Alamo Cove Rehab and Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop a comprehensive resident-specific treatment plan for Enhanced Barrier Precautions (EBP) for 1 resident (Resident #306) of 4 residents reviewed for comprehensive care plans resulting in the potential for unmet care needs and the spread of infection to a vulnerable population.Findings include:Resident #306 (R306)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R306 admitted to the facility on [DATE] with pertinent diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms (enlargement of prostate gland causing squeezing of the bladder). Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R306 was cognitively intact.During an observation on 5/27/2026 at 9:13 AM, R306 was observed to be lying on his bed and had a urinary catheter (thin flexible tube inserted into the bladder to drain urine). An Enhanced Barrier Precautions (EBP) sign 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 review and revise care plan interventions to accurately reflect resident care needs for 1 (Resident #5) of 19 residents reviewed for revision of care planning, resulting in a potential for staff not knowing how to properly care for the resident.Findings include:Resident #5Review of an admission Record revealed Resident #5 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: congestive heart failure (condition in which blood may back up/fluid may accumulate in the body causing shortness of breath, fatigue, swelling) and peripheral vascular disease (circulation disorder involving narrowing or blocking of vessels which may cause numbness in the lower legs).Review of a Minimum Data Set (MDS) assessment for Resident #5 with a reference date of 2/27/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 13/15, which indicated the resident was cognitively intact. Section GG revealed…

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 interventions were implemented to prevent the development of and/or worsening of pressure ulcers in 1 (Resident #88) of 2 residents reviewed for pressure ulcers resulting in the potential for the development of and/or the worsening of an existing pressure ulcer.Findings include: Resident #88Review of an admission Record revealed Resident #88 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: dementia, history of falling, and history of/healed fracture.Review of a Minimum Data Set (MDS) assessment for Resident #88, with a reference date of 1/30/2026 revealed Mobility, Resident #88 was dependent on staff for mobility, and Skin conditions, Resident #88 was at risk for developing pressure ulcers.In an observation and interview on 4/28/26 at 12:30 PM, Resident #88 was sitting in a broda chair (a high back reclinable wheelchair), and her heel protectors (soft padded material…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an environment free from hazards for 2 (Resident #5 and #48) of 5 resident reviewed for accidents, resulting in an increased risk for falls. Findings include: Resident #5 Review of an admission Record revealed Resident #5 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: congestive heart failure (condition in which blood may back up/fluid may accumulate in the body causing shortness of breath, fatigue, swelling) and peripheral vascular disease (circulation disorder involving narrowing or blocking of vessels which may cause numbness in the lower legs). Review of a Minimum Data Set (MDS) assessment for Resident #5 with a reference date of 2/27/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 13/15, which indicated the resident was cognitively intact. Section GG revealed Resident #5 required substantial/maximal (helper does more than half the effort) to transfer from…

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 pre and post dialysis treatment assessment and monitoring communication between themselves (the facility) and the dialysis provider (Name Omitted) was maintained for 1 (Resident #11) of 1 resident reviewed for dialysis services resulting in the potential for unrecognized adverse reactions or resident decline due to adverse reactions of dialysis treatments and disruption in the continuity of care.Findings include: Resident #11Review of an admission Record revealed Resident #11 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: Type 2 diabetes (a chronic conditions including insulin resistance and high blood sugar levels) and dependence on renal dialysis (a medical treatment that removes waste products, excessive fluids, and toxins from the blood when the kidneys are unable to perform those functions naturally).Review of Care Plan for Resident #11 revealed .Resident on hemodialysis r/t…

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 find a pharmacy recommendation for 1 resident (Resident #86) of 5 residents reviewed for medications resulting in the potential for the resident to experience avoidable medication side effects and/or receive unnecessary medications. Findings include: Resident #86 (R86)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R86 admitted to the facility on [DATE] with pertinent diagnoses including depression, psychotic disorder with delusions (mental health condition by holding false beliefs), agoraphobia (intense, irrational fear of being in situations where escape might be difficult or unavoidable), anxiety and post-traumatic stress disorder (mental health condition triggered by witnessing terrifying, life threatening or violent events). Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R86 was cognitively intact.Review of R86's Medication Regimen Review completed by the pharmacist on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain a medication error rate of less than 5% (total error rate of 10%) in 2 of 8 sampled residents (Resident #48 and Resident #59) reviewed for medication administration, resulting in the potential for reduced medication effectiveness and increased risk of adverse reaction and/or side effects.Findings include: Resident #48Review of an admission Record revealed Resident #48 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: hypertension (high blood pressure), cerebral infarction (stroke), and vertigo (dizziness).Review of a Minimum Data Set (MDS) assessment for Resident #48, with a reference date of 1/30/26 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #3 was severely cognitively impaired.During an observation and interview on 4/30/26 at 8:19 AM, Agency- Licensed Practical Nurse (LPN) BBB dispensed medications for Resident #48.…

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 2661176, 2728846, 2638850. Based on observation, interview, and record review, the facility failed to provide appropriate Activities of Daily Living (ADL) care for 5 (Resident #101,#103,#110, #113, and #114) of 7 residents reviewed) reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for resident's who are dependent on staff for assistance. Findings include: Resident #101 Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE] with pertinent diagnoses which included need for assistance with personal care and muscle weakness. Review of Resident #101's Care Plan revealed, Resident has an ADL (Activities of daily living) self-care performance deficit .Date Initiated: 06/16/2025. Goal: Resident will improve current level of function in mobility, strength through the review date. Resident will be able to: assist with self-care. Date Initiated: 06/16/2025. Interventions: .…

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 PASSAR (Preadmission Screening/Annual Resident Review) for a Level I OBRA evaluation and OBRA Level II evaluation were completed timely for 1 resident (Resident #109) of 2 residents reviewed, resulting in the potential for unmet behavioral health needs. Findings include: .Under the PASRR program, all persons seeking admission to a nursing facility who are seriously mentally ill and/or have an intellectual/developmental disability are required to be evaluated to determine whether the nursing facility is the most appropriate place for them to receive services and whether they require specialized behavioral/mental health services. https://www.michigan.gov/mdhhs/keep-mi-healthy/mentalhealth/mentalhealth/obraResident #109: Review of an admission Record revealed Resident #109 was a female with pertinent diagnoses which included paranoid schizophrenia, dementia, and cognitive communication deficit (progressive degenerative brain disorder resulting in difficulty with thinking and how someone uses language).…

