Medilodge of Westwood

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents received care in accordance with professional standards in 2 residents (Resident #21 & #540) of 18 residents reviewed for quality of care, resulting in medication not being administered per physician order for the treatment of a mental disorder for Resident #21, wound care not provided per physician order for Resident #540, and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #21 Review of an admission Record revealed Resident #21 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: bipolar disorder (mental disorder characterized by periods of depression and periods of abnormal elevated mood), depression and suicidal ideations. Review of Resident #21's Care Plan revealed, .at risk for an impaired mood/psychiatric status related to history of suicidal ideations (no plan or attempt) and bipolar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a positioning device was consistently applied for 1 (Resident #56) of 1 resident reviewed for positioning, resulting in the potential for decreased range of motion and related complications, skin breakdown, worsening of contracture (hardening of the muscles, tendons, and other tissues) and pain. Findings include: Resident #56 Review of an admission Record revealed Resident #56 was a male, with pertinent diagnoses which included: hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) affecting right dominant side. Review of a Minimum Data Set (MDS) assessment for Resident #56, with a reference date of 3/9/25 revealed Resident #56 had a functional limitation in range of motion in upper extremity. Review of Resident #56's current Care Plan revealed a focus of Resident has an ADL (activities of daily living) self-care performance deficit related to weakness,…

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 that supplemental oxygen was continuously supplied at the rate ordered by the physician for 1 (Resident #37) and 2). Obtain physician orders for use of a continuous positive airway pressure (CPAP) machine and provide routine cleaning of CPAP mask for 1 (Resident #81) of 2 total residents reviewed for respiratory care resulting in the potential for excessive oxygen administration, improper use and/or inaccurate settings of an CPAP machine, and respiratory infection. Findings include: Resident #37 Review of an admission Record revealed Resident #37 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, need for assistance with personal care, and reduced mobility. Review of a Minimum Data Set (MDS) assessment for Resident #37, with a reference date of 5/6/2025 revealed a Brief Interview…

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

Based on interview and record review the facility failed ensure post dialysis assessment and monitoring was completed and documented for 1 (Resident #6) of 1 resident reviewed for dialysis care, resulting in the potential for the resident to not meet his highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #6 Review of an admission Record revealed Resident #6 was a male, with pertinent diagnoses which included: end stage renal disease (a disease in which the kidneys don't filter excess waste and fluid from the blood effectively) and dependence on renal dialysis (a treatment that filters excess waste and fluid from the blood when the kidneys don't function properly). Review of Resident #6's current Order Summary revealed no physician's orders for monitoring and assessment of Resident #6 upon return to the facility from his dialysis treatments. In an interview on 6/3/25 at 1:09 PM, Licensed Practical Nurse (LPN) Z reported when Resident #6 returned from dialysis, the nurse was supposed to check his weight and vital signs. 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 observation, interview, and record review the facility failed to identify post-traumatic stress disorder (PTSD) triggers and develop individualized care plan interventions to mitigate triggers for 2 (Resident #83, #63) of 18 residents reviewed for trauma informed care, resulting in the potential of re-traumatization due to staff not being informed and knowledgeable of the resident's past trauma. Findings include: Resident #83 Review of an admission Record revealed Resident #83 was a female with pertinent diagnoses which included below the knee amputation, bilaterally, frostbite with tissue necrosis of right foot, frostbite with tissue necrosis of left foot, gangrene, bipolar, schizophrenia, and respiratory failure with hypoxia. Review of current Care Plan for Resident #83, revised on 2/26/25, revealed the focus, .Resident is at risk for an impaired mood/psychiatric status related to bipolar disorder, schizophrenia . with the interventions .Administer medications and treatments as ordered .Behavioral…

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 specialized and individual mental health services for 1 (Resident #63) of 1 resident reviewed for mental health services resulting in psychological support service recommendations not being addressed, support services not being initiated when ordered by the physician, and the potential for a decline in psychological well-being. Findings include: Resident #63 Review of an admission Record revealed Resident #63 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: acute respiratory failure, generalized anxiety disorder, and major depressive disorder. Review of a Minimum Data Set (MDS) assessment for Resident #63, with a reference date of 4/15/2025 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #63 was cognitively intact. In an interview on 6/4/25 at 9:59 am, Resident #63 reported she was told when she was first admitted to the facility, she 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 maintain a medication error rate less than 5% in 2 residents (Resident #33 & #21) of 5 residents reviewed for medication administration, resulting in the potential for medication adverse effects and complications. Findings include: Resident #33 During an observation of medication administration on 06/03/25 at 08:32 AM Registered Nurse (RN) EE prepared an insulin (used to manage blood sugar levels) injection (when a needle is used to administer medication) for Resident #33. The medication was labeled Lantus (a long acting insulin) Pen and was dated as opened on 4/26/25 (38 days ago). Observed RN EE inject 10 units of the Lantus into Resident #33's right abdomen. RN EE administered insulin from a pen that was over 28 days past the open date. In a subsequent interview on 6/3/25 at 8:35 AM, RN EE reported that the facility goes by the manufacturer expiration date for insulin pens and not the open date. During an observation of the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store drugs per manufacturer instructions and facility policy in 2 out of 6 medication carts, resulting in the potential for decreased efficacy of medications. Findings include: During an observation of medication administration on [DATE] at 08:32 AM on 100 hall, Registered Nurse (RN) EE prepared an insulin (used to manage blood sugar levels) injection pen (when a needle is used to administer medication) for Resident #33. The medication was labeled Lantus pen (a long acting insulin) and was dated as opened on [DATE] (38 days ago) with an expiration date of [DATE]. RN EE was observed injecting 10 units of the Lantus into Resident #33's right abdomen. The insulin was labeled use within 28 days of opening from the manufacturer. In a subsequent interview on [DATE] at 8:35 AM, RN EE also reported that the facility goes by the expiration date for insulin pens, and she had never came across one that was expired. During an observation 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 fully implement a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe storage and consumption. This deficient practice resulted in unknown discard dates and potentially hazardous foods being held passed their discard date, increasing the risk of contamination and food borne illness among residents who store personal food product in the facility. Findings include: During the initial kitchen tour with Regional Registered Dietitian (RRD) MM on 6/2/25 at 9:53 AM at the Resident Refrigerator, the following was noted: prepared macaroni salad that was opened but not labeled with an opened or discard date; prepackaged apples with a good through date of 5/15/25; a bottle of sweet tea that was opened but not labeled with an opened or discard date; 2 bottles of thickened lemon water that were not labeled with an opened or discard date; and an opened bottle of ranch dressing that was not labeled with an opened or discard date. In an interview on 6/4/25 at 8:41 AM, RRD…

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: MI00147428. Based on interview and record review, the facility failed to take prompt action to resolve resident concerns of lengthy call light wait times in 3 (Resident #107, #106, and #101) of 3 residents reviewed for concern resolution, resulting in dissatisfaction with call light response and the potential for feelings of frustration as well as the potential for additional care concerns to go unaddressed. Findings include: Review of Resident Council Minutes for 7/18/24 meeting revealed concern with long call light response on 2nd shift and on all shifts on the weekends. There was no indication in the documentation that any follow up occurred. Review of Resident Council Minutes for 10/24/24 meeting revealed concern with call lights not being answered. The Plan/Action was continue to audit. Review of Resident Council Minutes for 1/15/25 meeting revealed contineud concern with long call light response on 2nd and 3rd shifts. There was no indication in the documentation that any follow up occurred. Resident #107 Review of an admission Record 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.

