The Orchards at Harper Woods

Based on interview and record review, the facility failed to ensure certified nurse aides (CNAs) completed the required 12 hours of in-service education annually for three (E, F, and G) of five CNAs reviewed for inservice education. Findings include: A review of the following three certified nurse aide annual 12-hour nurse aide training/ in-services were reviewed: CNA E was hired on 3/1/22. There were no 12-hour training/ in-services provided by the facility. CNA F was hired on 3/16/22. There were no 12-hour training/ in-services provided by the facility. CNA G was hired on 3/14/17. There were no 12-hour training/ in-services provided by the facility. On 3/25/25 at 3:37 PM, Staff Developer B was asked about the missing 12 hours of training, and explained that she is new in the position, and acknowledged that she has been trained differently on when and how CNA's 12 hours of training annually were met. On 3/25/25 02:00 PM, the Director of Nursing (DON) was asked about the 12 hours of CNA training not being completed, and she explained her expectation is that CNAs meet their required…

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 timely revise care plans to accurately reflect identified problems and interventions for one resident (R55) of one residents. Findings include: On 3/23/23 at 9:00 AM, R55 was noted in their room noted laying halfway off the bed and on the floor. R55 was noted to be in a wet brief which was hanging off. When asked about about the care, R55 appeared confused and stated they were unsure about what to do. On 3/24/25 at 8:45 AM, R55 was observed in their room with a shirt on, no brief, no non-slip socks, looking for something to eat. On 03/25/25 at 9:00 AM, R55 observed in their room walking barefoot. A review of R55's electronic medical record revealed R55 was admitted on [DATE] with multiple diagnoses including Acute Respiratory Failure, Dementia, Anxiety and Macular Degeneration. A review of R55's Minimum Data Set (MDS) assessment dated on 12/26/2024 revealed a Brief Interview of Mental status (BIMS) assessment of 13 indicating resident is…

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 adaptive equipment for one resident (R40) out of three reviewed for Activities of Daily Living (ADLs). Findings include: On 3/24/2025 at 2:18 PM, R40 was observed in their room eating lunch. R40 was observed trying to pick their water cup up and dropped the cup on themselves. R40's water cup was noted to be in a foam cup. R40 reported they usually have a smaller sippy cup that makes it easier for them to drink their water. R40 reported the cup broke about two months ago and someone stated they were ordering a new one. R40 indicated they had not heard anything else about the new cup. A review of the medical record revealed that R40 admitted into the facility on [DATE] with the following medical diagnoses, Epilepsy and Dysphagia. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status assessment score of 10/15 indicating an impaired cognition. R40 also required staff assistance with bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete and document skin treatments for one resident (R93) of one reviewed for skin treatments/documentation. Findings include: On 3/23/25 at 9:24 AM, R93 was observed sitting on the side of their bed, right leg observed wrapped in a bandage and undated. R93 explained that they had gotten into an accident which caused the wound on their leg, but was unsure of the last date their bandage had been changed. A review of R93's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Cellulitis of the Right Lower Limb and Peripheral Vascular Disease. Further review revealed that the resident was cognitively intact and required limited assistance with toilet use, bathing, and dressing. Further review of the medical record revealed the following physician order dated 1/8/25, Right Lower Leg: Cleanse with Wound Cleaner, pat dry apply medihoney cover with Abd (abdominal pads) and kerlex. every day…

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 turn, reposition, and implement offloading interventions to prevent further skin breakdown for one resident (R85) of three residents reviewed for pressure ulcers. Findings include: On 3/24/25 at 2:29 PM, R85 was observed laying on their backside without pillows under either side of R85's body. On 3/25/25 at 9:12 AM and 11:15 AM, R85 was observed laying on their backside without pillows under either side of R85's body. A pillow was observed under R85's feet. On 3/25/25 at 12:19 PM, an observation of R85's wound was made, the wound was clean, with some slough present, and scar tissue was observed surrounding wound. On 3/25/25 at 2:05 PM, R85 was observed laying on their backside without pillows under either side of R85's body. Three pillows were observed laying in a chair. A review of R85 medical record revealed, R85 was admitted to the facility on [DATE] with diagnosis of Encephalopathy. A review of R85's quarterly Minimum Data Set (MDS)…

