Mission Point Nursing & Physical Rehabilitation Ce

Based on observation and interview, the facility failed to maintain general cleanliness and repair. This resulted in the potential for contamination of linens and domestic water. Findings Include: During a tour of the facility, with Maintenance Director (MD) G, starting at 12:23 PM on 7/15/24, the following environmental concerns were noted: Observation of the Beauty shop hair wash sink was found to not have proper backflow prevention on the hose for the hair sprayer. The hose was able to drop below the overflow rim of the sink and be a submerged inlet with no inline atmospheric vacuum breaker. Observation of the 200 Hall linen closet found an open wire rack shelving with no bottom barrier on the bottom rack to protect against contamination from cleaning or accumulation of debris on the floor. At this time the floor underneath the clean linen was found with a heavy accumulation of dust and paper trash debris. During a tour of the Garden utility room it was found that underneath rack storage shelving found accumulation of dust along with paper and packaging debris. During a tour 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 maintain a safe and clean homelike environment for two facility Residents (R42 and R23). R42 Review of the Electronic Medical Record (EMR) admission Record reflected R42 originally admitted to the facility 3/6/23 with pertinent diagnoses that include Repeated Falls, Unsteadiness on Feet, and Morbid Obesity. Review of the MDS dated [DATE] reflected R42 requires partial/moderate assistance with transfers but is non-ambulatory and is confined to a motorized wheelchair for mobility. The medical record reflected R42 is cognitively intact and is her own responsible party. On 7/15/24 at 10:42 AM in the room of R42 it was observed that all flat surfaces to include over the bed table, dresser/ nightstand and counter tops were full and stacked in an unorganized manner with the resident's belongings. An observation and interview were conducted on 7/15/24 at 3:18 PM with R42 in her room. It was observed that the room remained cluttered on all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 # MI00145106 Based on observation, interview, and record review, the facility failed to facilitate administration of, and monitor, a bowel preparation protocol for one Resident (R30) and get him to an appointment for a scheduled colonoscopy, resulting in the resident becoming distraught due to lack of staff assistance to meet his medical needs. Findings: Review of the Minimum Data Set (MDS) dated [DATE] reflected R30 admitted to the facility 3/2/23 and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the Resident was cognitively intact. Section E of the MDS, which reviews Behavior, reflected R30 had displayed verbal behaviors toward others less than daily. Review the Electronic Medical Record (EMR) admission Record reflected R30 has pertinent diagnoses that include Schizoaffective Disorder and Irritable Bowel Syndrome. The EMR also reflected that R30 can make his own decisions. On 7/16/24 at 11:19 AM an observation and interview were conducted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, and record review, the facility failed to implement care to prevent skin break down and maintain range of motion related to a severe contracture for 1 Resident (R6), resulting in R6 having intermittent skin irritation and the potential for skin breakdown. Findings included: Review of R6's face sheet dated 7/15/24, revealed she was admitted on [DATE] and had diagnoses that included: Hemiplegia and hemiparesis (paralyzed one side of body) following unspecified cerebrovascular disease affecting left non-dominant side, moderate protein-calorie malnutrition, diabetes mellitus with diabetic neuropathy (affection nerves), and unspecified symptoms and signs involving cognitive functions following unspecified cerebrovascular disease. R6 was not her own responsible party. R6 was observed in bed on 7/15/24 at 9:54 AM. R6's left hand was in a fist position. (no air space between finger or palm of her hand). R6 was observed in bed on 7/16/24 at 1:48 PM. R6's left hand was in a fist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 thorough assessment of PTSD (post-traumatic stress disorder) and develop and implement an individualized care plan for 1 resident (Resident #60). Findings: Review of the facility admission Record reflected R60 admitted to the facility on [DATE] with a diagnosis of PTSD. The resident was not their own responsible party and had a Legal Guardian (LG H). Review of an admission H and P (History and Physical) dated 6/10/24, documented by Medical Director (MD) J reflected Past Medical and Surgical History: F43.12 - Post-traumatic stress disorder, chronic, F72 - Severe intellectual disabilities . H54.8 - Legal Blindness, as defined in the USA . R44.3 Hallucinations, unspecified, Z62.819 - Personal history of unspecified abuse in childhood. The narrative indicated R60 had been hospitalized from [DATE]th until June 7th (2024) According to a brief hospital note, she has a past history of bilateral blindness, bilateral deafness,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 collaborative hospice care for I Resident (R6) of 2 Residents reviewed for hospice care, resulting in the potential for unmet needs. Findings included: Review of R6's face sheet dated 7/15/24, revealed she was admitted on [DATE] and had diagnoses that included: Hemiplegia and hemiparesis (paralyzed one side of body) following unspecified cerebrovascular disease affecting left non-dominant side, moderate protein-calorie malnutrition, diabetes mellitus with diabetic neuropathy (affection nerves), and unspecified symptoms and signs involving cognitive functions following unspecified cerebrovascular disease. R6 was not her own responsible party. During an interview with Certified Nurse Aide (CNA) C on 7/16/24 at 1:48 PM, CNA C was asked when R6 receives hospice care and what care they provide. CNA