Medilodge of Howell

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to initiate their bowel protocol for one resident (R123) of one resident reviewed for bowel and bladder, resulting in constipation and verbalized complaints of pain and discomfort. Findings include: On 12/9/25 at 11:56 AM, R123 was observed in their bed. At that time, an interview was conducted and R123 reported they had not had a bowel movement in a week. They were asked if staff were aware of his situation and said they were, and someone told them they were going to get a suppository later on in the day. R123 expressed feelings of anxiousness, pain, and discomfort in their stomach. They further reported they had several of their thoracic vertebrae fused in their spine and at home they were on a strict bowel regimen to ensure regularity. They expressed frustration with staff not listening to them and said they had been hospitalized in the past because of constipation and feared having to be hospitalized again. A review of R123's clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure dressings were changed in a timely manner for a peripherally inserted central catheter for one resident (R185), of one resident reviewed for peripherally inserted central catheters, resulting in the potential for the development of infection. Findings include: On 12/9/25 at 12:17 PM, R185 was observed in their room seated in their wheelchair. An interview was conducted at that time and R185 expressed some concerns with their IV (intravenous) antibiotic medications. R185 was asked how they received their IV medications and said they had a PICC (peripherally inserted central catheter) line in their right arm. With their permission, an observation of the line and the insertion site was conducted and it was noted the dressing on the PICC line was dated 12/2/25. On 12/10/25 at 10:32 AM, a second observation of R185's PICC line dressing revealed it remained with the date of 12/2/25. They were asked if the dressing to their PICC line had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure adequate documentation/monitoring of suctioning administration and cleaning were followed for one resident (R46) of one resident reviewed for oral suctioning. Findings include: On 12/09/2025 at approximately 10:29 a.m., R46 was observed in their room, laying in their bed. R46 was observed to have a suctioning machine (a machine used to expel secretions) next to their bed. R46's suctioning machine was observed to have multiple tubes attached to it that were observed to have dried mucus inside. R46's suctioning container was observed to be 3/4 full of dried green mucus. No dating was observed on the tubing or the container to document the last time it had been changed and emptied. On 12/10/25 at approximately 9:42 a.m., R46 was observed in their room, laying in their bed. R46 was observed to have a suctioning machine (a machine used to expel secretions) next to their bed. R46's suctioning machine was observed to have multiple tubes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain complete and accurate electronic medical records for two (R60 and R142) of two residents reviewed for medical records. Findings include:A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) revealed an allegation It was reported the facility failed to protect the resident from a resident to resident physical abuse incident which did not result in injury. Documentation revealed the incident occurred on 11/3/25 but no time was included in the incident summary provided.The facility's investigation documented, in part: .On 11/3/2025, resident (R60) had a disagreement in the Unit 2 common area over the loudness of the television as she requested for the television to be turned down. As a result, resident (R142) intervened and contact was made by (R60's) quad point cane to (R142's) leg. Pain and skin assessment completed. There was a small bump to (R142's) leg. No pain and resident (R142) indicated that she was fine. There…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2600758Based on interview and record review the facility failed to ensure timely administration of an ordered and requested pain medication (Oxycodone) for one resident (R101) of one reviewed for pain. Findings include:Findings include:Clinical record review revealed R101 sustained trauma resulting in necrotizing fasciitis (also known as flesh-eating disease, an infection that kills the body's soft tissue) of the left upper extremity and lower extremity. R101 underwent emergent debridement (surgical procedure that involves the removal of dead, damaged, or infected tissue) and fasciotomy (surgical procedure involves cutting through the tissues that surround muscles) of the left anterior (front) thigh and left forearm, underwent multiple debridement's, left femoral muscle flap graft and required a Wound VAC (vacuum-assisted closure technique that pulls tissue of a wound together and promotes healing). R101's pain regimen included Oxycodone 10 milligram (mg) every four hours as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 #MI00152565. Based on interview and record review, the facility failed to ensure sufficient Nursing staff