Iron River Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY All times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on observation and interview, the facility failed to effectively maintain the physical plant including resident bathrooms. This resulted in water damage to the walls in resident rooms (shared bathrooms) 203/205 and 207/209, missing bathroom baseboard tiles, bathtub used for storage and the increased likelihood for further water damage, cross-contamination and bacterial harborage, with a possible decrease in the satisfaction of living, for residents who use these areas. Findings Include In an observation on 8/12/2025 at 2:50 PM., it was noted in the shared bathroom of rooms 203/205 the wall behind the toilet paint was bubbled out. This surveyor felt the wall and noted it to be wet towards the baseboards, and damp upwards behind the toilet. The drywall underneath was noted to have water damage on the entire backside wall of the toilet. This softened area of the wall extended upward approximately 3 1/2 feet, and when pushed lightly 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 is related to Intake MI00148048 an MI00148473 Based on observation, interview, and record review the facility failed to ensure comfortable temperatures for a homelike environment for four Residents (#1, #2, #3, & #4) of four residents reviewed for comfortable temperature and homelike environment., resulting in expressions of physical discomfort. Findings include: Resident #1 (R1) Review of R1's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses including: arthritis, coronary artery disease (CAD), and Alzheimer's disease. R1 scored a 13 of 15 on the Brief Interview of Mental Status (BIMS) reflective of intact cognition. During an interview on 12/23/24 at approximately 10:15 a.m., R1 stated, It was cold in here a couple days ago . it has been cold in here for quite some time and it was cold in here a week ago when the weather changed . the staff have been wearing extra clothes and jackets to stay warm. Resident #2 (R2) Review of R2's…

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

Based on interview and record review, the facility failed to accurately report Payroll Based Journal (PBJ) information to CMS (Centers for Medicare and Medicaid Services). This deficient practice resulted in the facility triggering for excessively low weekend staffing with the potential to affect all 54 residents. Findings include: (All times are recorded in Eastern Daylight Time unless otherwise noted.) Review of the CMS PBJ Staffing Data Report FY (fiscal year) Quarter 2 2024 (January 1- March 31) revealed the metric Excessively Low Weekend Staffing Triggered with Submitted Weekend Staffing is excessively low with infraction dates being : 1/6/24, 1/7/24, 1/13/24, 1/14,24, 1/20/24, 1/21/24, 1/27/24, 1/28/24, 2/3/24, 2/4/24, 2/10/24, 2/11/24, 2/17/24, 2/18/24, 2/24/24, 2/25/24, 3/2/24, 3/3/24, 3/9/24, 3/10,24, 3/16/24, 3/17/24, 3/23/24, 3/24/24, 3/30/24, and 3/31/24. During an interview on 8/28/24 at 12:47 p.m., Business Office Manager/Human Resources G stated, I submit the PBJ information, but the system generates the information .I don't review the data. During an interview 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.

Based on interview and record review, the facility failed to ensure required members of the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly, resulting in the potential for decreased quality of care for all 54 residents living in the facility. Findings include: All times recorded in Eastern Daylight Time (EDT), unless otherwise noted. Review of the QAPI committee meeting attendance logs with the Nursing Home Administrator (NHA) and the Corporate Director of Clinical Services, Registered Nurse (RN) A on 8/28/2024 at 4:23 p.m., revealed meetings were held on 8/14/2023, 1/30/2024, and 5/01/2024. Further review of the attendance logs revealed the following: 8/14/2023: Medical Director or designee not in attendance. 1/30/2024: Medical Director or designee not in attendance. Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI), last reviewed 4/22/2024, revealed the following, in part: The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan. The QAA…

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 All times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on observation, interview, and record review, the facility failed to: 1. Ensure the correct use of personal protective equipment (PPE), 2. Post visual alerts at the entry for staff and visitors regarding information for hand hygiene and source control, and; 3. Post the process for everyone entering the facility of the recommended actions to prevent transmission of COVID-19 in accordance with standards of practice and Centers for Disease Control (CDC) recommendations for COVID-19, during an outbreak. Findings include: On 8/26/24, at approximately 12:30 p.m. the door to the facility's main entrance was observed closed for construction for the pouring of a concrete slab. The door at the end of the 100 unit was being utilized for entering and exiting the facility until construction was completed. On 8/26/24 at 12:30 p.m., Staff B said there was one resident who was positive for COVID-19. Staff B did not know when the resident tested positive…