C went to the communication board on the unit, and she was not able to locate a hospice care calendar for R6. CNA C recalled a hospice care giver came…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevention measures for 1 Resident (Resident #6) of 2 Residents reviewed for Foley Catheter, resulting in the potential for infection. Findings included: Review of R6's face sheet dated 7/15/24, revealed she was admitted on [DATE] and had diagnoses that included: Hemiplegia and hemiparesis (paralyzed one side of body) following unspecified cerebrovascular disease affecting left non-dominant side, moderate protein-calorie malnutrition, diabetes mellitus with diabetic neuropathy (affection nerves), and unspecified symptoms and signs involving cognitive functions following unspecified cerebrovascular disease. R6 was not her own responsible party. On 7/17/24 at 8:05 AM, R6 was observed in bed. R6's urinary collection bag/tubing and biliary drain bag (medical device used to collect bile (digestive fluids) was observed to be in contact with the floor. CNA (certified nurse aide) E entered the room. CNA E was asked if R6'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 monitor a diabetic resident's blood sugars with insulin administration for 1 resident (Resident #105) of 3 residents reviewed for diabetic care, resulting in the potential for unnoticed hyperglycemia and hypoglycemia and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an admission Record revealed Resident #105 admitted to the facility on [DATE] with pertinent diagnoses which included diabetes mellitus and congestive heart failure. Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 2/24/2024 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #105 was moderately cognitively impaired. Review of Resident #105's May 2024 blood sugar documentation in the electronic medical record revealed blood sugar checks were being performed once a day in April 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 is related to intakes #'s: MI00-141306, MI00-141353, MI00-141884, MI00-142008, MI00-141471, and MI00-142016. Based on observation, interview, and record review, the facility failed to ensure (a) call lights were answered and resident needs were met in a timely manner, (b) that call lights were within reach and accessible, and (c) that fluids were available or within reach for 6 of 6 residents ( Resident #127, Resident #100, Resident #101, Resident #104, Resident #119, and Resident #116), reviewed for accommodation of needs, resulting in delays for staff to meet the residents needs and residents unable to hydrate with or without staff assistance. Findings: Resident #127 (R127) Review of an admission record revealed R127 was a [AGE] year old female, admitted to the facility on [DATE] with pertinent diagnoses of high blood pressure, diabetes mellitus type 2, atrial fibrillation, congestive heart failure, and history of a stroke without residual affects. Review of care plans for R127 identified the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #s: MI00-141471 and MI00-142016 Based on interview and record review the facility failed to follow professional standards of nursing practice for medication administration for 4 residents (Resident #111, #112, #113, and #114), out of 6 residents reviewed for the provision of nursing services, resulting in medication not administered following the physician order and medications administered outside of the physician ordered parameters. Findings: Resident #111 (R111) Review of an admission Record revealed R111 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: hypotension. Review of R111's Physician Order with a start date of 1/6/24 revealed, Midodrine HCl (anti-hypotensive) Tablet 5 MG Give 1 tablet by mouth three times a day for Hypotension Hold if BP (blood pressure) is greater than 130/70. This medication was ordered to be administered at 7:00 AM, 12:00 PM, and 5:00 PM. R111's blood pressure was to be assessed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: MI00-141465 and MI00-141884 Based on observation, interview and record review, the facility failed to 1.) provide care following the comprehensive care planned interventions and facility policy to prevent the development and worsening of avoidable pressure injuries and 2.) assess, monitor, and provide ordered treatment for residents with new/worsening pressure injuries/wounds for 2 residents (Resident #116 and #117) out of 6 residents reviewed for pressure injuries/wounds resulting in increased pain, skin impairment, and the worsening of a wound. Findings: Resident #116 (R116) Review of an admission Record revealed R116 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: muscle weakness, chronic pain, and dysphagia (difficulty swallowing). Review of a Minimum Data Set (MDS) assessment for R116, with a reference date of 11/19/23 revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor and assess 1 of 2 residents (Resident #101) reviewed for positioning. Findings: Resident #101(R101) Review of an admission record revealed R101 was a [AGE] year old male, originally admitted to the facility on [DATE], with pertinent diagnosis of cerebral palsy, epilepsy, paraplegia, gastrostomy with tube feed for hydration and nutrition, and non dominant side monoplegia of upper limb (cannot use his left arm). Review of a Brief Interview for Mental Status (BIMS) dated 01/03/24, revealed a score of 4 out of 15 which indicated R101 had severe cognitive impairment. R101 was dependent on staff to meet all of his needs. During an observation on 01/30/24 at 7:26 AM, R101 laid in bed with no protective boots on, and his feet were rolled in and pressed against each other. R101 stated that he is not able to move his legs to reposition his feet apart. During the same observation the foley collection bag hung (almost full with 1400…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #s: MI00-141465 and MI00-142016 Based on interview and record review, the facility failed to maintain clear