Mission Point Health Campus of Jackson

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide person centered care to two dependent residents (R31, R55) out of three residents investigated for ALD's.Findings Include Resident #31 (R31) Review of the medical record reflected that R31 was admitted to the facility on [DATE]. Diagnoses of displaced Tri malleolar fracture of right lower leg, history of a stroke, polyneuropathy, obesity and rheumatoid arthritis. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2026 revealed R31 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R31 needed substantial assistance with showering and personal care. R31 was dependent on toileting, lower body dressing, and perineal hygiene. During an observation and interview on 03/01/2026 at 8:57 AM, R31stated she had only received 1 shower since admission of 02/03/2026. R31 was in her hospital gown, hair was messy,…

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 provide meaningful activities to one resident (R31) out of one resident investigated.Findings IncludeResident #31 (R31)Review of the medical record reflected that R31 was admitted to the facility on [DATE]. Diagnoses of displaced Tri malleolar fracture of right lower leg, history of a stroke, polyneuropathy, obesity and rheumatoid arthritis.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2026 revealed R31 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R31 needed substantial assistance with showering and personal care. R31 was dependent on toileting, lower body dressing, and perineal hygiene.During an observation and interview on 03/01/2026 at 8:56 AM, R31 stated she doesn't get down to the activities because it took so much to get her up in her wheelchair and taken down there. Writer asked…

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 prevent a significant weight loss for one resident (resident 5) of 2 reviewed from a total sample of 16.Findings include: Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed Resident #5 (R5) was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses dementia, depression, depression, Transient Ischemic Attack. R5 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status. On 03/01/2026 at 10:04 am, R5 was observed in his room, there was scrambled egg observed in two areas on the floor. R5 was sitting up in his wheelchair he was noted to have some tremors in both hands. When queried if he had breakfast yet, he replied he did but he didn't like it. R5 elaborated in great length that he wants oatmeal and asks for it every day, but depending on which Certified Nursing Assistant (CNA) is working he may or may not get it. When queried if he had met with Registered…

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 Physician Orders for enteral (tube) feeding and accurately document enteral feeding acceptance for one (R1) of one reviewed.Findings include: Review of the medical record reflected R1 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included pneumonia, malignant neoplasm (cancerous tumor) of middle third of esophagus, unspecified severe protein-calorie malnutrition and gastrostomy status (surgical opening into the stomach). The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/30/26, reflected R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and received 51% or more of their total calories through parenteral of tube feeding. On 03/01/2026 at 11:48 AM, R1 was observed in bed, with the head of the bed elevated. They reported receiving bolus tube feeding (specified amount of feeding administered over a brief…

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 dental services for two residents (#5, #40) out of three resident's review for dental services. Findings include: Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed Resident #5 (R5) was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses dementia, depression, depression, Transient Ischemic Attack. R5 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status. On 03/01/26 at 10:00 am, during an interview with R5, he was observed sitting in his room in his wheelchair. R5 complained of mouth pain and was observed to have some missing teeth. R5 reported he's told several staff members that he needed to see dentist again due to the pain but hasn't gotten any response. Review of the Physician order dated 01/07/26 reflected R5 was in need of a referral to oral surgeon, per dentist consult patient #20 tooth pain and causing sore on patient tongue. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain complete and accurate medical records for one (R1) of 16 reviewed. Findings include:Review of the medical record reflected R1 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included pneumonia, malignant neoplasm (cancerous tumor) of middle third of esophagus, unspecified severe protein-calorie malnutrition and gastrostomy status (surgical opening into the stomach). The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/30/26, reflected R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and received 51% or more of their total calories through parenteral of tube feeding. On 03/01/2026 at 11:48 AM, R1 was observed in bed, with the head of the bed elevated. They reported receiving bolus tube feeding (specified amount of feeding administered over a brief period of time) via feeding tube. R1 reported they were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to effectively maintain the resident call system for 2 (R21, R55) of 16 sampled residents affecting 2 residents, resulting in the increased likelihood for resident negative outcomes related to delayed and/or no emergency response.Findings include:Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] BIMS of 14, revealed Resident #21 was a [AGE] year-old female admitted on [DATE] with diagnosis of dysphonia (impairment in voice production, characterized by hoarseness, breathiness, strain or breaks in voice quality) depression and anxiety. On 03/01/2026 at 2:17 PM, the call light was tested in R21's (room and bathroom) with another surveyor. While testing the call light, Director of Nursing (DON) B brought in a [NAME] bell and handheld service bell and placed in on R21's overbed table. Interview with Licensed Practical Nurse (LPN) V stated the bathroom light should light up red. When the cord was pulled there 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 interview and record review, the facility failed to treat two (R202, R204) of five residents reviewed with dignity and respect.Findings include:This citation pertains to intake 2726697R202Review of the clinical record revealed R202 was admitted into the facility on 9/25/25 with diagnoses that included: Alzheimer's disease, depression, and anxiety. According to the Minimum Data Set (MDS) assessment dated [DATE], R202 scored 8/15 on the Brief Interview for Mental Status exam (which indicated moderately impaired cognition).On 1/27/26 at 3:06 PM R202 was observed sitting up in his wheelchair. R202 reported feeling tired and answered questions appropriately.A review of the Facility Reported Incident file pertaining to R202, the facility administrator was notified of inappropriate language being used by LPN G with R202, after an unwitnessed fall on 1/8/26. It also revealed the following witness statements:LPN G: I was called to room (room number redacted) because the resident was on the floor. I went into the…

