Regency at Jackson

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their abuse policy and procedure for one Resident (#7) of one resident reviewed for alleged abuse.Findings Include:Resident #7 (R7)Review of the medical record reflected R7 was initially admitted to the facility on [DATE] through 05/01/2026 with diagnoses including displaced comminuted fracture of shaft of right femur, subsequent encounter for closed fracture with routine healing, epilepsy, diabetes mellitus type 2, symptoms involving the musculoskeletal system, and surgical aftercare.The most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/01/2026 revealed R7 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section GG0103, Activities of Daily Living (ADL) Assistance, R7 required maximum assist to dependent on personal care and used a wheelchair as an assistive device.During an interview on 05/20/2026 at 11:30 am, Certified Nursing Assistant (CNA) M stated she…

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 off interviews and record review the facility failed to report alleged abuse for one Resident (#7) of one reviewed for alleged abuse.Findings IncludeResident #7 (R7)Review of the medical record reflected R7 was an initial admission to the facility on [DATE] through 05/01/2026. Diagnoses of displaced comminuted fracture of shaft of right femur, subsequent encounter for closed fracture with routine healing, epilepsy, Diabetes Mellitus 2, symptoms involving the musculoskeletal system, surgical aftercare.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/01/2026 revealed R7 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section GG0103, Activities of Daily Living (ADL) Assistance reveals R7 was maximum assist to dependent on personal care and used a wheelchair as an assistive device.During an interview on 05/20/2026 at 11:30 am, Certified Nursing Assistant (CNA) M stated she was told not to go back in R7's room by Licensed Practical…

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 3017894 and 2963604 Based on interview and record review the facility failed to thoroughly investigate an injury of unknown source for one Resident (#3) and failed to thoroughly investigate an allegation of verbal abuse for one Resident (#7) from a total of three residents reviewed for abuse. Findings include:Resident #3 (R3) Review of the clinical record including the Minimum Data Set (MDS) dated [DATE] revealed Resident #3 (R3) was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, dementia and depression. R3 scored 7 out of 15 (severe cognitive impairment). Of note, R3 expired on [DATE]. Review of the Kardex (a care guide for staff) on [DATE] require two staff for bed mobility and repositioning. Review of the incident reported dated [DATE], it reflected that Certified Nursing Assistant (CNA) H reported to License Practical Nurse (LPN) F on [DATE] after the first bed check that while repositioning R3 she heard a Popping sound.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to complete wound care as directed by physician orders for two Residents (#10 & #13) of three residents reviewed. Findings include:Resident #10 (R10)On 5/21/26 at 12:25 PM, R10 was observed sitting up in his wheelchair. R10 confirmed he had a wound on his butt which was supposed to be changed every day but had not been changed for 2-3 days. A review of the clinical record revealed R10 was admitted into the facility on 2/3/19 with diagnoses that included: chronic kidney disease. According to the Minimum Data Set (MDS) assessment dated [DATE], R10 scored 14/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).On 5/27/26 at 1:32 PM, R10's wound care dressings were observed with LPN J. LPN J reported that all 3 dressings had been changed that day, however none of the dressings were dated. All 3 (right and left hip, and coccyx) were observed to be covered with a boarder foam dressing which were observed to be clean,…

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 an avoidable fall for one Resident (#2) of three residents reviewed. Findings include:Resident #2 (R2)On 5/20/26 at 3:05 PM, R2 was observed lying in bed on her back and reported feeling sore with specific reports of pain in her right hip. R2 did not recall details of a fall.A review of the clinical record revealed R2 was admitted into the facility on 3/4/21 with diagnoses that included: catatonic schizophrenia and vascular dementia. According to the Minimum Data Set (MDS) assessment dated [DATE], R2 scored 8/15 on the Brief Interview for Mental Status exam (which indicated moderately impaired cognition).A review of an incident report for R2 dated 1/19/26, revealed the following: Pt (patient) was observed laying on her right side. Pt complaining of pain of the head and her right arm. Ambulance notified and pt was sent to ER (Emergency Room) for evaluation. In the Notes section dated 1/20/26 it was documented IDT (Interdisciplinary…

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 perform catheter care consistent with professional standards for one Resident (#10) of three residents reviewed. Findings include:Resident #10 (R10)On 5/21/26 at 12:25 PM, R10 was observed sitting up in his wheelchair. R10 confirmed he had a suprapubic catheter. R10 reported it had recently gotten clogged and there were orders in place to keep it open (by flushing it regularly) but it has not been done.A review of the clinical record revealed R10 was admitted into the facility on 2/3/19 with diagnoses that included: chronic kidney disease. According to the Minimum Data Set (MDS) assessment dated [DATE], R10 scored 14/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).A review of a Urology Office Visit note, dated 4/21/26, documented in part .presents today at the outpatient Urology office regarding urinary retention.He resides at a nursing facility and the catheter has been previously ordered to be changed…

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 accurately document wound care for one Resident (#13) of three residents reviewed. Findings include:On 05/21/2026 at 11:51 AM, during an interview with R13, he reported he had a current wound to his left foot. R13 stated the dressing is ordered to be changed every day and was not being completed, but instead it was being done when they get around to it, which he reported was about every 2 days.A review of the clinical record revealed R13 was admitted into the facility on [DATE] with diagnoses that included: Type 2 Diabetes, peripheral vascular disease and acute osteomyelitis, right ankle and foot. According to the Minimum Data Set (MDS) assessment dated [DATE], R13 scored 12/15 on the Brief Interview for Mental Status exam (which indicated moderately impaired cognition).On 5/27/26 at 1:32 PM, an observation of R13's wound dressing was completed with RN K. Dressing was observed to be clean, dry and intact (covered with rolled gauze). No…

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 grievances were promptly documented, investigated, tracked and resolved for four residents of four resident reviewed for grievances (R107, R111, R112, and R113). Findings include: Resident #107 (R107)Review of the Face Sheet and Minimum Data Set (MDS), with Assessment Reference Date, dated 2/10/26, reflected R107 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included severe morbid obesity, cervical disc degeneration, muscle wasting and atrophy, major depression and anxiety. The MDS reflected that R107 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for transfers, showering and toileting.During an interview on 2/19/26 at 8:45 a.m., Nursing Home Administrator (NHA) A reported had been employed at the facility for about five months. This surveyor requested all allegations of abuse for review for past…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act.Findings include:Resident #107 (R107)Review of the Face Sheet and Minimum Data Set (MDS), with Assessment Reference Date, dated 2/10/26, reflected R107 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included severe morbid obesity, cervical disc degeneration, muscle wasting and atrophy, major depression and anxiety. The MDS reflected that R107 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for transfers, showering and toileting.During an interview on 2/19/26 at 8:45 a.m., Nursing Home Administrator (NHA) A reported had been employed at the facility for about five months. This surveyor requested all allegations of abuse for review for past 30 days. NHA A reported…