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 the return or destruction of Resident medications brought in from home and previously opened for nine Residents out of the total facility population of 54 Residents. This deficient practice resulted in the potential for medication diversion, and administration of undated, opened medications with the potential for reduced efficacy and cross-contamination of infectious organisms. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. During an observation on 8/28/24 at 3:21 p.m., four pink bins with individual Resident medication bottles, boxes, patches, tubes, drops, and powders were found in the medication storage room upper wall cabinets. The four pink bins contained the following items: 1st Bin: Five opened, undated, unlabeled tubes of topical medication; one opened, undated bottle of stoma powder; and one opened, undated bottle of antifungal medication. 2nd Bin: Four prescription…

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 completion of monthly medication regimen reviews for four Residents (#41, #43, #46 and #9) of five residents reviewed for unnecessary medications, resulting in the potential for administration of unnecessary or inappropriate medications and adverse effects of administered medications. Findings include: All times recorded in Eastern Daylight Time (EDT), unless otherwise noted. Resident #41 (R41) Review of R41's Medication Regimen Review(s),' found in the electronic medical record (EMR) revealed the following: 7/23/2024 at 10:24 p.m. Medication Regimen Review completed. One or more recommendations were made for this resident. To see these and other recommendations please refer to the Director of Nursing [DON] monthly consultation report. Further review of R41's EMR revealed no consultation report indicating what the pharmacist recommendations were, when it was received by the facility and provider, or how and when the facility followed up 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 interview and record review, the facility failed to ensure legal guardianship was renewed and active for one Resident (#41) declared incompetent by a court of law, of two residents reviewed for advance directives, resulting in the potential for unauthorized decisions made on the Resident's behalf. Findings include: All times recorded in Eastern Daylight Time (EDT), unless otherwise noted. Resident #41 (R41) Review of R41's electronic medical record revealed a court document titled Report of Physician or Mental Health Professional, dated and signed by the court appointed physician on [DATE] deeming R41 not presently able to make informed decisions in the following areas: determining where to live; consenting to supportive services; handling personal financial affairs; and authorizing or refusing medical treatment. The prognosis for improvement in the individual's conditions is poor. Review of the Order Regarding Appointment of Temporary Guardian of Incapacitated Individual, dated and signed on [DATE],…

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

Based on interview and record review, the facility failed to provide responses to concerns/grievances for 4 Confidential Residents (CR301, CR302, CR303, CR305) reported during the Resident Council survey task. This deficient practice has the potential to result in unresolved resident concerns and a decreased quality of life. Findings include: (All times are recorded in Eastern Daylight Time unless otherwise noted.) During a confidential group meeting on 8/27/24 at 11:00 a.m., CR301 stated, we have a lot of the same complaints during resident council and they don't get taken care of. CR302 CR303, and CR305 all agreed. CR302 stated, We have the same concerns every month during resident council .we never hear anything back from the concerns we have, nothing changes. During an interview on 8/28/24 at 8:51 a.m., the Activity Director reviewed the resident council minutes and stated, I am not doing a very good job of reviewing the concerns and documenting them .I guess I could do a better job in charting the concerns or when they are reviewed with the resident council. Review of facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report and allegation of potential sexual abuse between two Residents (Residents #3 and #205) of four residents reviewed for abuse. This deficient practice resulted in the potential for undetected abuse. Findings include: (All times are recorded in Eastern Daylight Time unless otherwise noted.) Resident #3 (R3) Review of R3's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 2/24/23, with active diagnoses that included: anxiety disorder, depression, heart failure, and hypertension. R3 scored 8 of 15 on the Brief Interview for Mental Status (BIMS) reflective of moderate cognitive impairment. Resident #205 (R205) Review of R205's MDS assessment dated [DATE], revealed admission to the facility on 3/23/20, with active diagnoses that included: coronary artery disease, hypertension, non-Alzheimer's dementia, and depression. R205 scored a 3 of 15 on the BIMS assessment reflective of severe cognitive impairment. Review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate an allegation of potential sexual abuse between two Residents (Residents #3 and #205) of four residents reviewed for abuse. Findings include: (All times are recorded in Eastern Daylight Time unless otherwise noted.) Resident #3 (R3) Review of R3's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 2/24/23, with active diagnoses that included: anxiety disorder, depression, heart failure, and hypertension. R3 scored 8 of 15 on the Brief Interview of Mental Status (BIMS) reflective of moderate cognitive impairment. Resident #205 (R205) Review of R205's MDS assessment dated [DATE], revealed admission to the facility on 3/23/20, with active diagnoses that included: coronary artery disease, hypertension, non-Alzheimer's dementia, and depression. R205 scored a 3 of 15 on the BIMS assessment reflective of severe cognitive impairment. Review of a resident grievance form, dated 3/2/24, under the section, Nursing…

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.