were available to meet resident medical and supervision needs for 15 residents (R901 and R907) and 13 anonymous residents residing on Mum Unit 2, resulting in delayed medication administration and inadequate resident supervision. Findings include: On 5/1/25 a concern submitted to the State Agency was reviewed that alleged the facility was short on Nursing staff on 4/25/25 through 4/26/25 and were not able to provide adequate supervision. On 5/1/25 at approximately 11:37 a.m., Certified Nursing Assistant I (CNA I) was queried if they were one of the CNA's providing care for R901 on 4/25/25 into 4/26/25 and they reported they were. CNA I was queried regarding the incident between R901 and R907 and they reported they heard R907 yelling out for help and when they got to R901's room, they found R907 and R901 in R901's bed but there was a little space between them. CNA I explained that both residents were intoxicated and R901 had liquor in there 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 This citation pertains to intake #MI00152565 Based on observation, interview and record review, the facility failed to report allegations of abuse/mistreatment to the State Agency (SA) involving two residents (R901 and R907) of three residents reviewed for abuse/neglect/mistreatment. Findings include: On 5/1/25 a complaint submitted to the State Agency was reviewed which alleged R901 touched R907 inappropriately in their room on the midnight shift between 4/25/25 and 4/26/25 and that R901 was seeking out other women in the facility for sexual activity. R901 On 5/1/25 at approximately 1:22 p.m., R901 was observed in their room, laying in their bed. R901 was queried regarding the night of 4/25/25 into the early morning of 4/26/25. R901 reported they were aware of the night and that he was drinking alcohol in their room with R907. R901 indicated he likes female companionship. R901 was queried if the staff had to come in after R907 was yelling help and he indicated they did but that they did not do anything do them.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00151369 Based on interview and record review, the facility failed to timely address a change of condition for one resident (R#904) of one resident reviewed for a change of condition, resulting in delayed treatment, and failed to ensure the necessary documentation was completed to obtain a medically necessary power tilt recline wheelchair for one Resident (R#905) of two reviewed for rehab services. Findings include: On 5/1/25 at 9:20 AM, a review of R904's closed clinical record was conducted and revealed they admitted to the facility on [DATE] and most recently discharged to the hospital on 3/23/25. A review of R904's progress notes was conducted and revealed the following: A Pertinent Charting-Change of Condition note dated 3/17/25 at 7:43 AM entered into the record by Nurse 'M' that read, .Change identified: Confusion .general weakness, Increased urinary frequency, abdominal cramping .Assessment: .Needing 2 people assist with all transfers due to weakness .Needed to use 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 #MI00151369 Based on interview and record review, the facility failed to ensure timely laboratory services for one resident (R904) of one resident reviewed for laboratory services, resulting in a delay for the treatment of a urinary tract infection. Findings include: On 5/1/25 at 9:20 AM, a review of R904's closed clinical record revealed they admitted to the facility on [DATE] and discharged to the hospital on 3/23/25. R904's progress notes were reviewed and included the following: A note dated 3/17/25 that read, .Change identified: Confusion .Increased urinary frequency, abdominal cramping .Needing 2 people assist with all transfers due to weakness . Needed to use the bathroom about every hour during the night. c/o (complains of) of pain during urination .Collected urine culture to check for UTI (urinary tract infection) . A note dated 3/18/25 entered into the record by NP (Nurse Practitioner) 'H' that read, Per nursing pt (patient) has increased confusion for the past few…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 MI00149526 Based on interview and record review, the facility failed to ensure administration of an enteral tube feeding (a liquid form of nourishment that is delivered via a surgically inserted tube into the body) in accordance with a Physician order for one (R906) of five reviewed for hydration, resulting in the increased potential for dehydration and clinical compromise. Findings include: On 2/25/25, A clinical record review revealed R906 was admitted to the facility on [DATE]. R906 was a pedal cycle driver injured in a collision with an automobile resulting in multiple bone fractures, diffuse brain injury with loss of consciousness, and required a craniotomy (a surgical procedure in which a part of the skull is temporarily removed to expose the brain and perform an intracranial procedure). R906 was at risk for altered nutrition related to the accident and required eternal feeding for nutrition and hydration. A Brief Interview for Mental Status (BIMS) was unable 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.