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 thoroughly investigate allegations of abuse for four residents (R107, R111, R112, R113) of seven reviewed.Findings include:Resident #107 (R107)Review of the Face Sheet and Minimum Data Set (MDS), with Assessment Reference Date, dated 2/10/26, reflected R107 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included severe morbid obesity, cervical disc degeneration, muscle wasting and atrophy, major depression and anxiety. The MDS reflected that R107 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for transfers, showering and toileting.During an interview on 2/19/26 at 8:45 a.m., Nursing Home Administrator (NHA) A reported had been employed at the facility for about five months. This surveyor requested all allegations of abuse for review for past 30 days. NHA A reported R107 recently alleged no care for 14…

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: 2747784, 2727148, 2724902, 2720062Based on observation, interview, and record review the facility failed to ensure seven out of seven residents (R105, R106, R107, R110, R111, R112, R113) received activities of daily living (ADL) care per the plan of care. Findings Included:Resident #107 (R107) Review of the Face Sheet and Minimum Data Set (MDS), with Assessment Reference Date, dated 2/10/26, reflected R107 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included severe morbid obesity, cervical disc degeneration, muscle wasting and atrophy, major depression and anxiety. The MDS reflected that R107 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for transfers, showering and toileting. During an observation and interview on 2/20/26 at 12:15pm, R107 was sitting in room in recliner and appeared calm, pleasant and able to answer questions without…

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: 2740492, 2724902, 2747784, 2720062Based on observation, interview, and record review, the facility failed to ensure adequate staff to meet the resident needs for 7 residents (R105, R107, R110, R111, R112, R113) reviewed for staffing, resulting in resident care and needs not being consistently met and the potential for negative outcomes for all residents.Findings include:Resident #107 (R107)Review of the Face Sheet and Minimum Data Set (MDS), with Assessment Reference Date, dated 2/10/26, reflected R107 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included severe morbid obesity, cervical disc degeneration, muscle wasting and atrophy, major depression and anxiety. The MDS reflected that R107 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for transfers, showering and toileting.Review of R107 concern form, 2/16/26, for care concern from 2/14/26.…

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 2747784Based on interview and record review, the facility failed to notify the family of one of one resident (R106) nor the on-call provider of a change in condition requiring to be sent out to the hospital. Findings Include;Resident #106 (R106)Review of the medical record reflected that R106 was admitted to the facility on [DATE]. Diagnoses of Pneumonitis due to inhalation of food and vomit, severe protein-calorie malnutrition, non-pressure related ulcers in the lower extremities, Dementia and peripheral vascular disease.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/11/2026 revealed R106 had a Brief Interview of Mental Status (BIMS) of 03 (Severe cognitive impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R106 needed substantial assistance with showering and personal care. R106 was dependent on toileting and perineal hygiene.During an interview on 02/24/2026 at 10:15 AM, R106's family member M…

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 2743515Based on observations, interviews, and record review the facility failed to protect the resident's(R103) right to be free from sexual abuse by another resident (R104).Findings include:Review of the Face Sheet and Minimum Data Set (MDS) with Assessment Reference Date, dated 2/12/26, reflected R103 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included cerebral infarct(stroke), anxiety, depression, altered mental status, substance use disorder, aphasia (impaired ability to speak, understand, read, or write), and required assistance with person care. The MDS reflected R103 had a BIM (assessment tool) score which indicated her ability to make daily decisions was moderately impaired-decisions poor, and she required one-person physical assist with transfers, dressing, hygiene, bathing and two-person physical assist with toileting.During an interview on 2/19/26 at 8:45 a.m., Nursing Home Administrator (NHA) A reported had been employed at 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 give the bed hold policy, transfer/discharge paperwork to one of one resident (R106) as he was transferred to the hospital with a change in condition.Findings Include;Resident #106 R106Review of the medical record reflected that R106 was admitted to the facility on [DATE]. Diagnoses of Pneumonitis due to inhalation of food and vomit, severe protein-calorie malnutrition, non-pressure related ulcers in the lower extremities, Dementia and peripheral vascular disease.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/11/2026 revealed R106 had a Brief Interview of Mental Status (BIMS) of 03 (Severe cognitive impact) out of 15.Under section G0100, Activities of Daily Living (ADL) Assistance reveals R106 needed substantial assistance with showering and personal care. R106 was dependent on toileting and perineal hygiene.During an interview on 02/24/2026 at 10:15 AM, R106's family member M stated R106 was only at that 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 ensure comprehensive care plans were in place for two out nine residents (Residents 104 & 108) related to leave of absence (LOA).Findings Included:Resident #104 (R104):Per the facility face sheet R104 was admitted to the facility on [DATE]. Record review of a Determination to Leave the Facility Against Medical Advice not dated, revealed R104 was not cleared by the Physician to be allowed to leave the facility due to being a high risk for an accident, falls, or other acute illness/condition as a result of being outside of the facility unsupervised, which may result in a serious negative health outcome. R104 signed the document with the understanding of any consequences. The signed document also revealed under number 5) The resident (R104) had participated in care planning related to his/her decision to leave the facility unsupervised and agrees to abide by the plan of care. The resident is aware that the plans of care will be reviewed periodically and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure for one out of three residents (R108) an evaluation was completed to determine ability for leave of absence (LOA).Findings Included:Per the facility face sheet Resident #108 (R108) was admitted to the facility on [DATE].Record review of a Minimum Data Set (MDS) dated [DATE], revealed R108 had a Brief Interview of Mental Status (BIMS) score of 13 out of 15 which indicated R108 cognition was intact.During an interview with R108 on 2/25/2026 at 12:02 PM, R108 was observed lying in bed and answered all questions appropriately.Per progress notes dated 2/11/2026, R108 had signed out LOA with another resident, and upon returning to the facility R108 did not use the crossed walk to cross back over the street. Upon crossing the street, R108 was struck by a vehicle that was aggressively driving over the speed limit. R108 was found to have fractured spleen, rib, and laceration of the scalp. Record review of a care plan dated 10/25/2026,…

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 2720063.Based on interview and record review the facility failed to ensure immunizations were administered for one out of three residents (Resident #108) who consented to receiving the Pneumococcal (PCV) and the Respiratory Syncytial Virus (RSV) vaccinations.Findings Included:Per the facility face sheet Resident #108 was admitted originally admitted to the facility on [DATE]; with a most recent admission date of 2/14/2026.Review of a consent form revealed R108 had signed the consent on 10/28/2025 to receive the vaccination.Review of a consent form revealed R108 had signed a consent on 10/28/2026 to receive the vaccination.Review of R108's electronic medical record (EMR) revealed under immunizations that the RSV and PCV20 immunizations were pending immunization with a confirmation date of 10/28/2025.Record review of R108's Physician orders for the month of October 2025 through 2/26/2026 revealed no Physician's order was ever written for either of the vaccinations to be…