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: 2638850Based on observation, interview, and record review, the facility failed to implement resident comprehensive care plans for 3 (Resident #103, #109, and #112) of 13 residents reviewed for care planning implementation, resulting in a lack of service for residents to maintain their highest practicable physical, mental, and psychosocial well-being.Findings include: Resident #103: Review of an admission Record revealed Resident #103 was a male with pertinent diagnoses which included repeated falls, multiple sclerosis (a chronic autoimmune disease where the immune system attacks the protective myelin sheath of nerves in the brain and spinal cord causing communication issues, incurable), dementia, anxiety, and weakness. Review of current Care Plan for Resident #103, revised on 6/24/25, revealed the focus, .Resident has limited physical mobility r/t (related to) weakness, hx (history) of falls, infection, medication use, schizoaffective disorder, depression. with the intervention…

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 #2745481Based on interview and record review, the facility failed to assess the need for an indwelling catheter for 1 (Resident #108) of 5 residents reviewed for incontinence care resulting in pain, frustration, and a delay in the removal of a foley catheter (medical device that helps urine drain from your bladder). Findings include:Review of an admission Record revealed Resident #108 was originally admitted to the facility on [DATE] with pertinent diagnoses which included essential hypertension (high blood pressure). Review of Resident #108's Urology After Visit Summary dated 6/25/25 revealed, . Scheduling instructions: OK to remove foley catheter; if unable to void after 6 hours or experiencing a post void residual of greater than 250 please replace catheter and call for follow up .Review of Resident #108's Progress Note dated 6/25/25 revealed, pt (patient) was seen at (Local Urology office) today for his follow up appointment from his recent procedure. ureteral stent (thin,…

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 care was provided consistent with professional standards of practice for residents who received enteral nutrition (tube feeding) in 1 (Resident #107) of 2 residents reviewed for tube feeding, resulting in the potential for aspiration pneumonia.Findings include: Resident #107: Review of an admission Record revealed Resident #107 was a male with pertinent diagnoses which included stroke, malnutrition, dehydration, starvation, GERD (stomach acid flows back into the esophagus), and dysphagia (difficulty initiating a swallow, impaired control of food or liquid within the mouth). Review of current Care Plan for Resident #107, revised on 5/31/25, revealed the focus, .Resident has a swallowing problem r/t (related to) Coughing or choking during meals or swallowing med, difficulty with thin liquids. with the intervention .Diet to be followed as prescribed. Review of current Care Plan for Resident #107, revised on 10/16/25, revealed the focus, . Resident has nutritional problem or potential nutritional problem…

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 2728846, 2661176, and 2638850. Based on interview and record review, the facility failed to maintain accurate medical records for 3 residents out of a total of 13 residents (Resident #101, #103 and #112) reviewed for complete and accurate medical record documentation, resulting in the potential for staff and providers mismanaging care for residents. Findings include:Resident #101 Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE] with pertinent diagnoses which included need for assistance with personal care and muscle weakness. Review of Resident #101's January 2026 Treatment Administration Record (TAR) revealed, left inner knee, ruptured blister, cleanse with NS (normal saline), pat dry, applysmall piece of xeroform and cover with dry border gauze everyday shift for wound care. Noted that there was missing documentation to indicate if the treatment had been completed or refused on the following dates: 1/25/26. Review of…

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

This citation pertains to intake: 2612703Based on interview and record review, the facility failed to ensure residents received care in accordance with professional standards upon admission for 1 resident (Resident #106) of 8 residents reviewed for quality of care, when nursing staff failed to implement hospital discharge orders timely for medication administration, resulting in the potential for worsening of health conditions and a delay in treatment.Findings include:Resident #106Review of an admission Record revealed Resident #106 was a female, with pertinent diagnoses which included: gastroparesis (delayed gastric emptying). In an interview on 9/17/25 at 8:44 AM, Resident #106 reported that she returned from the hospital on 9/4/25 and did not receive her medications that the hospital had prescribed for nausea and vomiting and ended up back in the hospital on 9/6/25.Review of Resident #106's Hospital Discharge Summary dated 9/4/25 at 12:04 PM revealed, .Start taking these medications: Dimenhydrinate 50 mg (milligrams) tablet Take 1 tablet by mouth every 6 hours as needed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #1359687.Based on observation, interview and record review the facility failed to implement physician orders for Enhanced Barrier Precautions (EBP: an infection control strategy where gloves and gowns are worn during high-contact resident care to reduce the spread of and/or risk of acquiring drug-resistant bacteria) for 1 resident (Resident #108) of 3 residents reviewed for infection control, resulting in the potential for residents to acquire avoidable drug-resistant infections.Findings include: Review of an admission Record revealed Resident #108 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: pressure ulcer of sacrum (tailbone). Review of Resident #108's Physician Orders start date 8/26/25 revealed, Enhanced barrier precautions r/t (related to) foley (urine catheter) and pressure wounds.Review of Resident #108's Kardex (direct care guide) revealed, Gloves and Gowns (enhanced barrier precautions/EBP) Required for following: dressing,…

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: (1) effectively clean and maintain food service equipment, (2) label and store food products, (3) date mark all potentially hazardous ready-to-eat food products, and (4) maintain plumbing fixtures effecting 84 residents, resulting in the increased potential for cross-contamination, bacterial harborage, and resident foodborne illness. Findings include: On 02/25/25 at 10:10 A.M., A comprehensive tour of the kitchen was conducted with Dietary Director X. The following items were noted: 1 of 2 hand sink basins were observed draining slowly. Dietary Director X indicated she would contact maintenance for necessary repairs as soon as possible. The 2022 FDA Model Food Code section 5-205.15 states: A plumbing system shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. Pantry: Plastic forks were observed uncovered resting within a plastic sleeved clear container without an appropriate cover lid. Plastic spoons were also observed uncovered resting within two clear plastic containers 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.