This citation pertains to intake MI00147428. Based on interview and record review, the facility failed to provide food products at a palatable temperature for 2 (Resident #106 and Resident #101) of 3 residents reviewed for food, resulting in dissatisfaction with meals and the potential for nutritional decline. Findings include: Resident #106 Review of an admission Record revealed Resident #106 was a female, with pertinent diagnoses which included: type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood) with diabetic nephropathy (diabetic kidney disease) and long term (current) use of insulin. Review of a Minimum Data Set (MDS) assessment for Resident #106, with a reference date of 12/17/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #106 was cognitively intact. In an interview on 2/18/25 at 9:43 AM, Resident #106 reported the food was hardly ever hot enough and that the residents deserved to have a decent meal. Resident #101 Review of an admission Record…

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 MI00147428. Based on interview and record review, the facility failed to ensure residents received requested food items for 2 (Resident #106 and Resident #101) of 3 residents reviewed for food, resulting in dissatisfaction with meals and the potential for nutritional decline. Findings include: Resident #106 Review of an admission Record revealed Resident #106 was a female, with pertinent diagnoses which included: type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood) with diabetic nephropathy (diabetic kidney disease) and long term (current) use of insulin. Review of a Minimum Data Set (MDS) assessment for Resident #106, with a reference date of 12/17/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #106 was cognitively intact. In an interview on 2/18/25 at 9:43 AM, Resident #106 reported she often did not receive what she ordered on her meal tray. Resident #106 reported this morning for breakfast she was supposed to get 2…

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 administer oxygen per physician order and professional standards of practice, and store oxygen tubing in a manner to prevent cross-contamination in 1 of 4 residents (Resident #104) reviewed for oxygen administration, resulting in the potential for respiratory distress, worsened respiratory status, and the spread of infection. Findings include: Review of an admission Record revealed Resident #104 was a female, with pertinent diagnoses which included obstructive lung disease, heart failure, anemia, kidney disease, asthma, and dementia. Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 6/16/24, revealed a Brief Interview for Mental Status (BIMS) score of 2, out of a total possible score of 15, which indicated she had severe cognitive impairment. Review of a current Care Plan for Resident #104 revealed the focus .Resident has an impaired pulmonary/respiratory status related to COPD (chronic obstructive pulmonary disease)/Emphysema (oxygen at 2 Liters per minute) via (nasal…

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 sanitary conditions in the kitchen resulting in the potential to spread food borne illness potentially affecting all 87 residents that reside in the facility. Findings Include: During an initial kitchen tour on 6/11/2024 at 8:33 AM, the following was observed in the reach in refrigerator: The outside temperature gauge temperature was at 53 degrees. The inside temperature gauge was at 46 degrees. On 6/11/2024 at 11:52 AM, it was observed the reach in refrigerator outside temperature gauge was 52 degrees and the inside temperature gauge was 45 degrees. The reach in refrigerator was still packed with food. During an interview on 6/11/2024 at 12:25 PM, Maintenance Director (MD) FF stated that ice froze up on the fan in the reach in refrigerator and he was trying to chip it away so it could start working again and the temperatures should come back down. On 6/11/2024 at 1:41 PM, it was observed the reach in refrigerator outside…

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 and interview the facility failed to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120°F. This resulted in an increased risk of injury among residents who reside in the B hall. Findings Include: During a tour of the B hall shower room, at 10:07 AM on 6/12/24, the hot water was checked with a rapid read digital thermometer and found to be 127F. When asked if hot water temperatures were taken today, Maintenance Director (MD) FF stated yes, Maintenance (M) O usually does it in the morning. Observation of the B hall soiled utility room sink, at 10:09 AM on 6/12/24, found the hot water to reach 128F. When asked if each hall has their own hot water system, MD FF stated yes. Observation of the B hall boiler room, at 10:11 AM on 6/12/24, found that the thermometer showing outgoing hot water to the B hall domestic fixtures read 128F with no mixing valves at point of use to further temper the water. An interview with MD FF, at 10:15 AM on 6/12/24, found that M O checked the water temperatures this morning and found it under 120F in the B…

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 has two deficient practice statements. Deficient Practice Number 1. Based on observation, interview, and record review, the facility failed to ensure proper infection control protocols and practices in seven of 20 residents reviewed for infection control (Resident #46, Resident #57, Resident #48, Resident #49, Resident #65, Resident #15, Resident #83) including 1. Enhanced Barrier Precautions (EBP) per national standards of practice, 2. Routine cleaning and proper storage of continuous positive airway pressure (CPAP) machines and tubing 3. Proper use of PPE (Personal Protective Equipment) during catheter care and dressing changes, 4. Keeping an intravenous therapy (IV) pole clean, 5. Tube feeding practices and 6. Proper wheelchair cleaning resulting in the potential for the spread of infection, cross-contamination, and disease transmission for residents residing in the facility. Findings include: During an observation on 6/11/2024 at 10:14 AM down D-Hall, one cart with PPE was noted to not have any…

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 #MI00145044. Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from verbal and physical abuse by a resident for 2 residents (Resident #15 & #40) of 4 residents, reviewed for abuse, resulting in the potential for physical harm, pain and mental anguish. Findings include: Resident #15 Review of a Minimum Data Set (MDS) assessment for Resident #15, with a reference date of 5/28/24 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated Resident #15 was cognitively impaired. Review of Resident #15's Care Plan revealed, .Resident has behavior as evidenced by: verbally aggressive toward staff such as yelling and cursing. Resident may also become resistive or display verbal threats towards staff when providing care and/or transfers .Resident has an antagonistic joking relationship with another resident. Resident has a history of grabbing hair/head and staffs clothing, throwing trays. 6/9/24 resident aggressive to other resident .Date…

