dated 2/5/20, revealed .It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for wandering/elopement. All residents so identified will have these issues addressed in their individual plan of care .Residents who have been assessed at risk for elopement/wandering shall be provided at least one of the following safety precautions by the facility .An adult electronic monitoring safety device will be used to notify/alert staff by sounding an alarm when the resident enters the perimeter around an alarmed…

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 # MI00146994. Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records in 1 of 4 residents (Resident #107) reviewed for accuracy of medical records, resulting in an inaccurate behavior record and the potential for providers to not have an accurate picture of resident status and condition. 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. Review of an admission Record revealed Resident #107 was a male, with pertinent diagnoses which included dementia, high blood pressure, malnutrition, chronic pain, and a history of falls. Review of a Minimum Data…

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 implement posted transmission-based precautions and don required Personal Protective Equipment (PPE) prior to entering COVID-19 positive resident rooms in 2 of 2 rooms reviewed for transmission-based precautions, resulting in the potential for cross-contamination and the development and spread of infection to a vulnerable population. Findings include: Review of the policy/procedure COVID-19 Core Practices, dated 5/11/23, revealed .The facility will follow recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Resident placement for suspected or confirmed SARS-CoV-2 (COVID-19) .It is recommended that the door to the room remain closed to reduce transmission of SARS-CoV-2 .Staff members entering a resident room with suspected or confirmed SARS-CoV-2 should use all recommended PPE, which includes use of a NIOSH approved N95 or equivalent or higher-level respirator, eye protection (eye goggles or a face shield that covers the front and sides of the face), gloves, 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.

Based on observation, interview, and record review, the facility failed to assess and ensure the right to safe self-administration of medication in 1 (Resident #105) of 3 residents reviewed for medication administration, resulting in the potential for unsafe self-administration of medication, medication errors, and medications not being stored in a secure manner. Findings include: Resident #105 Review of an admission Record revealed Resident #105 was a male, with pertinent diagnoses which included: anemia in other chronic diseases; hemiplegia (muscle weakness or partial paralysis on one side of the body), unspecified affect; dysphagia (swallowing difficulty), oropharyngeal phase; and bipolar disorder, unspecified. Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 4/1/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #105 was cognitively intact. During an observation and interview on 4/23/24 at 10:54 AM, Resident #105, who granted permission for this surveyor 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.

This citation pertains to intake: MI00143463. Based on interview and record review, the facility failed to respond timely to a request for medical records in 1 (Resident #105) of 6 residents reviewed for resident rights, resulting in delayed access to the resident's medical records and resident frustration. Findings include: Resident #105 Review of an admission Record revealed Resident #105 was a male, with pertinent diagnoses which included: PTSD (post-traumatic stress disorder). Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 4/1/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #105 was cognitively intact. In an interview on 4/23/24 at 10:54 AM, Resident #105 reported that on 2/12/24, he had asked one of the nurse aides how to get a copy of his medical records. Resident #105 went on to say that the aide explained the process to him, he followed the protocol, but didn't get any response. Resident #105 reported he waited a few days and still didn't get any…

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: MI00143329. Based on interview and record review the facility failed to implement their Abuse and Neglect policy following an incident of visitor to resident verbal abuse in 1 (Resident #104) of 6 residents reviewed for abuse resulting in a delay in reporting the Facility Reported Incident (FRI) to the State Agency and a delay in the removal of the visitor pending an investigation. Findings include: Resident #104 Review of an admission Record revealed Resident #104 was a male, with pertinent diagnoses which included: acquired absence of left leg (amputation), acquired absence of right leg (amputation) major depressive disorder, and cognitive communication deficit. Review of a FRI Intake Information report revealed, Date of Alleged Event: 02/29/2024 Time: 3:00 PM .Facility incident report received via online submission on: 3/1/24, 2:58 PM .Investigation Summary .Date of Incident: 2/29/2024 @ (at) 3:00 pm Brief Description of Event: At approximately 3:00 pm on 2/29/2024, (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.