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 interviews and record review the facility failed to ensure the hiring process, orientation and competencies were completed per regulation requirements.Intakes 2710396, 2710425, 2701621Findings IncludeDuring an interview and record review on 01/08/2026 at 3:35 PM, Nursing Home Administrator (NHA) A brought in the requested personnel file of Certified Nursing Assistant (CNA) K. Record review of the personnel file revealed CNA K was hired on 10/09/2025 and was terminated on 12/15/25, with her last day worked was 12/14/25. CNA K Personnel file did not contain the completed orientation plan nor new hire paperwork as state and federally mandated. CNA K personnel file did not have a completed background check, certification verification, I-9, fingerprinting or drug screening with pre-hire physical. Requested this information from the NHA A. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care, as well as to orient…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure one dependent resident (Resident #9) of one resident received bed baths and personal careFindings Include:This pertains to Intake 2701621Resident #9 (R9)Review of the medical record reflected that R9 was admitted to the facility on [DATE] and admitted to hospice on 06/17/2024. Diagnoses of Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Major Depression, Chronic Pain Syndrome, Fractures with routine healing of T5-T6, T9-T10, T11- T12, Compression Fracture of first lumbar vertebra and generalized weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) revealed R9 had a Brief Interview of Mental Status (BIMS) of 14 (Cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R9 was dependent of all personal care.During an observation on 01/08/2026 at 2:30 PM. R9 was asleep in his bed, wearing his oxygen at 2.5 lpm. No date on the tubing.…

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 interviews and record review, the facility failed to protect resident #7's (R#7) from a fall from bed with staff. Findings IncludeIntake: 2702557Resident #7 (R7) Record review of the facility reported incident revealed the incident accrued on 12/15/2025, R7 fell out of bed or rolled out of bed, landed on her face, split her lip open and broke off a tooth, incident was reported and R7 was sent to ER. Transfer report documented that R7 only needed assistance with toileting and transfers and was not dependent on care. Facilities response was to report the incident to the State of Michigan in the form of a facility reported incident also known as FRI. CNA involved was suspended pending the outcome of the investigation. Inservice scheduled and the police were notified. Action to be taken, resident told policy she rolled out of bed. Interview with one nursing staff were typed up by NHA, not reported in staff members' own words and writing, and staff did not sign this interview as being present and validating the interview, NHA signed the typed interview.Interview between NHA A…

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

Based of interview and record review the facility failed to enforce the use of a mask as mandated by their infection control program related to Covid.Findings IncludeDuring an interview and observation on 01/09/2026 at 7:55 AM, writer toured the kitchen as breakfast was being served. Observation made of Dietary Manager G not wearing the mask as deemed mandatory from the Infection Preventionist following two other staff testing positive for Covid. Dietary Manager G looked at writer and smiled and giggled stating I was just going to put a mask on.During an interview on 01/09/2026 at 12:20 PM, DON B stated when staff reported they had covid, management team requested they conduct a second covid test, if it was positive, they tested all staff and residents. DON B stated they follow the CDC guidelines and tested on the first day, third day and fifth day. DON B stated now that they have tested negative, they will test everyone two times a week for the next 14 days. DON B also stated that wearing mask was mandated for all staff working.

This citation pertains to intake 2677950Based on interview and record review the facility failed to provide adequate nursing staffing to meet residents' needs for 14 days out of 30 days reviewed for nursing staff.Findings included:During an interview on 12/18/2025 at 01:38 p.m. Nursing Schedular (NS) C explained that Nursing Staffing is based on an average daily census. Once this core number of staffing was identified, the nursing staff needs may be adjusted based on the acuity of the resident in the facility. NS C explained that if vacant positions are present then other staff would be called and/or managers would be asked to work the vacant positions. During an interview on 1218/2025 at 02:08 p.m. Nursing Home Administrator (NHA) A reviewed facility staffing sheets since 11/17/2025. During the review the following staff sheet demonstrated that the required number of staff was not present:1. 11/19/25 (Census 68) Staff actual days Aides 7, required 8 therefore 1 short staffed. 2. 11/20/25 (Census 69) Staff actual afternoons Aides 4, required 5 therefore 1 short staffed. 3. 11/21/25-…

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 numbers: MI00152521 and MI00152424. Based on observation, interview, and record review, the facility failed to thoroughly and accurately conduct an investigation of a fall that sustained a left hip fracture for one Resident (R#501) of four (4) sampled residents reviewed for fall. Findings include: Resident #501 (R501) On 5/1/25 at 10:27 AM, Resident 501 (R501) was observed grimacing and complaining of severe, unbearable pain in bed. R501 revealed she fell and broke her hip, but could not recall how it happened or when it happened. R501 attempted to get up and indicated she wanted me to stay until she returned. She said she was going to the bathroom when asked where she was going. R501's call light was not within reach during the observation. However, R501 was observed holding the wall lamp metal chain cord and was pressing on the metal bell at the tip of the metal string. Like she was pressing a call light button. R501, during a brief interview, was observed to be very confused…

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 numbers: MI00152521 and MI00152424. Based on observation, interview, and record review, the facility failed to thoroughly assess and monitor for pain and neurologic assessment after two falls (unwithnessed and witnessed) that sustained a left hip fracture for one Resident (R#501) of four (4) sampled residents reviewed for fall resulting in delay in treatment, increased experience in physical distress and worsening of pain. Findings include: Resident 501 (R501) On 5/1/25 at 10:27 AM, Resident 601 (R601) was observed grimacing and complaining of severe, unbearable pain in bed. R501 revealed she fell and broke her hip but could not recall how it happened or when it happened. R501, during a brief interview, was observed to be very confused and expressed that she was in extreme pain. A review of R501's Electronic Medical Record (EMR) conducted on 5/1/25 at 10:45 AM revealed R501 was [AGE] years old, admitted on [DATE] with the diagnosis of Dementia, Difficulty Walking, Schizophrenia,…

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 numbers: MI00152521 and MI00152424. Based of interview and record review, the facility failed to timely revise/update care plans for one resident (R#501) of four residents reviewed for care plan revision resulting in care plans not being revised as the status and needs of the residents changed related to pain and post surgical site skin care. Findings include: Resident #501 (R501) A review of R501's Electronic Medical Record (EMR) conducted on 5/1/25 at 10:45 AM revealed R501 was [AGE] years old, admitted on [DATE] with the diagnosis of Dementia, Difficulty Walking, Schizophrenia, and Type II Diabetes in addition to other diagnoses. On 4/17/25, R501 fell twice and was sent to the hospital the following day on 4/18/25. R501 returned on 4/23/25 with an additional diagnosis of Displaced Intertrochanteric Fracture of the left Femur, subsequent encounter for closed fracture with routine healing, and an encounter for other orthopedic aftercare. The Minimum Data Set, dated [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 observation, interview, and record review, the facility failed to maintain best practices in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: During a tour of the kitchen, starting at 9:27 AM on 4/14/25, an interview with Certified Dietary Manager (CDM) D found that most potentially hazardous foods are held for three to seven days. At this time, observation inside of the walk-in cooler, found the following items: hot dogs dated 4/12 to 5/11, sliced ham dated 4/14 to 4/27, and a large chunk of ham dated 4/14 to 4/22. A follow up of the walk-in cooler, at 2:57 PM on 4/14/25, found a new container of hot dogs in the walk-in cooler dated 4/14 to 5/11. An interview with CDM D stated she is still training some new staff on proper date marking. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN…