This citation Pertains to intake #: MI00146952 Based on observation and interview, the facility failed to effectively maintain the resident call system that had capability to directly alert the caregivers and or there were no audible or visual alerts systems for care givers which had the potential to affect all 142 residents at the facility. This deficient practice had an increased likelihood for delayed emergency response and/or negative resident outcomes. An initial facility rounds were completed on 9/16/24 at approximately 10:15 AM on the hallway with Rooms 180-195. There was a computer monitor on the hallway mounted on the wall.This Surveyor observed staff members periodically walking to the monitor to check and when the surveyor asked what it was (that they were looking at) staff members reported that was the call light monitor. There was a nursing work area in the adjacent to the opposite hallway. There were no call light (audible or visual) alert systems in the work area and that was later confirmed by the facility staff and leadership. There were no alerts outside resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure nursing staff adhered to professional standards for three (R81, R53 and R16) of seven reviewed for medication administration. Findings include: On 9/16/24 at approximately 10:24 AM, R81 was observed sitting in their wheelchair in their room. On their tray table was a prescription for Ciclopirox (a medication used to treat fungal infections). R81 was asked if they could identify the medication and whether they administered the medication on their own. R81 reported that staff administers the medication to their toes daily before putting on their socks. A second observation was made on 9/16/24 at approximately 11:21 AM and the medication Ciclopirox was still on R81's tray table. On 9/16/24 at approximately 11:25 AM, Nurse A was interviewed regarding R81's medication. Nurse A was asked if R81 was able to have the medication left unlocked in their room. Nurse A reviewed R81's medical orders and noted that they did not believe 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 provide activity of daily living care including showers for one (R27) of three residents reviewed for activities of daily living. Findings include: On 9/16/24 at 11:11 AM, R27 was observed in bed, lying on her back. R27 reported that they don't get showers like they should. R27 reported that their hair was saturated with sweat and when they ask staff for a shower or a bath, they tell her tomorrow, tomorrow. A review of the clinical record revealed R27 was admitted into the facility originally on 6/5/18 with the most recent re-admission on [DATE] with diagnoses that included: mixed incontinence, functional diarrhea, muscle weakness and anxiety disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R27 was dependent for toileting hygiene and scored 14/15 on the Brief Interview for Mental Status (BIMS) exam (which indicated intact cognition). A review of R27's Treatment administration record (TAR) revealed that R27 should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews the facility failed to consistently ensure infection control standards, practices and protocols were consistently followed by the facility staff for six (R's 136, 110, 122, 102, 139 & 119) of 28 sampled residents, this deficient practice had the ability to affect all residents residing in the facility at the time of the survey. Findings include: On 9/16/24 at 11:22 AM, Registered Nurse (RN) B and Certified Nursing Assistant (CNA) C was observed exiting the room of R136, with their Personal Protective Equipment (PPE) on that included a gown, gloves, mask & shield. A record review revealed R136 was diagnosed with COVID-19. The signage on R136's door documented the resident was on Droplet/Contact/Airborne precautions. Review of the CDC (Centers for Disease Control and Prevention) protocol documented to discard the gloves and gown before exiting the room and to remove respirator after exiting the room. At the time of the observation the facility's Assistant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 #: MI00146952 Based on interview and record review facility failed to document and promptly resolve grievances reported to the facility staff for one (R79) of one Resident reviewed for grievances. Findings include: R79 R79 was admitted to the facility on [DATE]. R79's admitting diagnoses included heart failure, diabetes, muscle weakness, mild cognitive impairment, and legal blindness. Based on Minimum Data Set (MDS) assessment dated [DATE], R79 had a Brief Interview for Mental Status (BIMS) score of 14/15. R79 needed staff assistance with their Activities of Daily Living (ADLs) such as dressing, bathing, toileting etc. A complaint received by State Agency revealed that the concern (s) that were brought to the attention of facility staff were not resolved in a timely manner. An