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

Based on observations, interviews, and record reviews the facility failed to: (1) effectively clean and maintain food service equipment, and (2) date mark all potentially hazardous ready-to-eat food products effecting 39 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness. Findings include: On 12/10/24 at 07:35 A.M., An initial tour of the food service was conducted with Director of Food and Nutrition Services D and Dietary [NAME] L. The following items were noted: The ceiling surface was observed (etched, scored, particulate), adjacent to the pot and pan storage rack. The damaged ceiling surface measured approximately 6-inches-wide by 12-inches-long. The damaged ceiling surface also contained a black watery substance, within the opening. The 2017 FDA Model Food Code section 6-501.11 states: PHYSICAL FACILITIES shall be maintained in good repair. The South Bend convection oven interior surfaces were observed soiled with accumulated and encrusted food residue. The South Bend stove/oven(s) were observed soiled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, 1 (#5) non-sampled resident, and 5 (#21, #35, #145, #146, #243) of 12 sampled residents the facility failed to provide palatable food products effecting 39 residents, resulting in the increased likelihood for resident decreased food acceptance and nutritional decline. Findings include: On 12/10/24 at 11:00 A.M., An interview was conducted with Resident #243 regarding facility food products. Resident #243 stated: It's not very good. Resident #243 also stated: Generally the food is not very warm. Resident #243 additionally stated: Food items were missing from my meal tray. Resident #243 further stated: My coffee is always cold from the kitchen. On 12/10/24 at 11:10 A.M., An interview was conducted with Resident #21 regarding facility food products. Resident #21 stated: Food tastes like s--t (poo) sometimes. Resident #21 also stated: Too much pasta. and When you get potatoes and gravy, you don't receive much. Resident #21 additionally stated: Soup is always warm.…

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 proper personal protective equipment (PPE) use for COVID-19 transmission-based precautions in one (R145) of two reviewed and failed to ensure proper disinfection of items for two (R145 and R20) of three reviewed. Findings include: Upon entrance into the facility on [DATE] at 7:20 AM, it was reported by Nursing Home Administrator (NHA) A that the facility had two residents who were positive for COVID-19; one of which was R145. Resident # 145 (R145) Review of the medical record revealed R145 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included end stage renal disease, dependence on renal dialysis, diabetes, and COVID-19. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/29/24 revealed R145 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Nursing Progress Note dated 12/8/24…

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

Based on observations, interviews, and record reviews the facility failed to effectively clean and maintain the physical plant effecting 40 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 12/10/24 at 02:55 P.M., An interview was conducted with Director of Environmental Services J regarding the facility maintenance work order system. Director of Environmental Services J stated: We use to have Maintenance Care. Director of Environmental Services J also stated: We just started the TELS program a few weeks ago. On 12/11/24 at 08:30 A.M., A common area environmental tour was conducted with Maintenance Technician K. The following items were noted: Town Square Soiled Utility Room: The waste hopper basin was observed soiled with accumulated and encrusted dirt/grime. Maintenance Technician K indicated he would have housekeeping staff thoroughly clean and sanitize the soiled waste hopper basin as soon as possible. Staff/Visitor/Resident Restroom: The toilet seat was observed (etched, scored, particulate). Maintenance…