Based on observation, interview, and record review, the facility failed to effectively clean and maintain the physical plant effecting 84 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality. Findings include: On 02/26/25 at 09:30 A.M., A common area environmental tour was conducted with Maintenance Aide CC. The following items were noted: Service Corridor Staff Break Room: 2 of 2 microwave ovens were observed (etched, scored, corroded, particulate). The Rival toaster interior was also observed (corroded, burnt, soiled). Janitor Closet: The flooring surface was observed soiled with accumulated dust and dirt deposits. The room was also observed in complete disarray. Maintenance Aide CC stated: I will have staff take care of the room. 100 Hall Soiled Utility Room: The countertop was observed missing laminate, adjacent to the waste hopper. The missing laminate surface measured approximately 30-inches-long. Maintenance Aide CC indicated he would make necessary repairs as soon as possible. Skilled Equipment Room: The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans in 4 of 19 residents (Resident #13, #38, #44, & #76) reviewed for comprehensive care plans, resulting in the unmet needs related to incontinence care, pressure ulcer prevention, skin integrity, respiratory care, and the potential for an overall decline in physical, mental, and psychosocial wellness. Findings include: Resident #13 Review of an admission Record revealed Resident #13 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #13, with a reference date of 12/13/24 revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #13 was cognitively impaired. Review of the Functional Abilities revealed that Resident #13 was dependent on staff for all toileting and personal hygiene needs. Review of Resident #13's Braden Scale for Predicting Pressure Sore Risk dated…

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, record review the facility failed to provide palatable food products in 2 (#17, #45) of 18 sampled residents, and 11 of 11 residents from the confidential group meeting, effecting 84 residents, resulting in the increased likelihood for decreased resident food acceptance and nutritional decline. Findings include: On 02/25/25 at 11:33 A.M., An interview was conducted with Dietary Director X regarding the resident food tray delivery schedule. Dietary Director X stated: We deliver to 400 Hall, 200 Hall, 100 Hall, 500-600 Hall, 300 Hall, Sunroom, and Main Dining Room last. On 02/25/25 at 11:47 A.M., Resident lunch meal food trays were observed leaving the food production kitchen, within an insulated Cambro food transportation cart. On 02/25/25 at 11:50 A.M., Resident lunch meal food trays were observed arriving to the 100 Hall corridor, within an insulated Cambro food transportation cart. On 02/25/25 at 11:55 A.M., Food product temperatures were monitored utilizing a ThermoWorks…

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, record review the facility failed to honor resident food choice preferences in 5 (#63, #44, #73, #17, and #21) of 18 residents and 2 of 11 residents from the confidential group meeting, resulting in the increased likelihood for decreased resident food acceptance and nutritional decline. Findings include: Resident #63 On 02/25/25 at 12:10 P.M., An interview was conducted with Resident #63 regarding facility food products. Resident #63 stated: Gravy and Peas., referring to her lunch meal card dislikes list. On 02/25/25 at 12:20 P.M., Record review of Resident #63's lunch meal card revealed the following: Dislikes: Corn, Onions; Other-All Condiments and Gravy; Other-Small Veggies; Peas. On 02/27/25 at 11:15 A.M., Record review of the Policy/Procedure entitled: Resident Allergies, Preferences, and Substitutes dated 11/01/17 revealed under Policy: To identify and record food allergies of residents prior to feeding in an attempt to prevent allergic reactions. Food service staff will…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper glove use during incontinence care and injection administration, and ensure sanitary storage of respiratory equipment in 3 residents (Resident #13, #44, and #76) of 18 residents reviewed for infection control, resulting in the potential for skin breakdown, UTI (urinary tract infection), bacterial harborage, cross contamination and the spread of disease to a vulnerable population. Findings include: Resident #13 Review of an admission Record revealed Resident #13 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #13, with a reference date of 12/13/24 revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #13 was cognitively impaired. Review of the Functional Abilities revealed that Resident #13 was dependent on staff for all toileting and personal hygiene needs. During an observation and interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services to promote dignity and respect in 3 of 3 residents (Resident #13, #44, & #54) reviewed for dignity/respect, and 11 of 11 residents from the confidential group meeting, resulting in unmet care needs and the potential for feelings of diminished self-worth, sadness, and frustration. Findings include: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 1589-1592). Elsevier Health Sciences. Kindle Edition.Time management, therapeutic communication, patient education, and compassionate implementation of bedside skills are just a few of the essential skills you need. It is important for your patients to leave the health care setting with a positive image of nursing and a feeling that they received quality care. Your patients should never feel rushed. They need to feel that they are important and are involved in decisions and that…

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 ensure residents did not self-adminster medications that were not assessed as safe to self-administer in 2 of 11 residents (Resident #28, #69) reviewed for self administration, resulting in the potential for mismanagement of medications and worsening medical conditions. Findings include: Resident #28 During an observation on 02/24/25 at 09:41 AM in Resident #28's room, a medication cup containing 5 pills was sitting on the resident's tray table. Resident #28 reported that the nurse had left the pills for him to take later. Review of Resident #28's Self-Administration of Medications Assessment revealed no assessment or orders in the record. Resident #69 During an observation of medication administration on 02/25/25 at 08:12 AM on north hall, Resident #69 ambulated into the hall with a medication cup. Resident #69 reported that she knew what most of her pills were and stated, .what is this one? LPN (Licensed Practical Nurse) RR reported that it was a pancreatic enzyme pill. LPN RR reported that she had given…

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 #MI00149980 Based on interview and observation, the facility failed to protect the resident's right to be free from mental, verbal and physical abuse by staff for 1 resident (Resident #49) of 2 residents reviewed for abuse, resulting in verbal intimidation and physical restraint. Findings include: Resident #49 Review of an admission Record revealed Resident #49 was originally admitted to the facility on [DATE] and expired in the facility on [DATE]. Review of Resident #49's Care Plan revealed, Resident is resistant to care (showers, alterative offered and adl (activities of daily living) care) r/t (related to) Alzheimer's. Date initiated: [DATE] .Allow resident to make decisions about treatment regimen, to provide sense of control. Revision [DATE] .If resident resists with ADLs, reassure resident, ensure safe environment, leave and return 5-10 minutes later and try again. Date initiated: [DATE]. May resist care: triggers for resisting care are (adl care and showers). De-escalate…