and concise controlled substance counts and failed to accurately document administration of controlled substances for 4 residents (Resident #101, #122, #123, and #124). Resident #101 (R101) Review of an admission Record revealed R101 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: epilepsy and neuralgia (nerve pain.) Review of R101's Physician Order with a start date 12/5/23 revealed, PHENobarbital Oral Tablet 64.8 MG (Phenobarbital) Give 1 tablet via NG-Tube at bedtime for Seizure. Review of R101's Controlled Substance Log (narcotic count sheet) revealed Phenobarbital was not administered at bedtime on 1/16/24 or 1/23/24. Review of R101's January Medication Administration Record revealed the Phenobarbital was documented as administered on 1/16/24 or 1/23/24. Review of R101's Physician Order with a start…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 is related to intake # MI00-141456 and MI00-141884 Based on observation, interview, and record review, the facility failed to follow established procedures regarding the storage of medication and controlled substances in 3 of 5 medication carts, 1 of 2 medication store rooms and, 1 of 1 refrigerators used to store controlled substances, reviewed for the labeling and storage of drugs. Findings: During an observation on [DATE] at 10:40 AM, the medication cart sitting outside of room [ROOM NUMBER] contained 7 loose pills in the bottom of the top drawer that held medication cards. During an interview at the time of the observation, the Director of Nursing (DON) indicated that there should not be any loose pills in the medication carts and that there was no way to tell if those medications had actually been given to the resident(s) that they were prescribed to. The pills were given to the DON for identification, however they were inadvertently disposed of. During an observation on [DATE] at 10:46 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement appropriate infection prevention and control practices in 1 of 2 shower rooms reviewed, and 4 residents observed for skin and wounds (Resident #100, #113, #202 and #201) out of 8 residents reviewed for quality care, resulting in cross contamination and the potential for the spread of pathogens throughout the facility affecting all residents. Findings include: Review of a policy Infection Prevention and Control Program dated 1/2024 reflected The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The policy specified, Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: MI00-141471 and MI00-141884 Based on interview and record review, the facility failed to address and resolve grievances for 1 of 4 residents (Resident #108) reviewed for grievances. Findings: Resident #108 (R108) Review of an admission Record revealed R108 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia. During an interview on [DATE] at 11:15 AM, Guardian (G) JJ reported R108 was to have a (colon cancer screening test name omitted) completed approximately 2 years ago. There was an attempt made to submit the test, but it was cancelled due to the facility submitting the specimen outside the guidelines (24 hours). A second test was attempted but that test was also cancelled due to a facility error. G JJ reported that facility has not made any additional attempts to get the test completed. Review of R108's Order Summary revealed (colon cancer screening test name omitted) with a start date of [DATE] and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that nebulizer and supplemental oxygen supplies were maintained and stored appropriately for 1 resident (Resident #108) out of 4 residents reviewed for respiratory care, resulting in the potential for respiratory illness from cross contamination. Findings include: Review of a facility policy Administration Procedures for All Medications revised 08/2020 reflected procedures for nebulized medication administration and specified When treatment is complete, turn off the nebulizer and disconnect the T-piece, mouthpiece, and medication cup . Rinse and disinfect the nebulizer equipment according to manufacturer's recommendations or wash the pieces (except tubing) with warm soap water daily. Rinse with hot water. Allow the components to air dry completely on a paper towel .When equipment is completely dry, store in a plastic bag marked with the resident's name and the date. Resident #108 (R108) Review of an admission Record reflected R108…

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

Based on interview and record review, the facility failed to implement its Antibiotic Stewardship Program for 1 resident (Resident #100) out of 14 residents reviewed for quality care, resulting in the potential for antibiotic resistance. Findings: Review of a policy Antibiotic Stewardship Program last reviewed/revised 1/2023 reflects, It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The Policy Explanation and Compliance Guidelines specified 1. The infection Preventionist, with oversight from the Director of Nursing, serves as the leader of the Antibiotic Stewardship Program; 2. The Medical Director, Consultant Pharmacist, and Attending Physicians and/or Midlevel Providers support the program via active participation in developing, promoting, and implementing a facility wide system for monitoring the use of antibiotics; 3. Licensed nurses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate infection prevention and control practices in 1 of 2 shower rooms reviewed, and 4 residents observed for skin and wounds (Resident #100, #113, #202 and #201) out of 8 residents reviewed for quality care, resulting in cross contamination and the potential for the spread of pathogens throughout the facility affecting all residents. Findings include: Review of a policy Infection Prevention and Control Program dated 1/2024 reflected The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The policy specified, Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 M100140108, M100140527 and M100141143. Based on observation, interview