Valley View Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake #MI00149109 Based on observation, interview, and record review the facility failed to ensure that residents were free from significant medication errors in 2 (Resident #2 and Resident #9) of 2 residents reviewed for significant medication errors resulting in Resident #2 experiencing an altered level of consciousness, lethargy (decreased alertness and response), decreased oral intake, decreased blood pressure, and the need for supplemental oxygen. Findings include: Resident #2 Review of an admission Record revealed Resident #2 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: Type 2 diabetes (a long-term condition where the body does not use insulin properly and there is too much sugar circulating in the blood), hypertension (high blood pressure), and dementia. Review of a Minimum Data Set (MDS) assessment for Resident #2, with a reference date of 1/2/2025 revealed a Brief Interview for Mental Status (BIMS) score of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure staff implemented infection control measures by: 1). Implementing enhanced barrier precautions (EBP) for a resident with a urinary catheter in 1 (Resident #2) of 1 resident reviewed for EBP implementation and 2.) provide adequate storage of a CPAP (continuous positive airway pressure) mask for 2 (Resident #5 and Resident #6) of 2 resident reviewed for CPAP mask use, resulting in the potential for the introduction of infection, cross contamination, and disease transmission. Findings include: Resident #2 Review of an admission Record revealed Resident #2 was a female who was originally admitted to the facility on [DATE]. On 3/13/25 at 1:05 pm, a urinary drainage bag was noted on Resident #2 bed frame, indicating the use of a urinary catheter. No signage was noted outside of the room indicating the use of enhanced barrier precautions. Review of Order Summary for Resident #2 on 3/13/25 revealed Foley catheter 16 fr (French) for buttock…

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 store, prepare, distribute, or serve 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 who consume food from the kitchen. Findings include: During an initial tour of the kitchen, at 9:31 AM on 10/8/24, an open bottle of lemon juice was found stored on a dry storage shelf with spices and seasonings. Observation of the bottle found that roughly 20% of the contents was left. The contents were observed milky and discolored and further observation of the manufacturer's label found that the item states Refrigerate After Opening. The bottle was shown to Dietary Manager (DM) EEE and was discarded at this time. According to the 2017 FDA Food Code section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C ) 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.

This citation pertains to intake MI00146660. Based on observation, interview, and record review, the facility failed to provide sufficient staff to meet resident needs for 6 (Resident #19, Resident #20, Resident #71, Resident #333, Resident #51, and Resident #60 ) of 3 residents and residents from the confidential group interview reviewed for staffing, from a total sample of 27 residents, resulting in long call light wait times and resident care needs not being consistently met with the potential for unmet care needs for all residents residing in the facility. Findings include: During an interview on 10/10/24 at 1:00 PM, Scheduler RR reported that she was responsible for scheduling nurses and certified nursing assistants (CNA's) in the facility based on the acuity and needs of the residents. Scheduler RR reported that she had received workload concerns from the facility staff all the time. Scheduler RR reported that she had received the most complaints about staffing on the facility's 200 and 500 hall, which seemed to have the heaviest workload for staff. This writer informed…

