Villa at Borgess Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure proper use of personal protective equipment (PPE) during cares while in enhanced barrier precautions for 1 (Resident #5) of 3 residents reviewed for PPE use during cares while in enhanced barrier precautions (EBP), resulting in the potential for the introduction of and/or the spread of infection.Findings include:Resident #5Review of an admission Record revealed Resident #3 was a female who admitted to the facility on [DATE] and had pertinent diagnosis which included: intraspinal abscess and granuloma (a localized collection of pus around the spinal canal, typically resulting from infections, and a mass of tissue that forms as a response from inflammation). On 12/10/25 at 12:59 PM, observed signage outside of Resident #5's room indicated enhanced barrier precautions were in place during cares for Resident #5. The sign indicated that staff were to wear a gown and gloves when providing high contact care for Resident #5.On 12/10/25 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain best practices in accordance with professional standards of food service safety. The deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.Findings include: On 8/11/25 at 7:40 AM, an interview with Manager in Training (MIT) HHH found that the kitchen date marks items made in house for 7 Days and would datemark sliced meats for 10 days. On 8/11/25 at 7:46 AM, observation of the walk-in cooler found a large chunk ham open with some pieces sliced from it. The ham was dated 8/6 to 9/15. On 8/11/25 at 8:02 AM, observation of the four door Traulsen cooler found the following items: a container of hardboiled eggs with no date, a container with sliced chunk ham dated 8/5 to 9/5, and a container of hot dogs dated 8/8 to 8/20. On 8/11/25 at 3:24 PM, observation of the Spiritual Garden kitchen found the following items: Sliced ham with no date, hot dogs in a plastic bag…

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

Based on observation, interview, and record review, the facility failed to provide care and services to promote dignity and respect for 8 of 8 residents who attended a confidential group meeting, resulting in feelings of frustration, decreased self-worth and embarrassment.Findings include: During an observation on 8/12/25 at 10:00am, an unknown Certified Nursing Assistant (CNA) on the heirloom unit, sat outside a resident's room and conducted a personal conversation using the speakerphone feature on her personal cellphone. The conversation could be heard from inside the occupied resident room.In a confidential group meeting on 8/12/25 at 1:00pm, 8 of 8 residents in attendance reported staff members used their personal cellphones, sometimes with earbuds, while providing care to them. One resident reported a staff member joined him in the bathroom, to assist with personal hygiene and completed the task while talking to someone via the use of earbuds. When queried, the resident reported he felt unimportant and embarrassed by the situation. A female resident reported she was left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 #2586142Based on observation, interview, and record review the facility failed to: 1. provide an environment that was free from accident hazards for 2 residents (Resident #73 and Resident #40) of 5 residents reviewed for accidents. This deficient practice resulted in an elopement for Resident #73 and Resident #40 repeatedly walking unassisted thereby creating the potential for more than minimal harm. 2. To ensure wander alert equipment was working properly and effectively to ensure the safety of residents at risk for elopement. This deficient practice has the potential to impact 10 residents who currently require the use of personal wander alert devices and are at risk for elopement. Findings include: Resident #73 Review of an admission Record revealed Resident #73 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: parkinson’s disease (a disorder of the central nervous system that affects movement that may also cause hallucinations (sensory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 # 2586142Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records in 5 of 18 residents (Resident #10, #99, #100, #73 & #47) reviewed for accuracy of medical records, resulting in inaccurate treatment records and the potential for providers to not have an accurate picture of resident status and condition.Findings include: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing.High-quality documentation is necessary to enhance efficient, individualized patient care. Quality documentation has five important characteristics: it is factual, accurate, complete, current, and organized . Accessed from: Kindle Locations 24106-24108). Elsevier Health Sciences. Kindle Edition. Resident #10: Review of an admission Record revealed Resident #10 was a female with pertinent diagnoses which included paralysis on her right dominant side, stroke, long term use of insulin, pain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the explanation of their binding arbitration agreement was explained in a clear and concise manner to residents to ensure understanding at admission for 3 (Resident #71, Resident #37, and Resident #27) and 8 more residents during a confidential group meeting, resulting in residents expressing confusion and concerns regarding entering into and agreeing to a binding arbitration agreement.Findings include:In an interview on 8/11/2025 at 9:15 am, Nursing Home Administrator (NHA) A reported the facility did not maintain a list of residents who signed a binding arbitration agreement. NHA A informed this surveyor arbitration agreements were in the resident's records and cold be viewed there. This surveyor requested a list of current residents who had signed a binding arbitration agreement.Review of a word document provided by NHA A including a list of residents who signed a binding arbitration agreement, included Resident #27, Resident #37, and Resident…