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 a baseline care plan with necessary healthcare information for one (R145) of 12 reviewed. Findings include: Review of the medical record revealed R145 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included end stage renal disease, dependence on renal dialysis, diabetes, and COVID-19. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/29/24 revealed R145 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R145's care plans and orders revealed no details pertaining to the type or location of R145's dialysis access site. There were also no orders to assess or monitor the site. In an interview on 12/11/24 at 11:13 AM, Licensed Practical Nurse (LPN) E reported R145 recently started dialysis, but they were not sure where R145's access site was located or any assessment/monitoring of the site that 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 interview and record review, the facility failed to ensure the attending physician documented in the medical record that identified medication irregularities were reviewed, the action taken, and/or the rationale for no changes to the medications for three (Resident #20, #21, and #35) of five reviewed. Findings include: Resident #21 (R21) Review of the medical record revealed R21 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus with use of insulin, heart, failure, stage 4 kidney disease and osteomyelitis(infection of the bone). The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/23/24 revealed R21 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R21 Medication Regimen Review, dated 10/24/24 revealed, 1) Glucophage (Metformin) is best given with meals to avoid GI irritation. 2) Long term therapy with Metformin can result in sub-therapeutic vitamin B-12 and folate levels.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a duration of use for as needed (PRN) medication for one (Resident #20) of five reviewed for unnecessary medications, resulting in the potential for unnecessary medications and adverse reactions. Findings include: Review of the medical record revealed R20 admitted to the facility on [DATE] with diagnoses that included anxiety disorder and depression. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/16/24 revealed R20 scored 5 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 12/12/24 at 2:13 PM, R20 was observed dressed, nicely groomed and resting in his recliner. Review of the Physician Orders revealed an order for Xanax (anti anxiety medication) Oral Tablet 0.25 MG (milligrams) give one tablet by mouth every 8 hours as needed for anxiety. The Physician order was continuous until discontinued on 7/18/24. Review of the Physician Orders revealed an 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 their medication error rate was below 5% when five medication errors were observed from a total of 29 opportunities for two residents (R20 and R30) of three reviewed resulting in a medication error rate of 17.24%. Findings include: Resident #30 (R30) Review of the medical record revealed R30 admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/9/24 revealed R30 scored 6 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 12/10/24 at 7:59 AM, Licensed Practical Nurse (LPN) F was observed preparing and administering medications to R30. LPN F crushed omeprazole 20 milligrams (mg) tablet, aspirin 81 mg enteric coated tablet, and ferrous sulfate 325 mg tablet. When asked if they had a list of medications that could not be crushed,…

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 #MI00146888 Based on interview and record review, the facility failed to arrange and provide transportation to a medical appointment for one (R1) out of three residents reviewed resulting in a missed appointment and the potential for delay of care. Findings include: Resident #1 (R1) Review of the medical record revealed R1 admitted to the facility on [DATE] with diagnosis which included malignant neoplasm of the skin. Review of R1's After Visit Summary dated 8/30/24 revealed R1 had an upcoming Return visit Physician's appointment scheduled for 9/5/24. Review of the medical record revealed no mention of an appointment for R1. In an interview on 9/26/24 at 4:21 PM, Licensed Practical Nurse (LPN) E reported that resident's appointments are scheduled and tracked via an online shared calendar. In an interview on 9/27/24 at 9:39 AM, LPN G reported she was working on 9/5/24 when the facility realized that R1 had an out of town appointment that transportation was not arranged for. LPN 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.

This citation pertains to Intakes MI00145676 and MI00145685. Based on interview and record review the facility failed to permit a resident to return to the facility after stabilization following emergency transport to the hospital for one resident (R214) of three residents reviewed. Findings include: Review of the electronic medical record (EMR) revealed that R214 was admitted to the facility 7/9/24 with a pertinent diagnosis of Unspecified Dementia, Severe, with Mood Disturbance (a condition that affects thinking, behavior, and the ability to perform everyday tasks). Review of the admission Assessment titled Admission/readmission Assessment dated 7/9/2024, reflected the finding that R214 had placed himself on the floor and was crawling around speaking to people . who are not there. On 9/5/24 at 9:07 AM during interview Unit Manager Licensed Practical Nurse (LPN) H recalled that resident was kind of sedated when he came (on admission) kind of out of it and explained that during the stay R214 went from 0 to 100 . R214 was described as having developed frightening behavior, screaming…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written reason for transfer/discharge for two residents (Resident #212, #214) of three reviewed for transfer/discharge, resulting in residents and/or responsible parties not being informed, in writing, of the reason for transfers/discharges. Findings include: Resident #212 (R212) Review of the medical record revealed that R212 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/7/24 indicated that R212 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). A Progress Note dated 6/16/24 revealed that R212 was being transferred to the hospital due to a change in condition. Review of the Electronic Medical Record showed no evidence of a bed hold or a transfer notice for R212. In an interview on 9/5/24 at 12:33 PM, Licensed Practical Nurse I R212s transfer was discussed. LPN I stated that when a resident is transferred out of the facility, the transfer…