All times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on interview and record review, the facility failed to provide written transfer notification to the Resident and/or Resident's Representative for two Residents (R7 and R15) of three residents reviewed for facility initiated transfers. Findings include: Resident #7 (R7) was transferred to the hospital on 7/19/24. The medical record did not indicate a written notification of transfer was provided to R7 or R7's resident representative. Resident #15 (R15) was transferred to the hospital on 6/27/24. The medical record did not indicate a written notification of transfer was provided to R15 or R15's resident representative. On 8/28/24 at 12:45 p.m., the Nursing Home Administrator (NHA) conveyed the facility did not issue the written notifications to R7 or R15 or their resident representatives when the residents were transferred to the hospital. On 8/28/24 at 2:40 p.m., the Corporate Director of Clinical Services (DCS) confirmed written notifications of transfer were required and provided a policy Transfer 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.

All times are in Eastern Daylight Time (EDT) unless otherwise noted Based on interview and record review, the facility failed to ensure two Residents (R7 and R15) of three residents reviewed for hospital discharges, were provided with written notification of the bed hold policy. Findings include: Resident #7 (R7) was transferred to the hospital on 7/19/24. The medical record did not indicate the bed hold policy was provided to R7 or R7's resident representative. Resident #15 (R15) was transferred to the hospital on 6/27/24. The medical record did not indicate the bed hold policy was provided to R15 or R15's resident representative. On 8/28/24 at 12:45 p.m., the Nursing Home Administrator (NHA) said the facility did not provide the bed hold policy to R7 or R15 or their representatives when the residents were transferred to the hospital. The facility policy Bed Hold Policy dated 5/28/24 read, in part: .At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies 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 develop and implement a comprehensive, person-centered and trauma-informed care plan for one Resident (#41) of one resident reviewed for mood and behaviors, resulting in the potential for psychosocial distress and decreased quality of life. Findings include: All times recorded in Eastern Daylight Time (EDT), unless otherwise noted. Resident #41 (R41) R41 was admitted to the facility on [DATE] with a primary diagnosis of dementia with behavioral disturbance. Review of R41's Minimum Data Set (MDS) assessment, dated 6/9/2024, revealed severe cognitive impairment and was assessed as being easily annoyed and short tempered . 12-14 days (nearly every day), during the assessment look back period. R41 was assessed as exhibiting the following behavior symptoms 1-3 days of the look back period: physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing .); verbal behavioral symptoms directed toward others (e.g.,…

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 safe resident handling during transfers for one Resident (#18) of one resident reviewed for accidents, resulting in a skin tear and the potential for serious injury. Findings include: All times recorded in Eastern Daylight Time (EDT), unless otherwise noted. Resident 18 (R18) R18 was admitted to the facility on [DATE] and had diagnoses including dementia, difficulty walking and muscle weakness. Review of R18's Minimum Data Set (MDS) assessment dated [DATE], revealed she required substantial/maximal assistance with sitting to standing, chair/bed-to-chair, toilet and shower/tub transfers. Further review of R18's MDS assessment revealed she had severe cognitive impairment and highly impaired hearing. Review of R18's electronic medical record (EMR) revealed the following: 8/25/2024 6:35 p.m. Central Daylight Time (CDT), Incident Note: This writer went in to give the resident her am medication as [Certified Nursing Assistant, CNA N] was just…

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 All times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on interview and record review, the facility failed to ensure one Resident (R15) of three residents reviewed for urinary catheters had physician orders for the catheter and a care plan for the catheter. Findings include: Resident #15 (R15) was readmitted to the facility on [DATE] with an indwelling urinary catheter. The diagnoses of R15 included but were not limited to retention of urine, history of urinary tract infections, and urosepsis (an infection that moves from the urinary tract into the bloodstream). On 8/28/24, the physician's orders in R15's medical record were reviewed for information regarding the urinary catheter. There was no physician's order for the catheter. There were no physician's orders for the frequency or indication for catheter changes, and no orders for changing the urinary drainage bag. The care plans for R15 did not contain a plan of care for the urinary catheter. There were no interventions regarding the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure completion of trauma assessments and failed to identify behavioral triggers for one Resident (#41) out of one resident reviewed for mood and behaviors with a history of physical abuse, resulting in inaccurate information available to Mental Health professionals and the potential for uninformed and misguided care. Findings include: All times recorded in Eastern Daylight Time (EDT), unless otherwise noted. Resident #41 (R41) R41 was admitted to the facility on [DATE] with a primary diagnosis of dementia with behavioral disturbance. Review of R41's Minimum Data Set (MDS) assessment, dated 6/9/2024, revealed she had severe cognitive impairment and was assessed as being easily annoyed and short tempered . 12-14 days (nearly every day), during the assessment look back period. The MDS assessment revealed R41 exhibited the following behavior symptoms 1-3 days of the look back period: physical behavioral symptoms directed toward others (e.g., hitting,…