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

Based on observation and interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living. Findings include:During an observation on 08/11/2025 at 8:21 AM, This writer observed outside of room T64 was a sit to stand, the base of it had white powder, dust debris on the it and the footrest had it on it as well. This writer observed the pad where the knees go between the pad and the metal frame had dirt, debris, and white powder. During an observation on 08/11/2025 at 9:19 AM, This writer observed outside of room T67 there was a sit to stand there which had a plastic bag with wipes in it, The foot base and the metal bar where the pad and straps meet at there was dirt and debris there as well. During an observation on 08/12/2025 at 8:47 AM, This writer observed outside of room T64 was a sit to stand, the base of it had white powder, dust debris on the it and the footrest had it on it as well. This writer observed the pad where the knees go…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper documentation and accurate advanced directive information was in place for 2 residents (Resident #102, Resident #98) of 3 residents reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility with accurate documentation to support it. Findings include: Resident #102 (R102) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R102 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 12 out of 15 which indicated R102 had moderate cognitive impairment (8 to 12 cognitively impaired). Review of R102's Facesheet revealed Code Status: Advance Directives: DNR (Do not resuscitate). Review of R102's Orders revealed Advance Directive: DNR. Review of R102's chart revealed no documentation or signed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 2569824Based on interviews and record review, the facility failed to protect the resident's right to be free from sexual abuse by staff for 1 (Resident #81) of 3 residents reviewed for abuse, resulting Resident #81 experiencing mental anguish, intimidation, and fear. Findings include: Resident #81: Review of an admission Record revealed Resident #81 was a female with pertinent diagnoses which included depression, and malaise (general feeling of discomfort). Review of a Brief Interview for Mental Status (BIMS) conducted on 5/1/2025, revealed, .BIMS score of 13 out of 15 which indicated Resident #81 was cognitively intact. Review of Care Plan for Resident #81 revised on 2/13/25, revealed the focus, .(Resident #81) has actual impairment to skin integrity to bilateral breasts and abd (abdominal) fold r/t (related to) yeast . with the intervention .antifungal treatment in place .Apply barrier cream per facility protocol to help protect skin from excess moisture .Monitor skin when providing cares, notify nurse of any changes in skin appearance . 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 that PRN (as needed) psychotropic medications were limited to 14 days in 1 (Resident #12) of 5 residents reviewed for unnecessary medications.Findings include:Resident #12Review of an admission Record revealed Resident # 12 as a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: depression and anxiety disorder.Review of Physician Order for Resident #12 revealed Lorazepam oral tablet 0.5mg Controlled drug level 4, 1 tablet by mouth PRN every 4 hours start 8/12/2025 with an end date as indefinite.In an interview on 8/13/2025 at 1:14pm, Licensed Practical Nurse (LPN) D reported that PRN medications did not have to have a specific stop date unless the provider indicated a stop date.In an interview on 8/13/2025 at 1:16 pm Nurse Manager/Licensed Practical Nurse (NM/LPN) M reported that all PRN medications should be ordered for only 14 days unless a rationale was provided by the provider.In an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #2586142Based on interview, and record review, the facility failed to report 2 elopements and an allegation of abuse to the State Agency in a timely manner for 2 (Resident #73, Resident #66) of 3 residents reviewed for abuse and reporting, resulting in the potential for ongoing mistreatment, as well as additional incidents of elopements and alleged abuse to go unreported.Findings include: Resident #73 Review of an admission Record revealed Resident #73 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: parkinson’s disease (a disorder of the central nervous system that affects movement that may also cause hallucinations (sensory experiences that seem real but are created by the mind), metabolic encephalopathy (disorder that affects the brain’s function), weakness and anxiety (persistent state of worry). Review of a Minimum Data Set (MDS) assessment for Resident #73 with a reference date of 6/22/25, revealed a Brief Interview for Mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a proper bedhold notification was completed for 1 resident (Resident #66) of 1 resident reviewed for hospitalization, resulting in Resident #66's not receiving a written notice of bedhold. Findings include:Resident #66Review of an admission Record revealed Resident #66 was a female, with pertinent diagnoses which included: Alzheimer's Disease (a form of dementia) with late onset, psychotic disorder with delusions due to known physiological condition, and visual hallucinations.Review of Resident #66's Census Screen in the electronic medical record revealed effective date 8/6/25, STOP BILLING.In an interview on 8/12/25 at 8:49 AM, Social Services Director (SSD) FF reported resident #66 was sent to a psych (psychiatric) hospital due to ongoing physical behaviors and hallucinations. In an interview on 8/12/25 at 2:41 PM, Nursing Home Administrator (NHA) A reported the facility did not have a behold for Resident #66 for her hospitalization and could not provide evidence that one had been provided to Resident #66.In an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a baseline care plan related to sexual behaviors for 1 resident (Resident #99) of 18 reviewed for care plans resulting in some staff being unaware of Resident #99's behaviors and sexual history.Findings include:Resident #99 (R99)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R99 admitted to the facility on [DATE] with pertinent diagnoses including spinal fracture and alcohol abuse. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R99 was cognitively intact (13 to 15 cognitively intact). R99 had a previous admission at the facility from 4/10/2025 to 4/23/2025.During an observation on 8/11/2025 at 8:18 AM, Certified Nursing Assistant (CNA) KK was sitting outside R99's bedroom door. CNA KK stated that R99 was on a 1:1 observation at all times for several days but she didn't know why. During an interview on 8/11/2025 at 8:38 AM, R99 stated that he was on 1:1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and record review, the facility failed to provide timely ADL (activities of daily living) care for 1 resident (Resident #109) of 2 residents reviewed for ADL Care, resulting in Resident #109 not receiving timely incontinence care on 8/10/25 when a Certified Nursing Assistant (CNA) mistakenly thought the resident was independent with personal care. This deficient practice resulted in the potential for skin breakdown, feelings of embarrassment, and unmet care needs. Findings include: Review of an admission Record revealed Resident #109 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: aphasia following a stroke (language disorder that affects a person's ability to verbally communicate), weakness and hemiplegia (paralysis on one side of the body) following a stroke.Review of a Minimum Data Set (MDS) assessment for Resident #109 with a reference date of 8/11/25, revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated Resident #109…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that follow up with pharmacy recommendations occurred for 1 resident (Resident #57) and monitoring of side effects of psychotropic medications (any medication that affects the mind and alters mental processes such as antidepressants, antipsychotics, anxiolytics, sedatives and stimulants) occurred for 2 residents (Resident #57, Resident # 64) of 5 residents reviewed for medications resulting in the potential for unnecessary medications and no monitoring and follow-up of potential side effects of medications.Findings include:Resident #57 (R57)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R57 admitted to the facility on [DATE] with pertinent diagnoses including schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly and is characterized by thoughts or experiences that seem out of touch of reality, disorganized speech or behavior and decreased participation in daily activities),…