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

Based on observation, interview, and record review, the facility failed to apply a splint/brace for one resident (R34) out of two reviewed for limited mobility. Findings include: On 3/24/2025 at 8:30 AM, R34 was observed laying in the bed, a towel was observed rolled up in their left hand. No brace/splint was observed to be in place. A review of the medical record revealed that R34 admitted into the facility with the following medical diagnoses, Dysphagia and Cerebral Infarction. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 99, indicating they were unable to complete the assessment. R34 also required staff assistance with bed mobility and transfers. Further review of the physician orders revealed the following orders, B/L (Bilateral) elbow splint/hand splint .Active. On 3/25/2025 at 8:58 AM, R34 was observed laying in the bed, a towel was observed rolled up in their left hand. No brace/splint was observed to be in place. On 3/25/2025 at 11:57 AM, an interview was conducted with the Director of Nursing (DON). The DON…

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 meals were served at a preferred and palatable temperature for three sampled residents (R20, R31, and R94) from a total of three sampled residents reviewed for food palatability. Findings include: R20 On 3/23/25 at 9:30 a.m., R20 was observed laying in the bed. R20 expressed several concerns pertaining to the meals. R20 saying, it is a shame that my daughter has to spend money to buy food so I can have something decent to eat. The vegetables served last week were cold and hard. A review of R20's electronic medical record revealed R55 was admitted on [DATE] with multiple diagnoses including Chronic Obstructive Pulmonary Disease, Bilateral Osteoarthritis of the knee, Major Depressive Disorder and Alcohol Abuse. A review of R20's Minimum Data Set (MDS) assessment dated on 2/08/2025 revealed a Brief Interview of Mental status (BIMS) assessment of 15 indicating resident is cognitively intact. R31 On 3/23/25 at 9:26 AM, R31 reported the…

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

Based on interview and record review, the facility failed to obtain consent and/or declination for influenza and pneumococcal immunizations for two residents (R34 and R92) out of five reviewed for immunizations. Findings include: On 03/25/2025 at 11:30 AM, the infection control task was completed with the Director of Nursing (DON) and acting Infection Control Preventionist (ICP) C. R34 A request was made to review the influenza and pneumonia consents and/or declinations for R34. ICP C stated they knew the responsible party for R34 refused all vaccinations, however they did not know where the papers were with the refusals. A review of the medical record revealed that R34 admitted into the facility with the following medical diagnoses, Dysphagia and Cerebral Infarction. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 99, indicating they were unable to complete the assessment. R34 also required staff assistance with bed mobility and transfers. No consent or declination was received by the end of survey. R92 A request was…

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

Based on interview and record review, the facility failed to obtain consent or declination for the COVID-19 immunization for two residents (R34 and R92) out of five reviewed for immunizations. Findings include: On 03/25/2025 at 11:30 AM, the infection control task was completed with the Director of Nursing (DON) and acting Infection Control Preventionist (ICP) C. R34 A request was made to review the Covid-19 consent or declination for R34. ICP C stated they knew that the responsible party for R34 refused all vaccinations, however they did not know where the papers were with the refusal. A review of the medical record revealed that R34 admitted into the facility with the following medical diagnoses, Dysphagia and Cerebral Infarction. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 99, indicating they were unable to complete the assessment. R34 also required staff assistance with bed mobility and transfers. No consent or declination was received by the end of survey. R92 A request was made to review the Covid-19 consent or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a tube feeding pole and floor in a sanitary manner for three sampled residents (R3, R19, and R85) out of five reviewed for tube feeding. Findings include: R3 On 3/23/25 at 10:01 AM, R3 was observed in bed with a tube feeding pole next to the bed. The pole and floor were observed with large amounts of dried formula on them. On 3/24/25 at 9:04 AM and at 2:27 PM, the tube feeding pole and floor was observed in the same condition. A review of R3's medical record noted, R3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Debility, Cardiorespiratory Conditions. A review of R3's annual Minimum Data Set (MDS) assessment, dated 2/2/25 noted, R3 with a severely impaired cognition and dependent of staff for activities of daily living (ADLs). A review of R3's order noted, in the evening Jevity 1.5 @60cc/hr x 16 hrs (hours) Up at 6pm for 16 hours or until dose complete to provide 960cc (cubic centimeter)…

