Harold and Grace Upjohn Community Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess and ensure the right to safe self-administration of medication in 1 of 18 residents (Resident #16) reviewed for medication administration, resulting in the potential for unsafe self-administration of medication, medication errors, and medications not being stored in a secure manner.Findings include:Resident #16Review of an admission Record revealed Resident #16 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: schizoid personality disorder (chronic mental health condition characterized by limited emotional expression, strong preference for isolation and lack of motivation) and depression (a serious, common mental illness causing persistent sadness).Review of a Minimum Data Set (MDS) assessment for Resident #16 with a reference date of 2/6/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. Section D of the…

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

Based on observation, interview, and record review, the facility failed to provide an environment that promoted resident dignity in 1 (Resident #29) of 4 residents reviewed for dignity, resulting in the potential of feelings of humiliation, embarrassment, and loss of self-worth.Findings include:Resident #29:Review of an admission Record revealed Resident #29 was a male with pertinent diagnoses which included diabetes, mild cognitive impairment (noticeable memory or thinking changes), acquired absence of left eye, strep group B (bacteria can cause sepsis) in left knee, and arthritis due to bacteria in left knee. Review of current Care Plan for Resident #29, revised on 3/24/26, revealed the focus, .I am at risk for falls d/t (due to) impaired safety awareness. with the intervention .Anticipate my needs, round to my room frequently and ask if there is anything I need.Remind resident to push call light and wait for assistance.In an interview on 04/14/2026 at 9:58 AM, Resident #29 reported when he pressed his call light it would take the staff too long to respond even though he would…

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 arrange room furniture in a functional manner, provide adequate power outlets for adaptive equipment and implement low-vision modifications to promote independence for one (Resident #2) of three residents reviewed for accommodation of needs, resulting in feelings of frustration, loss of independence and lack of an individualized environment.Findings include:Resident #2Review of an admission Record revealed Resident #2 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: legal blindness (severe visual impairment with some usable vision, often able to see light, shapes or large print) as defined in the USA (United States of America), diabetic retinopathy (damage to the retina caused by high blood sugar levels, resulting in blurry vision, dark floaters in the visual field, poor night vision and color changes), and surgical amputation of right leg.Review of a Minimum Data Set (MDS) assessment for Resident…