Based on observation, interview, and record review, the facility failed to implement care planned interventions or document refusals of care planned interventions to prevent further skin breakdown for 1 (Resident #109) of 3 residents reviewed for pressure ulcer prevention, resulting in the potential for further skin breakdown, worsening of existing pressure ulcers, infection, and overall deterioration in health status. Findings include: Resident #109 Review of an admission Record revealed Resident #109 was a male, with pertinent diagnoses which included: end-stage renal (kidney) disease, type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood), and pressure ulcer of other site, unstageable. Review of a Minimum Data Set (MDS) assessment for Resident #109, with a reference date of 4/8/24 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #109 was cognitively intact. Review of Resident #109's current Care Plan revealed a focus of The resident has DTI (deep tissue…

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: MI00142037. Based on interview and record review, the facility failed to ensure timely and consistent documented follow-up by a qualified nutrition professional following significant weight loss and skin breakdown in 1 (Resident #101) of 3 residents reviewed for nutritional care resulting in undocumented re-evaluation and assessment of resident nutritional needs and care and the potential for unmet nutritional needs. Findings include: Resident #101 Review of an admission Record revealed Resident #101 was a male, admitted on [DATE] and discharged on 2/3/24, with pertinent diagnoses which included: multiple sclerosis. Review of a Mini Nutritional Assessment for Resident #101 dated 12/28/23 and completed by Registered Dietitian (RD) D revealed a risk score of 10 which indicated resident was at risk of malnutrition. Review of a Dietary Evaluation for Resident #101 completed by RD D on 1/8/24 revealed, .II B. Most Recent Weight 191.0 Date 12/27/23 C. Most Recent Height 70.0 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.

Based on interview and record review, the facility failed to provide a written reason and/or give notifications of the transfer/discharge for 3 residents (#48, #72, & #115 ) reviewed for hospitalizations/transfers/discharges, resulting in the Long-Term Care Ombudsman not being notified of transfers/discharges and the potential for residents and/or family being un-informed of the reason for transfer/discharge. Findings include: Resident #48 Review of Resident #48's Electronic Medical Record (EMR) revealed: Progress note: on 7/6/2023 Resident #48 was transferred to the Emergency Room (ER) for Acute Care Transfer .Observations and Assessment (Reason for Transfer): (Resident #48) hypotensive/dizzy post unwitnessed fall. Medical Provider Notification and Orders: (send to) ER for evaluation Review of Resident #48's Electronic Medical Record (EMR) revealed: Progress note: on 7/20/2023 Resident #48 was transferred to the Emergency Room (ER) for Acute Care Transfer .Observations and Assessment (Reason for Transfer): (Resident #48) abnormal vital signs: hypotensive, tachycardic, febrile,…

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 standards of practice and ensure 1.) proper hand hygiene was completed during meal services, as well as when staff entered and exited resident rooms which included Transmission Based Precaution (TBP) rooms for residents with infections including but not limited to Covid-19 2.) failed to ensure required PPE supplies/equipment were available to staff and visitors for use prior to entering TBP rooms, resulting in the potential for the introduction of infection, cross-contamination, and disease transmission. Findings include: During an observation on 1/09/24 at 2:08 PM in the hall outside of room [ROOM NUMBER] the hand sanitizer machine was not working properly. According to the admission Record, R228 was admitted on [DATE] with diagnoses that included acquired absence of right leg, diabetes mellitus, hypertension, and chronic kidney disease. During an observation and record review on 1/9/2024 at 2:10 PM, R228's door had signage stating,…

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(Resident #105 ) of 2 residents reviewed for accommodation of needs resulting in the resident's inability to call for staff assistance with the potential for unmet care needs. Findings include: Resident #105 Review of an admission Record revealed Resident #105 was originally admitted to the facility on [DATE] with pertinent diagnoses which included difficulty in walking and muscle weakness. Review of Resident #105's Care Plan revealed, (Resident #105) is at risk for falls r/t (related to) left-sided paralysis and expressive aphasia (difficulty producing speech) r/t MVA (motor vehicle accident). Date initiated: 11/15/22 .Interventions .Be sure call light is within reach, provide cueing and reminders for use as appropriate due to level of cognition. Date initiated: 4/12/23 . Review of Resident #105's Care Plan revealed, (Resident #105) has a communication and/or comprehension concern r/t Receptive…