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 have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Findings include: During a tour of the facility with Maintenance Director (MD) J, at 1:29 PM on 4/14/25, observation of the third-floor soiled utility room found the facility had removed the hopper basin but still had active water lines. When asked if these lines get flushed, MD J was unsure. During a tour of the facility with MD J, at 1:49 PM on 4/14/25, observation of the second-floor tub room found it full of equipment and the tub removed. On the far wall water lines that used to be connected to the tub were found protruding from the wall with shut of valves. When asked if the old tub lines were flushed, MD J stated he believed they were 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 Based on observation, interview and record review, the facility failed to provide necessary care and services to ensure a resident's abilities in activities of daily living (ADL) did not diminish in two (Resident #20 and Resident #24 ) of two residents reviewed for comprehensive care planning, resulting in increased levels of assistance provided by staff with ADL care. Findings Include: Resident #20 (R20) Review of the medical record reflected R20 was an initial admission to the facility on [DATE] and readmitted on [DATE]. Diagnoses of Spinal stenosis, Lumbar region without neurogenic claudication (narrowing of the spinal canal of the lower back), Lumbosacral plexus disorders (cause a painful mixed sensorimotor disorder of the corresponding limb), abnormalities of gait and mobility, benign prostatic hyperplasia with lower urinary tract symptoms (inability to completely empty the bladder), dysphagia (difficulty swallowing), muscle weakness and chronic pain. The most recent Minimum Data Set (MDS), with an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide for one out of one resident (Resident #6) care and services to prevent and promote healing of pressure ulcers resulting in worsening wounds. Findings Include: Resident #6 (R#6) Review of the medical record reflected R6 was an initial admission to the facility on [DATE] and readmitted on [DATE].R6 was admitted to hospice on 08/24/2024. Diagnoses of cerebral atherosclerosis, Diabetes Mellitus with neuropathy, pressure ulcer of the sacral region, stage 4, history of a stroke, benign prostatic hyperplasia with urinary symptoms and suprapubic catheter, spinal stenosis in the cervical region, left side hemiplegia and hemiparesis following the stroke and muscle weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/03/2025 revealed R6 had a Brief Interview of Mental Status (BIMS) of 08 (moderately impaired) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R6 is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the attending physician documented in the medical record the rationale for not implementing the pharmacy recommendation for one (R11) of five reviewed. Findings include: Review of the medical record revealed R11 was admitted to the facility on [DATE] with diagnoses that included vascular dementia and catatonic schizophrenia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/23/25 revealed R11 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Physician's Order dated 1/7/25 revealed an order for carbamazepine (anticonvulsant medication) 600 milligrams (mg) one time a day. R11 had been prescribed this medication since 2021. Review of the New admission Medication Review dated 12/15/24 revealed a high drug therapy problem identified was that carbamazepine requires lab monitoring. The recommended action for the provider was Recommend 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 ensure medication laboratory monitoring was completed for one (R46) of five reviewed. Findings include: Review of the medical record revealed R46 admitted to the facility on [DATE] with diagnoses that included borderline personality disorder, post-traumatic stress disorder, anxiety, and depression. The MDS with an ARD of 2/8/25 revealed R46 scored 14 out of 15 (cognitively intact) on the BIMS. Review of the Physician's Order dated 9/4/24 revealed an order for Depakote 125 mg by mouth two times a day for mood stabilization/borderline personality/depression. Review of the Consultant Pharmacist Recommendation to Physician dated 9/8/24 revealed This resident is taking Depakote. The recommended routine lab work includes VPA [valproic acid] level and Ammonia level. The Response was listed as Obtain scheduled lab work as follows: VPA/Ammonia [every] 6 months. The Physician signed the form, but the date was not legible. Review of R46's laboratory results 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.

Based on observation, interview, and record review the facility failed to provide clinical justification for the continued use of PRN (as needed basis) psychotropic medication (Lorazepam) for one resident (#16) out of five residents reviewed for the potential of unnecessary medication. Findings Included: Resident #16 (R16) Review of the medical record revealed R16 was admitted to the facility 09/16/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD) respiratory failure, asthma, dysphagia (difficulty swallowing), chronic pain, hypomagnesemia (low magnesium), myocardial infarction (heart attack), recurrent dislocation of right shoulder, venous insufficiency, persistent mood disorder, hearing loss, constipation, spinal stenosis, bipolar disorder, major depression, anxiety, and gastro-esophageal reflux. The most recent Minimum Data Set (MDS), with an assessment reference date of 03/20/2025, demonstrated a Brief Interview for Mental Status (BIMS) of 8 (moderately impaired cogitation) out of 15. During observation and interview on 04/14/25 at 11:30 a.m. R16 was…

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

Based on observation, interview, and record review the facility failed to serve food at the preferred temperature for one resident (#16) of one resident reviewed for food palatability resulting in dissatisfaction during meals. Findings Included: Resident #16 (R16) Review of the medical record revealed R16 was admitted to the facility 09/16/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD) respiratory failure, asthma, dysphagia (difficulty swallowing), chronic pain, hypomagnesemia (low magnesium), myocardial infarction (heart attack), recurrent dislocation of right shoulder, venous insufficiency, persistent mood disorder, hearing loss, constipation, spinal stenosis, bipolar disorder, major depression, anxiety, and gastro-esophageal reflux. The most recent Minimum Data Set (MDS), with an assessment reference date of 03/20/2025, demonstrated a Brief Interview for Mental Status (BIMS) of 8 (moderately impaired cogitation) out of 15. During observation and interview on 04/14/2025 at 11:27 a.m. R16 was observed sitting up in her wheelchair at her bedside. R16…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one out of five medication carts were locked while unattended. Findings Included: During an observation on 1/29/2025 at 12:17 PM on the second floor, a medication cart was observed at the end of the hall next to room [ROOM NUMBER] unlocked. No staff were observed to be in sight of the cart or on the hall. At 12:19 PM, no staff were observed to approach the medication cart, and the cart remained unlocked. At 12:21 PM, no staff were observed to approach the medication cart, and the cart remained unlocked. At 12:23 PM, there was no change in observation. At 12:30 PM the cart remained unlocked with no staff in attendance of the cart. At 12:35 PM the medication cart was locked by Assistant Director of Nursing (ADON) C. In an interview on 1/29/2025 at 12:40 PM, (ADON) C, who was the nurse observed to lock the cart, confirmed that Registered Nurse (RN) D was the nurse on the medication cart. ADON C said the cart was to be locked all the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 53 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality. Findings include: On 05/14/24 at 10:50 A.M., The flooring surface within resident room [ROOM NUMBER] was observed extremely tacky and sticky. Numerous dead insect carcasses (flies) were also observed within the restroom bathtub. On 05/14/24 at 01:19 P.M., Human feces was observed within the 2nd Floor Shower 1 Room shower stall, directly beneath the polyvinyl chloride (PVC) shower chair. The human feces measured approximately 1-inch-wide by 3-inches-long. On 05/15/24 at 09:05 A.M., A common area environmental tour was conducted with Director of Environmental Services C. The following items were noted: 2nd Floor The Northeast exterior window screen was observed loose-to-mount, allowing potential pests (flying insects) to enter the building. Two acoustical…