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 an environment that promoted and resident dignity in 2 (Resident #60 and #71) of 3 residents reviewed for dignity, resulting in the potential of feelings of humiliation, embarrassment, and loss of self-worth, and a negative psychosocial outcome for the residents impacting their quality of life. Findings include: Resident #60: Review of current Care Plan for Resident #60, revised on [DATE], revealed the focus, .Risk of falls r/t (related to) COPD, HTN (high blood pressure), PVD (peripheral vascular disease) . with the intervention .Septic arthritis of right ankle .WBAT (weight bearing as tolerated) with RLE (right lower extremity with surgical boot .Ambulation with 1 PA (physical assist) . In an interview on [DATE] at 02:48 PM, Resident #60 reported the staff took a long time to come to assist him when he needed to use the restroom and he soiled himself and needed to have his clothes changed. Resident #60 was upset by this 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 ensure call lights were in reach for 2 (Resident #82 & #126) of 27 residents reviewed for accommodation of needs, resulting in the inability to call for staff assistance and the potential for unmet care needs. Findings include: Resident #82 Review of a Minimum Data Set (MDS) assessment for Resident #82, with a reference date of 9/10/24 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #82 was moderately cognitively imparied. Review of Resident #82's Care Plan revealed, .Focus: Due to my Parkinson's, I hold my arms close to my chest and hand closed and shake up and down my chest .I have an actual ADL (activities of daily living) deficit R/T (related to): Parkinson's .Resident is cognitively intact .Risk for falls R/T Parkinson's .Interventions: .Call light accessible. Date initiated: 12/07/2023 . During an observation on 10/09/24 at 09:54 AM in Resident #82's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate code status (a physician's order that determines the type of medical treatment a person will receive if their heart or breathing stop) was in place for 1 (Resident #62) of 27 residents reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers. Findings include: Review of an admission Record revealed Resident #62 was originally admitted to the facility on [DATE] with pertinent diagnoses which included chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe). Review of a Minimum Data Set (MDS) assessment for Resident #62, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #62 was cognitively intact. 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 interview, and record review, the facility failed to accurately complete Minimum Data Set (MDS) assessments in 1 (Resident #131) of 27 residents reviewed for accuracy of assessments, resulting in an inaccurate reflection of the resident's discharge status. Findings include: Resident #131 Review of an admission Record revealed Resident #131 was originally admitted to the facility on [DATE], and discharged to (name of a different nursing home) on 7/26/24. Review of a MDS assessment for Resident #131 with a reference date of 7/26/24 revealed, Resident #131 discharged to a short-term general hospital on 7/26/24. This information was not consistent with the resident's admission record. Review of Resident #131's Progress Note dated 7/26/2024 at 09:13 AM revealed, D/c (discharge) instructions given to patient; he verbalized understanding. Resident dc with dc instructions and belongings via (another nursing home) transportation. In an interview on 10/10/24 at 02:03 PM, MDS Nurse L reported that Resident #131…

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 confirm the Pre-admission Screening and Resident Review (PASARR) Level II determination request was sent to the Community Mental Health Services Program (CMHSP) for a Level II OBRA review and/or evaluation for 2 (Resident #49 and #26) of 3 residents, resulting in the potential for the residents to not receive or have delayed mental health services. Findings include: Review of OBRA - Specialized Nursing Homes dated 2023, revealed, .This review process begins with the completion of a screening form (Level I DCH-3877) usually by a nursing facility, hospital, or community agency/provider. If the responses to the questions on the form indicate the presence of a mental illness and/or an intellectual/developmental disability (or a related condition), the person is referred to the local community mental health services program (your local OBRA Coordinator) to assess if a comprehensive evaluation (Level II) is needed. This evaluation and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement a comprehensive, person-centered care plan for 1 (Resident #11) of 3 residents reviewed for pressure ulcer prevention, resulting in an incomplete reflection of the resident's care and monitoring needs for pressure ulcer preventative Findings include: Review of an admission Record revealed Resident #11 was originally admitted to the facility on [DATE] with pertinent diagnoses which pressure ulcers stage 4. Review of Resident #11's Kardex (individualized-personalized resident care guide for staff use) with no date revealed: (Resident#11) I need my soft heel offloading boots on both of my feet at all times, remove for morning and evening care and for skin inspection . During an observation on 10/08/24 at 4:55 PM., on 0/09/24 at 12:30 PM., and on 10/09/24 at 2:10 PM Resident #11 was laying in his bed. It was noted Resident #11 was not wearing any sort of soft boot, nor were any soft boots noted in and or around Resident #11's room.…

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 revise a comprehensive care plan with new interventions after a fall in 1 (Resident #15) of 2 residents reviewed for falls resulting in an inaccurate reflection of the resident's care needs and the potential for unmet medical, physical, mental, and psychosocial needs. Findings include: Resident #15 Review of an admission Record revealed Resident #15 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness. Review of Resident #15's Incident Report dated 7/4/24 revealed Incident description: Called to room by CENA (Certified Nursing Assistant).(Resident #15) was observed sitting on the floor with her legs bent at the knees and her lower legs alongside her buttocks, in front of her chair. Her tray table had also tipped over and she was sitting between the tray table and the chair, leaning to the left with her arm pressed and lower back pressed up against the tray table . notes: 30 minutes after incident…

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 dependent residents received assistance with activities of daily living (ADL), specifically personal hygiene and getting out of bed were provided for 2 (Resident #19 & #20) of 4 residents reviewed for ADL care, resulting in unmet care needs and the potential for avoidable declines in overall health and wellness. Findings include: Resident #19 Review of an admission Record revealed Resident #19 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: parkinsons (a disorder of the central nervous system (brain and spinal cord) that causes difficulty with movement.) Review of a Minimum Data Set (MDS) assessment for Resident #19, with a reference date of 8/8/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #19 was cognitively intact. Review of Resident #19's Care Plan revealed, Focus: .At risk for urinary/bowel…