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 #MI00149980 Based on interview and record review, the facility failed to 1. investigate an allegation of abuse for 1 resident (Resident #37) 2. provide an accurate investigation and prevent the potential for further abuse after an allegation of abuse for 1 resident (Resident #49) of 2 total residents reviewed for abuse resulting in the potential for the allegation to not be thoroughly investigated and further abuse to occur. Findings include: Resident #37 (R37) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R37 admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia (low level of oxygen in body tissues), chronic obstructive pulmonary disease (lung disease), diabetes {disease that affects how the body uses blood sugar (glucose)}, depression and anxiety. Brief Interview for Mental Status (BIMS) reflected a score of 12 out of 15 which indicated R37 was cognitively intact (13 to 15 cognitively intact).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident/resident representative of the facility bed hold policy and provide a written copy upon hospital transfer for 2 residents (Resident #37, Resident #43) of 3 residents reviewed for hospitalizations, resulting in the potential of residents and/or resident representatives being uninformed of the bed hold policy. Findings include: Resident #37 (R37) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R37 admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia (low level of oxygen in body tissues), chronic obstructive pulmonary disease (lung disease), diabetes {disease that affects how the body uses blood sugar (glucose)}, depression and anxiety. Brief Interview for Mental Status (BIMS) reflected a score of 12 out of 15 which indicated R37 was cognitively intact (13 to 15 cognitively intact). Resident was discharged from the facility on 2/24/2025. Review of R37's chart…

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 the facility failed follow professional standards for medication administration for 1 out of 11 residents (Resident #332) reviewed for standards of practice, resulting in the potential for cross contamination. Findings include: During an observation of medication administration on 02/25/25 at 08:30 AM in Resident #332's room, LPN RR was observed administering and insulin injection (medication that is administered using a needle and injected under the skin) with no gloves on. LPN RR then left the resident's room and returned to the medication cart, but did not perform any hand hygiene. At 08:32 AM LPN RR walked into a different resident's room, discussed pain medication, and then carried that resident's meal tray to the cart in the hallway. LPN RR did not perform hand hygiene prior to entering the resident's room. In an interview on 02/25/25 at 08:41 AM, LPN RR reported that she did not wear gloves for the insulin injection and/or perform hand hygiene, because she was not dealing with blood or body fluids. According to the Centers for Disease Control,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide activities of daily living (ADL) to dependent residents, including showers, shaving, nail care, and the application of ted hose (stocking) to 2 (Resident #19 and Resident #76) of 4 residents reviewed for activities of daily living, resulting in an unkempt appearance and the potential for unmet care needs. Findings include: Resident #19 Review of an admission Record revealed Resident #19 was a female who initially admitted to the facility on [DATE] and had pertinent diagnoses which included: localized edema (edema noted in one area of the body), atrial fibrillation (an irregular and fast heartbeat that can lead to blood clots), and aphasia following a cerebral infarct (difficulty speaking following a stroke). Review of Order Summary for Resident #19 revealed ted hose (compression style stockings) to resident on in am/off at hs (evening) every morning and at bedtime with a start date of 7/5/2024. Review of Kardex (a quick reference…

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 preventative care, consistent with professional standards of practice for 2 of 2 residents (Resident #13 & #44) reviewed for at risk to develop pressure injuries, resulting in the potential for the development of an avoidable pressure ulcer, infection, and overall deterioration in health status. Findings include: Resident #13 Review of an admission Record revealed Resident #13 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #13, with a reference date of 12/13/24 revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #13 was cognitively impaired. Review of the Functional Abilities revealed that Resident #13 was dependent on staff for all toileting and personal hygiene needs. Review of Resident #13's Braden Scale for Predicting Pressure Sore Risk dated 12/11/24 revealed, 11, which indicated that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to 1.) ensure safe transport in a wheelchair with foot pedals in place for 1 resident (Resident #63); 2.) implement gait belt (a device put on a resident who has mobility issues, by a caregiver, prior to that caregiver moving the resident) use for safety during transfers for 2 (Resident #63 and Resident #37) of 3 total residents reviewed for transport safety and transfers resulting in the potential for injury. Findings include: Resident #63 Review of an admission Record revealed Resident #63 was a female who initially admitted to the facility on [DATE] and had pertinent diagnoses which included: repeated falls and weakness. Review of a Minimum Data Set (MDS) assessment for Resident #63, with a reference date of 11/22/2024 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #63 was cognitively intact. (BIMS score 12-15 indicates cognitively intact). On 2/24/25 at 12:03 PM., Certified Nurse Assistant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide timely incontinence care and perform hand hygiene in accordance with standard infection control practices in 2 residents (Resident #13 & #44) of 2 residents reviewed for bowel/bladder incontinence, resulting in the potential for skin breakdown and UTI (urinary tract infection). Findings include: Resident #13 Review of an admission Record revealed Resident #13 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #13, with a reference date of 12/13/24 revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #13 was cognitively impaired. Review of the Functional Abilities revealed that Resident #13 was dependent on staff for all toileting and personal hygiene needs. Review of Resident #13's Kardex (care guide) revealed, Bowel/Bladder: Apply barrier cream to perineal area after each incontinence episode and as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the maintenance, and storage in a sanitary manner of CPAP (continuous positive airway pressure machine increases the air pressure in the throat to prevent airway collapse) machine equipment according to professional standards for 1 of 18 residents (Resident #76) reviewed for respiratory care, resulting in an increased potential for respiratory infection and respiratory distress. Findings include: Review of an admission Record revealed Resident #76 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: obstructive sleep apnea (when someone stops breathing in their sleep). Review of a Minimum Data Set (MDS) assessment for Resident #76's, with a reference date of 1/27/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #76 was cognitively intact. Review of the Special Treatments revealed that Resident #76 had a CPAP…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that PRN (as needed) psychotropic medications were limited to 14 days unless documented rationale by the physician was present in the medical record in 1 (Resident #9) of 5 residents reviewed for unnecessary medications. Findings include: Resident #9 Review of an admission Record revealed Resident #9 was a female who initially admitted to the facility on [DATE] and had pertinent diagnoses which included: PTSD (Post traumatic stress disorder), bipolar disorder (mental health disorder that causes extreme mood swings), anxiety disorder, and dementia. Review of a Minimum Data Set (MDS) assessment for Resident #9, with a reference date of 11/29/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #9 was cognitively intact. (BIMS score 12-15 indicates cognitively intact). Review of Physician Recommendations for Resident #9 dated 12/27/24 revealed This resident is currently receiving Xanax 1mg (milligram) BID…