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 four out of four observed resident room call lights were answered timely, resulting in the potential for unmet needs. Findings Included: In an observation on 5/14/2024 at 11:44 AM, the call light for room [ROOM NUMBER] was observed to be on. Two staff members were observed to pass by room [ROOM NUMBER] and not stop to answer the call light. At 11:47 AM the call light for room [ROOM NUMBER] was observed to be on, and one staff member was observed to walk by room [ROOM NUMBER] and not stop to answer the call light. At 11:48 AM a nurse was observed to walk past room [ROOM NUMBER], and go into room [ROOM NUMBER] without addressing the call light for room [ROOM NUMBER]. At 11:56 AM, the call light for room [ROOM NUMBER] was observed to be on, and at 11:58 AM, a staff member was observed to look up at the call light but turned and walked away without responding to the call light. At 12:07 PM room [ROOM NUMBER] call light was observed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff for one (Resident #359) of three reviewed. Findings include: Review of the medical record revealed Resident #359 (R359) admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, depression, history of wedge compression fracture of thoracic vertebra, anxiety, and cerebral palsy. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/8/24 revealed R359 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 5/14/24 at 9:32 AM, R359 was observed lying in bed. R359 reported yesterday, she was in her chair from 2:00 PM to 5:00 PM and had to go to the bathroom. R359 reported she took herself to the bathroom because her call light was not in reach. R359 reported afterwards, she transferred herself into her bed which was not made with a sheet or blanket. R359 reported Certified 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to report an allegation of abuse to the State Agency for one (Resident #359) of three reviewed. Findings include: Review of the medical record revealed Resident #359 (R359) admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, depression, history of wedge compression fracture of thoracic vertebra, anxiety, and cerebral palsy. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/8/24 revealed R359 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 5/14/24 at 9:32 AM, R359 was observed lying in bed. R359 reported yesterday, she was in her chair from 2:00 PM to 5:00 PM and had to go to the bathroom. R359 reported she took herself to the bathroom because her call light was not in reach. R359 reported afterwards, she transferred herself into her bed which was not made with a sheet or blanket. R359 reported Certified Nursing Assistant (CNA) V came…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent further potential abuse for one (Resident #359) of three reviewed. Findings include: Review of the medical record revealed Resident #359 (R359) admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, depression, history of wedge compression fracture of thoracic vertebra, anxiety, and cerebral palsy. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/8/24 revealed R359 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 5/14/24 at 9:32 AM, R359 was observed lying in bed. R359 reported yesterday, she was in her chair from 2:00 PM to 5:00 PM and had to go to the bathroom. R359 reported she took herself to the bathroom because her call light was not in reach. R359 reported afterwards, she transferred herself into her bed which was not made with a sheet or blanket. R359 reported Certified Nursing Assistant (CNA) V came into her room and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for 1 (Resident #14) of 14 reviewed resulting in the potential for decreased safety, increased injury risk, and unmet care needs. Review of the medical record revealed that Resident #14 (R14) was readmitted to facility 1/10/24 with diagnoses including vascular dementia, catatonic schizophrenia, specified disorder of bone density and structure, muscle weakness, and abnormalities of gait and mobility. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/18/24 revealed that R14 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 6 (severe cognitive impairment). Review of R14's ADL (Activities of Daily Living) Care Plan reflected that R14 required assist of one for bed mobility and bathing and assist of 2 for toilet use and transfers. In an observation and interview on 5/14/24 at 8:47 AM, R14 was observed lying in bed, on back, with body…

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 1) ensure blood glucose values were documented in the medical record for one (R22) and failed to implement assessment/intervention for bowel constipation for one resident (R408) of 14 reviewed for quality of care. Findings include: Resident #22 Review of the Face Sheet revealed Resident #22 (R22) was admitted to the facility on [DATE] with diagnoses that included muscle weakness, unspecified severe protein calorie malnutrition, delirium due to known physiological source, Alzheimer's disease, and metabolic encephalopathy. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/19/24 revealed R22 scored 3 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Care Plan revealed R22 required assistance of one staff member for toileting. Review of the MDS revealed R22 was coded always incontinent for bowels. On 05/14/24 at 3:56 PM, R22 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure two out of three residents (Resident #6 and 32) had water available at the bedside, resulting in the potential for dehydration. Findings included: Resident #6 (R6): Per the facility face sheet R6 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnosis included dysphasia (difficulty in swallowing). In an observation and interview on 5/14/2024 at 11:00 AM, R6 was observed to have no water in his room. A small 7 oz clear cup was observed on the over the bed table that had juice in it, no other fluids were noted. R6 was asked why he did not have any water in his room, in which R6 stated that the staff would not let him have any water. R6 said he had to have thicken fluids and did not like the taste of the thickened water. In an observation and interview on 5/15/2024 at 2:34 PM. R6 was observed to be in his room sitting on the side of his bed. A small Styrofoam cup with a lid and straw was observed to be on the same…

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 a medication was administered within the prescribed parameters and not in excessive dose for one (Resident #38) of six reviewed. Findings include: Review of the medical record revealed Resident #38 (R38) admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included fracture of lower end of right femur and hemiplegia and hemiparesis following a stroke. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/10/24 revealed R38 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). On 5/14/24 at 10:55 AM, R38 was observed in a Broda chair near the window in the dining room. Review of the Physician's Order dated 4/3/24 revealed an order for acetaminophen (Tylenol) give 1000 milligrams (mg) every 6 hours for pain not to exceed 3000 mg in 24 hours. Review of the Medication Administration Records (MAR) dated April and May 2024, revealed 1000…