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 MI00148002. Based on interview and record review, the facility failed to ensure the right to manage finances and assist with community banking services for one resident (R700) of three residents' reviewed for residents rights. Findings include: On [DATE] at approximately 10:00 AM, an interview was conducted with R700 regarding concerns with finances. R700 stated facility was harassing them about paying their bill and issued them an involuntary discharge notice. R700 presented the involuntary discharge form that was served to resident on [DATE]. R700 said I am upset because I like it here. I have the money but have trouble getting it from bank and my drivers license had expired. I want to pay it and stay here. My debit card only let's me get $500 a day. A review of R700's medical record revealed R700 was admitted on [DATE] with multiple diagnoses including spinal stenosis, osseous and subluxation stenosis of intervertebral foramina of the lumbar region, inflammatory spondylopathy,…

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 MI00147481. Based on interview and record review, the facility failed to permit readmission and/or provide proper notice of facility-initiated discharge for one resident (R702) following a hospitalization out of one reviewed for transfers and discharges. Findings include: A review of intake MI00147481 noted the following, Patient was seen and cleared by our behavioral health psych social worker on 10/10/24.Patient was also medically cleared to return to nursing facility on 10/10/24. [Facility name] refused to take patient back into their facility. Patient is a long-term resident at the facility and has been residing at the facility since March 2024. A review of the medical record revealed R702 admitted into the facility on 2/28/2024 with the following diagnoses, Unspecified Dementia without Behavioral Disturbances and Anxiety. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 5/15 indicating an impaired cognition. R702 also required assistance with bed mobility and transfers. Further review of the…

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

This citation pertains to Intakes MI00147184 and MI00147299. Based on observation, interview, and record review, the facility failed to provide fresh water in a timely manner for residents (R701, R702, R703, and R705) out of five reviewed for hydration. Findings include: A review of Intake MI00147299 noted the following, Complainant states [they] are not receiving fresh water daily. R701 On 10/9/2024 at 10:16 AM, R701's water was observed on the bedside table. The water was noted to be dated 10/9/2024 from 11PM-7AM. The water cup was noted to be warm and empty. At 12:04 PM and 12:54 PM, R701 was observed with the same water cup dated 10/9/2024 from 11PM-7AM. R701 stated they never provide them with fresh water and it is an ongoing problem. R702 On 10/9/2024 at 10:51 AM, R702's water was observed on the bedside table. The water was noted to be dated 10/9/2024 from 11PM-7AM. The water cup was noted to be warm and half full. On 10/9/2024 at 12:05 PM, R702 was noted to be in their wheelchair. R702 water cup was observed to be the same cup dated 10/9/2024 from 11PM-7AM. R702 stated they…

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 MI00147226. Based on observation, interview, and record review, the facility failed to ensure dignity and respect was maintain for one sampled resident (R704) of two reviewed for respect and dignity. Findings include: A review of the Intake allegations revealed, An allegation was reported the resident (R704) was verbally abused by an employee (Certified Nursing Assistant (CNA) C). On 10/09/24 at 10:20 AM, R704 was asked about the incident with CNA C. R704 explained that during care, CNA C called them out of their name and referred to their buttocks as a rump roast. R704 further explained this was not the first time they had a problem with CNA C, and they were trying to deal with the ongoing things CNA C would say. R704 was asked if they shared the experiences they had with CNA C. R704 stated, they had conversations with the Unit Manager and the Wound Care Nurse (WC Nurse). R704 was asked how the incident affected them. R704 stated, I felt less than human. R704 continued and explained…