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 MI00145685 Based on interview and record review the facility failed to administer medication as ordered for one resident (R214) of three residents reviewed potentially resulting in a relapse and escalation of psychologically disturbed behaviors. Findings Include: Review of the electronic medical record (EMR) revealed that R214 was admitted to the facility 7/9/24 with a pertinent diagnosis of Unspecified Dementia, Severe, with Mood Disturbance (a condition that affects thinking, behavior, and the ability to perform everyday tasks). Review of the admission Assessment titled Admission/readmission Assessment dated 7/9/2024, reflected the finding that resident had placed himself on the floor and was crawling around speaking to people . who are not there. Further review of the EMR revealed that one of the medications ordered for R214 was Ziprasidone 20 mg HCL (an atypical antipsychotic which rebalances dopamine and serotonin in the brain to improve thinking, mood, and behavior). Ziprasidone HCL was ordered to be given BID (two times per day). R214 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 MI00142852. Based on interview and record review, the facility failed to ensure freedom from physical restraints for one (Resident #1) of three reviewed for restraints. Findings include: Review of the medical record reflected Resident #1 (R1) admitted to the facility on [DATE], with diagnoses that included COVID-19, pneumonia, unspecified injury of head, unspecified fall and unspecified psychosis not due to a substance or known physiological condition. The admission Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 2/3/24, reflected R1 scored one out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R1 required partial/moderate assistance for transfers and to transition from a sitting to standing position. R1 discharged from the facility on 3/1/24 and did not reside in the facility at the time of the survey. A facility investigation reflected a written statement from Certified Nurse…

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 MI00142852. Based on interview and record review, the facility failed to report an allegation of abuse to the Nursing Home Administrator (NHA) and State Agency timely for one (Resident #1) of three reviewed for abuse. Findings include: Review of the medical record reflected Resident #1 (R1) admitted to the facility on [DATE], with diagnoses that included COVID-19, pneumonia, unspecified injury of head, unspecified fall and unspecified psychosis not due to a substance or known physiological condition. The admission Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 2/3/24, reflected R1 scored one out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R1 required partial/moderate assistance for transfers and to transition from a sitting to standing position. R1 discharged from the facility on 3/1/24 and did not reside in the facility at the time of the survey. A facility investigation…

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: (1) effectively date and label food products, and (2) maintain the walk-in cooler refrigeration unit effecting 40 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness. Findings include: On 01/11/24 at 08:40 A.M., A comprehensive tour of the food service was conducted with Director of Food and Nutrition Services (DFMS) F and Senior Regional Dietician S. The following item was noted: The Walk-In Cooler refrigeration unit was observed with accumulated ice [NAME], adjacent to the bottom and rear of the unit. DFMS F indicated she would contact the contractual vendor for repairs as soon as possible. The 2017 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall…

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 observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 40 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality. Findings include: On 01/11/24 at 10:32 A.M., An environmental tour of the facility Laundry Service was conducted with Director of Environmental Services T. The following item was noted: The drywall surface was observed (etched, scored, particulate), adjacent to the two commercial washing machines. The damaged drywall surface measured approximately 16-feet-long by 4-feet-high. Director of Environmental Services T indicated he would repair the damaged drywall surface as soon as possible. On 01/11/24 at 01:30 P.M., A common area environmental tour was conducted with Director of Environmental Services T. The following items were noted: Entrance Foyer: 1 of 2 overhead light bulbs were observed non-functional. One mounting screw was also missing on the double door weather stripping plate. Living Room: The emergency exit door…