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

Based on interview and record review, the facility failed to allow resident choice regarding personal care in 1 of 1 resident (Resident #1) reviewed for self-determination, resulting in Resident #1 not receiving care (showers/baths) at her preferred time of day. Findings include:Resident #1:Review of Care Plan for Resident #1, revised on 3/3/26, revealed the focus, .I have an ADL (activities of daily living) deficit and need assistance with daily care r/t (related to) weakness/debility. with the intervention .ADL care to meet my needs.Review of Kardex (care guide) for Resident #1 revealed, .ADL-Bathing 1 assist extensive Thursday and Saturday.Personal hygiene: independent following set-up. During an observation and interview on 04/14/2026 at 10:55 AM, Resident #1 reported she didn't get her shower on Saturday as the staff member came at 10:00 PM and the shower was not offered for the next day. Resident #1 reported she had declined the shower due to it being late, she was tired and not up to taking a shower that late. Resident #1 reported she was scheduled to get her showers 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 interview, and record review, the facility failed to provide and document evidence of prompt resolution of grievances in 2 of 2 residents (Resident #2 & #1) reviewed for resolution of grievances, resulting in the potential to experience frustration, apprehension, helplessness, and a negative psychosocial outcome for the residents impacting their quality of life.Findings include:Resident #2 Review of an admission Record revealed Resident # 2 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: legal blindness (severe visual impairment with some usable vision, often able to see light, shapes or large print) as defined in the USA (United States of America), diabetic retinopathy(damage to the retina caused by high blood sugar levels, resulting in blurry vision, dark floaters in the visual field, poor night vision and color changes), and surgical amputation of right leg. Review of a Minimum Data Set (MDS) assessment for Resident #2 with a reference date of 2/2/26,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to 1.) provide adequate supervision and implement appropriate care planned interventions to prevent a fall in 1 resident (Resident #57) reviewed for falls, 2.) ensure safe transfer for 1 resident (Resident #5) and 3.) ensure safe wheelchair transport in 1 resident (Resident #37) of 3 residents reviewed for safety resulting in the potential for residents to sustain a fall and/or injury.Findings include: Resident #57: Review of an admission Record revealed Resident #57 was a male with pertinent diagnoses which included dementia, physical debility, anxiety, seizures, stroke, and hearing loss. Review of Care Plan for Resident #57 revealed the focus, .I am at risk for falls d/t (due to) generalized weakness, impaired mobility, physical limitations. with the interventions .Routine visual checks.Anticipate my needs, round to my room frequently and ask if there is anything I need.Bed in lowest position.Bolster(s) (long thick pillow that is placed to provide a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the necessary care and services were in place for a Foley catheter (tube inserted into bladder to drain urine) for 1 resident (Resident # 41) and failed to provide timely incontinence care for 1 resident (Resident #7), from a sample of 3 residents reviewed for incontinence care, resulting in the potential for trauma due to an unsecure Foley catheter, and skin breakdown and recurrent UTI's (urinary tract infections) due to inadequate incontinence care. Findings include:Resident #41Review of an admission Record revealed Resident #41 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: pressure ulcer of sacral (tailbone) region stage unspecified. Review of a Minimum Data Set (MDS) assessment for Resident #41, with a reference date of 3/11/26 revealed a Brief Interview for Mental Status (BIMS) score of severe cognitive impairment. Review of the Functional Abilities revealed that Resident #41…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a physician (provider) supervised the medical care of residents and participated in the resident's wound assessments and treatment plans for 1 resident (Resident #53) of 18 residents reviewed for physician supervised care, resulting in the potential for a decline in overall health due to worsening of wounds. Findings include: Resident #53Review of an admission Record revealed Resident #53 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Pressure ulcers of sacral (coccyx, tailbone) region and heel, both unspecified. Review of a Minimum Data Set (MDS) assessment for Resident #53, with a reference date of 2/5/26 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #53 was cognitively intact. Review of Resident #53's Braden Scale for predicting Pressure Ulcer Risk Evaluation dated 2/5/26 revealed, 12 indicating at high risk to develop…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure timely physician follow up with pharmacy recommendations for 3 residents (Resident #3, Resident #10, and Resident #57) of 5 reviewed for medications resulting in the potential for residents to experience avoidable medication side effects and/or receive unnecessary medications.Findings include: Resident #3 Review of an admission Record revealed Resident #3 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: insomnia (common sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or waking up to early, leading to unrefreshed sleep and daytime impairment). Review of a Minimum Data Set (MDS) assessment for Resident #3 with a reference date of 3/20/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 12/15, which indicated the resident was moderately cognitively impaired. Section N of the MDS revealed Resident #3 received a hypnotic medication. Review of a…

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

Based on interview and record review, the facility failed to ensure the Medical Director fulfilled their responsibility of implementing Medication Regimen Review (MRR) policies/procedures to include coordination of care between the facility and the consulting pharmacist/pharmacy for 3 (Resident #10, #57 and #3) of 5 residents reviewed for medications. This deficient practice has the potential to affect all residents that reside at the facility. Findings include: During an interview on 4/17/2026 at 1:01 PM, Interim CEO B confirmed that the facility did not have documentation to confirm that Medical Director (MD) CCC had been completing monthly pharmacy recommendation reviews for Resident #10, #53 and #3. Interim CEO B confirmed that MD CCC was responsible for ensuring that all resident pharmacy reports were reviewed and signed by MD CCC, and he was unable to explain why MD CCC had missed completing the monthly reviews. This writer attempted to contact Medical Director (MD) CCC via telephone on 4/17/2026 at 12:36 PM. MD CCC did not return this writer's phone call by survey exit.…

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 #2591271. Based on interview and record review, the facility failed to notify a resident's emergency contact regarding emergency incidents including 1) A resident fall, 2) resident injury, 3) An emergency transfer to an acute care hospital for 1 resident (Resident #3) of 4 residents reviewed for falls resulting in Resident #3's emergency contact being unaware of her fall, injury and subsequent transfer to an acute care hospital for evaluation and treatment. Findings include: Resident #3 (R3)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R3 admitted to the facility on [DATE] with pertinent diagnoses including dementia (decline in cognitive abilities, memory and thinking skills that interfere with daily life), repeated falls, anxiety and depression. Brief Interview for Mental Status (BIMS) reflected a score of 7 out of 15 which indicated R3 was severely cognitively impaired (00 to 07 is severe cognitive impairment).Review of R3's fall report 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 This citation pertains to intake #2591271 and #2581648. Based on observation, interview, and record review, the facility failed to ensure a resident received the necessary care and services, consistent with professional standards of practice to identify and promote the healing of a pressure ulcer in 1 resident (Resident #6) of 3 residents reviewed for pressure ulcers/skin conditions resulting in the potential for worsening and/or reoccurrence of pressure injuries due to not having the appropriate treatment in place to help with wound healing. Findings include:In an observation on 9/17/25 at 1:50 PM, observed Resident #6 in bed. DON “B” and resident rolled to right side. Observed on both left and right buttocks quarter size stage II healing pressure ulcers. Resident reported no pain with touch. Noted blanching in the surrounding area. No drainage noted. Resident #6 (R6)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R6 admitted to the facility on [DATE] with pertinent diagnoses…