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

Based on observation, interview and record review, the facility failed to ensure appropriate infection control practices during wound care for two (Resident #3 and #5) of two reviewed for wound care, resulting in the potential for cross contamination and the spread of infection. In a wound care observation on 5/15/24 at 1:34 PM, Licensed Practical Nurse (LPN) I removed her gloves, entered R3's bathroom, and washed her hands with soap and water for approximately four seconds. In an observation on 5/15/24 at 1:41 PM, Licensed Practical Nurse (LPN) N removed her gloves, entered R3's bathroom, and washed her hands with soap and water for approximately five seconds. In a wound care observation on 5/15/24 at 1:55 PM, LPN I removed her gloves, entered R5's bathroom, and used soap and water to wash her hands for approximately five seconds. In a wound care observation on 5/15/24 at 1:57 PM, LPN I entered R5's bathroom, and washed her hands with soap and water for approximately four seconds. In an wound care observation on 5/15/24 at 1:59 PM, LPN I doffed gloves, entered R5's bathroom, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00142408. Based on interview and record review, the facility failed to ensure the physician documented required transfer/discharge information for one (Resident #3) of three reviewed. Findings include: Review of the medical record revealed Resident #3 (R3) was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, insomnia, and anxiety. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/9/23 revealed R3 was independent with cognitive skills for daily decision making. The MDS with an ARD of 2/7/24 revealed R3 had an unplanned discharge to a short-term general hospital with a return to the facility anticipated. R3 was not in the facility at the time of the survey. Review of the Care Plan initiated 11/17/22 revealed I wish to return back to the community when I am able. The goal of I will safely discharge to a lesser care environment within a reasonable time frame was initiated on 10/25/23 and had a target date of 5/9/24.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00142408. Based on interview and record review, the facility failed to permit a resident to return to the facility after hospitalization for one (Resident #3) of three reviewed, resulting in R3 being denied return/readmission to the facility and having to find alternate placement at another facility. Findings include: Review of the medical record revealed Resident #3 (R3) was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, insomnia, and anxiety. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/9/23 revealed R3 was independent with cognitive skills for daily decision making. The MDS with an ARD of 2/7/24 revealed R3 had an unplanned discharge to a short-term general hospital with a return to the facility anticipated. R3 was not in the facility at the time of the survey. Review of the Care Plan initiated 11/17/22 revealed I wish to return back to the community when I am able. The goal of I will safely discharge…

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 MI00138322. Based on observation, interview, and record review, the facility 1) failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act and 2) failed to immediately report an allegation of abuse to the Nursing Home Administrator (NHA) and State Agency for one (Resident #2) of three reviewed, resulting in a sexual abuse allegation to go unreported to the NHA and State Agency and a reasonable suspicion of a crime to go unreported. Findings include: Review of the medical record revealed Resident #2 (R2) was admitted to the facility on [DATE] with diagnoses that included dementia, avoidant personality disorder, major depressive disorder, insomnia, and anxiety. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/24/23 revealed R2 scored 9 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00138322. Based on observation, interview, and record review, the facility failed to investigate a sexual abuse allegation for one (Resident #2) of three reviewed, resulting in a sexual abuse allegation to not be investigated and the potential for abuse. Findings include: Review of the medical record revealed Resident #2 (R2) was admitted to the facility on [DATE] with diagnoses that included dementia, avoidant personality disorder, major depressive disorder, insomnia, and anxiety. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/24/23 revealed R2 scored 9 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the complaint filed with the State Agency revealed The resident has made a complaint about a third shift nurse named [Licensed Practical Nurse (LPN) 'G]. She said he stuck his fingers in her vagina. She's told multiple cnas [Certified Nursing Assistants] and nurses. When it was…

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

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 58 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 02/13/23 at 08:47 A.M., An initial tour of the food service was conducted with Dietary Manager D. The following items were noted: One 6-inch-wide non-stick fry pan interior food contact surface was observed severely (etched, scored, particulate). One 10-inch-wide non-stick fry pan interior food contact surface was observed severely (etched, scored, particulate). One 16-inch-wide non-stick fry pan interior food contact surface was observed severely (etched, scored, particulate). The 2017 FDA Model Food Code section 4-202.11 states: (A) Multiuse FOOD-CONTACT SURFACES shall be: (1) SMOOTH; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices; and (4) Finished to have SMOOTH welds and joints. The can opener assembly and mounting…

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 # MI00134460 Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for five out of 16 residents (Residents #14, 22, 61, 261 and 263), resulting in the potential for unmet care needs. Findings Included: Resident #22 (R22) Review of an admission Record revealed Resident #22 (R22) admitted to the facility on [DATE] with pertinent diagnoses which included alcohol induced chronic pancreatitis, chronic obstructive pulmonary disease, abnormality of gait and mobility, unspecified severe protein-calorie malnutrition, dementia with unspecified severity with other behavioral disturbances, orthostatic hypotension, epilepsy, anemia, and prediabetes. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/5/23, reflected R22 scored 12 of out 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a qualified Activity Director was employed by the facility to provide a meaningful and individualized activity program for one resident (#61) of two residents reviewed for activities with the potential to affect all 59 residents at the facility resulting in the potential for lack of meaningful and resident individualized activities. Findings Included: Resident #61 (R61) Review of the medical record revealed R61 was admitted to the facility 10/24/2022 with diagnoses that included myocardial infarction (heart attack), opioid use, morbid obesity, bilateral osteoarthritis (wearing down of cartilage at the end of bones), spinal stenosis (spinal narrowing) of lumbar region, radiculopathy (disease at the root of a nerve) cervical region, gastroesophageal reflux, post-traumatic stress disorder (PTSD), cocaine abuse, abnormalities of plasma proteins, anxiety disorder, gout (increase in uric acid crystallization and deposit in bone…

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 Resident 23 According to the Minimum Data Set (MDS) dated [DATE], Resident 23 (R23) scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 02/13/23 at 09:50 AM, during an interview with (R23) she voiced complaints of long call light response times. R23 stated this was frequently an hour or longer and the identified a pattern of particularly long wait times on second shift. R23 stated she had complained to Director of Nursing (DON) B and Social Worker G. R23 stated this had been an ongoing problem for several and had filed grievances with no resolution , the usual response staff get busy. R23 reported due to the delay in call light response time she has had to sit in soiled briefs for an extended periods of time. On 2/14/23 at 11:28 am during a phone interview with former employee J it was reported that staffing levels were terrible and impossible to achieve or complete assigned duties such as repositioning, getting residents dressed, showered, fed, toileted, changed, oral…

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, the facility failed to effectively provide palatable food products effecting 58 residents and 6 of 6 from the confidential group meeting, resulting in the increased likelihood for resident decreased food acceptance and nutritional decline. Findings include: On 02/13/23 at 11:25 A.M., Food product temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded: Meat Loaf - 199.9 Mashed Potatoes/Brown Gravy - 139.9 Roasted Carrots - 194.1 Fruit & Yogurt Parfait - 61.2* Cornbread - 145.2 Beverage (2% Milk) - 47.3* (*) The 2017 FDA Model Food Code section 3-501.16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under 3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roasts…