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 Intakes MI00147299 and MI00147184. Based on observation, interview, and record review, the facility failed to ensure call lights were answered, functioning and within reach for two residents (R702 and R704) out of three reviewed for call lights. Findings include: R702 On 10/9/2024 at 10:51 AM, R702 was observed in bed and stated they were ready to get dressed and in the chair. R702 was asked if they had pressed (activated) their call light. R702 stated they did not know where the call light was at. An observation of the call light unit on the wall noted that there was no cord for R702 to push the call light. R702 was asked how long they have been without a call light. R702 stated they did not know. On 10/9/2024 at 10:53 AM, Certified Nursing Assistant (CNA) B was shown the call light unit on the wall and R702 did not have a call light button. CNA B proceeded to switch the call light cord out and stated they were going to notify maintenance. CNA B stated they did not know the call light button for R702 was missing. On 10/9/2024 at 12:05 PM, R702 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 citiation pertains to Intake: MI00146442 Based on observation and interview, the facility failed to maintain a sanitary environment potentially affecting all 129 residents whom reside in the facility. Findings include: On 9/5/24 at 9:03AM, 10:19 AM, 11:10 AM, and at 12:20 AM, a wheelchair was observed in the hallway outside room [ROOM NUMBER] with a pile of dirty clothing on it. On 9/5/24 at 9:18AM, 10:24 AM, and 11:10 AM, a bag of dirty linen was observed on the floor next to the wall in room [ROOM NUMBER]. On 9/5/24 at 9:21 AM, 10:23 AM, and 11:10 AM, a bag of dirty linen was observed on the counter in the anteroom outside room [ROOM NUMBER]. On 9/5/24 at 9:24 AM, 10:20 AM, and 12:20 AM, a pile of dirty linen was observed on the floor by the window in room [ROOM NUMBER]. On 9/5/24 at 10:12 AM and 11:08 AM, a dirty towel and a dirty pair of socks were observed on the windowsill in room [ROOM NUMBER]. On 9/5/24 at 10:15AM, 11:33 AM, and 1:00PM, A bag of trash and a bag of dirty linen were observed in 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 citiation pertains to intake: MI00145394. Based on observation, interview, and record review, the facility failed to provide scheduled showers for one sampled resident (R903) of three residents reviewed for activities of daily living (ADL). Findings include: R903 was admitted to the facility on [DATE] with diagnosis of Juvenile rheumatoid Polyarthrititis. A review of R903's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed, R903 with an intact cognition and dependent of staff to complete activities of daily living (ADL). On 9/5/24 at 12:00 PM, R903 was observed lying in bed, above their bed there was a sign that noted, Shower Schedule M (Monday) & Th (Thursday) 7pm -7am. R903 was asked about the sign and explained that is to remind staff but they still don't get their showers. R903 was asked the last time they had a shower. R903 was unable to remember but did say it was in August. A review of shower documentation revealed, N/A (not applicable) on 8/1/, 8/8, 8/15, 8/29, and 9/2/24. On 9/5/24…

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 citiation pertains to Intake: MI00146442. Based on interview, and record review, the facility failed to provide timely podiatry care for one resident (R902) out of one reviewed for foot care. Findings include: On 9/5/2024 at 11:40 AM, during an interview, R902 explained their toenails were very long and it was painful to put shoes on and it took a long time to get them cut. On 9/5/2024 at 11:56 AM, Social worker (SW) A was asked to review R902's record for podiatry care. SW A then replied R902 was admitted in October (2023) and was not seen by podiatry until August (2023). Then stated It looks like she may have been seen in April (2024), but was unable to provide a treatment record. SW A said that even if R902 was seen in April they would have been due for another visit at least in June and confirmed that visit did not take place. SW A was asked if there was a written policy and procedure for podiatry care to which she responded no. A review of R902's electronic medical record revealed that they were…

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

Based on observation and interview, the facility failed to maintain sanitary conditions in the kitchen and employee breakroom resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 127 residents who receive meal services (4 nothing by mouth residents, or NPO) out of the facility's total census of 131 residents. Findings include: On 3/5/24 at 10:05 AM, the kitchen's steamer was observed in use and outside of the cooking lines exhaust hood. Further inspection of the area revealed an accumulation of condensation and water droplets on the ceiling above the unit and above the clean equipment storage rack containing cutting boards, plastic containers, and lids. On 3/5/24 at 10:25 AM, upon interview with Certified Dietary Manager, staff A, the surveyor inquired if the steamer had always been in its current location, to which they stated, since I started working here about two years ago. At this time staff A acknowledged the additional moisture in this area. Review of 2017 U.S. Public Health Service Food Code, Chapter 6-304.11…