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 #2591271.Based on interview and record review, the facility failed to maintain accurate documentation in resident medical records in 1 resident (Resident #1) of 4 residents reviewed for ADLs (activities of daily living) resulting in not knowing whether the resident received or refused a shower.Findings include:Resident #1 (R1)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R1 admitted to the facility on [DATE] with pertinent diagnoses including type 2 diabetes, bipolar disorder, anxiety and depression. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R1 was cognitively intact (13 to 15 cognitively intact). Resident discharged from the facility on 3/17/2025.During an interview on 9/17/2025 at 11:22 AM, R3's Family Member (FM) Y stated that she had several concerns when R3 was at the facility and had a meeting with management. One of her concerns was whether R3 was receiving showers/bed baths to check her…

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

This citation pertains to Intake: 2575125 Based on interview and record review, the facility failed to implement the abuse policy for reporting and response to allegations of abuse in 1 of 3 residents (Resident #102) reviewed for abuse, resulting in the potential for further allegations of abuse to be unreported. Findings include:Resident #101Review of an admission Record revealed Resident #101 was a male, with pertinent diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; mild cognitive impairment of uncertain or unknown etiology; and cognitive communication deficit. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 5/1/25 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #101 was severely cognitively impaired. Resident #102Review of an admission Record revealed Resident #102 was a male, with pertinent diagnoses which included: legal blindness, as defined in USA;…

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: 2575125 Based on interview and record review, the facility failed to provide adequate supervision to prevent a resident-to-resident altercation for 2 (Resident #101, Resident #102) of 3 residents reviewed for abuse, resulting in Resident #101 making racial accusations to Resident #102 and Resident #102 hitting Resident #101 in the stomach. Findings include:Resident #101 Review of an admission Record revealed Resident #101 was a male, with pertinent diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; mild cognitive impairment of uncertain or unknown etiology; and cognitive communication deficit. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 5/1/25 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #101 was severely cognitively impaired.Review of Resident #101's Care Plan in place on 7/27/25 (at the time of the altercation)…

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 prepare and store food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: During a tour of the walk-in cooler, at 10:40 AM on 3/10/25, it was observed that a 3 gallon container of chicken breast, and two single gallon containers of rice and gravy, were found in the walk in cooler dated for 3/9. The containers were found with noticeable condensation on the inside with a temperature of 42F. An interview with Dining Services Manager (DSM) R found that staff should log cooling when it is done. An interview with [NAME] YY, at 10:43 AM on 3/10/25, found that the chicken breasts were cooked yesterday and left out on the counter for awhile until she placed them in the cooler. When asked if she logged any times or temperatures to ensure the food properly cooled, [NAME] YY stated no. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to respond timely to call lights to maintain resident dignity for 5 (Residents #4,#10, #22, #36 and #237) of 7 residents reviewed for dignity, resulting in episodes of incontinence and feelings of frustration and loss of self-worth with the potential for overall deterioration of psychological well-being. Findings include: Resident #4 Review of an admission Record revealed Resident #4 was originally admitted to the facility on [DATE] with pertinent diagnoses which included type 1 diabetes. Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 2/18/25 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #4 was moderately cognitively impaired. During an interview on 3/10/25 at 2:32 PM Resident #4 reported that he was frustrated with the long call light wait times. Resident #4 reported that he had recently had to wait almost an hour for staff assistance after he had a bowel…

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 confidential resident health information was protected and private for 1 of 1 (Residents #71) residents reviewed for privacy and federally regulated HIPAA (Healthcare Insurance Portability and Accountability Act). Findings include Review of an admission Record revealed Resident # 71 was originally admitted to the facility on [DATE] with pertinent diagnoses which included type 2 diabetes. During an observation on 3/12/25 at 10:30 AM, Licensed Practical Nurse (LPN) K was preparing medications at her medication cart. After preparing medications, LPN K walked away from her cart and entered a resident's room. It was noted that the computer screen was left open, with multiple resident names noted on the screen in view of anyone that walked down the hallway and past the medication cart. LPN K was noted to be away from the cart for 6 minutes. During an observation on 3/12/25 at 10:42 AM, LPN K was preparing medications at her medication…