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 clean and maintain the physical plant effecting 59 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 02/14/23 at 10:30 A.M., A common area environmental tour was conducted with Nursing Home Administrator (NHA) A and Director of Maintenance C. The following items were noted: First Floor Occupational Therapy: The refrigerator interior appliance light bulb was observed non-functional. Physical Therapy: Staff restroom return air ventilation grill was observed heavily soiled with dust and dirt deposits. Staff Break Room: The microwave oven interior was observed (corroded, particulate, bubbled). The (NHA) indicated she would have the damaged microwave oven replaced as soon as possible. Main Dining Room: The Old Fashioned Theatre Popcorn Machine interior (side window and ceiling) surfaces were observed soiled with accumulated and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00129395. Based on observation, interview, and record review, the facility failed to honor resident choices for bathing schedule in 1 of 1 resident reviewed for choices (Resident #47), resulting in bathing preferences not honored. Findings include: Resident #47 (R47) R47's Minimum Data Set (MDS) assessment dated [DATE], revealed she was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 15 (13-15 Cognitively Intact), and was totally dependent for bathing care. In review of R47's medical record, under tasks, her preference for showers was on Monday and Thursday afternoons and as needed. The same document revealed in the last 14 days, R47 received a bed bath on 2/08/23, 2/11/23, and 2/12/23; none of which was on a Monday or Thursday or a shower per R47's preference. There was no documentation in R47's record that a shower was refused or changed due to resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act in one of 5 reviewed for abuse (Resident #8), resulting in the potential of misappropriation of resident property. Findings include: Resident #8 (R8) R8's Hospital Discharge Summary indicated he was hospitalized from [DATE] to 10/21/22. Admitting diagnoses included frequent falls at home, COVID-19 with pneumonia, failure to thrive, Alcohol use, heart, and lung disease. The same summary revealed R8 was alert and orientated to person and place, and was often forgetful. R8's Minimum Data Set (MDS) dated [DATE] revealed he admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 11 (8-12 Moderate Impairment). In review of R8's progress note dated 11/21/22 at 4:19 PM, the 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 MI00129119. Based on observation, interview, and record review, the facility failed to investigate an allegation of misappropriation of property in one of 5 reviewed for abuse (Resident #8), resulting in the potential of misappropriation of resident property and unmet needs. Findings include: Resident #8 (R8) R8's Hospital Discharge Summary indicated he was hospitalized from [DATE] to 10/21/22. Admitting diagnoses included frequent falls at home, COVID-19 with pneumonia, failure to thrive, Alcohol use, heart, and lung disease. The same summary revealed R8 was alert and orientated to person and place, and was often forgetful. R8's Minimum Data Set (MDS) dated [DATE] revealed he admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 11 (8-12 Moderate Impairment). In review of R8's progress note dated 11/21/22 at 4:19 PM, the nurse attempted to review discharge information…

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 # MI00134460 Based on observation, interview, and record review the facility failed to complete an accurate level I and level II screening for one (Resident #61) of two residents reviewed for Preadmission Screening/Annual Resident Review (PASARR) resulting in the potential for the resident to not receive appropriate mental health treatment and services. Findings Included: Resident #61 (R61) Review of the medical record revealed R61 was admitted to the facility 10/24/2022 with diagnoses that included myocardial infarction (heart attack), opioid use, morbid obesity, bilateral osteoarthritis (wearing down of cartilage at the end of bones), spinal stenosis (spinal narrowing) of lumbar region, radiculopathy (disease at the root of a nerve) cervical region, gastroesophageal reflux, post-traumatic stress disorder (PTSD), cocaine abuse, abnormalities of plasma proteins, anxiety disorder, gout (increase in uric acid crystallization and deposit in bone joints), hyperlipidemia (high levels of fat in the blood), hypertension, major depression, chronic pain,…

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 # MI00134460 Based on interview and record review the facility failed to develop and implement a baseline care plan for one (Resident #61) of sixteen residents reviewed, resulting in the potential failure of those residents to receive effective and person-centered care that meets professional standard of quality care. Findings Include: Resident #61 (R61) Review of the medical record revealed R61 was admitted to the facility 10/24/2022 with diagnoses that included myocardial infarction (heart attack), opioid use, morbid obesity, bilateral osteoarthritis (wearing down of cartilage at the end of bones), spinal stenosis (spinal narrowing) of lumbar region, radiculopathy (disease at the root of a nerve) cervical region, gastroesophageal reflux, post-traumatic stress disorder (PTSD), cocaine abuse, abnormalities of plasma proteins, anxiety disorder, gout (increase in uric acid crystallization and deposit in bone joints), hyperlipidemia (high levels of fat in the blood), hypertension,…

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 revise the care plan for 3 residents (#'s 22, 210, and 263) and failed to involve the participation care planning process for one resident (#40) of 16 reviewed for care plans, resulting in unmet care needs. Findings include: Resident #40 According to the clinical record including the Minimum Data Set (MDS) with as Assessment Reference Date (ARD) of 1/12/23, Resident # 40 (R40) was an [AGE] year old female admitted to the facility with diagnoses that included depression, bilateral hearing loss and dementia. R40 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status. On 2/13/23 at 9:10am R40 was observed sitting in her room watching television, R40 engaged in conversation without difficulty. R40 voiced complaints about the food, specifically food preferences not being honored, R40 also stated she was in need of new glasses. When queried if she had spoken to anyone about her concerns, R40 stated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake number MI000134041. Based on observation, interview, and record review the facility failed to provide activities of daily living for one of 4 sampled residents (Resident #12), resulting in failure to give showers. Findings include: Resident #12 (R12) Review of an admission Record revealed Resident #12 (R12) admitted to the facility on [DATE] with pertinent diagnoses which included paraplegia, unspecified urethral stricture, cutaneous abscess of groin, and muscle weakness. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/23/23, reflected R12 scored 14 of out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R12 did not walk and requires extensive assistance of two or more people to transfer, toilet, and maintain person hygiene. In an observation and interview on 02/13/23 at 09:20 AM, R12 reported that he had been a paraplegic since the 1980's and lived at home prior to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI000134460 During observation, interview, and record review the facility failed to provide failed to provide meaningful, individualized activities for one resident (#61) of two residents reviewed for activities resulting in the potential for depression, boredom, and feelings of lack of self-worth. Findings Included: Resident #61 (R61) Review of the medical record revealed R61 was admitted to the facility 10/24/2022 with diagnoses that included myocardial infarction (heart attack), opioid use, morbid obesity, bilateral osteoarthritis (wearing down of cartilage at the end of bones), spinal stenosis (spinal narrowing) of lumbar region, radiculopathy (disease at the root of a nerve) cervical region, gastroesophageal reflux, post-traumatic stress disorder (PTSD), cocaine abuse, abnormalities of plasma proteins, anxiety disorder, gout (increase in uric acid crystallization and deposit in bone joints), hyperlipidemia (high levels of fat in the blood), hypertension, major depression,…

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 facility facilied to provide dressing changes as ordered for 1 (R12) of two reviewed for dressing changes resulitng in the potential of delay in healing. Findings include: Resident #12 (R12) Review of an admission Record revealed Resident #12 (R12) admitted to the facility on [DATE] with pertinent diagnoses which included paraplegia, unspecified urethral stricture, cutaneous abscess of groin, and muscle weakness. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/23/23, reflected R12 scored 14 of out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R12 did not walk and requires extensive assistance of two or more people to transfer, toilet, and maintain person hygiene. In an observation and interview on 02/13/23 at 09:20 AM, R12 reported that he had been a paraplegic since the 1980's and lived at home prior to admission to the facility. R12 reported that he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assist in access to hearing services in one of two residents reviewed for communication (Resident #33), resulting in unmet needs. Findings include: Resident #33 (R33) R33 was observed lying in bed and stated he had hearing aids, but his hearing aids were broken. R33 stated he had received his hearing aids from the Veteran's Administration (VA) and would like to return there for services. R33's Minimum Data Set (MDS) dated [DATE] revealed he admitted to the facility on [DATE]. R33 had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 14 (13-15 Cognitively Intact). Ear Care Exam dated 01/03/23 indicated R33 reported he had hearing aids for both ears from the VA but stated he had not used then for a year and a half because they did not work. The same document indicated R33 may benefit from a hearing test from an audiologist for hearing loss. Social Worker G 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.