e-mail request was sent on 9/17/24 to the facility administrator to provide the grievances and the facility follow up for R79. Review of grievances and facility follow-up revealed that R79 had concerns…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 #MI00146952 Based on observation, interview, and record review, the facility failed to obtain a podiatry appointment as ordered after an infection for one (R79) of one Resident reviewed for foot care. This deficient practice has the potential to deteriorate the mobility and overall wellbeing of the resident. Findings include: A record review revealed that R79 was admitted to the facility on [DATE]. R79's admitting diagnoses included heart failure, diabetes, muscle weakness, mild cognitive impairment and legal blindness. Based on the Minimum Data Set (MDS) assessment dated [DATE], R79 had a Brief Interview for Mental Status (BIMS) score of 14/15. R79 needed staff assistance with their Activities of Daily Living (ADLs) such as dressing, bathing, toileting etc. and for their mobility. An initial observation was completed on 9/16/24 at approximately 1:10 PM. The first part of the observation was completed from the hallway outside of R79's room. A CNA (Certified Nursing Assistant) 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 oxygen was administered per Physician's order and the appropriate cannula was provided and changed for two residents (R149 and R112) of two residents reviewed for respiratory care. Findings include: R149 On 09/17/24 the medical record for R149 was reviewed and revealed the following: R149 was initially admitted to the facility on [DATE] and had diagnoses including Respiratory failure whether with hypoxia or hypercapnia, Hypoxemia, Pulmonary emphysema and Pulmonary edema. A review of R149's MDS (minimum data set) with an ARD (assessment reference date) of 7/11/24 revealed R149 needed assistance from facility staff with most of their activities of daily living. A Nurse Practitioner (NP) Evaluation dated 7/11/24 revealed the following: Date of Service: 7/11/2024 .General: [AGE] year-old female with chief complaint of shortness of breath. Patient was recently in the hospital for hypercapnia. Patient CO2 was 80. Patient seen and examined…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medically related social services were provided for two residents (R16 and R124) of two residents reviewed for Social Services. Findings include: R124 On 9/16/24 the medical record for R124 was reviewed and revealed the following: R124 was initially admitted to the facility on [DATE] and had diagnoses including Dementia, Restlessness and Agitation and Delirium. A review of R124's MDS (minimum data set) with an ARD (assessment reference date) of 6/29/24 revealed R124 required set-up assistance from staff. R124's BIMS score (brief interview for mental status) was three indicating severely impaired cognition. A review of R124's comprehensive plan of care revealed the following: Focus-Resident has impaired cognitive function related to: unspecified dementia with behavioral disturbance/hallucinations/delirium and BIMS score. Date Initiated: 06/27/2024 . A review of R124's demographic profile-facesheet revealed R124 did not have an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate reconciliation for controlled medications for two residents (R10, R79) of four reviewed for narcotic storage. On 9/18/24 at 5:10 PM, the North Tulip medication cart, was observed with Register Nurse (RN) CC. A record review of the narcotic binder revealed R10 was administered one tablet of Hydrocodone/Acetaminophen 10/325 milligrams (mg) (a narcotic medication) at 2:26 PM by RN CC and five tablets remained. The blister pack was observed having four tablets. RN CC commented that they were pulled into an isolation room to assist another resident and forgot to administer the medication to R10. On 9/18/24 at 5:30 PM, the Back Mum medication cart was reviewed with RN Y. A record review of the narcotic binder revealed R79 was provided one tablet of Tramadol (an opioid pain medication) last given on 9/16/24 at 9:18 PM and 13 tablets remained. The blister pack revealed 12 tablets of Tramadol. RN Y acknowledged that the tablet was administered to R79 prior to dinner and forgot to reconcile the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a Physician ordered laboratory (lab) diagnostic was completed for one resident (R149) of one residents reviewed for diagnostics. Findings include: On 09/17/24 the medical record for R149 was reviewed and revealed the following: R149 was initially admitted to the facility on [DATE] and had diagnoses including Respiratory failure whether with hypoxia or hypercapnia, Hypoxemia, Pulmonary emphysema and Pulmonary edema. A review of R149's MDS (minimum data set) with an ARD (assessment reference date) of 7/11/24 revealed R149 needed assistance from facility staff with most of their