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

Based on interview and record review, the facility failed to provide written notification to the State Long-Term Care (LTC) Ombudsman of facility-initiated transfers/discharges in November 2024 and December 2024 resulting in the potential for all residents to be discharged without an advocate who can inform them of their options and rights. Findings include: On 3/6/25 at 1:40 PM, Ombudsman XX reported that the facility had not been consistently sending notices of transfers and discharges. During an interview on 3/12/25 at 9:52 AM, Manager of Case Management (MCM) MM reported that she was the staff member responsible for sending the transfer and discharge information to the ombudsman. MCM MM reported that she was unsure if she had missed sending any in the last year. This writer requested that MCM MM provide documentation of the transfer notices that she had sent to the ombudsman. On 3/11/25 at 2:01 PM, a picture was sent to this writer of MCM MM 's emails that were sent to the ombudsman with the subject transfer report. It was noted that MCM MM did not send a report in November 2024…

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 adequate assessment for 1 (R237) of 1 resident reviewed for quality of care when, resulting in R237 receiving a delay in treatment for abrasions. Findings include: According to R237's medical record, the resident's BIMS (Brief Interview Mental Status) dated 3/4/24, score was 13/15 (cognitively intact). R237's diagnoses included fracture of left femur (thigh bone) start date 1/2/25, history of falling start date 10/22/16. Review of R237's Incident Fall Report dated 3/9/25 at 11:50 AM indicated the resident was noted on the floor face forward and had stated he had slid off wheelchair. The resident was assessed for injuries and pain then assisted back to his wheelchair. Injuries included a skin tear 2.5 cm x 2.5 cm to forehead, and both the right and left knee along with bruises to right side of face, neck, and chest. Review of R237's Order summary dated 3/10/25, revealed, Monitor steri strips (thin adhesive bandages to close wound) to right knee skin tear for placement - allow to naturally remove. every…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident received proper treatment to maintain vision abilities for 1 of 1 resident (Resident #4), reviewed for vision services, resulting in the inability of the resident to attain or maintain the highest practicable level of physical, mental, and psychosocial well-being. Findings include: Resident #4 Review of an admission Record revealed Resident #4 was originally admitted to the facility on [DATE] with pertinent diagnoses which included type 1 diabetes. Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 2/18/25 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #4 was moderately cognitively impaired. Review of Resident #4's Care Plan revealed, I (Resident #4) have impaired visual function. Start date: 11/18/24. Interventions: Arrange consultation with eye care practitioner as required. Date initiated: 11/18/24 . Review of Resident #4's Orders 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 and record review, the facility failed to provide coordination of care and services for a Foley catheter (flexible tube inserted through the urethra and into the bladder to drain urine) according to professional standards of practice for urinary catheters for 1 of 2 residents (Resident #42) reviewed for catheter care, resulting in Resident #42 continuing to experience urinary tract infections (UTI) with the potential for complications related to urinary tract infections. Findings include: Resident #42 Review of an admission Record revealed Resident #42 was originally admitted to the facility on [DATE] with pertinent diagnoses which included obstructive and reflux uropathy (a condition where urine flow is blocked and can back up in the kidneys). Review of Resident #42's Care Plan revealed, I have an indwelling catheter: Neurogenic bladder (a condition that occurs when the nervous system connection to the bladder is disrupted, causing bladder control issues). Date initiated:…

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

Based on interview, and record review, the facility failed to ensure the physician reviewed and responded to the licensed pharmacist's monthly medication regimen review recommendations in a timely manner in 1 of 5 residents (Resident #14) reviewed for unnecessary medications, resulting in the potential for medication interactions and adverse side effects. Findings include: Resident #14 Review of an admission Record revealed Resident #14 was a male, with pertinent diagnoses which included diabetes, insomnia, anxiety, and depression. Review of a pharmacy Consultation Report for Resident #14, dated 1/10/25, revealed .(Resident #14) frequently requires insulin per sliding scale (despite) a routine basal-bolus insulin regimen. The patient is averaging 105 units of insulin daily between the basal-bolus insulin regimen and sliding scale .Recommendation: Please discontinue the sliding scale, change insulin glargine to 54 units daily (50% of total daily insulin), change insulin Lispro to 17 units TID (three times per day) (50% of total daily insulin / 3 meals) and draw QID (four times per…