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 interventions to prevent skin breakdown for residents at risk for pressure ulcers, for 1 (Resident #20) of 5 residents reviewed for pressure ulcers, resulting in the potential for the development of an avoidable pressure ulcer, infection, and overall deterioration in health status. Findings include: Resident #20 Review of an admission Record revealed Resident #20 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: paraplegic (inability to move lower body), myasthenia gravis (skeletal muscle weakness) and osteomyelitis (bone infection) of the lower spine. Review of a Minimum Data Set (MDS) assessment for Resident #20, with a reference date of 8/29/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #20 was cognitively intact. Review of Resident #20's Braden Assessment (used to predict risk of pressure ulcers) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00146660. Based on interview and record review, the failed to ensure documentation of resident medical records were completed for 2 (Resident #17 and #43) residents, of total sample of 27, reviewed for comprehensive and accurate medical records, resulting in an inaccurate reflection of the resident's medical treatments administered resulting in the potential for providers to not have an accurate picture of resident status and condition. Findings include: Resident #17 Review of an admission Record revealed Resident #17 was originally admitted to the facility on [DATE] with pertinent diagnoses which included hypertension (high blood pressure). Review of Residents Treatment Administration Record (TAR) revealed, Orders: Cleanse right heel with normal saline, pat dry, apply foam dressing. Change every 3 days and PRN (as needed). One time a day every 3 day(s). Start Date: [DATE]. It was noted that on [DATE], and [DATE] and [DATE], there was missing documentation that the treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control practices for proper hand hygiene, maintain clean resident wheelchairs for 2 (Resident #79, #40) of 2 residents, and sanitize resident shared equipment creating unsanitary conditions for commonly touched/utilized items reviewed for infection control practices resulting in the potential for the spread of infection, cross-contamination, and disease transmission for all residents residing in the facility. Findings include: In an observation on 10/08/24 at 10:30 AM., noted a sit to stand lift the base (where residents plant their feet while being raised from a seated to a standing position for transfers to and from chairs, beds, toilets. etc ) was heavily soiled with dust, debris and food crumbs. During an observation on 10/09/24 at 4:04 PM., Licensed Practical Nurse (LPN) U was observed exiting a resident room after assisting Certified Nurse Aide (CNA) Z. LPN U exited the resident room without using hand sanitizer…

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 MI0014870. Based on interview, and record review, the facility failed to notify the responsible party of a change in resident condition in 1 of 5 residents (R102) reviewed for notification of changes, resulting in the resident representative not being made aware of a seizure, resulting in the lack of ability to participate in timely medical decision-making. Findings include: According to R102's medical records diagnoses included multiple sclerosis (MS) (chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord), and epilepsy (seizure). Review of R102's Order Summary 4/7/23, reported Glatiramer Acetate subcutaneous (under the skin) solution prefilled syringe 20mg/ml. Inject 1 ml subcutaneously one time a day related to Multiple Sclerosis . epilepsy. Review of R102's Medication Administration Record (MAR), dated 2/1/24-2/29/24, reported a documented refusal dose of Glatiramer on 2/4/24. Review of R102's MAR, dated 1/1/24-1/31/24, reported a documented dose of Glatiramer on 1/15/24 and 1/30/24.…