activities of daily living. A Nurse Practitioner (NP) Evaluation dated 7/11/24 revealed the following: Date of Service: 7/11/2024 .General: [AGE] year-old female with chief complaint of shortness of breath. Patient was recently in the hospital for hypercapnia. Patient CO2 (carbon dioxide) was 80. Patient seen and examined today and talked with her husband states that her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to complete a periodic rehabilitation screening and/or evaluation and initiate maintenance interventions upon discharge for a one (R108) of one Resident reviewed for rehabilitation services resulting in the likelihood for further decline in range of motion, impairment with skin integrity, and increase in pain during Activities of Daily Living (ADL). Findings include: Record review revealed R108 was a long -term resident of facility, admitted on [DATE]. R108 had a recent hospitalization and they were readmitted back to the facility on 5/31/24. R108's admitting diagnoses included contracture of Right and Left hand, dementia, failure to thrive, depression, and anxiety disorder. R108 was confined to bed and needed extensive staff assistance with their Activities of Daily Living (ADL - mobility in bed, dressing, eating etc.). Based on a Minimum Data Set (MDS) assessment with an assessment reference date of 8/20/24, R108 had a Brief interview 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 Based on interview and record review, the facility failed to ensure the pneumonia vaccine was administered after consenting for one (R79) of five sampled residents reviewed for immunizations. Findings include: R79 was admitted to the facility on [DATE] with medical diagnoses that included heart failure, hypertension, diabetes, high cholesterol, and dementia. A Brief Interview of Mental Status (BIMS) score totaled 14/15 indicating R79 was cognitively intact. Record review revealed R79 was offered and signed a consent for the pneumonia vaccine on 6/17/24. Review of the Electronic Medical Record documented R79 refused the pneumonia vaccine. On 9/19/24 at 11:56 AM, an interview was conducted with Infection Preventionist E who confirmed the pneumonia vaccine was documented as refused, and reviewed R79 consented to receive the vaccine. E acknowledged the vaccine has not been administered. On 9/19/24 around 3:00 PM, An interview with Corporate Clinical Services BB acknowledged the facility failed to ensure the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the COVID-19 vaccine was offered and timely administered after consent for two (R136, R29) of five sampled residents reviewed for immunizations. Findings include: R136 Clinical record review revealed R136 was admitted to the facility on [DATE] with medical diagnoses including cancer, hypertension, blood clots, vascular disease, and renal failure. A Brief Interview of Mental Status (BIMS) score totaled 11/15 indicating R136 had moderate cognitive impairment. On 9/19/24, A clinical record review revealed the SpikeVax Moderna COVID-19 was not offered to R136 until 9/19/24 after a random sample of residents was provided to the Infection Preventionist E. When Infection Preventionist E was questioned why was R136 was just offered today (9/19/24), E responded R136 must of slipped through the cracks.Infrection Preventionist E was inquired of the facility policy regarding offering the vaccine and acknowledged it should have been offered within 72 hours…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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(s): MI00145518 Based on interview and record review, the facility failed to ensure administration of a scheduled long acting antipsychotic medication for one (R601) of three residents reviewed for medication administration. Findings include: A review of a complaint submitted to the State Agency revealed an allegation that the facility did not administer R601's injectable antipsychotic medication that she required every two weeks. It was alleged the missing injection resulted in an increase in mental health symptoms and R601 was no longer at her mental health baseline . A review of a Contact Notes written by R601's Community Mental Health Case Manager (CMH CSM 'D') revealed the following documentation: An in person contact note dated 6/13/24 at 2:35 PM documented, (CSM 'D') arrive to (facility) to deliver (R601's) Haldol (an antipsychotic medication) injection. CSM informs (R601) they are delivering injection for the purpose of this visit. CSM directly hands unit manager,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 #MI00142965, and MI00139952. Based on observation, interview and record review, the facility failed to ensure the required assistance level for bed mobility was provided to one (R913) of four residents reviewed for accidents. Findings include: Review of allegations reported to the State Agency included concerns with R913 having