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 a resident's advanced directive (Code status) for 1 resident (R228) of 25 residents reviewed for advanced directives resulting in the potential for failing to follow the resident's code status wishes. Findings include: According to the admission Record, R228 was admitted on [DATE] with diagnoses that included acquired absence of right leg, diabetes mellitus, hypertension, and chronic kidney disease. During an interview on 1/11/2024 at 10:30 AM, R228 stated, No one has asked me what I wanted for code status when I was admitted . It was noted during conversations, the resident was alert, oriented (person, place, time, date, and why he was at the facility), and able to hold a sensical conversation with humor. During an interview and record review on 1/11/2024 at 1:30 PM, Social Worker (SW) U stated when reviewing R228's medical records, It was brought to my attention today, that (R228's) code status was not done. The admission nurse usually does…

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 notify the responsible party of a change in resident condition in 1 of 25 residents (R99) reviewed for notification of changes, resulting in the resident representative not being made aware of a dental abscess resulting in the lack of ability to participate in timely medical decision-making. Findings include: According to the Minimum Data Set (MDS), dated [DATE], R99 was cognitively impaired with a score of 5/15 on his BIMS (Brief Interview Status). Diagnoses included Alzheimer's disease, dementia, and depression. Section J-Pain Management reported the resident had not been on a scheduled, PRN (as needed), or non-medication intervention for pain management regimen in the last 5 days of the quarterly OBRA quarterly review. Section L-Dental did not have documentation regarding R99's dental status. Further review of R99's MDS admission assessment dated , 6/19/2023, reported that the resident did have tooth fragments or missing natural teeth (edentulous),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #76 Review of an admission Record revealed Resident #76 was a male, with pertinent diagnoses which included: mild cognitive impairment and psychotic disorder with delusions. On 1/10/24 at 1:08 PM, Resident #76's medical record was reviewed for evidence of facility coordination with OBRA (Omnibus Budget Reconciliation Act) for Preadmission Screening and Annual Review (PASARR) Level II screening. A review of a document dated 9/12/22 from State of Michigan Department of Health and Human Services for Resident #76 revealed, To Whom It May Concern: (OBRA Representative name omitted) completed an OBRA Level II Evaluation on the above-named individual and made the recommendation on placement and services. Based on the information provided by this agency, The State of Michigan Department of Health and Human Services made the following .If the above-named individual remains in the nursing facility, a Level II Evaluation is needed by September 11, 2023. A review of Resident #76's medical record revealed no…

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

This citation pertains to intake MI00141497. Based on interview, and record review, the facility failed to implement an effective discharge planning process and complete an accurate discharge plan of care in 1 of 2 residents (R128) reviewed for discharge, resulting in the resident being discharged without planned housing or medical care. Findings include: During an interview on 1/04/2024 at 3:14 PM, Complainant JJJ stated, (R128) did not have discharge papers or a discharge plan when he came here. He is an older man and would die on the streets if he had no other place to go. When (name of facility) discharged him, he had to walk across 4 lanes of a very busy divided road (name of a State of Michigan highway) while using a walker. He then used every cent of money he had on a hotel room. The manager from that hotel called us (name of a transitional housing for homeless men). (R128) came with no medications, no clothes, no doctor; just came with the clothes on his back and a walker. He was told by the facility his insurance days were up. My facility has taken other residents from them…

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 failed to 1.) perform neurological checks after falls for 2 (Resident #110 and #70) of 25 sampled residents, and 2.) ensure that a provider assessment was completed when requested by the Registered Dietician for 1 (Resident #70) of 25 sampled residents reviewed for quality of care resulting in the lack of assessment, monitoring, and documentation and the potential for the worsening of a medical condition and the delay in treatment. Findings include: Resident #110 Review of an admission Record revealed Resident #110, was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and difficulty in walking. Review of Resident #110's eINTERACT SBAR Summary for Providers note dated 1/8/24 revealed, Situation: The change in condition/s reported on this CIC evaluation are/were: Fall .Outcomes of physical assessment: no information was entered. Positive findings reported on the resident/patient evaluation for this change…