and record review, the facility failed to respond to call lights timely for 3 (Resident #13, Resident #19, and Resident #20) of 4 residents reviewed for call light responses and accommodation of needs. Findings include: Review of concerns reported to the State Agency about a resident having to wet the bed because staff would not answer the call light. Resident #13 (R13) Review of the Face Sheet revealed R13 admitted [DATE] with pertinent diagnoses of stage 4 pressure ulcer, diabetes, and paraplegia. Review of the Minimum Data Set (MDS) revealed R13 is cognitively intact and has limited range of motion on bilateral lower extremities and needs substantial/maximal assistance to roll left to right. R13 In an interview on 11/29/23 at 8:10 AM, R13 was in bed and reported that he will turn on his call light for help to get repositioned and staff will come in and turn off his call light without meeting his needs. He…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes MI00140221 and MI00140108. Based on observation, interview and record review, the facility failed to provide showers for 2 (Resident #2 and Resident #12) of 5 residents reviewed for showers. Findings include: Resident #12 (R12) Review of a Face Sheet revealed R12 originally admitted to the facility on [DATE] and has pertinent diagnoses of hemiplegia and hemiparesis (one sided weakness) and dementia. During an observation on 11/28/23 at 1:26 PM, R12 was observed being transported by staff from the dining room to the main intersection of the hallway where Certified Nursing Assistant (CNA) N was observed brushing R12's hair that was oily, matted and tangled. Review of a Shower documentation schedule dated 10/31/23 to 11/24/23 for R12 revealed: Shower Scheduled FRIDAY MORNING AND TUESDAY EVENING - I prefer showers so my hair can get washed. Please do not give me bed baths. The resident received one shower and 5 bed baths total. Review of the Care Plan intervention last revised on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation is linked to intake #MI00140108 Based on observation, interview, and record review, the facility failed to follow facility policies/procedures and best practice standards for 1 of 2 residents (Resident #17) reviewed for tube feed services, resulting in the potential for (a) the incorrect amount of nutrition and hydration delivered to the resident, (b) contaminated equipment inserted into the G-tube, and (c) growth of bacteria on disposable and time limited supplies. Findings: Resident #17 (R17) Review of an admission record revealed R17 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses of Huntington's Disease, dysphasia (difficulty swallowing), and the need for and presence of a feeding tube placed in her stomach. R17 had severe cognitive impairment and relied totally on staff for nutrition and hydration. Review of an electronic medication administration record (Emar) dated November 2023 for R17, reflected an order for tube feed Glucerna 1.2 cal,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 is linked to intake #MI00139451 Based on interview and record review, the facility failed to follow procedures for administering and documenting the use of controlled substances for one of two residents (Resident #1) reviewed, resulting in the potential for medication diversion and the resident not receiving physician ordered pain medications as prescribed. Findings: Resident #1 (R1) Review of an admission Record revealed R1 was a [AGE] year old male, last admitted to the facility on [DATE], with pertinent diagnoses of several pain related conditions including migraines, trigeminal neuralgia (a disorder that involves sudden, severe facial pain), polyneuropathy (the simultaneous malfunction of nerves throughout the body), knee pain, and other chronic pain. Review of physician orders for R1 reflected an order for the controlled substance Morphine Sulfate (MS) 15 milligrams (mg) IR (immediate release) one tablet by mouth every 4 hours as needed for pain management. Review of the electronic medication…

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

Based on observation, interview, and record review, the facility failed to maintain locked treatments carts, for 3 of 4 treatment carts, out of 4 carts observed, resulting in the potential for accidental ingestion and misappropriation of physician ordered treatments. Findings: During an observation on 11/28/23 at 8:50 AM, the treatment cart located in the short hall, outside the garden unit and near the garden unit sign, and next to the exit door, was unlocked and unattended. The cart contained prescription medications including but not limited to Diclofenac and Triamcinolone and the over the counter (OTC) medications antifungal cream and zinc oxide. During an observation on 11/28/23 at 9:10 AM, the treatment cart located on the garden unit was unlocked and unattended. The cart contained prescription medications including but not limited to Diclofenac and Ketoconazole and the OTC medication hydrocortisone cream. The cart also contained two bottles of bug spray: Off and Cutter. During an interview on 11/28/23 at 9:15 AM, Registered Nurse (RN) T indicated that treatment carts were to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake M100141143. Based on interview and record review, the facility failed to address and resolve grievances for 1 (Resident #13) of 1 resident reviewed for grievances. Findings include: Resident #13 (R13) Review of the Face Sheet revealed R13 admitted [DATE] with pertinent diagnoses of stage 4 pressure ulcer, diabetes, and paraplegia. Review of the Minimum Data Set (MDS) revealed R13 is cognitively intact and has limited range of motion on bilateral lower extremities and needs substantial/maximal assistance to roll left to right. R13 In an interview on 11/29/23 at 8:10 AM, R13 was in bed and reported he had a shower on Monday (11/27/23) and his pressure ulcer dressing came off and it was not put back on him until the following day. He reported the staff had