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 MI00142998. Based on interview and record review, the facility failed to report mistreatment to the State Agency for one (Resident #101) of three residents reviewed for abuse, resulting in the potential for the resident not being protected from abusive individuals. Findings include: Resident #101 (R101) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R101 admitted to the facility on [DATE] and had diagnoses of cerebrovascular vascular accident with left side weakness, delusional disorder, and mild cognitive impairment. Brief Interview for Mental Status (BIMS) score was a 14 which indicated his cognition was intact (13-15 cognitively intact). Resident was discharged to the hospital on 2/23/2024 and didn't return to the facility. Review of R101's chart revealed a Social Service Note from 2/14/2024 Resident has called APS (Adult Protective Service) stating he is being mistreated. SW (Social Worker) called resident APS Worker and left a message to call this SW 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 This citation pertains to MI00142998. Based on interview and record review, the facility failed to ensure the protection of other residents by thoroughly investigating allegations of mistreatment for one (Resident #101) of three reviewed for abuse, resulting in the potential for abuse to occur with other residents. Findings include: Resident #101 (R101) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R101 admitted to the facility on [DATE] and had diagnoses of cerebrovascular vascular accident with left side weakness, delusional disorder, and mild cognitive impairment. Brief Interview for Mental Status (BIMS) score was a 14 which indicated his cognition was intact (13-15 cognitively intact). Resident was discharged to the hospital on 2/23/2024 and didn't return to the facility. Review of R101's chart revealed a Social Service Note from 2/14/2024 Resident has called APS (Adult Protective Service) stating he is being mistreated. SW (Social Worker) called resident APS Worker and left 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 treated with dignity and respect in 1 (Resident #87) of 3 residents reviewed for dignity and respect, resulting in feelings of frustration. Findings include: Resident #87 Review of an admission Record revealed Resident #87, was originally admitted to the facility on [DATE] with pertinent diagnoses which included heart failure and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #87, with a reference date of 7/27/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #87 was cognitively intact. During an interview on 10/02/23 at 10:49 AM, Resident #87 reported concerns with the way staff treated her. Resident #87 reported that two staff members, Certified Nursing Assistant (CNA) X and CNA LL were often rude and abrupt when caring for Resident #87, and would complain about working, and answering Resident #87's call lights in front of her. Resident #87 also 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.

Based on interview and record review, the facility failed to resolve resident concerns for 1 (Resident #87) of 1 sampled residents reviewed for resolution of concerns resulting in feelings of frustration and a potential decline in psychosocial and mental well-being. Findings include: Review of a Minimum Data Set (MDS) assessment for Resident #87, with a reference date of 7/27/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #87 was cognitively intact. Review of Resident #87's Concern/Grievance Form dated 7/21/23 did not reveal any concerns related to Resident #87's report of staff treatment towards her. Review of Resident #87's Concern/Grievance Form dated 8/8/23 did not reveal any concerns related to Resident #87's report of staff treatment towards her. During an interview on 10/02/23 at 10:49 AM, Resident #87 reported concerns with the way staff treated her. Resident #87 reported that she had reported her concerns to nursing staff, the Assistant Director of Nursing (ADON), and Director of Nursing (DON), but did not feel that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report a incident of neglect (failure to follow the care plan) causing rib fractures in 1 resident (Resident #79) of 3 resident reviewed for accidents, resulting in a fall with major injury after staff did not follow a care plan and it was not reported to the state survey agency within the two-hour required timeframe. Findings include: Review of an admission Record revealed Resident #79 admitted to the facility on [DATE] with pertinent diagnoses which included quadriplegia, depression, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #79, with a reference date of 9/13/2023 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #79 was cognitively intact. Further review of same MDS assessment revealed Resident #79 was totally dependent on 2 persons with bed mobility. Review of a current activities of daily living Care Plan intervention for Resident #79,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an annual Level I evaluation was completed for 1 (Resident #82) of 3 residents reviewed for Preadmission Screening and Resident Review (PASARR), resulting in the potential for unmet mental health and psychiatric care needs. Findings include: Review of an admission Record revealed Resident #82, was originally admitted to the facility on [DATE] with pertinent diagnoses which included major depressive disorder, anxiety, and schizoaffective disorder. Review of Resident #82's Preadmission Screening (PAS)/Annual Resident Review (ARR) dated 6/15/22 indicated the following. Questions 1-4 in section II were marked Yes: 1. Resident #82 had a current diagnosis of mental illness. 2. Resident #82 had received treatment for mental illness. 3. Resident #82 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 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 This citation pertains to intake MI00137950. Based on interview and record review the facility failed to administer prescribed medication in a timely manner after admission for 1 resident (Resident #329) of 6 residents reviewed for medication orders, resulting in the resident not receiving prescribed medication for over 24 hours and 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 #329 admitted to the facility on [DATE] with pertinent diagnoses which included depression, anxiety, schizoaffective disorder, and hypertension. Review of Resident #329's Nurses Note, dated 6/12/2023 at 6:13 PM, revealed Resident #329 admitted to the facility at 6:01 PM on 6/13/2023. Review of Resident #329's June 2023 Medication Administration Record revealed several of her ordered prescription medications did not begin until the evening of June 14th or the morning of June 15th, over 24 hours after she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide consistent, meaningful, and person-centered activities for 1 resident (Resident #67), from a total sample of 26 residents, resulting in the potential for loss of interaction, connectedness, creativity, pleasure, and comfort. Findings include: Review of an admission Record revealed that Resident #67 originally admitted to the facility on [DATE], with pertinent diagnoses which included: Down Syndrome and Alzheimer's Disease. Review of a Minimum Data Set (MDS) assessment for Resident #67, with a reference date of 6/8/23 revealed a Staff Assessment for Mental Status indicated that Resident #67 was severely cognitively impaired. Review of Resident #67's Life Enrichment (LE) Preferences Care Plan revealed, .such as reading, television, strolls, being read to, sensory items, common area, spending time with roommate, social events, music groups. Date initiated 6/6/23 .Interventions: Encourage guest to participate in common area activities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident received proper treatment to maintain hearing abilities for 1 of 1 resident (Resident #44), reviewed for hearing services, resulting in the inability of the resident to attain or maintain the highest practicable level of physical, mental, and psychosocial well-being. Findings include: Review of an admission Record revealed Resident #44 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: cognitive communication deficit. Review of a Minimum Data Set (MDS) assessment for Resident #44, with a reference date of 8/2/23 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #44 was cognitively intact. In an interview on 10/02/23 at 01:21 PM, Resident #44 reported that she had concerns because she could not hear well even with her hearing aides and stated, .someone was supposed to come back and clean my ears .its been a while .…