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 adaptive dining equipment for 2 (Residents #3 and #4) of 2 residents reviewed for adaptive dining equipment resulting in spills, frustration, decreased independence with eating and drinking, and the potential for weight loss or dehydration. Findings include: Resident #3 During an observation and interview on 03/10/25 at 12:56 PM, Resident #3 was lying in bed with her bedside table over her. The bedside table had a disposable foam cup (no handles) with lid and straw that contained what appeared to be water. There was also a dual handled cup with spout lid containing another beverage. Resident #3 reported she used the dual handled cup because she is blind and it helps her drink and avoid spilling on herself which she reported she had done previously with other cups. Resident #3 confirmed the dual handled cup helps her drink independently. During an observation and interview on 03/11/25 at 12:46 PM, Certified Nurse Aide (CNA) EE 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 ensure that Quality Assessment and Process Improvement (QAPI) meetings had the Medical Director as a mandatory attendee at least quarterly resulting in the potential for the Medical Director to not be notified of quality deficiencies occurring in the facility. Findings include: During an interview on 3/12/25 at 1:35 PM, Nursing Home Administrator (NHA) A reported that he had been the interim NHA since 2/2025. NHA A reported that facility had recently changed their QUAPI meetings to quarterly and adding an ad hoc (when necessary) when they determined a need to meet. NHA A reported that the facility had an ad hoc QUAPI meeting on 3/6/25 which Medical Director (MD) JJ attended. NHA A was able to provide a sign in sheet to verify MD JJ's meeting attendance for 3/6/25. When this writer asked to review the sign in sheets for the facility's quarterly QUAPI meetings in the past year, NHA A reported that he did not know where they were and that he would need to look for them. In a follow up interview on 3/12/25 at 2:35 PM, NHA A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1.) use appropriate personal protective equipment for enhanced barrier precautions and/or appropriate infection control practices for 2 (Resident #38 and #42) of 3 residents reviewed for high contact care activities and catheter care and 2.) don appropriate personal protective equipment for 1 (Resident #27) of 5 residents reviewed for transmission based precautions, resulting in the potential for spread of infection. Findings include: Resident #27 During an observation and interview on 03/10/25 at 11:16 AM, Hospice Registered Nurse (RN) RR was observed entering Resident #27's room whose door had a transmission based precaution sign indicating the room was under droplet precautions. The droplet precaution signage on the door stated, Droplet Precautions .EVERYONE MUST: .Make sure their eyes, nose and mouth are fully covered before room entry and had pictures showing use of a face shield or appropriate eye goggles. This sign was noted to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure COVID-19 consents or declinations were obtained for 1 resident (Resident #71) of 5 residents reviewed for immunizations resulting in residents/family members not being aware of the vaccination and the risks/benefits of having it administered. Findings include: Resident #71(R71) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R71 admitted to the facility on [DATE] with diagnoses including type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy) and surgery of the digestive system. Brief Interview for Mental Status (BIMS) reflected a score of 6 out of 15 which indicated R71 was severely cognitively impaired (00 to 07 is severe cognitive impairment). Review of R71's immunization record revealed that COVID-19 wasn't listed and as a result it was unknown whether R71 received or refused the vaccine. Review of the facility list titled Covid Vaccine Resident List 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 This citation pertains to Intake MI00146941. Based on observation, interview, and record review, the facility failed to 1.) Follow enhanced barrier and contact precautions for 2 (Resident #104 and #105) of 5 sampled residents reviewed for infection prevention and control 2.)Provide notification of confirmed Covid-19 infections in the facility and 3.) Wear personal protective equipment (PPE) appropriately resulting in the potential for the development and transmission of communicable diseases and infections. Findings include: Resident #104 Review of an admission Record revealed Resident #104 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dementia. Review of Resident #104's Orders revealed, Enhanced Barrier Precautions (EBP) are in place to prevent the spread of MDRO'S (Multidrug-resistant organisms) every shift. For safety all staff are to wear gown and Gloves when providing high contact care. Start date: 6/17/24. During an observation on 12/27/24 at 9:24 AM, Resident…