adequate interventions to prevent falls. On 4/22/24 at 2:40 PM, R913 was observed laying in bed on their back. Their bed had an air mattress with a wider width mattress in place. There were no assist rails or bars observed in use. R913 was asked about their fall on 4/20/24 and reported the aide was changing her brief and the linens and they rolled out of the bed. When asked how many staff were present at the time, R913 reported only one. When asked if there were any adaptive rails or bars to the bed that they could hold onto when they were rolled over, they reported no but they felt that might help them. Review of the clinical record revealed R913 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 #MI00142965 Based on interview and record review, the facility failed to ensure physician ordered laboratory tests were completed for one (R910) of one resident reviewed for laboratory services. Findings include: Review of R910's clinical record revealed R910 was initially admitted to the facility on [DATE], readmitted on [DATE] with diagnoses that included: major depression, chronic respiratory failure and diabetes. A review of R910's physicians orders revealed an order from 1/30/24 for Skin script <sic> of left hand finger webs to rule out scabies. On 4/22/24 at 12:10 PM, an interview was conducted with infection preventionist B. When queried about results for the skin scraping order from 1/30/24 she was unable to provide results. On 4/22/24 at 12:40 PM, verbally requested results from 1/30/24 skin scraping order from NHA (Nursing Home Administrator). On 4/22/24 at 3:13 PM, an email was received from the NHA and stated that they have been unsuccessful in locating the result for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes: MI00138638, MI00137343. Based on observation and interview, the facility failed to maintain a sanitary and odor free environment, and maintain the physical environment in good repair, resulting in offensive odors and a non-homelike environment, affecting all residents in the facility. Findings include: On 8/29/23 at 9:45 AM, the shower enclosure tile, located in the shower room near resident room [ROOM NUMBER], was observed to be stained with rust and biofilm. Additionally, a package of briefs was observed to be stored on the floor in the supply closet nearest to resident room [ROOM NUMBER]. On 8/29/23 at 9:47 AM, the ice machine, located in the hydration room, was observed to have biofilm accumulation on the ice machine deflector plate. Additionally, the ice scoop holder was observed to have biofilm accumulation. On 8/29/23 at 9:52 AM, the call light fixture for the toilet enclosure, located in the shower room on the 180 suite, was observed to not be provided with a call light…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a pest free environment, and maintain the facility free of pest harborage conditions, resulting in presence of pest, affecting all residents who consume food from the kitchen. Findings include: On 8/29/23 at 9:10 AM, drain flies were observed throughout the kitchen facility, appearing more concentrated in the dish machine area. Heavy accumulation of water was observed on the floor underneath the dish machine drain boards, sourcing from the dish machine leaking water onto the floor. At this time, Dietary Manager FF was queried on pest control efforts and stated that the pest control operator visits the facility once a week. On 8/29/23 at 9:22 AM, the tile grout, around the three-compartment sink area, was observed to be dissolving, resulting in gaps in the tile where water was accumulating and creating harborage conditions for pests. At this time, Dietary Manager FF stated that the dissolving grout was reported to the Maintenance Department yesterday for the second time. According to the Pest Control…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident's food preferences for four residents (R#'s 26, 62, 28, and 18) of 11 residents reviewed for food preferences, resulting in verbalized feelings of frustration. Findings include: R26 and R62 On 8/29/23 at 9:36 AM, an interview was conducted and R26 said the facility frequently did not provide their requested meal options. They said they fill out their ticket with their preferences, but frequently they do not get the items they request. They said they requested biscuits and gravy, but did not get them delivered. They said someone did eventually bring them some, but it took a long time and they were tired of always having to ask. On 8/29/23 at 12:09 PM, R26's meal was observed. They said they did not receive their caesar salad they requested with the spaghetti meal. A review of their menu revealed they circled they wanted to have a caesar salad. It was further observed a bowl of brown gravy was on the meal tray. They were asked why they were given a bowl of brown gravy with spaghetti and said 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.