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

Based on observation, interview, and record review the facility failed to 1). properly store medications in a secure manner in 2 of 6 medications carts: 2). ensure the interior of medication carts were clean: 3). ensure that medication refrigerators were secured with a lock: and 4). ensure consistent monitoring and documentation of refrigerator temperatures occurred.Findings include:On 8/12/2025 at 8:35 am, Registered Nurse (RN) PPP was observed placing into locked narcotic box on the medication cart for part of the flower unit, a medication cup with one white pill, which she placed tape over the top of the cup, wrote a resident's name on it before placing in the narcotic box and locking the box back up.In an interview on 8/12/2025 at 8:35 am, RN PPP reported the resident refused the pills she placed into the narcotic box. RN PPP reported she would need to waste the pill with another nurse as it was a hydrocodone (Norco) tablet.On 8/12/2025 at 8:57 am, Licensed Practical Nurse (LPN) P was observed placing into the top drawer of the enchanted medication cart a medication cup with two…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician ordered enhanced barrier precautions for 2 of 3 residents (R2 and R41) reviewed for infection control, resulting in the potential for the spread of infection to a vulnerable population. Findings include: Resident #2 (R2) Review of an admission Record revealed R2 was a [AGE] year-old female, originally admitted to the facility on [DATE] with pertinent diagnoses of a stroke causing left sided weakness and paralysis and a pressure wound on her coccyx. Review of a Brief Interview for Mental Status (BIMS), dated 08-13-25, revealed a score of 15 out of 15 which indicated R2's cognition was intact. During an observation on 09-17-25 at 10:15 AM, the door of R2's room had a sign posted that alerted staff and visitors that R2 required Enhanced Barrier Precautions (EBP) for certain close contact interactions. Review of a physician Order Summary for R2, reflected an order for Enhanced Barrier Precautions (EBP) with a start date 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.