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

Based on observation, interview, and record review, the facility failed to ensure equipment used in food service operation was maintained in a safe and sanitary operating condition, resulting in this food equipment not being protected against contamination from sewage or other sources of contamination, potentially affecting all residents consuming food from the kitchen. Findings include: On 3/5/24 at 8:40 AM, during the initial tour of the kitchen with the Certified Dietary Manager (CDM), the drain line from the two-compartment sink was observed to not have the required minimum one-inch air gap (an unobstructed vertical space between the end of the drain line and the flood rim of the floor drain). The CDM said the two-compartment sink was used for thawing frozen food and that there was not enough of an air gap. On 3/7/24 at 3:22 PM, the Nursing Home Administrator (NHA) said someone should have detected that the two-compartment sink was not properly air gapped and alerted the maintenance director right away. The 2013 FDA Food Code was reviewed and revealed the following in Section…

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

Based on observation and interview, the facility failed to maintain an effective pest control program, resulting in multiple resident complaints regarding pests, and the presence of live pests (gnats) in multiple areas of the facility. Findings include: On 3/5/24 at 8:50 AM, multiple gnats (too many to count) were observed swarming around the trash can located in the lower-level staff break room. During an interview with Resident #8 on 3/6/24 at 9:23 AM, gnats were observed flying around the resident's head. A resident group meeting was held on 3/6/24 at 10:00 AM with six residents, all of whom were alert, oriented, and able to express themselves without difficulty. A gnat was observed in the dining room during the group meeting. The following resident responses were given to the question, Do you have a concern with gnats in the building? - I have gnats in my room. Gnats are around the garbage, and they fly in your face. - I have seen them in my room and hallway. - I saw a gnat in my room. - I saw gnats in the dining room and in my room. - They're around you when you're eating. 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 and interview the facility failed to provide a safe and functional environment for the facilities census of 131 residents and its staff resulting in an increased potential for harm. Findings include: On 3/6/24 between 10:02 AM, and 11:18 AM, during an environmental tour of the facility the following observations were made: Privacy curtains were observed missing in resident rooms 12A and 11. A heat deflector was observed detached from the radiator in resident room [ROOM NUMBER]. Drywall was observed heavily damaged in resident room [ROOM NUMBER], and to the left of bed one in resident room [ROOM NUMBER]. A six inch by six inch square was observed missing in the vinyl flooring in resident room [ROOM NUMBER]. On 3/6/24 at 11:20 AM, upon interview with Maintenance Director, staff B, on how work orders are submitted to the maintenance department to be completed they stated, it is all electronic, and we check it three times a day. Once in the morning, around lunchtime, and before we leave for the…

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

Based on observation, interview and record review, the facility failed to hold scheduled care conferences for residents and resident representatives for two residents (R34 and R81) of two residents reviewed for care planning participation. Findings include: R81 On 3/5/24 at 1:16 PM, R81 was observed returning to their room from a shower. Attempts to interview the resident were unsuccessful due to their cognition however, the resident's guardian, Guardian N was asked about their involvement in the resident's care, specifically the development of the president's plan of care. Guardian N explained that they haven't had any meetings regarding the resident's care since they were first admitted in 2021. A review of R81's medical record was reviewed and revealed that they were admitted into the facility on 6/18/21 with diagnoses that included Vascular Dementia, Anxiety, and Cerebral Infarction. Further review revealed that the resident was severely cognitively impaired, and required dependence for toileting and showers. Further review of R81's medical record revealed that one care…

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

Based on observation, interview, and record review, the facility failed to honor the resident's preference regarding care for one resident (R34) of one reviewed for self-determination. Findings include: On 3/5/24 at 9:04 AM, R34 was observed lying in bed. Attempts to interview with the resident was challenging as they had a communication deficit however, the resident provided their resident representative's phone number who assisted with communication. On 3/5/24 at 10:37 AM, resident representative I was interviewed via phone and explained that the resident has been able to express to them that they would prefer showers instead of bed baths, and that the resident is rarely gotten out of bed, and has been the last 2 years in their room. A review of R34's medical record revealed that the resident was admitted into the facility on 4/9/21 with diagnoses that include Aphasia following Cerebral Infarction, Heart Failure, Morbid Obesity, and Mood Disorder. Further review of the medical record revealed that the resident was cognitively intact and was completely dependent on two staff for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two deficient practices. This citation pertains to Intake MI00135819. Based on observation, interview, and record review the facility failed promptly notify the legal guardian after elopement of a mentally impaired legally incapacitated resident, for one resident (R179) of three residents reviewed for closed record. Findings include: A review of the intake allegations noted, Complainant states on Friday, 04/14/23, the resident was sent on a [local hospital] transport for an appt. (appointment) The resident didn't return to the facility. The guardian, who the complainant works for, wasn't contacted until Saturday morning about his not returning to the facility. A review of R179's medical record revealed, R179 was admitted to the facility on [DATE] and discharged [DATE]. A review of R179's form titled, Minimum Data Set (MDS) Item Set Assessment by Patient, dated 2/20/23 noted, R179 with an moderate cognitive impairment. Further review of R179's medical record progress notes revealed, 4/14/2023…