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 a double-lock system for a controlled substance in the facility's medication refrigerator resulting in the potential for diversion and/or misappropriation of medication. Findings include: During an observation, interview, and record review on 4/30/35 at 8:40 AM, Licensed Practical Nurse (LPN) D entered the Nursing Station where the medication refrigerator was kept. LPN D did not have to use her key to enter the room. The keyed door was not locked; it was not shut all the way. In the room was the medication refrigerator which held narcotics in a locked box along with a box of back-up box of insulin. Other medications included were resident-specific non-narcotics and vaccines. LPN D stated, The door to this room should always be locked. You must make sure the door is shut behind you because it is hard to shut. The door counts as one of the double-locks the narcotics must be in. The refrigerator is not locked because the narcotics are kept in a locked box which counts as the second double-lock for the…

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

Based on observation, interview, and record review, the facility failed to follow protocol for one resident (R9) of 3 residents reviewed to ensure food brought into the facility was labeled and dated with an expiration date, resulting in the potential for food born illness. Findings include: Observed on 4/29/25 at 11:15 AM, on top of R9's bedside dresser was one-opened bottle of red-colored salad dressing, one-opened white-colored buttermilk salad dressing with manufacturing labeling that stated to be refrigerated after opening, and one-opened jar of bread and butter pickles. None of the three jars were labeled with R9's name or dated with an open date. R9 stated, No one said anything to me about keeping them cold. They been there for a while. During an interview on 4/30/35 at 3:12 PM, Director of Nursing (DON) B stated, If food is brought from home it is to be labeled and dated. If it is has to be refrigerated, within 3 days of dated when brought from home it must be thrown away per policy. (R9) should be care planned if she doesn't want it refrigerated. According to United States…

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 #MI00149360. Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of an allegation of abuse in 1 resident (Resident #114) of 15 residents reviewed for abuse reporting, resulting in the potential for a delayed investigation and further abuse. Findings include: Review of an admission Record revealed Resident #114 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: kidney failure. In an interview on 1/6/25 at 2:45 PM, Nursing Home Administrator (NHA) A reported that she had submitted a facility reported incident (FRI) that morning, after Social Worker (SW) C spoke with Family Member (FM) P. NHA A reported that FM P had informed SW C that Resident #114 alleged that he had been abused by staff at the facility. NHA A reported that she had started the 5 day investigation, but did not have any additional information at that time. In an interview on 1/6/25 at 3:08 PM, SW C 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 This citation pertains to intake #MI00149360. Based on observations, interviews and record review, the facility failed to provide increased supervision for 3 residents (Resident #114, #108, & #106) of 5 residents reviewed for being at risk for falls, resulting in repeated falls for all 4 residents, and Resident #114 sustaining fractured ribs. Findings include: Resident #114 Review of an admission Record revealed Resident #114 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: kidney failure. Review of Resident #114's Care Plan revealed, .at risk for falls r/t (related to) weakness, impulsive with transfer, seizures. Date initiated: 1/2/25, Revision on: 1/4/25. Interventions: PA (physician assistant) to review medication r/t low BP (blood pressure). dated initiated 1/2/25. Room Closer to nurse's station. date initiated: 1/5/25 .Ensure call light is within reach, provide cueing and reminders for use as appropriate with level of cognition. date initiated: 1/2/25. Ensure…

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 # MI00147413 Based on observation, interview, and record review, the facility failed to provide sufficient staff to meet resident needs in 3 residents (Resident #114, #108, & #106) of 15 residents reviewed for sufficient staffing, with the potential for all residents to be affected, resulting in a lack of supervision of residents at risk for falls. For additional information see citations F689. Findings include: In an interview on 1/8/25 at 10:52 AM, Scheduler (SCH) FF reported that she is only able to schedule staff based off of the census, and that the facility is currently using agency for licensed nurses, and not for Certified Nursing Assistants (CNA). SCH FF reported that on third shift for a census of 80 residents, she schedules 1 CNA for North hall, 1 for South hall, 1 for Rehabilitation hall, 1 for the Basic unit. There is no CNA scheduled for [NAME] hall, but there is a float CNA that is responsible for [NAME] hall, to help North hall, and cover all lunch breaks. SCH FF reported that there are 2 licensed nurses scheduled on third shift, 1 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.

Based on observation, interview and record review, the facility failed to consistently offer/provide HS (hour of sleep) snacks to 2 residents (Resident #102 & #113) of 4 residents reviewed for snacks, resulting in resident dissatisfaction. Findings include: In an interview on 1/2/25 at 11:35 AM, Resident #102 reported that the facility does not have snacks available in the evening. In an interview on 1/6/25 at 11:45 AM, Resident #113 reported that snacks are very limited in the facility, and that if your name isn't on the list when they are passed out at night, you do not get anything. Resident #113 reported that staff does not offer snacks in the evening. In an interview on 1/6/25 at 3:57 PM, CNA I reported that sandwiches are not available for residents after the kitchen closed at 8:00 PM, and that often times the kitchen only brought snacks for diabetic residents. CNA I reported that she could usually find a snack somewhere if a resident asked for one, but sometimes she had to go to the vending machine. In an interview on 1/6/25 at 12:00 PM CNA K reported that the kitchen was…