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 preventative care consistent with professional standards of practice and follow physician ordered treatment for pressure injury/wound care, for 3 of 3 residents (Resident #67, #21 and #79) reviewed for pressure ulcers, resulting in the potential for development of avoidable pressure ulcers for Resident #67, the potential for worsening and/or recurrent pressure ulcers for Resident #21, the delay in wound treatment for Resident #79. Findings include: Resident #67 Review of an admission Record revealed that Resident #67 originally admitted to the facility on [DATE], with pertinent diagnoses which included: down syndrome and alzheimer's disease. Review of a Minimum Data Set (MDS) assessment for Resident #67, with a reference date of 6/8/23 revealed a Staff Assessment for Mental Status indicated that Resident #67 was severely cognitively impaired. Review of Resident #67's Care Plan revealed, Potential for skin management r/t (related…

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 maintain the safety and implement the care plan causing a fall in 1 of 3 residents (Resident #79) reviewed for accidents, resulting in a fall to the floor from the bed and rib fractures. Findings include: Review of an admission Record revealed Resident #79 admitted to the facility on [DATE] with pertinent diagnoses which included quadriplegia, depression, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #79, with a reference date of 9/13/2023 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #79 was cognitively intact. Further review of same MDS assessment revealed Resident #79 was totally dependent on 2 persons with bed mobility. Review of a current activities of daily living Care Plan intervention for Resident #79, initiated 3/12/2021, directed staff that Resident #79 required the assistance of 2 persons with bed mobility. Review of facility…

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 consistently provide thickened liquids for 1 resident (Resident #122) of 2 residents reviewed for nutrition, resulting in the potential for aspiration and the resident to not meet her highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an admission Record revealed Resident #122 admitted to the facility on [DATE] with pertinent diagnosis of dysphagia (difficulty swallowing). Review of a Minimum Data Set (MDS) assessment for Resident #122, with a reference date of 8/21/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #122 was cognitively intact. Review of a current nutrition Care Plan intervention for Resident #122, with a revision date of 8/17/2023, indicated Resident #122 was to have honey thick liquids. Review of Resident #122's active Physician Orders, active 8/15/2023 revealed regular diet, mechanical soft…

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 # MI00139511. Based on interview, and record review, the facility failed to identify and eliminate/mitigate triggers related to a history of abuse/trauma in 1 of 1 resident (Resident #47) reviewed for trauma-informed care, resulting in the potential for re-traumatization. Findings include: According to National Alliance on Mental Illness (NAMI) .Post-traumatic stress disorder (PTSD) is an anxiety disorder that can occur after someone experiences a traumatic event that caused intense fear, helplessness, or horror. PTSD can result from personally experienced traumas (e.g., rape, war, natural disasters, abuse, serious accidents, and captivity) or from the witnessing or learning of a violent or tragic event .While it is common to experience a brief state of anxiety or depression after such occurrences, people with PTSD continually re-experience the traumatic event; avoid individuals, thoughts, or situations associated with the event; and have symptoms of excessive emotions. People with this disorder have these symptoms for longer than one month 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.