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 MI00135819. Based on observation, interview, and record review the facility failed to ensure elopement was reported to the State Agency for one resident (R179) of three residents reviewed for closed record. Findings include: A review of the intake allegations noted, Complainant states on Friday, 04/14/23, the resident was sent on a [local hospital] transport for an appt. (appointment) The resident didn't return to the facility . A review of R179's medical record revealed, R179 was admitted to the facility on [DATE] and discharged [DATE]. Further review of R179's medical record progress notes revealed, 4/14/2023 12:44 (12:44 PM) Nurses Note Text: Resident LOA (leave of absence) to [local hospital] via seat walker with 1 attendant. No issues noted upon departure. signed by Unit Manager O. 4/15/2023 06:59 (6:59 AM) Nurses Note Text: Resident went to [R179's] (outside medical) appointment and did not return back to the facility. [Local hospital] was contacted. Daughter called and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00135819. Based on observation, interview, and record review the facility failed to ensure a thorough and complete investigation was conducted after an elopement for one resident (R179) of three residents reviewed for closed record. Findings include: A review of the intake allegations noted, Complainant states on Friday, 04/14/23, the resident was sent on a [local hospital] transport for an appt. (appointment) The resident didn't return to the facility . A review of R179's medical record revealed, R179 was admitted to the facility on [DATE] and discharged [DATE]. Further review of R179's medical record progress notes revealed, 4/14/2023 12:44 (12:44 PM) Nurses Note Text: Resident LOA (leave of absence) to [local hospital] via seat walker with 1 attendant. No issues noted upon departure. signed by Unit Manager O. 4/15/2023 06:59 (6:59 AM) Nurses Note Text: Resident went to [R179's] (outside medical) appointment and did not return back to the facility. [Local hospital] was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure accuracy of a Minimum Data Set (MDS) Assessment for behaviors for two residents (R56 and R6) out six sampled residents reviewed, resulting in the potential for unmet care needs and behavioral health services. Findings include: R56 On 03/06/24 at 08:40 AM, R56 was observed sitting up in bed and eating her breakfast. R56 yelled, My sister is my guardian, and I want to go home. On 03/06/24 at 01:55 PM, R56 was observed walking in her room. R56 had several items on the floor and the bed was covered with items. When asked how are you today, R56 responded Why do you want to know and laughed loudly. On 03/07/24 at 09:08 AM, R56 observed lying bed watching television. R56 asked, Do I have an appointment today. Bye. A review of the medical record revealed that R56 admitted into the facility on 8/30/23 with the following diagnoses of schizoaffective disorder, bipolar type, violent behavior, paranoid personality disorder, and delusion…

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 update for a preadmission screening (PAS) and resident review (ARR) /Hospital Exempted Discharge for a Level II evaluation was completed for one (R56) of three residents reviewed for PASARR, resulting in the potential for unmet mental health services. Findings include: A review of the medical record revealed a Preadmission Screening with a hospital exemption dated on 8/30/23. There was no change in condition for hospital discharge within 30 days and the PASSAR should have been updated after thirty days. There was no additional PASARR forms nor was a Level II screening requested due to R56 having several diagnoses of mental illness. A review of the medical record revealed that R56 admitted into the facility on 8/30/23 with the following diagnoses of schizoaffective disorder, bipolar type, violent behavior, paranoid personality disorder, and delusion disorders. A review of the most recent Minimum Data Set assessment dated [DATE] was completed…