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

Based on interview and record review the facility failed to ensure that an agreement between themselves (the facility) and the dialysis provider (Name Omitted) was established and maintained, for 4 residents (Resident #61, #28, #20, & #75) of 4 reviewed for dialysis services resulting in the potential for disruption in the continuity of care and/or the interruption of dialysis treatments. Findings include: Resident #61: Review of an admission Record revealed Resident #61 was a male with pertinent diagnoses which included stroke, dialysis, dementia, anxiety, peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), aphasia (loss of the ability to understand or express speech caused by brain damage, like with a stroke), apraxia (neurological condition that makes it difficult or impossible to make certain movements), diabetes, and high blood pressure. Resident #28: Review of an admission Record revealed Resident #28 was a female with pertinent diagnoses which included stroke, anemia, heart failure, high blood pressure, end stage…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #335 Review of an admission Record revealed Resident #335 was a male, with pertinent diagnoses which included osteomyelitis of vertebra (bone infection), bacteremia (bacteria in the blood), sepsis (an immune response triggered by an infection), and diabetes. Review of an Order Summary Report for Resident #335 revealed the active physician order .cefTRIAXone Sodium Injection Solution Reconstituted 2 GM (Ceftriaxone Sodium) Use 2 gram intravenously one time a day . with a start date of 5/20/24. No active physician order noted for Enhanced Barrier Precautions (EBP). Review of a current Care Plan for Resident #335 revealed the focus .I am on IV (intravenous) Medications for osteomyelitis . revised 5/20/24. Review of an admission Summary note for Resident #335, dated 5/16/24 at 6:31 PM, revealed .Resident arrived with left PICC (peripherally inserted central catheter) line that is clean dry and intact . In an observation and interview on 5/22/24 at 9:27 AM, Registered Nurse (RN) X and Licensed Practical…

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

Based on observation, interview, and record review, the facility failed to ensure timely care and services to promote dignity and ensure a dignified environment during meal times in 3 of 5 residents (Resident #10, #331, & #6) reviewed for dignity/respect, resulting in long call light wait times with incontinence, meals left in front of a resident without timely assistance provided, and the potential for feelings of diminished self-worth, sadness, and frustration. Findings include: Review of the policy/procedure Promoting/Maintaining Resident Dignity, dated 3/5/24, revealed .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality .All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights .Respond to requests for assistance in a timely manner . Resident #10 Review of an admission…

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 accommodate a resident's right to make choices that were consistent with their assessment and plan of care for 1 of 20 sampled residents (Resident #61) reviewed for resident choices, resulting in the resident not meeting their highest practicable level of well-being. Findings include: Resident #61: Review of an admission Record revealed Resident #61 was a male with pertinent diagnoses which included stroke, dialysis, dementia, anxiety, peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), aphasia (loss of the ability to understand or express speech caused by brain damage, like with a stroke), apraxia (neurological condition that makes it difficult or impossible to make certain movements), diabetes, and high blood pressure. In an interview on 05/22/24 at 08:10 AM, Resident #61 reported he only gets a shower once a week. He reported he was able to get up and go to the restroom 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.

This citation pertains to intake MI00144151 Based on interview and record review the facility failed to provide written notice of transfer for 1 (Resident #15) of 1 resident reviewed for hospitalization resulting in the potential for the resident and/or the resident's representative to be unaware of the resident's transfer out of the facility, the reason for the resident's transfer out of the facility, and/or the resident's rights. Findings include: Resident #15 Review of an admission Record revealed Resident #15 had pertinent diagnoses which included: Type two diabetes mellitus without complications, bipolar disorder, and insomnia. Review of a Minimum Data Set (MDS) assessment for Resident #15, with a reference date of 3/20/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #15 was cognitively intact. Review of Health Status Note for Resident #15 dated 4/19/24 at 11:41 AM., revealed .referral has been placed to (Name Omitted) hospital and has been accepted for admission today. Secured transport for 1300 . Review of Health Status Note 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.

This citation pertains to intake MI00144151 Based on interview and record review the facility failed to provide written notice of bed hold policy for 1 (Resident #15) of 1 resident reviewed for hospitalization resulting in the potential for the resident and/or the resident's representative to be unaware of the facility's bed hold policy, including duration, expense, and return process. Findings include: Resident #15 Review of an admission Record revealed Resident #15 had pertinent diagnoses which included: Type two diabetes mellitus without complications, bipolar disorder, and insomnia. Review of a Minimum Data Set (MDS) assessment for Resident #15, with a reference date of 3/20/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #15 was cognitively intact. Review of Health Status Note for Resident #15 dated 4/19/24 at 11:41 AM., revealed .referral has been placed to (Name Omitted) hospital and has been accepted for admission today. Secured transport for 1300 . Review of Health Status Note for Resident #15 dated 4/19/24 at 13:28 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 accurately complete a Minimum Data Set (MDS) assessment for 2 (Residents #41 and #43) of 20 sampled residents reviewed for MDS accuracy, resulting in an inaccurate reflection of the residents' health status. Findings include: Resident #41 Review of an admission Record revealed Resident #41 was a female, admitted to the facility on [DATE], with pertinent diagnoses which included: post-traumatic stress disorder, unspecified. Review of a Minimum Data Set (MDS) assessment for Resident #41, with a reference date of 4/17/24 revealed, .Section I - Active Diagnoses in the last 7 days - Check all that apply . The check box next to Psychiatric/Mood Disorder .I6100. Post Traumatic Stress Disorder (PTSD) was not checked (indicating that the diagnosis did not apply to this resident). In an interview on 5/22/24 at 2:54 PM, MDS Coordinator (MDSC) LL reported she had completed Resident #41's MDS assessment dated [DATE], with input from other pertinent disciplines.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement resident comprehensive care plans for 1 (Resident #6) of 20 residents reviewed for care planning resulting in a lack of service for residents to maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual V1.17, Chapter 4, revealed, .the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident #6: Review of an admission Record revealed Resident #6 was a male with pertinent diagnoses which included dementia, stroke, muscle weakness, dysphagia (damage to the brain…