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

Based on interview and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices in 2 residents (Resident #112 & #115) of 5 residents reviewed for infection control practice, resulting in the potential for transmission of MDRO (multidrug-resistant organisms). Findings include: Review of the CDC (Centers for Medicare & Medicaid Services) Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Memorandum (Ref: QSO-24-08-NH) with an effective Date of April 1, 2024 revealed, .The new guidance related to EBP is being incorporated into F-880 Infection Prevention and Control .GUIDANCE Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes M100146395 and M100146349. Based on interview and record review, the facility failed to ensure an effective process for receiving and addressing grievances in 1 (Resident #2) of 1 resident reviewed for grievances, resulting in unresolved concerns. Findings include: In an interview on 8/28/24, Family Member (FM) M reported R2 was sent to the facility for care of her pressure ulcers. There was a malfunction with the wound vac (vacuum-assisted closure) for at least 3 days and R2 did not receive any other wound care when it was not working. She is now in the hospital because of it. FM M reported he filled out a grievance form on behalf of R2 who dictated to him what to write down because she was not feeling well and could not write herself. R2 was having concerns with pain and needed assistance with care and a nurse was mouthy, [NAME], and ignored her. A Certified Nursing Assistant (CNA) overheard what the staff member said and advised them to put it in writing. The CNA told him 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 This citation refers to MI0014459 and MI00146322. Based on interview and record review, the facility failed to follow physician orders for 1 of 8 residents ( R4) reviewed, resulting in R4 not receiving medications per the physician's order, and the physician not being notified of R4's high blood sugar readings per the physician's order. Findings include: A review of R4's admission Record, dated 8/26/24, revealed R4 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included diabetes. A review of R4's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 5/13/24, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) assessment which revealed R4 had short-term and long-term memory problems with inattention and disorganized thinking. In addition, R4's MDS revealed he had severely impaired cognitive decision-making skills. During an interview on 8/26/24 at 10:25 AM, 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.

This citation pertains to intake M100146395. Based on interview and record review, the facility failed to ensure there was adequate competencies to provide nursing related services for 1 (Resident #2) of 1 resident reviewed for skilled nursing services. Findings include: In an interview on 8/28/24, Family Member (FM) M reported R2 was sent to the facility for care of her pressure ulcers. There was a malfunction with the wound vac (vacuum assisted closure) for at least 3 days and R2 did not receive any wound care when it was not working. She is now in the hospital because of it. FM M reported he and R2 did express concerns to staff that wound care was not being done. In an interview on 8/27/24 at 4:00 PM, Confidential Informant (CI) N reported R2 did not have wound care services as ordered. The wound vac was not working because the nursing staff did not know how to use it. One time the wound vac was not working and R2 had a wet to dry dressing in place that was in place for several days. When it was finally changed, the dressing was dry and hard to get out of the wound. In 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 ensure residents had a functional nurse call system at all times resulting in the potential for serious psychosocial or physical harm for vulnerable residents who were often at times without a way to call for routine or emergency assistance. Findings include: Review of a facility Policy subject Call Light with an adopted date of 7/11/2018 revealed: POLICY: It is the policy of this facility to provide the resident a means of communication with nursing staff. PROCEDURE: 1. All facility personnel must be aware of call lights at all times. 2. Facility shall answer call lights in a timely manner. 3. Answer all call lights in a prompt, calm, courteous manner; turn off the call light as soon as you enter the room and attend to the resident needs. 4. Orient all new residents as appropriate to the call light at bedside as well as the call light in the bathroom and in the shower or tub rooms. 5. Nursing staff shall check all call lights daily 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 # MI00142619. Based on observation, interview, and record review, the facility failed to provide sufficient staff to meet resident needs in 5 of 8 residents (Resident #9, #10, #33, #41, & #55) reviewed for sufficient staffing, resulting in long call light wait times, residents being left wet and/or soiled for extended periods of time, missed showers/baths, late medications, and staff burnout. For additional information see citation F550 and F919. Findings include: Review of the Resident Council meeting minutes, dated 3/1/24, revealed .Residents not receiving showers on their selected day and time. Staff tell residents they are unable to give showers or tub baths due to not enough staff scheduled .Some residents have gone 8 days in a row without a shower .Residents wanting a tub bath are told they cannot get one due to time allowed and not enough staff .Residents who require a 2-person assist are only being assisted with 1 staff person. This happens often on 2nd and 3rd shift…

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 complete annual performance reviews for 5 Certified Nursing Assistants (CNA's) (CNA's T, U, V, S, and XX) of 5 reviewed for regular in-service training, resulting in the potential for unidentified CNA performance concerns, a lack of training related to staff performance review outcomes, and the potential for unmet care needs. Findings include: In an interview with NHA A on 5/1/24 at 4:19pm, annual performance reviews were requested for CNA's T, U, V, S, and XX. Review of personnel files for CNA's T, U, V, S and XX, revealed no annual reviews were present for the past 12 months. Further review of the employee files revealed all CNA's had been employed by the facility for more than 12 months. In an interview on 5/2/24 at 1:41pm, Regional Human Resources Director (HR) RR reported the facility had recently determined that some nursing staff had not received annual performance reviews in the past year. HR RR reported the previous owner's of the facility had relied solely on competency training to ensure staff the necessary…

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.) maintain an Infection Prevention and Control Program. 2). follow the standards of infection control for hand hygiene, and glove use during incontinence care for 3 residents (Resident #41, #33 and #9) of 5 reviewed for infection control. 3). to ensure infection control practices were followed for adequate cleanliness of resident shared equipment (including but not limited to: transfer lifts, bath/shower rooms and commonly used surfaces) resulting in the potential for bacterial harborage, cross contamination, and the spread of disease to a vulnerable population. Findings include: In an observation on 4/30/24 at 10:39 AM., noted room [ROOM NUMBER] with a shared bathroom for 3 residents. The bathroom sink had 3 toothbrushes placed on the sink, which was visibly soiled. 2 of the toothbrushes were touching one another, the other was noted in a small pool of water on the sink base near the faucet. During an interview on 4/30/24 at 1:40 PM.,…