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: MI00135805 Based on observation, interview and record review, the facility failed to provide nail care for one resident (R47) out of three reviewed for Activities of Daily Living (ADL). Findings Include: On 3/5/2024 at 9:30 AM, R47 was observed laying in bed. R47 fingernails were long with black debris underneath. R47 was noted to have a contracture of the left hand and their fingernails were digging into their hand. R47 was interviewed regarding their nails. R47 stated that they wanted their nails cut and had informed the Unit Manager that they wanted a particular certified nursing assistant (CNA) to cut them. R47 stated that they also reached out to the CNA that they wanted to cut their nails. On 3/6/2024 at 9:25 AM, R47 nails were still noted to be long with black debris underneath them. R47 stated that they were still waiting to get them cut and that they had told the Unit Manager again. On 3/6/2024 at 12:11 PM, the Director of Nursing (DON) was asked to come down and look at R47's nails. The DON asked R47 if they wanted their nails cut 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 MI00137493. Based on observation, interview, and record review, the facility failed to provide ancillary services related to a hearing impairment for one resident (R6) of one reviewed for hearing services. Findings include: On 3/05/24 at 12:44 PM, R6 was interviewed regarding their stay at the facility. During interview R6 was unable to hear the question which required the interview to be closer to R6's ear and at a louder volume. R6 was asked about their hearing aides. R6 was observed to pull a tissue out of their pocket and stated, Here they are, they don't work. I have lost the case for them, so I keep them in my pocket like this. On 3/06/24 at 9:31 AM, R6 was observed lying in bed asleep. A review of R6's care plan noted, Focus: I have a communication problem r/t (relate to) being HOH (hard of hearing). Date Initiated: 01/05/2022. Goal: I will be able to make basic needs known on a daily basis through the review date. Date Initiated: 01/05/2022. Interventions: Be conscious of…

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

Based on observation, interview and record review, the facility failed to ensure timely podiatry services for one resident (R16) of one reviewed for foot care. Findings include: On 3/5/24 at 12:24 PM, R16 was asked about their care in the facility, and explained that they wanted to be seen by the foot doctor to have their toenails cut, as they hurt when they rub against their socks and shoes. A review if R16's medical record revealed that they were admitted into the facility on 7/19/22 with diagnoses that included Diabetes, Chronic Obstructive Pulmonary Disease, and Peripheral Vascular Disease. Further review revealed that the resident has a moderate impaired cognition, and is dependent on staff for bathing, bed mobility and toilet use. Further review of the medical record revealed that the resident had not been seen for podiatry services since their admission. On 3/6/24 at 1:02 PM, surveyor observed R16's feet with Certified Nursing Assistant (CNA) P. R16's toenails were observed as elongated and approximately a half an inch in length. Upon observation, CNA P response was woah. R16…