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 clean and store BiPAP (bilevel positive airway pressure) equipment (a treatment used for sleep apnea - pressurized air is provided through a mask to prevent collapse of the airway) according to the physician's order for 1 resident (Resident #91) of 1 resident reviewed for respiratory care, resulting in an increased potential for respiratory infection and respiratory distress. Findings include: Review of an admission Record revealed Resident #91 admitted to the facility on [DATE] with pertinent diagnoses which included obesity, chronic obstructive pulmonary disorder, and obstructive sleep apnea. Review of a Minimum Data Set (MDS) assessment for Resident #91, with a reference date of 11/13/2023 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated Resident #91 was moderately cognitively impaired. Review of Resident #91's active Physician's Order, started 8/3/2023, revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure adequate pain monitoring and management for 1 resident (R99) of 25 residents reviewed for pain management, resulting in unrelieved dental pain that impacted the resident's eating and functional status of life. Findings included: According to the Minimum Data Set (MDS), dated [DATE], R99 was cognitively impaired with a score of 5/15 on his BIMS (Brief Interview Status). Diagnoses included Alzheimer's disease, dementia, and depression. Section J-Pain Management reported the resident had not been on a scheduled, PRN (as needed), or non-medication intervention for pain management regimen in the last 5 days of the quarterly OBRA quarterly review. Section L-Dental did not have documentation regarding R99's dental status. Further review of R99's MDS admission assessment dated , 6/19/2023, reported that the resident did not have tooth fragments or missing natural teeth (edentulous), broken natural teeth, mouth or facial pain, discomfort, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to coordinate dental extraction services, for 1 resident (R99) of 1 resident reviewed for dental care, resulting in delayed dental services and treatment, on-going tooth pain, and an abscessed tooth. Findings include: According to the Minimum Data Set (MDS), dated [DATE], R99 was cognitively impaired with a score of 5/15 on his BIMS (Brief Interview Status). Diagnoses included Alzheimer's disease, dementia, and depression. Section J-Pain Management reported the resident had not been on a scheduled, PRN (as needed), or non-medication intervention for pain management regimen in the last 5 days of the quarterly OBRA quarterly review. Section L-Dental did not have documentation regarding R99's dental status. Further review of R99's MDS admission assessment dated , 6/19/2023, reported that the resident did not have tooth fragments or missing natural teeth (edentulous), broken natural teeth, mouth or facial pain, discomfort, or difficulty with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident received food in an appropriate texture to optimize intake and meet individual needs for 1 resident (R99) of 25 residents reviewed for food and drink, resulting in food being difficult to chew and decreased food acceptance. Findings include: According to the Minimum Data Set (MDS), dated [DATE], R99 was cognitively impaired with a score of 5/15 on his BIMS (Brief Interview Status). Diagnoses included Alzheimer's disease, dementia, and depression. During an observation and interview on 1/9/2024 at 12:00 PM, Family Member (FM) FFF observed R99 with Surveyor. R99 sat himself up to the edge of his bed, opened his lunch tray. He opened an ice cream cup, place it in the right side of his mouth. The lower left side of his face appeared swollen. The resident did not eat any other food. R99 stated while placing his hand on the left side of his face, My tooth hurts. I cannot eat anything else. During an observation and 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 Based on interview and record review, the facility failed to maintain complete and accurate medical records in 1 (Resident #24) of 25 residents reviewed for accuracy of medical records, resulting in the potential for providers to not have an accurate picture of resident status and condition. Findings include: Review of an admission Record revealed Resident #24 was a female, with pertinent diagnoses which included: hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body), vascular dementia, and type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood). Review of a Physician's Order for Resident #24 revealed, Blue boot to right foot while in bed as tolerated every shift for DTI (deep tissue injury) Verbal Active Order Date 09/26/2023 Start Date 09/27/2023 Review of Resident #24's MAR/TAR (Medication Administration Record / Treatment Administration Record) for October, 2023 revealed opportunities (check boxes) for documentation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to MI00132640. Based on interview and record review, the facility failed to ensure post dialysis communication, assessment, and monitoring for 1 Resident (Resident #115) of 11 resident reviewed for quality of care, resulting in the potential for the resident to not meet her highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an admission Record revealed Resident #115 admitted to the facility on [DATE] with pertinent diagnoses which included end stage renal disease and dependence on renal dialysis. Review of a current Care Plan focus for Resident #115, with a revision date of 1/5/2022, revealed resident #115 required hemodialysis for end stage renal disease. Review of current dialysis Care Plan interventions for Resident #115, initiated 1/5/2022, revealed staff were directed to monitor Resident #115's shunt site and vitals signs as directed and as needed. In a telephone interview on 10/10/2023 at 10:49 AM, Family Member Y reported they visited…

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.