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 received care in accordance with professional standards of nursing practice for 2 of 20 residents (Resident #6, #61) reviewed for physician orders and documentation, resulting in the potential for the worsening of a condition and a delay in treatment. Findings include: Review of the Fundamentals of Nursing revealed, Patient care requires effective communication among members of the health care team. The medical record is an important means of communication because it is a confidential, permanent, legal documentation of information relevant to a patient's health care. The record is a continuing account of a patient's health care status and is available to all members of the health care team. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 24088-24091). Elsevier Health Sciences. Kindle Edition. Resident #6: Review of an admission Record revealed Resident #6 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 ensure the attending physician reviewed and responded to the registered pharmacist's monthly medication regimen review recommendations in a timely fashion for 1 (Resident #41) of 5 residents reviewed for medication regimen review, resulting in the registered pharmacist's recommendations not being addressed timely, and the potential for negative medication side effects or unnecessary medications as a result of the delayed response. Findings include: Review of an admission Record revealed Resident #41 was a female, with pertinent diagnoses which included: saddle embolus of pulmonary artery without acute cor pulmonale (a blood clot in the lungs). Review of a progress note dated 5/6/24 at 9:16 PM revealed, Type: Medication Regimen Review Note Text: Monthly medication regimen review performed __x__ Comment/Recommendation noted - see report . electronically signed by contracted pharmacist (name omitted). On 05/22/24 at 3:30 PM, Resident #41's electronic medical record was reviewed for evidence of the pharmacist's report 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 and interview the facility failed to ensure a sanitary environment for 1 of 1 (Resident #6) and personal and shared medical equipment reviewed for sanitary conditions, resulting in the potential for cross-contamination, infections, and bacterial harborage. Findings include: During an observation on 05/22/24 at 08:35 AM, outside of room [ROOM NUMBER] there was a broda chair left arm rest area inside had dried liquid/soiled, the back had a black pad and it was soiled with dirt and needed to be cleaned and wiped down, the foot rest had dirt/debris on it, the black thick cushion on the seat had white specks on it, the black pad on the left side lower area had a white dried smear and on the bottom middle area. Dirt and debris was in the crevice between the two blue pads. The left inside of the side guard armrest area had white material smeared on it. The blue pad behind the black pad on the seat on had splatters of dried brown/tan/white specks over the top of it. During an observation on 05/23/24…

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

This citation pertains to Intake # MI00143491. Based on observation, interview, and record review, the facility failed to ensure catheter tubing was secured to prevent pulling per physician order in 1 of 2 residents (Resident #103) reviewed for indwelling catheter care, resulting in the potential for dislodgement of the catheter tubing, the potential for urethral damage, and pain/discomfort. Findings include: Review of an admission Record revealed Resident #103 was a female, with pertinent diagnoses which included second-degree burn of thigh, skin infection, stroke with left sided weakness. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 2/8/24, revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, which indicated severe cognitive impairment. In an observation and interview on 4/10/24 at 9:57 AM, Resident #103 was in bed in her room, eating independently from her breakfast tray. Resident #103 reported she used to drink hot tea, but had a spill in the dining room which resulted in burns. Resident…