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

This citation pertains to intake #MI00145044. Based on observation, interview, and record review, the facility failed to implement interventions to prevent further abuse during an ongoing investigation of abuse for 2 residents (Resident #15 & #40) of 4 residents, reviewed for abuse, resulting in the potential for physical harm, pain and mental anguish. Findings include: Resident #15 Review of a Minimum Data Set (MDS) assessment for Resident #15, with a reference date of 5/28/24 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated Resident #15 was cognitively impaired. Review of Resident #15's Care Plan revealed, .Resident has behavior as evidenced by: verbally aggressive toward staff such as yelling and cursing. Resident may also become resistive or display verbal threats towards staff when providing care and/or transfers .Resident has an antagonistic joking relationship with another resident. Resident has a history of grabbing hair/head and staffs clothing, throwing trays. 6/9/24 resident aggressive to other resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #30 (R30) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R30's original admission date was on 4/7/2023 with diagnoses of dysphagia (difficulty swallowing), anxiety, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (stroke). Brief Interview for Mental Status (BIMS) reflected a score of 14 out of 15 which indicated R30 was cognitively intact (13-15 is cognitively intact). Resident was discharged to the hospital on 3/2/2024 due to congestion and shortness of breath and returned to the facility on 3/7/2024. During an interview on 6/11/2024 at 2:15 PM, R30 stated he had to go to the hospital several months ago due to pneumonia. R30 was unable to remember if he received a written transfer notice when he went to the hospital. Review of R30's chart revealed no evidence that R30 received a written notice of transfer when he went to the hospital and which included the following information: (i) The reason for transfer or discharge; (ii) The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident of the facility bed hold policy and provide a written copy upon hospital transfer for two residents (Resident #30, Resident #43) of four reviewed for hospitalizations, resulting in the potential of residents and/or resident representatives being uninformed of the bed hold policy. Finding include: Resident #30(R30) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R30's original admission date was on 4/7/2023 with diagnoses of dysphagia (difficulty swallowing), anxiety, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (stroke). Brief Interview for Mental Status (BIMS) reflected a score of 14 out of 15 which indicated R30 was cognitively intact (13-15 is cognitively intact). Resident was discharged to the hospital on 3/2/2024 due to congestion and shortness of breath and returned to the facility on 3/7/2024. During an interview on 6/11/2024 at 2:15 PM, R30 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for one (Resident #141) of 20 residents reviewed for the provision of nursing services, resulting in IV (intravenous) medications being administered outside of the physician ordered parameters. Findings include: Review of an admission Record revealed Resident #141 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: severe sepsis (life-threatening condition cause by infection) and cellulitis (infection in the skin). In an interview on 06/12/24 at 09:31 AM, Registered Nurse (RN) T reported that medication pass was running late that day. During an observation and interview on 06/12/24 at 11:04 AM in Resident #141's room. Resident #141 was lying in bed and there was an IV pole at the bedside with a bag and tubing attached. The tubing had a piece of tape on it that revealed, 6/12/24 10:30 (am). The bag of fluid was labeled…

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 identify a need for increased assistance with Activities of Daily Living (ADL) care and provide the necessary assistive devices, for one resident (Resident #67) of six reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for residents who are dependent on staff for assistance. Findings include: Resident #67 Review of an admission Record revealed Resident #67 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: pyogenic (infected) arthritis (inflammation of the joints). Review of a Minimum Data Set (MDS) assessment for Resident #67, with a reference date of 5/23/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #67 was cognitively intact. Review of Resident #67's ADL Care Plan revealed, .ADL self-care performance deficit related to pyogenic arthritis .weakness,…

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 # MI00143208 Based on observation, interview and record review, the facility failed to ensure residents received the necessary care and services to prevent the worsening of pressure ulcers in onr resident (Resident #15) of four residents reviewed for pressure ulcers, resulting in not receiving wound treatments per physician orders for pressure ulcers, and the potential for infection and worsening of pressure ulcers. Findings include: Resident #15 Review of an admission Record revealed Resident #15 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: heart and respiratory failure. Review of a Minimum Data Set (MDS) assessment for Resident #15, with a reference date of 5/28/24 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated Resident #15 was cognitively impaired. Review of Resident #15's Pressure Ulcer Care Plan revealed, .Chronic surgical ulcer stage 4 to left trochanter…

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 pre and post dialysis (procedure that removes excess water, solutes, and toxins from the blood for people whose kidneys cannot perform these functions) treatment assessment and monitoring communication between themselves (the facility) and the dialysis provider (Name Omitted) was maintained in one (Resident #17) of one resident reviewed for dialysis services resulting in the potential for unrecognized adverse reactions and/or resident decline related to adverse reactions of dialysis treatments. Findings include: Resident #17 Review of an admission Record revealed Resident #17 had pertinent diagnoses which included: end stage renal disease and dependence on renal dialysis. Review of a Minimum Data Set (MDS) assessment for Resident #17, with a reference date of 5/17/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #17 was cognitively intact. Review of Dialysis section of miscellaneous documents in Resident #17's medical record revealed the last uploaded dialysis…

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

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent in 2 of 4 residents (Resident #7 & #340) reviewed for medication administration, resulting in a medication error rate of 16% (4 errors from a total of 25 opportunities for error). Findings include: Review of Resident #7's Physician Orders revealed an active order for Aripiprazole 5 mg 1 pill every morning for intermittent explosive disorder. Review of Resident #7's Physician Orders revealed an active order for 3 tablets of Calcitriol (Vitamin D) 0.25 mcg to be administered every morning on Monday, Wednesday and Friday for end stage renal disease. Review of Resident #7's Physician Orders revealed an active order for Nepro (supplemental drink) 1 can in the morning for supplement. During medication administration observation and interview on 06/12/24 at 08:12 AM, Registered Nurse (RN) AA was preparing morning medications for Resident #7, and reported that Aripiprazole 5 mg was not available to administer as ordered, and that she had used the last dose…

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 appropriate storage of medication and a self-administration of medications evaluation was conducted for two (R140 and R49) of two residents reviewed for self-administration of medications, including narcotics, resulting in the potential for adverse reactions and overdose. Findings include: R140 According to the Minimum Data Set (MDS) dated [DATE], R140's BIMS (Brief Interview of Mental Status) had not been conducted as of 6/11/24. However, during observation and interview revealed the resident was attentive and interested during the interviews the surveyor conducted displaying a concrete thought process, with clear and concise speech. During an observation and interview on 6/12/24 at 8:37 AM, Registered Nurse (RN) T was observed leaving a medication cup (med cup) with various pills on R140's bedside table and exiting room without observing the resident taking them. R140 stated, The nurses do not normally leave meds with me. I've…