not done his dressing this morning at 5:00 AM and feared he probably would not get it done this day now. R13 reported the staff will wake him up at 5:00 AM to do his dressing changes when he is trying to sleep and complained that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 refers to MI00140350 Based on interview and record review, the facility failed to protect the resident's right to be free from physical restraints for 1 of 20 residents (R9), resulting in R9 being unable to move or use her call light for assistance for approximately 10 hours. Findings include: A review of the facility's Restraint Free Environment policy, revised 6/23, revealed, A physical restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot moved easily, which restricts freedom of movement or normal access to one's body. Physical restraints may include . Tucking in a sheet so tightly that the resident cannot get out of bed, or fastening fabric or clothing so that a resident's freedom of movement is restricted . A review of R9's admission Record, dated 11/30/23, revealed R9 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R9's admission Record revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake M100140527. Based on observation, interview and record review, the facility failed to provide toileting/incontinence care for 1 (Resident #12) of 2 residents reviewed for toileting/incontinence care. Review of concerns reported to the State Agency were allegations of staff not answering the call light and the resident had to wet the bed then forced to take herself to the bathroom using a walker. Resident #12 (R12) Review of a Face Sheet revealed R12 originally admitted to the facility with pertinent diagnoses of Hemiplegia and hemiparesis (one sided weakness), diabetes, and dementia. Review of the Minimum Data Set (MDS) dated [DATE] revealed severely cognitively ---- And has limited range of motion on one side of upper and lower extremities and is always incontinent. MDS is not completed. During several observation on 11/28/23 at approximately 10:00 AM, 11:00 AM, and 12:00 PM, R12 was observed in the dining room sitting in her wheelchair at the table alone with her eyes closed at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that nebulizer and supplemental oxygen supplies were maintained and stored appropriately for 1 resident (Resident #108) out of 4 residents reviewed for respiratory care, resulting in the potential for respiratory illness from cross contamination. Findings include: Review of a facility policy Administration Procedures for All Medications revised 08/2020 reflected procedures for nebulized medication administration and specified When treatment is complete, turn off the nebulizer and disconnect the T-piece, mouthpiece, and medication cup . Rinse and disinfect the nebulizer equipment according to manufacturer's recommendations or wash the pieces (except tubing) with warm soap water daily. Rinse with hot water. Allow the components to air dry completely on a paper towel .When equipment is completely dry, store in a plastic bag marked with the resident's name and the date. Resident #108 (R108) Review of an admission Record reflected R108…

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

Based on interview and record review the facility failed to implement its Antibiotic Stewardship Program for 1 resident (Resident #100) out of 14 residents reviewed for quality care, resulting in the potential for antibiotic resistance. Findings: Review of a policy Antibiotic Stewardship Program last reviewed/revised 1/2023 reflects, It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The Policy Explanation and Compliance Guidelines specified 1. The infection Preventionist, with oversight from the Director of Nursing, serves as the leader of the Antibiotic Stewardship Program; 2. The Medical Director, Consultant Pharmacist, and Attending Physicians and/or Midlevel Providers support the program via active participation in developing, promoting, and implementing a facility wide system for monitoring the use of antibiotics; 3. Licensed nurses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 # MI00136667 and MI000137509 Based on interview and record review, the facility failed to maintain clear and concise controlled substance count and failed to accurately document administration of controlled substances for 4 residents (Resident #53, #70, #71, and #60), resulting in the potential for overdose and/or ineffective management of pain, and the potential for drug diversion of controlled substances. Resident #53 (R53) Review of an admission Record revealed R53 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: chronic pain syndrome. Review of R53's Medication Administration Record revealed, traMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 2 tablet by mouth every 6 hours as needed for pain. Start Date 4/24/23. Review of R53's Controlled Substance Record revealed Tramadol 50mg was administered by Licensed Practical Nurse (LPN) T on: *8/10/23 at 2:00 PM 1 tab *8/13/23 1 tab with no administration time…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI000138229 Based on interview and record review, the facility failed to ensure residents were free from neglect for one resident (Resident #65) who was left unattended in a shower room for 45 minutes after staff forgot she was there, resulting in fear and ongoing anxiety. Findings: Review of the facility policy Abuse, Neglect and Exploitation last reviewed 6/2023 reflected It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy indicates that Neglect means the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy also reflected Possible indicators of abuse include but are not limited to .8. Failure to provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 # MI00136833 Based on observation, interview, and record review, the facility failed to assess, monitor, and care for a resident receiving enteral tube feedings per facility policy and professional standards of care for 