This citation pertains to Intake MI00134460. Based on observation, interview, and record review the facility failed to provide foot care services for one resident (#61) of one resident reviewed for foot care resulting in long toenails and the potential for discomfort. Findings Included: Resident #61 (R61) Review of the medical record revealed R61 was admitted to the facility 10/24/2022 with diagnoses that included myocardial infarction (heart attack), opioid use, morbid obesity, bilateral osteoarthritis (wearing down of cartilage at the end of bones), spinal stenosis (spinal narrowing) of lumbar region, radiculopathy (disease at the root of a nerve) cervical region, gastroesophageal reflux, post-traumatic stress disorder (PTSD), cocaine abuse, abnormalities of plasma proteins, anxiety disorder, gout (increase in uric acid crystallization and deposit in bone joints), hyperlipidemia (high levels of fat in the blood), hypertension, major depression, chronic pain, obstructive sleep apnea, atherosclerosis (buildup of cholesterol plaque in artery walls) of arteries of extremities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement interventions to prevent falls for two (Resident #22 and #263) of seven reviewed for accidents, resulting in the potential for falls and major injury. Resident #22 (R22) Review of an admission Record revealed Resident #22 (R22) admitted to the facility on [DATE] with pertinent diagnoses which included alcohol induced chronic pancreatitis, chronic obstructive pulmonary disease, abnormality of gait and mobility, unspecified severe protein-calorie malnutrition, dementia with unspecified severity with other behavioral disturbances, orthostatic hypotension, epilepsy, anemia, and prediabetes. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/5/23, reflected R22 scored 12 of out 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R22 required limited assistance one person to ambulate and perform personal hygiene activities,…

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 services and assistance to restore bowel and bladder continence (Resident #48), resulting in the potential for falls and worsening incontinence. Findings include: Resident #48 (R48) On 2/13/23 at 9:28 AM R48 was observed lying in bed. R48's Minimum Data Set (MDS) assessment dated [DATE] introduced a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 14 (13-15 Cognitively Intact). R48 required extensive assistance for toilet use and personal hygiene. R48 was occasionally incontinent of bowel and bladder and a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) had not been attempted on admission/reentry or since urinary/bowel incontinence was noted in the faciity. Physician Progress Note dated 1/02/23 revealed R48 had a history of dementia, gait instability, weakness, repeated falls, arthritis, depression, and anxiety. Licensed…

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 weights per policy for 2 of 6 reviewed for nutrition (Resident #8 & #261, resulting in risk of altered nutrition status. Findings Include: Resident #261 (R261) Review of an admission Record revealed Resident #261 (R261) admitted to the facility 5-25-21 and readmitted on [DATE] with pertinent diagnoses which included asthma, Chronic Obstruction Pulmonary Disease, Type Two Diabetes, Epilepsy, unspecified severe protein-calorie malnutrition, and repeated falls. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/6/22, reflected R261 scored 15 of out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R261 did not walk and required limited to extensive assistance of one or more people to transfer, toilet, and maintain personal hygiene. In an observation on 02/13/23 at 10:30 AM, R261 was observed in bed laying on her back with the call…

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 ongoing communication and collaboration with the contracted dialysis facility regarding dialysis care and continued assessment for one resident (#14) of one resident reviewed resulting in the potential of unmet care needs and possible complications for residents receiving dialysis services. Findings Included: Resident #14 (R14) Review of the medical record revealed R14 was admitted to the facility 01/03/23 with diagnoses that included osteomyelitis (bone infection) right ankle and foot, end stage renal failure, type 2 diabetes, diabetic neuropathy (nerve damage), anterior dislocation of left humorous, oxygen dependence, hypokalemia (low potassium levels in blood), elevated white blood cells, restless leg syndrome, congestive heart failure, atrioventricular second degree (heart block), atrial fibrillation, dependence on renal dialysis, major depression, chronic anemia (low red blood cells), hypertension, hyperlipemia (high levels of fat in the blood), sleep apnea, myocardial infarction (heart attack),…

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 honor food preferences for one resident (#40) of one resident reviewed for food preferences. Resulting in anger and the potential for weight loss. Findings include: Resident #40 According to the clinical record including the Minimum Data Set (MDS) with as Assessment Reference Date (ARD) of 1/12/23, Resident # 40 (R40) was an [AGE] year old female admitted to the facility with diagnoses that included depression, bilateral hearing loss and dementia. R40 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status. On 2/13/23 at 9:10am R40 was observed sitting in her room watching television, R40 easily engaged in conversation without difficulty. R40 voiced complaints about the food, specifically food preferences not being honored. When queried if she had lost weight , R 40 stated she hadn't but she attributed her ability to maintain her weight to her daughter bringing her food. On 02/13/23 at 12:23 PM, R40'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 This citation pertains to intake MI00133146. Based on observation, interview, and record review, the facility failed to follow the standards of infection control for catheters and use a barrier for medication administration, in a census of 59 residents, resulting in the potential for cross-contamination and bacterial harborage, which placed a vulnerable population at high risk for infections. Findings include: During a medication pass observation on 2/21/23 at 8:21 AM, Licensed Practical Nurse (LPN) U took a box of nasal spray into a residents room, placed the box on the seat of a chair in the resident room before administering the medication. After LPN U administered the nasal spray medication, it was returned to the box and the box was placed again on top of the seat of the chair in the residents room. LPN U placed the box on top of another medication cart that was outside the residents room and then returned the box to her medication cart, into the cart drawer. Infection Control Nurse T was interviewed 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 provide influenza vaccination to one resident (#30) of five residents, during Flu season, reviewed for influenza vaccination status resulting in the exposure of serious illness to the resident. Findings Included: Resident #30 (R30) Review of the medical record revealed R30 was admitted to the facility 01/02/2023 with diagnoses that included multiple fractures ribs, malignant neoplasm of bladder (bladder cancer), obstructive and reflux uropathy (blockage of urinary tract), hydronephrosis (enlargement of kidney), type 2 diabetes, severe protein calorie malnutrition, displacement of indwelling ureteral stent, adult failure to thrive, gastroesophageal reflux, major depression, chronic kidney disease, chronic anemia (low red blood cells), hyponatremia (low sodium), hyperkalemia (high potassium), diverticulosis (bulging pouches in the intestinal tract), and hemiplegia (paralysis on one side of body). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/13/2023, revealed R30 had a Brief Interview…

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