Based on interview and record review, the facility failed to ensure residents received the correct foods as outlined on the planned, posted menu, resulting in dissatisfaction with meal service and feelings of frustration. This deficient practice has the potential to affect all residents who consume food from the kitchen, out of a total census of 77.Findings include:In an interview on 6/3/25 at 12:33 PM, Resident #104 reported that she had ongoing concerns with the food at the facility. Resident #104 reported that the facility often substituted what was on the menu without notice. Resident #104 reported that she was frustrated with how often the facility was messing up the food menu, and feeling she never knew what was going to be served. In an interview on 6/4/24 at 9:29 AM, Certified Nursing Assistant (CNA) I reported that residents frequently reported concerns about the food at the facility, and that it seemed like the facility was not able to serve what was on the menu often. CNA I reported that it seemed like the facility was not ordering enough food, and they would run out 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 This citation pertains to intake MI00152495 and MI00153405. Based on observation, interview, and record review, the facility failed to ensure resident food preferences and portion sizes at meals were consistently honored, for 7 (Residents #104, #110, #111, #112, #113, #114, and #116 ) of 18 residents reviewed for food concerns, resulting in resident/representative complaints of food choices not being honored and the potential for decreased meal enjoyment, feelings of frustration, and the potential for weight loss and nutritional decline. Resident #104 Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 5/1/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #104 was cognitively intact. Review of Resident #104's Meal Ticket revealed, Diet order: Regular texture. Regular diet. Allergies: Cinnamon. Dislikes: Citrus, spicy foods, BBQ, biscuits and gravy, cabbage, coleslaw, onions, pepper, sausage, potatoes . In an interview on 6/4/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00153405. Based on observation, interview, and record review, the facility failed to ensure residents were cared for with dignity and respect for 3 (Resident #107, #110, and #117) of 8 residents reviewed for dignity, resulting in the potential for feelings of embarrassment, frustration, depression, loss of self-worth and an overall deterioration of psychological well-being. Findings include: Resident #107 Review of an admission Record revealed Resident #107 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dysphagia (difficulty swallowing). Review of a Minimum Data Set (MDS) assessment for Resident #107, with a reference date of 5/14/25 revealed a Brief Interview for Mental Status (BIMS) score of 1/15 which indicated Resident #107 was severely cognitively impaired. Review of Resident #107's Care Plan revealed, (Resident #107) has an actual ADL (activities of daily living ) self-care performance deficit . Interventions: .Dining: Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff fully implemented the abuse policy and identiry and report allegations of neglect to the abuse coordinator in a timely manner for 1 (Resident #118) of 1 residents reviewed for abuse and neglect, resulting in the potential for continued violations involving neglect go unreported. Findings include: Review of an admission Record revealed Resident #118 was originally admitted to the facility on [DATE] with pertinent diagnoses which included depression and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #118, with a reference date of 4/11/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #118 was cognitively intact. Review of Resident #118's Care Plan revealed, (Resident #118) has actual need for ADL (activities of daily living) self-care performance . Interventions: toileting: Check and change. Date initiated: 9/11/24 . In an interview on 6/9/25 at 2:35 PM, Licensed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received care in accordance with professional standards in 3 (Resident #104, #105 and #107) of 18 residents reviewed for quality of care, resulting in 1.) Resident #104 missing medication for multiple days in a row 2.) Nursing staff omitting neurological (neuro) assessments and inaccurately documenting assessments as completed after a fall for Resident #105 and 3.) Resident #107 missing a re-weight check ordered by a physician. Findings include: Resident #104 Review of an admission Record revealed Resident #104 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 5/1/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #104 was cognitively intact. Review of Resident #104's Orders revealed, Systane Ophthalmic Solution 0.4-0.3 %…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide assistance with toileting and eating for 2 (Resident #107 and Resident #118) of 9 residents reviewed for activities of daily living (ADL) care resulting in the potential for avoidable negative physical outcomes for resident's who are dependent on staff for assistance. Findings include: Resident #107 Review of an admission Record revealed Resident #107 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dysphagia (difficulty swallowing). Review of a Minimum Data Set (MDS) assessment for Resident #107, with a reference date of 5/14/25 revealed a Brief Interview for Mental Status (BIMS) score of 1/15 which indicated Resident # 107 was severely cognitively impaired. Review of Resident #107's Care Plan revealed, (Resident #107) has an actual ADL (activities of daily living ) self-care performance deficit . Interventions: .Dining: Resident requires feeding assistance x1. NO straws, single sips 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 Based on observation, interview, and record review, the facility failed to ensure an effective infection control program that included 1) implementation of Enhanced Barrier Precautions (EBP) per standards of practices for 2 of 3 residents (R101, and R103), and 2) ensure hand sanitizer was available outside a EBP room for 1 of 3 residents (R102) reviewed for infection control, resulting in the potential for cross-contamination, harborage of bacteria, and increased infections in a vulnerable population. Findings include: R101 Review of R101's medical chart, Diagnoses included orthopedic aftercare following surgical amputation. Review of R101's Order Summary dated 2/24/25 did not indicate EBP had been ordered for the resident's open wound. Review of R101's MAR/TAR (Medication/Treatment Administration Record dated 2/1/25-2/28/25 did not indicate EBP were being monitored. Review of R101's Care Plan did not indicate the resident had a wound vac or was placed on EBP. During an observation on 2/25/25 at 9:47 AM of…