1 resident (Resident #2-41) reviewed for enteral tube feedings, resulting in the potential for aspiration pneumonia and an overall deterioration of health status. Findings: Resident #2-41 (R2-41) Review of an admission Record revealed R2-41 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dysphagia (difficulty swallowing). Review of R2-41's Order Summary dated 3/13/23 revealed, Enteral Feed Order every shift Enteral 2b - Care: Elevate head of bed 30-45 degrees (semi-Fowler's position) during feedings and at least 1 hour after feeding to prevent aspiration/pneumonia. Review of R2-41's Care Plan revealed, I am unable to meet nutritional needs by mouth as evidenced by Dysphagia and need for 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 #: MI00129228 and MI00130172 Based on observation, interview, and record review the facility failed to; 1. Keep general cleanliness in the walk in cooler and dish area fans; 2. Properly store raw animal product; 3. Clean food and non-food contact surfaces to sight and touch; and 4. Ensure proper working order of the dish machine. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 84 residents who consume food from the kitchen. Findings Include: 1. During a tour of the kitchen, starting at 8:52 AM on 4/30/23, it was observed that an accumulation of debris was evident around the perimeter of the floor and around wheels of the storage racks. Further review found staining and spillage at the back left corner of the unit. At this time, an interview with Dietary Manager (DM) M found that the walk-in cooler should get swept out daily. During a tour of the dish machine area, at 9:39 AM on 4/30/23, it was observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 #MI00129228, MI0013017, MI00132506, MI00134457, MI00135649 and MI00135650. Based on observation, interview, and record review, the facility failed to maintain dignity and respect for 5 residents and members of the confidential resident council group, Resident #3 (R3), R33, R34, R47 and R75, reviewed for respect. This deficient practice resulted in feelings of disrespect and the potential for avoidable negative psychosocial outcomes for residents. Findings included: R33 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R33 admitted to the facility on [DATE] with diagnosis of (but not limited to) heart failure, chronic kidney disease and overactive bladder. Brief Interview for Mental Status (BIMS) reflected a score of 14 out of 15 which represented R33 was cognitively intact. R3 required extensive staff assistance of 1-2 with all activities of daily living. Review of the Bladder Care Plan dated 1/4/22 reflected a goal of, I will be continent during waking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete and provide 4 residents and their advocates baseline care plans within 48 hours of admission (R3, R137, R139, R238), resulting in the potential for unmet needs to be addressed in their plan of care. Finding include: Review of the facility policy, Baseline Care Plan - Person Centered, revealed, 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. B. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders. ii Physician order. iii Dietary orders. Iv Therapy services. V. Social services. Vi. PASSAR recommendation, if applicable. 3. A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. R3 Review of R3's face sheet dated, May 1, 2023, revealed she was an [AGE] year-old female admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide consistent, meaningful, and person-centered activities for 5 residents (Resident #1, #288, #60, #289, and #47) and residents in a confidential group meeting, resulting in the potential for loss of interaction, self-esteem, growth, sense of wellbeing, connectedness, creativity, pleasure, and comfort. Findings: Resident #1 (R1) Review of an admission Record revealed R1 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia. Review of R1's Activity Care Plan revealed, I am here for long term care and will be invited to participate in the activity program. Date Initiated: 04/01/2022 . I will maintain active participation in group and independent activities with set up and cues as needed .Please invite and encourage me to attend group activities of interest including music programs, religious programs, socials, crafts, exercise, active games, etc. I also enjoy…

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

During an observation on 08/30/23 at 12:40 PM, the Brookside-even medication cart contained a residents Insulin Glargine pen that had been opened and used, but was not labeled with an open date or an expiration date. During an observation on 08/30/23 at 12:55 PM, the Brookside-odd medication cart contained 1 and 1/2 loose unidentified pills in the second drawer. During an observation on 08/30/23 at 1:07 PM, the Lakeshore Med Storage Room: (a) contained an unlocked refrigerator that stored controlled substances, thereby storing controlled substances behind a single locked door and not double locked, (b) did not have a refrigerator temperature check set up. During an interview, at the time of the observation, the Assistant Director of Nursing (ADON) indicated that the refrigerator should have a temperature log set up so that it can be checked routinely by staff. During an observation on 08/30/23 at 1:45 PM, the Lakeshore medication cart: (a) was unlocked and unattended by staff, (b) contained an Insulin Glargine pen with a residents first name written on the cap of the pen, and that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 #: MI00129228, MI00130172, MI00132801, MI00134457 and MI135739. Based on observation, interview, and record review, the facility failed to provide 1.) meals in a timely manner, 2.) palatable food, and 3.) evening snacks to 1 resident (Resident #34) and residents in the confidential group meeting, resulting in the potential for decreased food consumption and nutritional decline. Findings: Review of the Resident Council Minutes dated 1/9/23 revealed, .Kitchen *Food always cold *I'm sick of my food being late. *Resident is wondering why they have to drop their menus off at the front desk. Wondering if there is more efficient way to do this . Review of the Resident Council Minutes dated 1/9/23 revealed, .Kitchen .Concerns: *Food is too cold *Don't get the food we order . During a confidential group interview, with 14 residents present, on 05/02/2023 at 11:05 AM, the following concerns were identified: 1 resident reported that the meals posted are not always served what we order we…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 offer different accommodations (offer a different room) to the 4 Residents in rooms [ROOM NUMBERS] while their hand sink ceased to function over the last several weeks, potentially affecting their needs for quality and continuity of care by staff and resulting in longer waits for care to be completed. Findings include: During the initial tour on 4/30/23, an aide was overheard walking of room [ROOM NUMBER] asking another aide When will this hand sink be fixed? During an interview on 5/3/23 at 2:05 PM, Certified Nurse's Aide (CNA) W revealed she tries to take the residents in 308 and 310 down to the shower room for care because it's easier when getting them residents cleaned up, especially if the glove becomes soiled or it breaks then a hand wash and new pair of gloves are required. CNA W further revealed it makes it easier on the residents during first and second shift to not leave them while I run down the hall to wash my hands and come…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriately formulate advance directives for 2 residents, Resident #33 (R33) and Resident #49 (R49) reviewed for advance directives. This deficient practice resulted in R33's advance directive signed by the non activated legal decision maker and R49's code status was unclear regarding treatments desired. Findings included: The facility provided a copy of the policy for Residents' Rights Regarding Treatment and Advance Directives, dated [DATE], last revised on 12/2020 for review. The policy reflected, 7. During the care planning process, the facility will identify clarify, and review with the resident or legal representative whether they desire to make any changes related to any advance directives. 8. Decisions regarding advance directives and treatment will be periodically reviewed, the existing care instructions and whether the resident wishes to change or continue these instructions . R33 Review of the Face Sheet and Minimum Data Set (MDS) 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 number MI00136215, and MI00135650. Based on interview and record review, the facility failed to implement the abuse policy to report abuse timely and thoroughly investigate for one resident, Resident #75 (R75), reviewed for abuse. This deficient practice resulted in R75 feeling unsafe and the potential for other residents to be at risk for ongoing abuse. Findings include: The facility provided a copy of the Abuse, Neglect and Exploitation dated 1/28/2002, last revised on 4/2023 for review. The policy reflected, III Preventions .D. The facility will identify by ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect (i.e., verbally, physically, or sexually aggressive behavior, wandering .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and other who might have knowledge of the allegations .6. Providing complete and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake number MI00135650. Based on interview and record review, the facility failed to implement interventions from a comprehensive care plan for 2 residents (Resident #41 and Resident #75), resulting in the potential for impaired physical, mental, and psychosocial well-being. Findings include: Resident #41 (R41) Review of an admission Record revealed R41 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dysphagia (difficulty swallowing) and pressure ulcer of sacral region, stage 4. Review of R41's nutrition Care Plan revealed, I am unable to meet nutritional needs by mouth as evidenced by Dysphagia and need for a Gastrostomy Tube (20FR.) Date Initiated: 03/03/2023 .I need the HOB (head of bed) elevated 30 degrees during and one hour after tube feed. Date Initiated: 03/03/2023 . Review of R41's wound Care Plan revealed, I have a Pressure Injury, Stage: 4. Location: Coccyx (buttocks) and malleolus (ankle). These wounds…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake number MI00135650. Based on observations, interview and record review, the facility failed to prevent accident hazards for 1 Resident (R75) and failed to have safety measures in place for 2 Residents (R68 and R139), resulting in R75 hitting her head during care, R68 not having proper head support during a lift transfer and the potential for injury when R139's cigarette's were not secured and she was signing out of the facility independently. Findings include: R68 Review of R68's face sheet dated 4/30/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnosis that included: hemiplegia (weakness one side of the body), vascular dementia and diabetes mellitus II. He was his own responsible party. On 5/2/23 at 2:17 PM, R68 was observed being transferred from his wheelchair to bed with an electronic full body lift, by Staff U and V. The sling was not supportive in the head/neck region. Staff U and V were asked about the equipment that goes into the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 1 Resident (R10) did not have unintended weight loss, resulting in R10 having unplanned weight loss and the potential to delay healing of pressure ulcers. Findings included: Review of R10's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (left sided weakness due to brain injury), epilepsy, abnormal posture, and chronic pain. She was not her own responsible party. Review of R10's weights for the last year revealed she weighted 236 pound a year ago. She had significant weight loss on 8/2/22 when she went from 246 pounds to 231.5 pounds. She dropped to her