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 #MI00143208. Based on observation, interview, and record review, the facility failed to ensure the accuracy of the documentation of pressure ulcer care and dressings changes for one (Resident #15) of four residents reviewed for pressure ulcers, resulting in the potential for inappropriate follow up care, lack of continued assessment, and worsening of the skin injury. Findings include: Resident #15 In an interview on 06/11/24 at 02:33 PM, Family Member (FM) OO reported that Resident #15's wound dressings did not get changed as frequently as they should and that she felt like that was why his wounds had not healed. Review of Resident #15's Progress Note dated 6/6/24 indicated that the resident had returned from the hospital at 4:45 PM that day. During an observation and interview on 06/12/24 at 12:15 PM in Resident #15's room. Registered Nurse (RN) S detached Resident #15's incontinence brief and a large white dressing was observed, dated June 7th with Wound Nurse (WN) X's initials on it. RN S removed the resident's sock on his left foot and a large…

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 #MI00144295 Based on observation and interview, the facility failed to maintain a clean homelike environment for 2 (Resident #33 and Resident #83) of 20 sampled residents resulting in an unclean room, unclean bathroom, and the potential for a reasonable person to experience feelings of embarrassment, shame, and/or loss of self -esteem. Findings include: Resident #33 Review of an admission Record revealed Resident #33 had pertinent diagnoses which included: unspecified dementia, mild cognitive impairment on uncertain or unknown etiology, and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #33, with a reference date of 4/4/24 revealed a Brief Interview for Mental Status (BIMS) score of 8/15 which indicated Resident #33 was moderately cognitively impaired. During an observation on 6/11/24 at 10:12 AM., Resident #33's room had an odor of urine, the floor was sticky while walking on it, and there appeared to be dirt and debris along the base boards of the room. Flying insects were noted in the room. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes: MI00136843, MI00137001 Based on observation, interview, and record review, the facility failed to maintain general cleanliness of the premises including floor care (Rooms 402, 306, 102, 203, 205), cleaning of high contact surfaces, and resident personal and shared equipment, resulting in the potential for the spread of infection. Findings include: During an observation on 2/9/24 at 9:37am, the floor in the doorway of room [ROOM NUMBER] was soiled with a dried dark liquid, within room [ROOM NUMBER] the floor was soiled by a dried, darkened area of residue that measured 5' wide and extended from the door to bed. In an interview on 2/9/24 at 9:39am, the resident who resided in room [ROOM NUMBER], stated my floor is dirty, and it bothers me. It's been like that since I came here then pointed to a large, darkened area of residue on her room floor. The resident reported the environment was not home-like and felt unclean. In an interview on 2/7/24 at 10:36am, Family Member (FM) UU…

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 #MI00140233. Based on interview, and record review, the facility failed to protect the residents right to be free from staff to resident verbal abuse in 1 of 4 residents (Resident #207) reviewed for abuse, resulting in the potential for a decline in physical, mental, and psychosocial well-being. Findings include: Review of an admission Record revealed Resident #207 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: overactive bladder and history of falling. Review of a Minimum Data Set (MDS) assessment for Resident #207, with a reference date of 10/3/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #207 was cognitively intact. Review of Resident #207's Kardex (care guide) indicated that she required assistance of 1 person for toileting and transfers. Review of Resident #207's Alleged Abuse Incident Report dated 10/4/23 at 10:00 PM revealed, .Resident reports…

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 # MI00141758. Based on interview, and record review, the facility failed to prevent the misappropriation of controlled resident medications in 2 of 5 residents (Resident #212 and #201) reviewed for misappropriation of property, resulting in loss of resident's pain medication, and the potential for uncontrolled pain and discomfort. Findings include: Resident #212 Review of a Minimum Data Set (MDS) assessment for Resident #212, with a reference date of 11/12/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #212 was cognitively intact. Review of Resident #212's Medication Administration Record (MAR) revealed orders for Percocet (narcotic pain medication) 10-325 mg one pill to be given as needed every 4 hours for pain. The record indicated that 47 of 48 doses had been administered between the hours of 8:00 AM and 11:00 PM for December 2023, and 1 dose had been documented as administered at 3:18 AM on 12/26/23 by RN II. In an interview on 2/9/24 at 12:15 PM, Resident #212…

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 # MI00141758. Based on interview and record review, the facility failed to implement policies and procedures for ensuring immediate reporting to the State Agency allegations of misappropriation of resident property (narcotics) and the investigation results to the State Agency within 5 working days, resulting in the potential for continued abuses to go unreported and for residents to not be protected from abusive individuals due to inaccurate investigations. Findings include: In an interview on 2/9/24 at 10:09 AM, Regional Registered Nurse (RRN) NN reported that she had been notified on 12/26/23 at approximately 8:00 AM by Registered Nurse (RN) I of a concern of narcotic diversion; RN II had documented the administration of Percocet (narcotic pain medication) to Resident #212 at 3:18 AM on 12/26/23, but the resident had reported that she did not request or receive the medication. RRN NN reported that the concern was discussed in morning meeting with NHA on 12/26/23, and then RRN NN began an investigation. RRN NN interviewed several staff members 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate post-fall assessment and monitoring for 1 (Resident #211) of 5 residents reviewed for falls, resulting in a delay of treatment for spinal fractures and the potential for unidentified neurological changes, when Resident #211 sustained an unwitnessed fall with reported head trauma, and staff did not implement spinal cord precautions (prevent movement of the spine) prior to transfer into bed, did not implement neurological checks and/or monitor vital signs. Findings include: Review of an admission Record revealed Resident #211 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: urinary tract infection, frequent falls, osteoporosis (condition in which bones become brittle and fragile), hypertension (high blood pressure), low back pain, hyponatremia (low sodium (electrolyte), and depression. Review of a Minimum Data Set (MDS) assessment for Resident #211, with a reference date of 1/23/24 revealed 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 #MI00137198. Based on observation, interview, and record review, the facility failed to provide scheduled showers/bathing for 2 (Resident #202 and Resident #203) of 3 residents reviewed for showers, resulting in the potential for skin irritation and breakdown and feelings of decreased dignity. Findings include: Resident #202 Review of an admission Record dated 8/25/22 revealed Resident #202 was admitted to the facility with pertinent diagnoses that included: hemiplegia following a cerebral infarction (loss of movement on one side of the body following a stroke), repeated falls, major depressive disorder (persistent depressed mood with loss of interests and motivation). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #202 scored 14/15 on a Brief Inventory for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Section GG indicated bathing was not attempted with Resident #202 during the 14-day assessment period. Review…