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 residents who were eligible for recommended vaccines were offered vaccination in a timely manner for 5 residents (Resident #9, #58, #56, #76, ½) out of 5 residents reviewed for immunizations resulting in the potential for developing vaccine preventable disease. Findings include: In an interview on 05/01/24 at 12:42 PM, Registered Nurse (RN) II reported that she was transitioning into the Infection Preventionist (IP) position, but was still trying to complete her certification course and stated, .so right now I am just doing it partially . RN II reported that the Interim DON (Director of Nursing) B was responsible for tracking resident vaccinations. In an interview on 05/01/24 at 12:46 PM, DON B reported that she pulls reports from Michigan vaccine registry upon admission for residents, but did not know who was responsible to ensure resident immunizations are up to date. In an interview on 05/01/24 at 12:49 PM, Regional Director of Clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' medical records included documentation that residents/resident representatives were educated, offered and/or received timely, the COVID-19 immunization as recommended by the Centers for Disease Control and Prevention (CDC) for 5 resident (Resident #9, #58, #56, #76, & #189) of 5 residents reviewed for immunizations, resulting in residents not receiving the Covid-19 immunization per CDC guidelines, the potential for incomplete vaccination, and the potential for serious illness and complications from COVID-19 (SARS-CoV-2). Findings include: In an interview on 05/01/24 at 12:42 PM, Registered Nurse (RN) II reported that she was transitioning into the Infection Preventionist (IP) position, but was still trying to complete her certification course and stated, .so right now I am just doing it partially . RN II reported that the Interim DON (Director of Nursing) B was responsible for tracking resident vaccinations. In an interview on…

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

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 81 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality. Findings include: On 05/01/24 at 08:15 A.M., An environmental tour of the facility Laundry Service was conducted with Director of Environmental Services BB. The following items were noted: Clean Laundry Room: 9 of 18 overhead 48-inch-long fluorescent light bulbs were observed non-functional. The return-air-exhaust ventilation grill was also observed heavily soiled with dust and dirt deposits. The flooring surface was further observed soiled with accumulated and encrusted dust and dirt deposits. Soiled Laundry Room: The flooring surface was observed soiled with accumulated and encrusted dust and dirt deposits. Director of Environmental Services BB indicated she would have staff thoroughly clean all surfaces as soon as possible. On 05/01/24 at 10:15 A.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 Based on observation and interview, the facility failed to maintain a dignified existence for 3 residents (Resident #81, Resident #9, and Resident #10) of 18 residents reviewed for dignity, resulting in long call light wait times, residents being left wet and soiled, and feelings of frustration, anxiety, and embarrassment. Findings include: Resident #81 Review of an admission Record revealed Resident #81, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: repeated falls, weakness, and age-related physical debility. Review of a Minimum Data Set (MDS) assessment for Resident #81, with a reference date of 3/18/24, revealed a Brief Interview for Mental Status (BIMS) which indicated Resident #81 was cognitively intact. Section D of the MDS revealed Resident #81 experienced feeling down, depressed, or hopeless during 2-6 days of the 14-day assessment period. Section E of the MDS revealed Resident #81 did not reject care. Review of a Care Plan for Resident #81 with a reference…

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 issue a Notice of Medicare Non-Coverage (NOMNC) for Medicare Part A services in 3 of 3 residents (Resident #89, #90, & #91) reviewed for timely provision of notifications, resulting in the potential for the resident or resident representative to be unaware of changes in regard to financial liability, frustration, and a delay in the ability to file an appeal. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) page titled Beneficiary Notices Initiative (BNI) revealed .Both Medicare beneficiaries and providers have certain rights and protections related to financial liability and appeals under the Fee-for-Service (FFS) Medicare and the Medicare Advantage (MA) Programs. These financial liability and appeal rights and protections are communicated to beneficiaries through notices given by providers . Retrieved from https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative Review of the Centers for Medicare 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 in 2 of 18 residents (Resident #11 & #13) reviewed for comprehensive care plans, resulting in the potential for falls/injury for Resident #11 and a lack of resident-centered interventions related to a history of trauma for Resident #13. Findings include: Resident #11 Review of an admission Record revealed Resident #11 was a female, with pertinent diagnoses which included Alzheimer's disease, depression, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #11, with a reference date of 3/29/24, revealed a Brief Interview for Mental Status (BIMS) score of 2, out of a total possible score of 15, which indicated severe cognitive impairment. Review of a current Care Plan for Resident #11 revealed the focus .I require Routine Fall Precautions per Fall Assessment . revised 2/20/24, with interventions which included .Gripper socks on when in bed . revised 2/5/24, and .Bed: [NAME]…

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 #MI00142619. Based on observation, interview, and record review, the facility failed to maintain professional standards of care and provide adequate incontinence care in 2 of 3 residents (Resident #9 & #41) reviewed for bowel and bladder incontinence, resulting in an increased risk for UTI (urinary tract infection) and the potential for skin breakdown. Findings include: Resident #9 Review of an admission Record revealed Resident #9 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: prostate gland enlargement that can cause urination difficulty. Review of a Minimum Data Set (MDS) assessment for Resident #9, with a reference date of 3/15/24 revealed a Brief Interview for Mental Status (BIMS) which indicated Resident #9 was cognitively impaired. Review of Resident #9's ADL (activities of daily living) Care Plan revealed, .self-care performance deficit r/t (related to) mobility deficit and continued coordination/motor panning challenges…

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 identify traumatization triggers and implement interventions to mitigate these triggers for 1 (Resident #13) of 18 residents reviewed for trauma informed care, resulting in Resident #13, who had recently survived a life-threatening fire, experiencing fear and anxiety during a fire drill, and a potential for unmet psychosocial needs. Findings include: Review of an admission Record revealed Resident #13, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: depression, anxiety disorder, bipolar disorder (disorder causing extreme mood swings). Review of a Minimum Data Set (MDS) assessment for Resident #13, with a reference date of 3/26/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #13 was cognitively intact. Section D of the MDS revealed: Resident #13 had experienced feeling down, depressed, or hopeless during half or more of the 14-day assessment period and had trouble…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that monthly medication regimen review (MRR) recommendations were documented in the resident's record and ensure timely physician response to pharmacy recommendations for 1 of 5 residents (Resident #9) reviewed for MRR, resulting in the potential for medication side effects and/or unnecessary medications. Findings include: Review of an admission Record revealed Resident #9 was originally admitted to the facility on [DATE]. Review of Resident #9's current Physician Orders revealed, Xarelto Oral Tablet 20 MG (Rivaroxaban) (inhibits the formation of blood clots) Give 1 tablet by mouth at bedtime related to PAROXYSMAL ATRIAL FIBRILLATION (irregular heartbeat) Active 2/15/2024. Review of Resident #9'sPharmacy Regimen Review's dated 2/17/24 and 4/11/24 indicated that the pharmacist had submitted a follow up report with physician recommendations. Review of documents in Resident #9's health record, did not include the corresponding reports. In 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 This citation pertains to intake #MI0014109 and intake #MI0014115 Based on observation, interview, and record review, the facility failed to provide a dignified dining experience for 2 (Resident #107 and Resident #104) of 8 residents reviewed for dignity, resulting feelings of frustration, a potential for decreasing feelings of self-worth, humiliation, and potential for injury related to inattention while physically assisting residents with eating. Findings include: Resident #107 Review of an admission Record dated 9/14/20 revealed Resident #107 was admitted to the facility with the following pertinent diagnoses: alzheimer's disease (disease characterized by progressive cognitive deterioration) and major depressive disorder (persistent sadness with loss of interest). Review of a care plan for Resident #107 dated 11/20/23 revealed problem/goal/approaches: Problem: I am at risk for nutrition due to my dementia and needing assistance with meal set up. Goal: Weight stable +/- 3%. Food Acceptance >75%. Approaches:…