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 issue a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) detailing estimated charges of continued services to 2 (Resident #25 and #235) of 3 reviewed for Beneficiary Notification, resulting in the potential for the resident and/or responsible party to be uninformed of the potential charges for continued stay and services at the facility. Findings include: Resident #25 (R25) Review of a SNF Beneficiary Notification Review worksheet reflected that R25's Medicare Part A start date was 7/28/23, and their last covered day of Medicare Part A service was 8/22/23. The worksheet reflected that R25 had exhausted benefit days, that a SNFABN was not provided as Benefits exhausted used all days, but that a NOMNC (Notice of Medicare Provider Non-Coverage) was provided. Resident #235 (R235) Review of a SNF Beneficiary Notification Review worksheet reflected that R235's Medicare Part A start date was 6/9/23, and their last covered day of Medicare Part A service was 7/13/23. The worksheet reflected that R235's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for 2 (Resident #9 and #17) of 12 residents reviewed resulting in the potential for unmet care needs. Findings include: Resident #9 Review of the medical record revealed that Resident #9 (R9) was admitted to facility 11/1/22 with diagnoses including atherosclerotic heart disease, aortic stenosis, chronic kidney disease stage 4, type 2 diabetes mellitus, and pulmonary hypertension. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/4/23 revealed that R9 was understood by and able to understand others with a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 9 (moderate cognitive impairment). In an observation and interview on 1/10/24 at 12:51 PM, R9 was observed sitting in wheelchair, at bedside, with oxygen tubing in place via nasal cannula connected to a running oxygen concentrator set at 2 liters per minute. R9 stated that she 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.

Based on observation, interview, and record review the facility failed to revise care plans for 1 resident (#3) receiving hospice services and 1 residents (#9) using compression stockings of 12 residents reviewed for care plan revision, resulting in the potential of unmet care needs. Findings Included: Resident #3 (R3) Review of the medical record revealed R3 was admitted to the facility 02/02/2023 with diagnoses that included congestive heart failure (CHF), atherosclerosis (thickening or hardening) of aorta, chronic kidney disease, history of pulmonary embolism, neuromuscular dysfunction of the bladder, dementia, anxiety, bilateral hearing loss, cognitive communication deficit, enlarged lymph nodes, pain in right shoulder, cervical disc degeneration, diverticulosis (condition of small, bulging pouches develop in the digestive tract), hyperlipidemia (high fat content in blood), osteoporosis (condition bones become weak and brittle), obstructive sleep apnea, hyponatremia (low sodium), asthma, vitamin D deficiency, and dependance on supplemental oxygen. The most recent Minimum Data…

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 provide assist with activities of daily living (ADLs) for one (Resident #4) of four residents reviewed for ADL care completion, resulting in missed showers and unmet care needs with the potential for a decline in emotional and physical health. Findings include: Review of the electronic medical record (EMR) revealed that Resident #4 (R4) was admitted to facility 2/1/23 with diagnoses including heart failure, hypertension, muscle weakness, anemia, and repeated falls. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/4/23 revealed that R4 was understood by and able to understand others with a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 12 (moderate cognitive impairment). Section GG of the same MDS revealed that R4 required partial/moderate assistance with transfers, personal hygiene, and showering/bathing. In an observation and interview on 1/10/24 at 11:40 AM, R4 was observed sitting in wheelchair, at bedside. A scabbed laceration was observed at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain updated physician's orders for oxygen therapy based on resident need/usage, complete routine monitoring of oxygen saturation levels, and complete thorough respiratory assessments for 1 (Resident #9) of 2 residents reviewed for respiratory care, resulting in the potential for respiratory complications. Findings include: Review of the medical record revealed that Resident #9 (R9) was admitted to facility 11/1/22 with diagnoses including atherosclerotic heart disease, aortic stenosis, chronic kidney disease stage 4, type 2 diabetes mellitus, and pulmonary hypertension. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/4/23 revealed that R9 was understood by and able to understand others with a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 9 (moderate cognitive impairment). In an observation and interview on 1/10/24 at 12:51 PM, R9 was observed sitting in wheelchair, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure medication regimen irregularities were reviewed and acted upon for two (Resident #19 and #21) of five reviewed, resulting in the potential for unnecessary medications and adverse reactions. Findings include: Resident #21 (R21): Review of the medical record reflected R21 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included malignant neoplasm (cancerous tumor) of left bronchus or lung, malignant neoplasm of right breast, malignant neoplasm of left kidney and chronic obstructive pulmonary disease (COPD). A Pharmacist's Recommendation to Prescriber document dated 8/22/23 reflected, .Resident is receiving the statin [medication that can lower cholesterol]: ATORVASTATIN TAB 40MG [milligrams]. Please consider adding a fasting lipid panel with next lab draw and annually. The section for the prescriber/provider to mark if they agreed or disagreed with the recommendation, and the sections for comments, provider signature…