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 #MI00141496 Based on interview and record review the facility failed to provide adequate supervision during a mechanical lift transfer for 1 (Resident #201) of 3 residents reviewed for falls, resulting in the potential for injury. Findings include: Review of an admission Record dated 9/28/23 revealed Resident #201was admitted to the facility with pertinent diagnoses that included: acquired absence of right leg below the knee (11/29/23), acquired absence of left leg below the knee (11/15/22), peripheral vascular disease (condition in which blood flow is reduced to the extremities), chronic pain. Review of a Minimum Data Assessment (MDS) assessment dated [DATE] revealed Resident #201was dependent for transfers (helper provided all the effort). Review of a Care Plan for Resident #201, dated 9/29/23, revealed a focus/goal/approach of: Focus/Goal/Interventions: Focus: Resident has an ADL self-care performance deficit, Goal: Resident's Activities of Daily Living needs will be met.…

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 appropriate monitoring and treatment for a resident experiencing symptoms of a Urinary Tract Infection (UTI), (confusion, painful and frequent urination, and cloudy urine with a strong odor) for 1 resident (Resident #211) out of 4 residents reviewed for urinary care, resulting in a lack of monitoring, a delay in the treatment of UTI (urinary tract infection), hospitalization, and the potential for sepsis (a life threatening complication of infection.) Findings include: Review of an admission Record revealed Resident #211 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: urinary tract infection, frequent falls, osteoporosis (condition in which bones become brittle and fragile), hypertension (high blood pressure), low back pain, hyponatremia (low sodium (electrolyte), and depression. Review of a Minimum Data Set (MDS) assessment for Resident #211, with a reference date of 1/23/24 revealed under the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate medical records for 1 out of 14 residents (Resident #211) reviewed for medical records, resulting in inaccurate fall risk assessment and incomplete fall documentation, and the potential for facility staff and providers not having all of the pertinent information to care for residents. Findings include: Review of an admission Record revealed Resident #211 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: urinary tract infection, frequent falls, osteoporosis (condition in which bones become brittle and fragile), hypertension (high blood pressure), low back pain, hyponatremia (low sodium (electrolyte), and depression. Review of Resident #211's Fall Risk Evaluation dated 1/18/24 at 1:07 AM indicated a history of 1-2 falls in the last 90 days with the last fall on 1/16/24, was independent and continent with toileting, no osteoporosis, no depression, no medications taken currently or…

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 During an interview on 05/11/23 at 10:57 AM, CNA VV reported that there was usually only two CNA's assigned to each hall, and that management did not help. CNA VV reported that the managers were aware of the concerns that the CNA's had regarding their current workload. CNA VV reported that she cannot provide the care that she would like for residents due to workload. CNA VV reported that the majority of the residents on the hall required two person assist, in addition to high fall risks and behaviors that required frequent supervision. CNA VV reported that showers get missed because they required two staff, and that would leave the rest of the residents unsupervised. Review of Facility Assessment indicated that 31 residents in the facility required limited to extensive assistance with 1-2 staff members, and 39 residents that were completely dependent on staff for assistance. During an interview on 5/11/23 at 03:18 PM, CNA EE reported that most days each hall had two CNA's and the workload was not manageable. CNA…

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 # MI00130764, #MI00132304, MI00134949 & # MI00133919. Based on observation, interview, and record review, the facility failed to provide palatable food products in 8 of 9 residents (Resident #8, #19, #42, #52, #22, #62, #44, & #57) reviewed for food palatability, and 6 of 13 residents from the confidential group interview, resulting in dissatisfaction with meals, decreased food acceptance, and the potential for nutritional decline. Findings include: Review of the policy/procedure Menus and Adequate Nutrition, dated 1/1/22, revealed .The purpose of this policy is to assure menus are developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs, while using established guidelines .Menus shall reflect input from residents and resident groups .The resident council will be included periodically in menu planning, and efforts will be made to accommodate requests . In a confidential group interview on 5/11/23 at 2:30 p.m., 6 of 13 residents in attendance reported a lack of variety in the menu. Review of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00134506. Based on interview, and record review, the facility failed to ensure the facility was administered in a manner that maintains the safety and care of residents so residents may reach their highest practicable physical, mental, and psychosocial well-being for all 78 residents who reside at the facility, resulting in quality care not being provided to residents, insufficient management of facility staffing, a lack of follow-up in regard to concerns voiced by staff, and unresolved resident grievances. Findings include: In an interview on 5/8/23 at 12:43 p.m., Ombudsman FFFF reported ongoing issues at the facility involving staffing, missed showers/baths, and unresolved resident grievances. Ombudsman FFFF reported attempts have been made to resolve these issues, however Administrator A is .difficult to work with . Ombudsman FFFF reported they have been working with corporate staff for many of these issues because .we didn't feel like we were getting anywhere with…

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 # MI00130764. #MI00132056, #MI00134949 & # MI00132304. Based on observation, interview, and record review, the facility failed to maintain shared resident equipment, spa rooms, and general cleanliness of resident rooms in 3 of 7 residents (Resident #8, #19, & #62) reviewed for environment, resulting in the potential for contamination, poor ventilation, and decreased satisfaction in living environment. Findings include: Resident #8 Review of an admission Record revealed Resident #8 was a female, with pertinent diagnoses which included heart failure. Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 2/15/23, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated she was cognitively intact. In an observation and interview on 5/9/23 at 9:18 a.m., Resident #8 was in bed in her room. Resident #8 reported she had a shower yesterday and stated .They need better ventilation in the shower…

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 provision of effective communication training for 103 staff review for communication training. This deficient practice had the potential affect all 79 residents in the facility. Findings include: Review of Vendor Course Completion Report dated 5/18/2023, revealed, 103 employees out of 126 employees had not completed the education for Effective Communication. No Therapy staff or Housekeeping staff listed on the report for completion of the education. Review of Facility Assessment reviewed by the QAPI Committee on 5/1/2023, revealed, the effective communication training was not referenced in the facility training topics as required training for facility staff. In an interview on 05/15/23 at 09:57 AM, Staff Development (SD) V reported the education in the vendor education system was assigned monthly to be completed by the end of the month. SD V reported halfway through the month she runs a report to see where the staff were in completing the educations. SD V reported the facility does not allow staff to complete…

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 provision of training for compliance and ethics requirements for 81 employees out of 126 employees reviewed for resident rights training. This deficient practice had the potential to result in all resident rights and the facility's responsbilities for care with the potential to affect all 79 facility residents. Findings include: Review of Vendor Course Completion Report dated 5/18/2023, revealed, 81 employees out of 126 employees had not completed the education for Resident Rights. No Therapy staff or Housekeeping staff listed on the report. Review of Facility Assessment reviewed by the QAPI Committee on 5/1/2023, revealed, the resident rights training was not referenced in the facility training topics as required training for facility staff. In an interview on 05/15/23 at 09:57 AM, Staff Development (SD) V reported the education in the vendor education system was assigned monthly to be completed by the end of the month. SD V reported halfway through the month she runs a report to see where the staff were in…