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 MI00138528. Based on interview and record review, the facility failed to ensure appropriate neurological assessments were completed after an unwitnessed fall for one resident (#479) out of five residents reviewed for falls, resulting in the potential delay to provide resident care needs following an unwitnessed fall. Finding include: It was reported to the State Agency that staff failed to provide timely medical evaluation. A review of the clinical record revealed R479 was initially admitted to the facility on [DATE] and readmitted on [DATE]. R479's diagnoses included seizure disorder, chronic drug abuse, peripheral neuropathy, panic disorder, and transient cerebral ischemic attack. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment, extensive one-person physical assistance for bed mobility, and extensive two-person physical assistance for transfers. On 3/6/24 at 3:35 PM with the Director of Nursing (DON), R479's Incident Note of 7/4/23 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two deficient practices. Deficient practice #1. Based on observation, interview, and record review, the facility failed to consistently assess and implement nutrition interventions for one resident (R63) of seven residents reviewed for maintenance or improvement in nutritional status, resulting in a delay in the identification of continued significant weight loss and the potential for further decline in nutritional status. Findings include: On 3/5/24 at 11:10 AM, during the initial tour of the facility, Resident #63 (R63) was observed asleep and lying in bed. R63 appeared very thin in appearance. A review of the clinical record for R63 documented an admission date of 2/2/22 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, cirrhosis of liver, and type 2 diabetes mellitus. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. A review of R63's care plans documented in part the following: Focus: I am at nutritional risk related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to label a bag of Intravenous (IV) fluids, an Intravenous (IV) line, and IV dressing for one resident (R52) out of six reviewed for IV fluids. Findings Include: On 3/5/2024 at 9:21 AM, an interview was conducted with R52. R52 stated that they had been receiving fluids for the last day or so. R52 was observed to be receiving fluids. R52 stated that IV was infusing on the side of their stomach. On 3/5/2024 at 9:24 AM, certified nursing assistant (CNA) G turned R52 over and no date was observed on the bag of fluids, IV line, and/or the dressing at the insertion site. A review of the medical record revealed that R52 admitted into the facility on [DATE] with the following diagnoses, Sepsis and Urinary Tract Infection. A review of Minimum Data Set assessment revealed a Brief Interview for Mental status score of 15/15 indicating an intact cognition. R52 also required assistance with bed mobility and transfers. On 3/7/2024 at 9:38 AM, an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two deficient practice statements. Deficient Practice Statement number one. Based on interview and record review, the facility failed to properly monitor an antipsychotic (AP) medication for one resident (R123) out of three reviewed for antipsychotic use. Findings Include: A review of the medical record revealed that R123 admitted into the facility on 1/15/2024 with the following diagnoses, Repeated Falls and Metabolic Encephalopathy. A review of the Minimum Data Set assessment revealed a Brief Interview Mental status score of 5/15 indicating an impaired cognition. R123 also required staff assistance with bed mobility and transfer. Further review of the physician orders revealed that R123 was currently prescribed Zyprexa (AP) two times a day for Dementia. Further review of the medical record revealed no Abnormal Involuntary Movement (AIMS) testing or psychiatric notes. On 3/6/2024 at 12:38 PM, an interview was conducted with Social Worker (SW) D. SW D stated that R123 has not been seen by…

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 properly store medication for two residents (R47 and R94) out of two reviewed for medication storage. Findings Include: On 3/5/2024 at 1:17 PM, R47 was observed in their room. R47 was noted to be laying in bed. A nebulizer machine was observed in the corner, unplugged. Under the television stand, 4 vials of albuterol inhalation liquid were observed sitting on a shelf. A review of the medical record revealed that R47 admitted into the facility on 9/25/2021 with the following diagnoses, Hemiplegia and Contracture, Left Hand. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 13/15 indicating an intact cognition. R47 was also dependent on staff for bed mobility and transfers. A review of the physician orders revealed the following, Order: Albuterol Sulfate Nebulization Solution 0.63 milligrams (MG)/3 milliter (ML). Directions: 1 vial inhale orally via nebulizer every 6 hours as needed for SOB AND 1 vial inhale orally via nebulizer every 6 hours for SOB . Status:…

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: MI00135865 Based on interview and record review, the facility failed to ensure nursing standards of practice for medication administration documentation were followed for three residents (#70, #74, #121) of three residents reviewed for maintenance of medical records, resulting in the potential for medication errors and compromise and complications in health. Findings include: A resident group meeting was held on 3/6/24 at 10:00 AM with six residents, all of whom were alert, oriented, and able to express themselves without difficulty. Resident #74 (R74) and Resident #121 (R121) indicated the following when queried if staff were available to assist them when needed: R74 verbalized a concern about getting medications in a timely manner. R121 said their pain meds were not provided for two days, multiple times. During an interview on 3/7/24 at 11:44 AM, R74 said they would be in pain when medications are late or not received. During an interview on 3/7/24 at 11:46 AM, R121 stated, I…

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: MI00133917. Based on interview and record review, the facility failed to notify the resident's representative of a fall for one resident (R901) of one reviewed for notification of changes, resulting in the resident's representative being unaware of the fall, and a delay in the opportunity to participate in medical decisions regarding care and treatment. Findings include: A review of MI00133917 revealed the following, On December 7th I was called regarding a fall [R901] had that resulted in no injury. The nurse mentioned that it was nothing like the fall [R901] had 2 days prior that had split [their] eyebrow open. I was shocked because they had never called to report this injury to me. When I arrived to check on [R901] on December 8th I observed a severe wound on [their] eyebrow and side of [their] eye. I questioned why I was never called about this injury as it is required by state law and they told me that it was a new nurse who was unaware of the requirement to report 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.