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 MI00140649. Based on observation, interview, and record review, the facility failed to ensure access to a call-light for 1 (R104) of 9 residents reviewed for call-light placement, resulting in the inability to call for assistance and the potential for unmet care needs. Findings include: According to R104's medical records, the resident's medical diagnoses included his principal diagnoses paralytic syndrome following cerebral infarction, bilateral (stroke affecting both sides). During an observation on 12/14/2023 at 1:15 PM, R104 was supine (on his back) in bed with his soft touch call light behind the head-of- bed almost touching the floor. During an observation on 12/14/2023 at 2:30 PM, R104 was supine in bed with his soft touch call light behind the head-of-bed almost touching the floor. During an observation on 12/14/2023 at 3:30 PM, R104 was supine in bed with his soft touch call light behind the head-of-bed almost touching the floor. During an observation and interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00141109 Based on interview and record review, the facility failed to immediately recognize and report allegations of abuse for 2 (Resident #105 and Resident #108) of 8 residents sampled for abuse, resulting in the potential for abuse to continue and go unreported. Findings include: Resident #105 Review of an admission Record revealed Resident #105 was admitted to the facility on [DATE] with the following pertinent diagnoses: unspecified dementia without behavioral, psychotic, or mood disturbance (condition characterized by progressive loss of intellectual functioning), and hemiplegia (loss of movement on one side of the body). Review of a Minimum Data Set (MDS) assessment for Resident #105 dated 11/10/23 revealed was usually able to make self understood, usually understood others. Resident #105 scored 11/15 on a Brief Inventory for Mental Status (BIMS) assessment which suggested he had a moderate cognitive impairment. Section E of the MDS revealed Resident #105 displayed 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 interview and record review, the facility failed to investigate an allegation of abuse for 1 (Resident #108) of 8 residents sampled for abuse, resulting in the potential for abuse to continue, for allegations to not be thoroughly investigated to remove the root cause of the problem, and identify interventions to prevent the reoccurrence of the problem. Findings include: Review of an admission Record for Resident #108 dated 1/23/19 revealed the resident was admitted to the facility with the following pertinent diagnoses: major depressive disorder (persistent feeling of sadness and loss of interest). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #108 scored 15/15 on a Brief Interview for Mental Status (BIMS) assessment which indicated she was cognitively intact. Section E of the MDS revealed Resident #108 had no delusions (misconceptions held contrary to reality) and no behaviors directed toward others. In an interview on 12/14/23 at 12:47pm, Resident #108 reported she felt…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes MI0014069 and MI00141115. Based on observation, interview and record review, the facility failed to provide care that meets the resident needs for the treatment and/or maintenance of a skin condition in 1 (R104) of 9 residents reviewed for quality of care, resulting in the potential of worsening of skin conditions, lack of monitoring, and effective treatment. Findings include: According to R104's medical records, the resident's medical diagnoses included his principal diagnoses paralytic syndrome following cerebral infarction, bilateral (stroke affecting both sides), seborrheic dermatitis (causes scaly patches, inflamed skin and stubborn dandruff), foot drop right and left, and contracture right and left hand. Review of R104's Care Plan, 10/12/2023, reported the resident was alert and oriented times 3 (person, place, and time) and was capable of making his own decisions. During an observation and interview in the resident room on 2/14/2023 at 1:15 PM, R104 stated, I can only…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes MI0014069 and MI00141115. Based on observation, interview and record review, the facility failed to float resident heels per the standards of practice to prevent the development of pressure ulcers in 1 (R104) of 9 residents reviewed for pressure ulcers, resulting in the potential for pressure ulcer developement. Findings include: According to R104's medical records, the resident's medical diagnoses included his principal diagnoses paralytic syndrome following cerebral infarction, bilateral (stroke affecting both sides), seborrheic dermatitis (causes scaly patches, inflamed skin and stubborn dandruff), foot drop right and left, and contracture right and left hand. Review of R104's Care Plan, 10/12/2023, reported the resident was alert and oriented times 3 (person, place, and time) and was capable of making his own decisions. During an observation on 12/14/2023 at 1:15 PM, R104 was supine (on his back) in bed with both of his heels directly on the bed. During an observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00141115 Based on observation, interview, and record review the facility failed to ensure that podiatry services were offered to one resident (R104) of 9 reviewed for ancillary services, resulting in dissatisfaction with services. Findings include: According to R104's medical records, the resident's medical diagnoses included his principal diagnoses paralytic syndrome following cerebral infarction, bilateral (stroke affecting both sides), seborrhea dermatitis (causes scaly patches, inflamed skin and stubborn dandruff), foot drop right and left, and contracture right and left hand. Review of R104's Care Plan, 10/12/2023, reported the resident was alert and oriented times 3 (person, place, and time) and was capable of making his own decisions. During an observation and interview on 12/14/2023 at 1:15 PM, R104 was supine in bed in the room covered with a sheet from his chest to his ankles. The resident's feet were uncovered. R104's 10 toes had nails that extended past the end of…

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