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

This citation pertains to Intake # MI00143491. Based on observation, interview, and record review, the facility failed to implement physician orders for pain management during wound care in 1 of 5 residents (Resident #103) reviewed for medication administration, resulting in pain during wound care and the potential for decreased quality of life. Findings include: Review of an admission Record revealed Resident #103 was a female, with pertinent diagnoses which included second-degree burn of thigh and skin infection. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 2/8/24, revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, which indicated severe cognitive impairment. In an observation and interview on 4/10/24 at 9:57 AM, Resident #103 was in bed in her room, eating independently from her breakfast tray. Resident #103 reported she used to drink hot tea, but had a spill in the dining room which resulted in burns. Resident #103 reported her burns are still healing, and she goes out to the wound…

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 # MI00137543. Based on interview, and record review, the facility failed to ensure a functional alarm system was in place in 1 of 5 residents (Resident #103) reviewed for elopement/supervision, resulting in the potential for elopement. Findings include: Review of the policy/procedure Elopement Prevention/Procedure/Reporting, dated [DATE], revealed .Definition of Elopement: When a cognitively impaired resident leaves the premises or a safe area without authorization and/or necessary supervision to do so .ELOPEMENT PREVENTION .A Plan of Care will be developed for those residents assessed as being at risk for elopement including interventions to prevent elopement .Residents determined to be at risk for elopement will have a wander guard signaling device as appropriate. The wander guard may be worn around a wrist or ankle and in unique situations on an assistive device. The wander guard is an electronic monitoring system with an audible warning signal for entrance/exit doors that is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake # MI00140204. Based on interview, and record review, the facility failed to provide showers per resident preference and plan of care in 1 of 4 residents (Resident #106) reviewed for Activities of Daily Living (ADL) care, resulting in dissatisfaction with care and the potential for poor hygiene, skin breakdown, and infection. Findings include: Personal hygiene affects patients' comfort, safety, and well-being. Hygiene care includes cleaning and grooming activities that maintain personal body cleanliness and appearance. Personal hygiene activities such as taking a bath or shower and brushing and flossing the teeth also promote comfort and relaxation, foster a positive self-image, promote healthy skin, and help prevent infection and disease. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 50742-50744). Elsevier Health Sciences. Kindle Edition. Review of an admission Record revealed Resident #106 was a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake # MI00137543. Based on interview, and record review, the facility failed to notify the responsible party of a change in condition in a timely manner in 1 of 5 residents (Resident #103) reviewed for notification of changes, resulting in the responsible party being unaware of an elopement on the date of occurrence, and the potential for the responsible party to not be fully informed and involved in care decisions. Findings include: Review of a Health Status Note for Resident #103, dated [DATE] at 6:29 PM, revealed .Resident took a shower at (5:45 PM), got dressed and went down to dining room for dinner at (5:48 PM). This nurse laid eyes on resident in dining room eating. At (5:48 PM) resident was in the facility. Resident at some point walked out of the facility. Resident (may) have walked to the store and walked back to the facility. Resident is safe in bed room at this time. Resident has no new skin concerns or pain noted. Will (continue) to monitor for changes . In an 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 This citation pertains to Intake # MI00137543. Based on interview and record review, the facility failed to immediately report an elopement incident (a situation involving possible neglect and a system failure) to the State Survey Agency in 1 of 5 residents (Resident #103) reviewed for elopement/supervision, resulting in the potential for a delayed/incomplete investigation. Findings include: In an interview on 11/13/23 at 12:55 PM, DON B reported she was not aware that Resident #103's Wander Guard bracelet was non-functional. DON B reported there was an order placed for more Wander Guard bracelets at one point, however they were on backorder. DON B reported she had a conversation with Family Member V in early October where they discussed Resident #103 going outside. DON B reported she and Family Member V agreed that it was OK for Resident #103 to be outside of the facility without supervision for ten minutes. DON B stated .He (Family Member V) was fine with that and agreed . DON B clarified that this…

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 # MI00137543. Based on interview and record review, the facility failed to thoroughly investigate situations involving potential neglect in 1 of 5 residents (Resident #103) reviewed for elopement/supervision, resulting in an incomplete facility investigation and a lack of documentation. Findings include: Review of a Health Status Note for Resident #103, dated 10/2/23 at 6:29 PM, revealed .Resident took a shower at (5:45 PM), got dressed and went down to dining room for dinner at (5:48 PM). This nurse laid eyes on resident in dining room eating. At (5:48 PM) resident was in the facility. Resident at some point walked out of the facility. Resident (may) have walked to the store and walked back to the facility. Resident is safe in bed room at this time. Resident has no new skin concerns or pain noted. Will (continue) to monitor for changes . In an interview on 11/13/23 at 2:37 PM, RN F reported in regard to Resident #103's elopement on 10/2/23 she was driving into work and observed…

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.