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 MI00144174. Based on observation, interview, and record review, the facility failed to ensure palatable meals at satisfactory temperatures were served to four Residents (R42, and three residents in a confidential group interview) of 14 residents sampled for issues related to the dining experience. This deficient practice had the potential to negatively impact Residents' oral intake, weight, and worsen their medical condition. Findings include: (All times are recorded in Eastern Daylight Time unless otherwise specified.) On 8/26/24 at 12:50 PM, the tray line for the lunch meal was underway. The cook (Staff L) was asked for her record of food temperatures. No temperatures were recorded for the lunch she was serving. Staff L said, I didn't record temps. I forgot. Staff L was asked to take the temperatures of the food on the tray line. The meat loaf measured 160 degrees, cauliflower was 152 degrees, potatoes were 129 degrees, carrots were 118 degrees, and the pureed meat was 130 degrees. Staff M stated the holding temperature must not fall below 135…

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

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by: A. Failing to ensure that potentially hazardous foods were kept free from contamination, labeled, dated, and discarded on or before the expiration date. B. Failing to ensure food preparation surfaces in the dietary department were properly disinfected. C. Failing to properly clean and disinfect dishes and utensils. This deficient practice had the potential to result in food borne illness among any or all the 52 residents in the facility. Findings include: (All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted.) During a dietary department tour on 8/15/23 at 1:56 PM with the Dietary Manager (DM) EE the following observations were made in the dry storage room: - French fried onions were opened and clipped and had no date when the product had been first opened or when it should be used by. When asked when this product was opened, DM EE did not know. DM EE was unsure if 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 Inake: MI00138093 Based on interview and record review, the facility failed to report to the State Agency resident to resident abuse for 2 residents (Resident #46, & Resident #37) of 6 residents residents reviewed for abuse, resulting in Resident #30 grabbing on to and twisting Resident #46's right wrist causing pain, fear and increased anxiety, Resident #42 being involved in 2 separate incidents of resident to resident abuse and the potential for continued abuse and falls with major injury of residents residing in the facility to go unrecognized and the potential for further harm. (All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted.) Findings include: Resident #46 Review of an admission Record revealed Resident #46, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: generalized anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #46, with a reference date of 6/20/23 revealed 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 This citation pertains to Intake: #MI00138093. Based on interview and record review, the facility failed to report to the State Agency resident to resident abuse for 2 residents (Resident #46, & Resident #37) of 6 residents residents reviewed for abuse, resulting in Resident #30 grabbing on to and twisting Resident #46's right wrist causing pain, fear and increased anxiety, Resident #42 being involved in 2 separate incidents of resident to resident abuse and the potential for continued abuse and falls with major injury of residents residing in the facility to go unrecognized and the potential for further harm. (All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted.) Findings include: Resident #46 Review of an admission Record revealed Resident #46, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: generalized anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #46, with a reference date of 6/20/23 revealed 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 observation, and interview, the facility failed to maintain a sanitary, home-like environment, resulting in the potential for pest harborage conditions and a non-home-like environment. (All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted.) Findings include: In an observation on 8/16/23 at 8:27 AM., noted the privacy curtains in room [ROOM NUMBER] were both heavily soiled with multiple stains in various areas of the curtain. In an observation on 8/16/23 at 8:29 AM., noted the privacy curtains in room [ROOM NUMBER] were both heavily soiled with multiple stains in various areas of the curtains. In an observation on 8/16/23 at 8:32 AM., noted the window curtains in room [ROOM NUMBER] were tattered and torn around the edges with threads hanging loose. The top portion of the curtains hooks (to attach the curtains to slider rod) were noted to be missing on both curtains in the middle area, leaving the curtain hanging loosely. Both curtains appeared tattered and worn and overall…