Based on observation, interview and record review the facility failed to ensure medications were appropriately stored in two of three medication carts and ensure one cart was locked, resulting in the potential for unauthorized entry, misuse and possible diversion of medications by staff, visitors, and residents. Findings include: On 8/29/23 at approximately 2:13 PM, the medication cart assigned to both Nurse C and Nurse AA on the Poppy Unit was observed to be unlocked and a set of keys was lying on top of the cart and the computer was showing the names of residents that receive medication. Nurse C reported that they were sharing the cart with Nurse AA and left the cart unlocked when they went to answer a phone call. The cart was reviewed, and an open undated Levemir Flex Pen (insulin) was observed. Nurse AA was asked about the undated Levemir Flex Pen and reported that the pen should have been labeled and dated. On 8/29/23 at approximately 2:30 PM, the medication cart located on the locked unit was reviewed with Nurse BB. Five unidentified pills were observed on the bottom of a…

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

Based on interview and record review, the facility failed to maintain an effective Antibiotic Stewardship program that included consistent implementation of protocols for appropriate antibiotic administration and ensured that infection criteria were met for six (R92, R95, R104, R70, R75 and R50) residents resulting in the potential for unnecessary antibiotic usage and the development of multiple drug resistant organisms. Findings include: On 8/31/23 at 11:28 AM, review of the facility's Antibiotic Stewardship program was conducted with the Director of Nursing (DON), who served as the Infection Control Nurse. The DON was asked about the risks of inappropriate antibiotic use. The DON explained it could cause antibiotic resistance. Review of the line listings revealed the following: R92 was documented as receiving Cefadroxil 500 mg (milligrams) two times a day continuously since 10/22/23 for, INFECTION FOLLOWING A PROCEDURE, DEEP INCISIONAL SURGICAL SITE. The DON was asked why R92 was on an antibiotic for 22 months. The DON explained the antibiotics had been ordered due to infected…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain ventilation, resulting in offensive odors and potential for breathing difficulties for residents, affecting residents on the Tulip hall. Findings Include: On 8/29/23 at 1:57 PM, the bathroom of room [ROOM NUMBER] was observed to have an offensive musty odor. At this time, the exhaust ventilation was tested using a paper towel held against the exhaust grid to see if the vent had sufficient air flow and the vent was observed to not be able to hold the paper towel, showing potential for non-functioning exhaust. On 8/29/23 at 2:00 PM, the bathroom of room [ROOM NUMBER] was observed to have an offensive urine odor. At this time, the exhaust ventilation was tested using a paper towel held against the exhaust grid to see if the vent had sufficient air flow and the vent was observed to not be able to hold the paper towel, showing potential for non-functioning exhaust. During an interview on 8/30/23 at 1:10 PM, Maintenance Director DD was queried on 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, interviews, and record review the facility failed to ensure timely formulation of advance directives and code status according to resident's wishes for one (R117) of three residents reviewed for advance directives with potential for resident preferences for medical care to not be followed by the facility. Findings include: R117 was admitted to the facility on [DATE] for short term skilled nursing and rehabilitation services. R117's admitting diagnoses included quadriplegia after recent spinal cord injury with 7th cervical vertebrae fracture with cervical fusion after fall from stairs at home, major depressive disorder, bipolar disorder, and muscle spasms. R117 was living independently in the community prior to this fall and spinal cord injury. R117 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicative of intact cognition. An observation was completed on 8/30/23 at approximately 2:40 PM. R117 was observed sitting in their wheelchair in their room. An interview 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 report to the State Agency (SA) an allegation of resident to resident physical abuse for one (R74) of three residents reviewed for abuse. Findings include: According to the facility's policy titled, Abuse, Neglect and Exploitation dated 10/24/2022: .Reporting of all alleged violations to the .state agency .within specified timeframes .Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . Review of the clinical record revealed R74 was admitted into the facility on 7/14/20 with diagnoses that included: Alzheimer's disease, impulse disorder, and mild intellectual disabilities. According to the Minimum Data Set (MDS) assessment dated [DATE], R74 had some communication deficits and sometimes made themselves understood, sometimes understood others, had severe cognitive impairment, exhibited no mood or behavioral concerns, and was independent with ambulation. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow up timely and obtain specialist follow up appointments as ordered for two (R84 and R92) of two Residents reviewed for follow up appointments and coordination of care with external providers. Findings include: R84 R84 was admitted to the facility on [DATE]. R84's admitting diagnoses included osteoarthritis, chronic pain, psoriatic arthritis, rheumatoid arthritis, failure to thrive with history of right knee surgery. R84 was admitted to the facility for long term care and did not have any family support or a home in the community. R84 had Brief Interview for Mental Status (BIMS) score of 15/15, indicative of intact cognition. Based on the Minimum Data Set (MDS) assessment with an Assessment Reference Date of 8/5/23, R84 needed extensive staff assistance with their mobility and Activities of Daily Living (ADL). R84 had range of motion impairment on both upper and lower extremities. R84 was using wheelchair and they were totally…