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 annual required abuse prevention education for 27 employees. This has the potential to affect all 79 residents residing in the facility at the time of the survey. Findings include: Review of Vendor Course Completion Report dated 5/18/2023, revealed, 27 employees out of 126 employees had not completed Understanding Abuse and Neglect and/or Recognizing, Reporting, and Preventing Abuse. No Therapy staff or Housekeeping staff listed on the report. Review of Facility Assessment reviewed by the QAPI Committee on 5/1/2023, revealed, the abuse training was not referenced in the facility training topics as required training for facility staff. In an interview on 05/15/23 at 09:57 AM, Staff Development (SD) V reported the education in the vendor education system was assigned monthly to be completed by the end of the month. SD V reported halfway through the month she runs a report to see where the staff were in completing the educations. SD V reported the facility does not allow staff to complete the trainings at home via 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 interview and record review, the facility failed to complete Quality Assurance and Improvement (QAPI) training for 126 staff reviewed out of 126 staff, resulting in the potential for staff for lack of knowledge of the elements and goals of the facility's QAPI program, their role and potential input, and unmet resident care needs due to an ineffective QAPI program. Findings include: Review of Vendor Course Completion Report dated 5/18/2023, revealed, 126 employees out of 126 employees had not completed the education for QAPI. No Therapy staff or Housekeeping staff listed on the report. Review of Facility Assessment reviewed by the QAPI Committee on 5/1/2023, revealed, the quality assurance resident rights training was not referenced in the facility training topics as required training for facility staff. In an interview on 05/15/23 at 09:57 AM, Staff Development (SD) V reported the education in the vendor education system was assigned monthly to be completed by the end of the month. SD V reported halfway through the month she runs a report to see where the staff were in…

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 provision of training for compliance and ethics requirements for 30 employees reviewed for compliance training. This deficient practice had the potential to result in unethical and unprofessional staff conduct, with the potential to affect all 79 facility residents. Findings include: Review of Vendor Course Completion Report dated 5/18/2023, revealed, 30 employees out of 126 employees had not completed at least one of the following educations, PSTG Compliance Code of Conduct and/or Basics of Corporate Compliance. No Therapy staff or Housekeeping staff listed on the report, per the regulatory updated requirements. Review of Facility Assessment reviewed by the QAPI Committee on 5/1/2023, revealed, the compliance and ethics training was not referenced in the facility training topics as required training for facility staff. In an interview on 05/15/23 at 09:57 AM, Staff Development (SD) V reported the education in the vendor education system was assigned monthly to be completed by the end of the month. SD V 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.

Based on interview and record review, the facility failed to ensure the provision of training for behavioral health care and services for 36 staff reviewed for behavioral health care training. This deficient practice had the potential to result in unmet behavioral health care needs and services for residents, with the potential to affect all 79 facility residents. Findings include: Review of Vendor Course Completion Report dated 5/18/2023, revealed, 36 employees out of 126 employees had not completed at least one of the following educations, Teepa Snow Challenging Behaviors and/or Dementia Care: Challenging Behaviors and Direct Care Staff. No Therapy staff or Housekeeping staff listed on the report. Review of Facility Assessment reviewed by the QAPI Committee on 5/1/2023, revealed, the behavioral management training was not referenced in the facility training topics as required training for facility staff. In an interview on 05/15/23 at 09:57 AM, Staff Development (SD) V reported the education in the vendor education system was assigned monthly to be completed by the end of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake # MI00130764. Based on observation, interview, and record review, the facility failed to ensure timely care and services to promote dignity, treat residents with dignity/respect, and ensure a dignified environment in 8 of 12 residents (Resident #4, #19, #9, #33, #62, #24, #17, & #16) reviewed for dignity/respect, resulting in long call light wait times, a cluttered, noisy environment, and the potential for feelings of diminished self-worth, sadness, and frustration. Findings include: Review of the policy/procedure Resident Rights, dated 1/1/22, revealed .Employees shall treat all residents with kindness, respect, and dignity .Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity . Resident #4 Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 1/3/23, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total…

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 # MI00130764 #MI00134506, #MI00131068 #MI00131761, & #MI00134949. Based on interview and record review, the facility failed to provide and document evidence of prompt resolution of grievances in 3 residents (Resident #430, #39 & #62) and 8 residents from a confidential interview from a total of 11 residents reviewed for resolution of grievances, resulting in unresolved grievances and the potential to experience frustration, apprehension, helplessness, and a negative psychosocial outcome for the residents impacting their quality of life. Findings include: Resident #430 Review of an admission Record revealed Resident #430, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: difficulty in walking and type 2 diabetes. During an interview on 5/09/23 at 01:25 PM, Family Member (FM) AAAA reported that Resident #430 was admitted to the facility on [DATE] with a purse that was placed in a larger beach bag which was then placed in Resident #430's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake # MI00130764, # MI00132304, & # MI00135661. Based on observation, interview, and record review, the facility failed to ensure showers/bed baths were provided per resident preference and plan of care in 8 of 13 residents (Resident #8, #32, #80, #48, #65, #49, #68, & #39) reviewed for Activities of Daily Living (ADL) care, resulting in the potential for dissatisfaction with care, hygiene concerns, skin irritation, and low self-esteem. Findings include: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 50742-50744). Elsevier Health Sciences. Kindle Edition.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,…

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 maintain complete and accurate medical records for 4 out of 24 residents (Resident #71, #5, #1, and #331) reviewed for medical records, resulting in inaccurate and incomplete medical records and the potential for facility staff and providers not having all of the pertinent information to care for residents. Findings include: According to the Fundamentals of Nursing, 6th Edition (Mosby, [NAME] A. [NAME], [NAME] G. [NAME], 2005 Page 481) High quality documentation and reporting are necessary to enhance efficient, individualized client care. Quality documentation and reporting have five important characteristics: They are factual, accurate, complete, current, and organized. Resident #71 Review of an admission Record revealed Resident #71 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: cerebral infarction (stroke) and hemiplegia (paralysis) effecting right dominant side. Review of a Minimum Data Set (MDS)…