lowest weight 8/23/22 at 224 pounds and has had weight fluctuations ever since. Her weight 3/28/23 was 235.8 pounds. Her last weight was 4/7/23 and was again back down to 224 pounds. Review of R10's Wound…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess, monitor, and care for a resident receiving enteral tube feedings per facility policy and professional standards of care for 1 resident (Resident #41) reviewed for enteral tube feedings resulting in the potential for aspiration pneumonia and an overall deterioration of health status. Findings: Resident #41 (R41) Review of an admission Record revealed R41 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dysphagia (difficulty swallowing). Review of R41's Order Summary dated 3/13/23 revealed, Enteral Feed Order every shift Enteral 2b - Care: Elevate head of bed 30-45 degrees (semi-Fowler's position) during feedings and at least 1 hour after feeding to prevent aspiration/pneumonia. Review of R41's Care Plan revealed, I am unable to meet nutritional needs by mouth as evidenced by Dysphagia and need for a Gastrostomy Tube (20FR.) Date Initiated: 03/03/2023 .I need 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 observations, interviews and record review, the facility failed to clean and label residents' respiratory equipment for 1 Resident (R31) in a manner that prevents contamination and the risk of respiratory illnesses, resulting in the potential for respiratory illnesses. Findings: Resident #31 Review of Resident #31's admission Record, dated 5/2/23, revealed R31 was admitted to the facility on [DATE] and had the following diagnoses: COPD, Essential Hypertension, Dementia with behavioral disturbance, depression, and chronic pain. party. Resident #31's Brief Interview of Mental Status (BIMS) quarterly assessment dated [DATE], reflected (under section C0100) that an interview should not be conducted because the resident is rarely/never understood. During an observation of R31's room on 04/30/23 at 9:05 AM, revealed an unlabeled oxygen concentrator and storage bag. Further observation reflected no date on the oxygen tubing. R31 was on 4L of O2 via nasal cannula during the observation. Observation of R31'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 observations, interviews and record review, the facility failed to adequately assess and address pain for 2 Residents (R3 and R10), resulting in both Residents experiencing uncontrolled pain for long periods of time. Findings include: Review of R3's face sheet dated, May 1, 2023, revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included vesicontestinal fistula (an opening between the bladder and the bowel), Dementia, protein-calorie malnutrition, and fracture of unspecified carpal bone right wrist. She was not her own responsible party. Review of R3's Hospice orders dated 4/25/23 at 5:00 PM, revealed R3 was started on hospice. Review of R3's physician orders dated, 4/30/23 revealed, Oxycodone HCL Oral Tablet 6 mg, give 1 tablet three times a day for Pain, may crush. Review of R3's physician orders dated, 4/30/23 revealed, Oxycodone HCL Oral Tablet 6 mg, give 1 tablet every 1 hour for Breakthrough Pain, SOB (shortness of breath). On 4/30/23 at 8:59 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure communication, collaboration, and coordination of care with the dialysis unit for one resident, Resident #77 (R77) reviewed for dialysis care. This deficient practice resulted in minimal assessments being conducted before and after dialysis treatments, communication, collaboration, or coordination of care between the facility and the dialysis unit for R77 and the potential for change in care or treatment to be missed or not provided. Findings: The facility provided a copy of the policy/procedure for Care Planning Special Needs- Dialysis with a Revised-on date of 12/20. The policy reflected: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving dialysis. Policy Explanation and Compliance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one resident (Resident #77) received his cancer medication according to physician order, resulting in a significant medication error when the facility failed to acquire and provide this necessary medication. Findings: Resident #77 Review of an admission Record revealed Resident #77 was admitted to the facility on [DATE], with pertinent diagnoses including type 2 diabetes mellitus complications, end stage renal disease, severe protein-calorie malnutrition, and malignant neoplasm of prostate. Brief Interview for Mental Status (BIM's) reflected a score of 15 out of 15 which means R77 is cognitively intact. During an interview on 5/1/23 at approximately 9:45 AM, resident mentioned a concern about the facility not always giving him his nightly cancer pills. Resident stated, I need my pills, I want to fight this, but the staff are not helping me! During an interview on 5/3/23 at 1:56 PM, resident stated, they are not giving me my cancer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interview and record review, the facility failed to provide collaborative hospice care for 1 Resident (R3) resulting in the potential for care and service to be missed. Findings include: Review of R3's face sheet dated, May 1, 2023, revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included vesicontestinal fistula (an opening between the bladder and the bowel), Dementia, protein-calorie malnutrition, and fracture of unspecified carpal bone right wrist. She was not her own responsible party. Review of R3's Hospice orders dated 4/25/23 at 5:00 PM, revealed R3 was started on hospice. On 4/30/23 at 8:59 AM, R3 was observed in bed talking to herself, please, please, please, help me. She was moaning in pain. Review of the narcotic administration sheets on 4/30/23 at 2:50 PM revealed R3 had not been given any narcotic pain medication on 4/30/23. On 4/30/23 at 3:00 PM, R3 was observed moaning in bed. During an interview with the Nursing Home…

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