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

This citation pertains to intake #MI00147450. Based on interview and record review the facility failed to ensure that residents were free from significant medication errors in 1 of 3 residents (R101) reviewed for medication errors resulting in R101 receiving insulin that was not ordered causing dizziness and general malaise. Findings include: Review of R101's Incident Report dated 10/5/2024 at 12:03 PM reported a medication error had been reported with insulin being given incorrectly. R101 stated to Unit Manager (UM) E that he felt dizzy and knew his sugar (blood sugar) had been checked and was poked in his arm by a shot. No statements by staff or notifications had been found or listed. Review of R101's MDS (Material Data Set) dated 11/22/24 revealed a BIMS (Brief Interview Status) of 10/15 indicating moderate cognitive function. Review of R101's Diagnoses did not have diabetes mellitus documented. Review of R101's Order Summary print date 2/11/25, did not have any insulin ordered for administration. During an interview on 2/10/25 at 9:47 AM, Family Member (FM) C stated, My brother…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 #MI00147450. Based on observation, interview, and record review, the facility failed to follow standards of practice for medication labeling, with the potential to cause side effects and infection control issues. Findings include: Review of R103's Medication Administration Record (MAR) dated 2/1/25 to 2/28/25 revealed, Lantus 100 unit/ml 8 units. During an observation, interview, and record review on 2/11/25 at 7:12 AM, Licensed Practical Nurse (LPN) Charge Nurse J compiled morning medications for R103 from the Enchanted Gardens med cart. On the resident's eMAR (electronic medication administration record) was a current and clear picture of him. Medications that the LPN gathered included Lantus 100 units/ml (millimeter) injectable pen. Approximately 80-90 units were left in the pen which originally held 100 units. The pen was labeled with the resident's name but was not labeled with the date it was opened nor the date the medication was to expire once opened. LPN J reported the insulin should have an open date for the integrity of the medication and…