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 identify quality deficiencies and implement appropriate corrective action plans in a timely manner, resulting in the potential for negative physical and psychosocial outcomes and decreased quality of life. Findings include: Review of the policy/procedure QAPI (Quality Assistance and Performance Improvement) Plan, dated 10/24/22, revealed .It is the policy of this facility to systematically collect data as part of the QAPI program to ensure the care and services it delivers meet acceptable standards of quality in accordance with recognized standards of practice. In addition the purpose of this document is to serve as a plan to assist the facility in development, implementation, and maintenance of an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The goal is to create a process that ensures care and services delivered meet accepted standards of quality .Key components of this plan may include .Identifying and prioritizing quality deficiencies…

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 call lights were within resident reach in 2 of 2 residents (Resident #32 & Resident #39) reviewed for call light placement, resulting in the inability to call staff for assistance and the potential for unmet care needs. Findings include: Resident #32 Review of an admission Record revealed Resident #32 was a male, with pertinent diagnoses which included stroke, diabetes, high blood pressure, aphasia (difficulty with speech expression), chronic pain, depression, arthritis, and muscle weakness, and a history of falls. Review of a Minimum Data Set (MDS) assessment for Resident #32, with a reference date of 1/2/23, revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated moderate cognitive impairment. Review of a current Care Plan for Resident #32 revealed the focus .The resident is at risk for falls related to: Bil. (bilateral) LE (lower extremity) amputation and impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to honor resident choice in regard to activities and schedules that are significant to the resident in 2 of 5 residents (Resident #19 & Resident #33) reviewed for choices, resulting in dissatisfaction with care provided and the potential for frustration. Findings include: Review of the policy/procedure Resident Rights, dated 1/1/22, revealed .Employees shall treat all residents with kindness, respect, and dignity .Residents are entitled to exercise their rights and privileges to the fullest extent possible .Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity . Resident #19 Review of an admission Record revealed Resident #19 was a female, with pertinent diagnoses which included heart failure, obstructive lung disease, heart disease, kidney disease, diabetes, depression, arthritis, muscle weakness, and reduced mobility. Review…

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 MI00133629. Based on interview and record review, the facility failed to inform the resident's physician and family/guardian of a change in condition for 2 of 2 residents (Resident #331 and #44) reviewed for notifications, resulting in the physician and family/guardian not being notified of resident change in condition and the potential for delayed medical intervention and care. Findings include: Resident #331 Review of an admission Record revealed Resident #331 admitted to the facility on [DATE] with pertinent diagnoses which included Alzheimer's Disease, cognitive communication deficit, and bipolar disorder. Review of a Minimum Data Set (MDS) assessment for Resident #331, with a reference date of 3/3/2023 revealed a Staff Assessment for Mental Status score of 3, which indicated Resident #331 was severely cognitively impaired. Review of a current dementia and anxiety Care Plan intervention for Resident #331, initiated 8/27/2018, directing staff to observe Resident #331 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 cite pertains to intake MI00134949. Based on observation, interview, and record review the facility failed to maintain an environment with comfortable sound levels for 1 of 24 residents (Resident #22) reviewed for [NAME] levels, resulting in the loss of a comfortable home like environment affecting the resident's quality of life. Findings include: Review of an admission Record revealed Resident #22 was a female with pertinent diagnoses which included fractured left acetabulum (hip fracture), cancer, anemia, high blood pressure, GERD, kidney disease, arthritis, stroke, and difficulty walking. Review of a Minimum Data Set (MDS) assessment for Resident #22, with a reference date of 3/22/23 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated Resident #22 was cognitively intact. In an interview on 05/09/23 at 09:14 AM, Resident #22 reported the call light alert buzzer on the wall outside of her room was very annoying. Resident #22 reported it beeps all day and night, it was…

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

This citation pertain intake MI00131068 Based on interview and record review, the facility failed to provide an environment free from verbal abuse for 1 (Resident #18) of 3 residents reviewed for abuse, resulting in the resident exposed to profanity, angriness and irritableness creating a hostile environment, and presenting themselves in an unprofessional manner. Findings include: Review of an admission Record revealed Resident #18 was a male with pertinent diagnoses which included paraplegia, stroke, neuropathy (numbness, weakness, and pain in hands and feet form nerve damage), diabetes, contracture (tightening of the tendon) of right hand, muscle weakness, osteoarthritis, and blood clotting disorder. Review of a Minimum Data Set (MDS) assessment for Resident #18, with a reference date of 12/26/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident #18 was cognitively intact. In an interview on 05/16/23 at 04:18 PM, Resident #18 reported Licensed Practical Nurse (LPN) X was in his room performing care on him with another nurse.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately report allegations of abuse and neglect for 2 (Resident #18, and #382) of 3 residents reviewed for abuse and neglect, resulting in allegations of abuse that were not reported to the State Agency timely and the potential for further allegations of abuse and neglect to go unreported. Findings include: Resident #18: In an interview on [DATE] at 04:18 PM, Resident #18 reported LPN X was in his room performing care on him with another nurse. Resident #18 reported the staff member was using profanity, complaining about having to work as a CNA that shift. Resident #18 looked at the other nurse and gave her a hush like signal moving his finger to his mouth and shaking his head so she would not say anything. Resident #18 did not want LPN X to react in an explosive manner as she was already using profanity and expressing her dissatisfaction with her assignment for the day. Resident #18 stated, her behavior and using inappropriate language was not…

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

Based on interview and record review, the facility failed to investigate an allegation of abuse for 1 (Resident #18) of 3 residents reviewed for abuse, resulting in an allegation of abuse not being identified and thoroughly investigated allowing for the potential for future mistreatment and/or abuse. Findings include: Review of an admission Record revealed Resident #18 was a male with pertinent diagnoses which included paraplegia, stroke, neuropathy (numbness, weakness, and pain in hands and feet form nerve damage), diabetes, contracture (tightening of the tendon) of right hand, muscle weakness, osteoarthritis, and blood clotting disorder. Review of a Minimum Data Set (MDS) assessment for Resident #18, with a reference date of 12/26/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident #18 was cognitively intact. In an interview on 05/16/23 at 04:18 PM, Resident #18 reported LPN X was in his room performing care on him with another nurse. Resident #18 reported the staff member was using profanity, complaining about having to work as a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments were completed in 3 of 24 residents (Resident #33, #52 & Resident #71) reviewed for accuracy of assessments, resulting in the potential for inaccurate care plans and unmet care needs. Findings include: Review of the MDS 3.0 RAI Manual v1.16, Chapter 1: Resident Assessment Instrument (RAI), revealed .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations .It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment . Resident #33 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an annual Level II evaluation was completed for 1 (Resident #16) of 3 residents reviewed for Preadmission Screening and Resident Review (PASARR Screening), resulting in the potential for unmet mental health and psychiatric care needs. Findings include: Review of Resident #16 admission Record revealed Resident #16, was originally admitted to the facility on [DATE] with pertinent diagnoses which included adjustment disorder with anxiety, psychotic disorder with delusions, major depressive disorder, post-traumatic stress disorder, and alzheimer disease with late onset. Review of a Minimum Data Set (MDS) assessment for Resident #16, with a reference date of 2/25/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #16 was cognitively intact. Review of Resident #16's Preadmission Screening (PAS) Annual Resident Review (ARR) dated 4/16/2022 indicated the following: Questions 1-4 in section II were marked…