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 resident privacy in 2 residents(Resident #15 and #46) reviewed for privacy, resulting in increased anxiety and the likelihood of prolonged feelings of embarrassment, fear and increased anxiety. Findings include: Resident #15 Review of an admission Record revealed Resident #15, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: chronic obstructive pulmonary disease, and generalized anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #15, with a reference date of 7/1/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #15 was cognitively intact. In an interview on 8/16/23 at 10:30 AM., Resident #15 was in her room laying in her bed. Resident #15 reported the large red and white velcro stop sign was draped across the entrance doorway to their (Resident #46-roommate) room because Resident #30 repeatedly has come into their room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview, and record review, the facility failed to appropriately revise and update care plans to reflect resident status for three Residents (#18, #20 and #40) of 14 Residents reviewed for care plans. This deficient practice resulted in the potential for implementation of interventions which were no longer appropriate and the potential for related complications from choking and/or aspiration. Findings include: (All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted.) Resident # 18 A review of Resident #18's medical record revealed an admission date of 2/3/23 with diagnoses including protein-calorie malnutrition, severe dementia with psychotic disturbance and depressive disorder. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score 0 of 15 signifying severely impaired cognition. The current Physician Orders for Resident #18 indicated a regular diet, with puree texture and nectar thick consistency liquids and had been…

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 #MI00132047. Based on observation, interview, and record review, the facility failed to provide services to meet professional standards of care for two Resident (#18, #10) of three residents reviewed for standards of practice. This deficient practice resulted in delayed removal of staples on Resident #18's head for over seven weeks, with the potential for infection, pain, and adverse medical outcomes, and lack of assessment for appropriate wheelchair seating and positioning for Resident #10, resulting in discomfort, decreased mobility, risk of pressure ulcers, and other adverse outcomes. Findings include: All times are noted in Eastern Daylight Time unless otherwise noted. Resident #18 Review of the Minimum Data Set (MDS) assessment, dated 8/22/22, revealed Resident #18 was admitted to the facility on [DATE], with diagnoses including dementia, thyroid disorder, atrial fibrillation (heart rhythm disorder), and depression. Resident #18 required limited, one-person assistance 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 observation, interview and record review, the facility failed to ensure ongoing assessment and monitoring for weight fluctuations for two Residents (#40, and #50) of 7 residents reviewed for nutritional needs. This deficient practice resulted in the potential for further clinical compromise. Findings include: (All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted.) Resident #40 A review of Resident #40's medical record revealed an admission date of 6/29/23 with diagnoses including morbid obesity, diabetes mellitus, and heart failure. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 signifying moderate cognitive impairment. The current Physician Orders for Resident #40 included No Added Salt (NAS), Carb (Carbohydrate) Controlled, Regular texture, NPO (Nothing By Mouth)/Fluid Restriction consistency with Fluid Restriction: 2000 cc . On 8/16/23 at 9:45 AM, Resident #40 was observed to have a 1/2 bottle…

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 physician visits were completed as required for two Residents (R45 and R104) out of four residents reviewed for timeliness of physician visits. This deficient practice resulted in the potential for unidentified and unaddressed medical care needs. Findings include: All times noted are Eastern Daylight Savings Times (EDST) unless otherwise noted. R45 Review of R45's Minimum Data Set (MDS) assessment, dated 6/18/23, revealed R45 was admitted to the facility on [DATE] with active diagnoses that included: cancer, peripheral vascular disease, end-stage renal disease, diabetes mellitus, Alzheimer's disease, stroke, non-Alzheimer's dementia, anxiety disorder and depression. The facility indicated the Brief Interview for Mental Status (BIMS) assessment was unable to be completed but R45 was documented with severe cognitive impairment. Review of R45's Practitioner Notes, which documented the physician and nurse practitioner visits for R45 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 Based on observation, interview, and record review, the facility failed to provide fluids in the prescribed texture/consistency for two Residents (Resident #18 and #20) and did not provide food in the proper form serving mechanical soft rather than pureed food for one Resident (Resident #18) of 2 residents reviewed for food/beverages served in proper form. This deficient practice resulted in the delivery of fluids and food of inappropriate consistency for the prescribed diet with the potential for choking and aspiration (accidental breathing of food or fluid into the lungs, which can cause pneumonia). Findings include: (All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted.) Resident # 18 A review of Resident #18's medical record revealed an admission date of 2/3/23 with diagnoses including protein-calorie malnutrition, severe dementia with psychotic disturbance and depressive disorder. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental 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 Based on interview and record review, the facility failed to ensure the electronic medical record contained accurate documentation for one Resident (R1-50) out of three residents reviewed for the comprehensive plan of care. This deficient practice resulted in the potential for unmet care needs related to the inaccuracy of the medical record. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. Review of R1-50's Incident and Accident reports between September 22, 2023, and October 10, 2023, revealed one fall without documented injury on 9/26/23. The Incident/Accident report documented a fall with no injury with Predisposing Environmental Factors of Wet Floor (box was checked), and Predisposing Situation Factors of Improper Footwear and Ambulating without Assist (boxes were checked). During an interview on 10/10/23 at 3:10 p.m., when asked about further details of the wet floor in R1-50's room as a potential causative factor for the fall the Director of Nursing (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.