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

Based on observation, interview, and record review, the facility failed to properly label an open bottle of tuberculin and dispose of an expired bottle of tuberculin in two of three medication rooms reviewed for Medication Storage and Labeling, resulting in the potential for decreased medication efficacy and adverse side effects in a current facility census of 40 residents. Findings include: On 1/11/24 at 9:44 AM, 300 Unit Medication Room was reviewed in the presence of Licensed Practical Nurse (LPN) E. During the review, it was noted that the medication refrigerator within the medication room contained an open Tuberculin bottle. No opened date was indicated on either the medication box or bottle. LPN E confirmed that the open bottle of Tuberculin was approximately ½ empty, stated that it was only good for 30 days after opening, and that it would be disposed of as did not know when it was opened as neither the box nor bottle contained an open date. On 1/11/24 at 10:14 AM, 200 Unit Medication Room was reviewed in the presence of Licensed Practical Nurse/Unit Manager (LPN/UM) J.…

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 coordinate hospice services for one resident (#3) out of one resident reviewed for coordination of hospice services resulting in the potential for care note being provided to resident receiving hospice services and the potential for residents not to be fully informed of hospice services provided Findings Included: Resident #3 (R3) Review of the medical record revealed R3 was admitted to the facility 02/02/2023 with diagnoses that included congestive heart failure (CHF), atherosclerosis (thickening or hardening) of aorta, chronic kidney disease, history of pulmonary embolism, neuromuscular dysfunction of the bladder, dementia, anxiety, bilateral hearing loss, cognitive communication deficit, enlarged lymph nodes, pain in right shoulder, cervical disc degeneration, diverticulosis (condition of small, bulging pouches develop in the digestive tract), hyperlipidemia (high fat content in blood), osteoporosis (condition bones become weak and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure timely consent for and administration of the influenza immunization for two (Resident #19 and #23) of five reviewed for immunizations, resulting in the potential for influenza infection and complications. Findings include: Resident #23 (R23): Review of the medical record reflected R23 admitted to the facility on [DATE], with diagnoses that included pulmonary hypertension and shortness of breath. R23's Vaccination History and Consent Form for influenza, pneumonia and Covid-19 reflected R23 consented to influenza, pneumonia and Covid-19 vaccination or booster on 12/6/23. R23's immunization history reflected an influenza vaccination was administered on 12/6/23. During an interview on 01/11/24 at 02:19 PM, Regional Director of Clinical (RDC) G reported the facility requested that influenza immunizations be ordered in August so they could be available and ready for influenza season, which started in October. During an interview with Health…

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 MI00140243. Based on interview and record review, the facility failed to facilitate a safe discharge for one (Resident #3) of three reviewed for discharge, resulting in Resident #3 being discharged from the facility, on two separate occasions, without the recommended equipment or services to ensure a safe transition of care. Findings include: Review of the medical record reflected Resident #3 (R3) admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD), unspecified fall and the presence of an artificial hip joint. R3 discharged from the facility on 10/14/23, with a return not being anticipated. R3 admitted to the facility on [DATE], from the hospital, with additional diagnoses that included wedge compression fracture of thoracic vertebrae 11 and 12, pneumonia and heart failure. R3 discharged from the facility on 11/24/23, with a return not being anticipated. A Progress Note, dated 8/18/23, reflected R3 was homeless, did not…

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 MI00140818. Based on interview and record review the facility failed to identify injury of unknown origin for one out of three residents (Resident #1), who had multiple facial abrasions, resulting in no facility investigation to identify if the origin of the injuries was the result of physical abuse/harm by a perpetrator, who continued to have access to residents, was the root cause of the multiple facial abrasions. Findings Included: Resident #1 (R1) no longer resided at the facility at the time of the onsite investigation. Per the facility face sheet R1 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Record review of a confidential document and source dated 10/31/2023, revealed R1 was transferred to the hospital on [DATE] for low blood pressure. The document also revealed that R1 was identified at the hospital to have seven to eight abrasions on his face, nose and eyes were swollen. Review of R1's electronic medical record (EMR) physician…

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.