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 a person centered, comprehensive care plan for 2 of 24 (Resident #49 and Resident #16) residents reviewed for care planning, resulting in the potential for re-traumatization, unmet care needs and inappropriate Resident care and services. Findings include: Resident #49 Review of an admission Record for Resident #49, dated 3/14/23 revealed pertinent diagnoses which included: unspecified sequelae of cerebral infarction(residual effects of a stroke), left hemiplegia and hemiparesis (loss of movement and paralysis on left side of the body), diabetes mellitus(chronic metabolic disease characterized by elevated blood sugar levels), malignant neoplasm of the lung (cancer of the lung that may spread to other parts of the body), major depressive disorder, muscle weakness, lack of coordination, reduced mobility. Review of a Minimum Data Set (MDS) assessment for Resident #49 dated 2/24/23, section G Functional Status revealed Resident #49…

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 pressure ulcer care and treatment consistent with professional standards of practice for 1 (Resident #80) of 5 residents reviewed for pressure ulcer treatment, resulting in the potential for further skin breakdown and overall deterioration in health status. Findings include: Review of an admission Record revealed Resident #80 admitted to the facility on [DATE] with pertinent diagnoses which included multiple sclerosis and quadriplegia. Review of a Minimum Data Set (MDS) assessment for Resident #80, with a reference date of 1/2/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #80 was cognitively intact. Review of Resident #80's local hospital documentation from her 12/6/2022 to 12/27/2022 admission revealed .(stage) 2 coccygeal and back decubitus ulcers - present on admission . Review of Resident 80's Electronic Health Record on 5/18/2023 at 10:54 AM revealed 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 This citation pertains to intake #MI00131068. 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) and maintenance of a suprapubic catheter (a tube inserted into the bladder through the abdominal wall to drain urine) according to professional standards of practice for urinary catheters for 2 of 5 residents (Resident #52 and Resident #73), resulting in the potential for unnecessary use of a catheter and infections. Findings include: Resident #52 Review of an admission Record revealed Resident #52 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: cerebral infarction (stroke) and Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms. Review of a Minimum Data Set (MDS) assessment for Resident #52, with a reference date of 12/29/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, out…

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 MI00133629. Based on interview and record review, the facility failed to ensure care and services were provided to maintain sufficient hydration for a resident at risk for altered hydration status for 1 (Resident #331) of 2 residents reviewed for hydration, resulting in the potential for dehydration, unmet resident needs, and unnecessary negative physical, mental, and psychosocial outcomes. Findings include: Review of an admission Record revealed Resident #331 admitted to the facility on [DATE] with pertinent diagnoses which included Alzheimer's Disease, cognitive communication deficit, and bipolar disorder. Review of a Minimum Data Set (MDS) assessment for Resident #331, with a reference date of 3/3/2023 revealed a Staff Assessment for Mental Status score of 3, which indicated Resident #331 was severely cognitively impaired. Review of a current potential for skin alteration Care Plan intervention for Resident #331, initiated 6/8/2022, directed staff to encourage good nutrition…

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 identify post traumatic stress disorder (PTSD) triggers and develop individualized care plan interventions to mitigate triggers for 1 (Resident #65) of 24 residents reviewed for trauma informed care, resulting in the potential of re-traumatization due to staff not being informed and knowledgeable of the resident's past trauma. Findings include: Review of an admission Record revealed Resident #65 was a female with pertinent diagnoses which included traumatic brain injury, diffuse traumatic brain injury (used to describe prolonged posttraumatic state in which there was loss of consciousness from the time of injury that continues beyond 6 hours), repeated falls, lack of coordination, contusion (bruising) and laceration (tears in brain tissue) of cerebrum with loss of consciousness, alcohol dependence with intoxication delirium (altered level of consciousness, impaired attention, disorientation, and visual hallucinations), anxiety, and cognitive social or emotional deficit following a stroke. Review of a Minimum…

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 MI00134146. Based on interview and record review, the facility failed to prevent significant medication errors in 1(Resident #24) of 2 residents reviewed for antibiotic use, resulting in the potential for infection and negative physical, mental, and psychosocial outcome. Findings include: Review of an admission Record revealed Resident #24 admitted to the facility on [DATE] with pertinent diagnoses which included spinal stenosis and right artificial hip joint. Review of a Minimum Data Set (MDS) assessment for Resident #24, with a reference date of 4/12/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #24 was cognitively intact. In an interview on 5/8/2023 at 2:28 PM, Resident #24 reported that she returned to the facility on [DATE] following hip surgery and instructed the nurse that her IV antibiotics were to start immediately. Resident #24 reported that it took a week for the facility to begin…

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 securely store and label resident medications for 1 of 6 residents (Resident #39) and 1 of 4 medication carts, resulting in the potential for the compromise of medications, and or the misappropriation of medications. Findings include: Resident #39 Review of Resident #39's admission Record revealed Resident #39, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: dysphagia (difficulty swallowing), cognitive communication deficit, muscle weakness, repeated falls, and difficulty in walking. Review of a Minimum Data Set (MDS) assessment for Resident #39, with a reference date of 3/9/2023 revealed a Brief Interview for Mental Status (BIMS) score of 6/15 which indicated Resident #39 was severely cognitively impaired. In an observation on 5/17/23 at 10:21 AM Resident #39 was observed lying in bed on his back with the head of the bed elevated to 45 degrees. Resident #39's tube feed (a tube used to 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.

Based on observation, interview and record review the facility failed to monitor personal refrigerators for 2 of 2 residents (Resident #52 and #8) reviewed for food storage, resulting in unsafe food storage and the potential for food borne illness. Findings include: Resident #52 Review of a Minimum Data Set (MDS) assessment for Resident #52, with a reference date of 12/29/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #52 was cognitively intact. Review of Functional Status revealed, Resident #52 was totally dependent on staff for transfers and moving between locations in his room once in his wheelchair. During an observation and interview on 05/09/23 at 10:31 AM in Resident #52's room, a small refrigerator was observed next to Resident #52's bed. The contents of the refrigerator included soda, condiments, an opened container of Eggnog with an expiration date of February 2023 and a container of butter with an expiration date of February 2023. None of the containers were dated with an open date.…

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