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

Based on interview and record review the facility failed to ensure three Certified Nursing Assistants (CNA's T, U and V) out of five CNAs reviewed for education had completed the required annual competency evaluation, including demonstration in skills and techniques necessary to care for residents. This deficient practice had the potential to affect all residents that resided in the facility. Findings include: The Director of Nursing (DON), who was responsible for annual competency evaluations and continued nursing training, was asked to provide competency evaluations for five CNAs. The DON reported that competency evaluations are done yearly based on the staff's hire date. The DON was able to provide two of five competency evaluations and noted that they did not complete competency evaluations for CNAs T, U and V. The DON noted that they should have been completed and they were on their list to complete. A review of the facility policy titled, Training Requirements (revised 10/24/23) documented, in part, Policy: It is the policy of this facility to develop, implement, and maintain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure timely assessment and follow-up interventions by behavioral health services were provided for two (R84 and R117) of three Residents reviewed for mood and behavior, resulting in delayed and/or unmet emotional and psycho-social well-being care needs and increased potential for direct care staff to be unaware of how to address the behaviors with further likelihood of unmet care needs. R117 R117 was admitted to the facility on [DATE] for short term for skilled nursing and rehabilitation services. R117's admitting diagnoses included quadriplegia after recent spinal cord injury with 7th cervical vertebrae fracture with cervical fusion after fall from stairs at home, major depressive disorder, bipolar disorder, Attention Deficit Hyperactivity Disorder (ADHD), and history of substance abuse. R117 was living with their family in the community prior to this fall and spinal cord injury. R117 was independent with all their Activities of Daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review the recommendations as stated on the Medication Regimen Review (MMR) for one (R71) of five residents reviewed for unnecessary medication resulting in the potential for adverse reactions from unnecessary medications. Findings include: Review of Pharmacy Recommendation notes for R71 revealed, in part, the following: 4/4/23: The resident is due for review of sertraline 100 mg (milligrams) PO (by mouth) daily, last Risk-Benefit from 6/2022. Please evaluate current dose and consider gradual taper to ensure resident is using the lowest possible effective/optimal dose. Federal regulations require gradual dose reduction (GDR) attempts . The document was signed by Physician CC with a note that said other: Psych consultation. 6/2/23 The Hospice resident is due for review of sertraline 100 mg PO daily, last Risk-Benefit from 6/2022. Please evaluate current dose and consider gradual taper to ensure resident is using the lowest possible effective/optimal dose. Federal regulations require gradual dose reduction attempts . The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to operationalize an antibiotic stewardship program which ensured appropriate clinical justification for the use of an antibiotic medication and the continuance of unnecessary antibiotics for one (R92) of six residents reviewed for unnecessary antibiotics. Findings include: On 8/31/23 at 11:28 AM, review of the facility's antibiotic stewardship with the Director of Nursing (DON), who was serving as the Infection Control Nurse, revealed R92 had been on Cefadroxil, an antibiotic, continuously since 10/22/21. The DON was asked why R92 was on an antibiotic for 22 months. The DON explained the antibiotics had been ordered due to infected hardware in R92's arm. The DON was asked if R92 had seen the Surgeon or an Infectious Disease Doctor to determine if the antibiotic was still needed. The DON explained R92 had not had follow-up appointments. Review of the clinical record revealed R92 was admitted into the facility on [DATE] and readmitted [DATE] with diagnose…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely follow through of an oral surgery referral for dental extractions was made for one resident (R63) of two residents reviewed for dental services resulting in a delay for oral surgery. Findings include: On 8/29/23 at approximately 10:16 a.m., R63 was observed in their room, up in their bed. R63 was queried if they had any concerns regarding their care in the facility and they reported they have been having mouth pain for months and have not been able to get all their extractions done in their mouth. On 8/29/23 the medical record for R63 was reviewed and revealed the following: R63 was admitted to the facility on [DATE] and had diagnoses including Osteoporosis and gastroesophageal reflux disease. R63's MDS (minimum data set) with an ARD (assessment reference date) of 7/12/23 revealed R63 needed extensive assistance from staff with personal hygiene. R63's BIMS score (brief interview for mental status) was 15, indicating intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that two (R17 and R111) residents/legal responsible representatives received a clear understanding of the facility's Binding Arbitration agreement prior to signing the document and ensured that the representative had the legal ability to sign the document. Findings include: During the entrance conference the facility reported that the Binding Arbitration was offered to all residents entering into the building. The facility provided a list of residents that had agreed to Binding Arbitration. The facility policy titled, Binding Arbitration Agreements was reviewed and documented, in part: This facility asks all residents to enter into an agreement for binding arbitration. We do not require binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, this facility .Binding Arbitration is a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between…

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