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

This citation pertains to intake # MI00147450. Based on interview, and record review, the facility failed to maintain an effective training program for agency staff consistent with their role in the facility to ensure the safety of resident in 1 of 3 residents (R101) reviewed for medication administration, resulting in R101 receiving an unordered medication and sustaining dizziness and overall malaise. Findings include: Review of R101's Incident Report dated 10/5/2024 at 12:03 PM reported a medication error had been reported with insulin being given incorrectly. R101 stated to Unit Manager (UM) E that he felt dizzy and knew his sugar (blood sugar) had been checked and was poked in his arm by a shot. No statements by staff or notifications had been found or listed. Review of R101's MDS (Material Data Set) dated 11/22/24 revealed a BIMS (Brief Interview Status) of 10/15 indicating moderate cognitive function. Review of R101's Diagnoses did not have diabetes mellitus documented. Review of R101's Order Summary print date 2/11/25, did not have any insulin ordered for administration.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 consistently monitor and assess one resident (R100) of two residents reviewed for pressure ulcer care, resulting in the potential of slow healing wounds, and/or new pressure ulcers developing and the mismanagement of treatment and not receiving adequate care required to maintain or achieve their highest practicable physical well-being. Findings include: R100 According to the Minimum Data Set (MDS) dated [DATE], R100 scored 13/15 (cognitively intact) on her BIMS (Brief Interview Mental Status), indicated dependence on staff for all cares, and diagnoses that included a sacral pressure ulcer. Section E reported the resident did not reject care that was necessary to achieve goals for health and well-being. During an interview on 9/13/2024 at 11:28 AM, Family Member (FM) F stated, Someone from the family is with my mother (R100) to visit with her and feed her lunch and dinner Monday through Friday. And at least once a day for lunch or dinner…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a gait belt was used during transfers for two of two residents (R100 and R102) reviewed for safe transfers, resulting in the potential for a fall or fall with injury. Findings include: R100 According to the Minimum Data Set (MDS) dated [DATE], R100 scored 13/15 (cognitively intact) on her BIMS (Brief Interview Mental Status), indicated dependence on staff for all cares, and diagnoses that included Parkinson's disease. Review of R100's Care Plan, dated 9/17/24, indicated a Focus needs assistance with ADLs due to Parkinson's, debility, and fatigue. The goal was for the resident was to maintain current level of function with interventions that included Transfers .requires 2 person moderate to maximum physical assistance. It was noted the survey start date was 9/17/24. During an observation on 9/17/24 at 9:35 AM R100 was transferred to a recliner next to her bed. Certified Nursing Assistant (CNA) E did not use a gait belt on R100…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate infection control practices were put in place to ensure proper PPE (Personal Protection Equipment) provided for two of two residents (R100 and R102) reviewed for infection control, resulting in an increased potential of cross-contamination of disease in a vulnerable population. Findings include: R100 According to the Minimum Data Set (MDS) dated [DATE], R100 scored 13/15 (cognitively intact) on her BIMS (Brief Interview Mental Status), indicated dependence on staff for all cares, and diagnoses that included Parkinson's disease and sacral pressure ulcer. Section E reported the resident did not reject care that was necessary to achieve goals for health and well-being. Review of R100's Order Summary, dated 8/1/2024, Coccyx wound . Review of R100's Order Summary, dated 8/27/2024, Enhanced Barrier Precautions due to wound Review of R100's Care Plan, dated 9/9/24, did not include a resident-specific plan for Enhanced Barrier…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents. Findings include: During the initial tour of the kitchen, at 9:35 AM on 8/27/24, observation of the walk-in cooler found some storage racks had heavy accumulation of gunk debris between portions of the shelf and the flat storage surface. Once the surfaces were pointed out to Director of Dining Services (DDS) N, he stated they needed to be cleaned. During the initial tour of the kitchen, at 9:41 AM on 8/27/24, an interview with DDS N found that clean utensil are stored in bins next to the hand sink. Observation of two clean utensil bins containing mechanical scoops and spoons found an increased amount of crumb debris present in the bottom of the bins. DDS N stated they should be getting cleaned weekly. During the initial tour 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 interview and record review, the facility failed to provide written notification to the State Long-Term Care (LTC) Ombudsman of facility-initiated transfers/discharges since November 2019, resulting in the potential for all residents to be discharged without an advocate who can inform them of their options and rights. Findings include: On 8/23/2024 at 1:41 PM, an email was received from the State LTC Ombudsman (Ombudsman) I which stated, .They (Borgess Gardens) are not sending the required notices for transfer and discharges (to her). During an interview on 8/28/2024 at 11:53 AM, Director of Social Work (DSW) X and Social Worker (SW) II stated that they haven't been sending the required notices for transfers and discharges to the State LTC Ombudsman. SW II said that they used to send it to the Ombudsman monthly but they haven't sent the notices in a long time. During another interview on 8/28/24 at 12:03 PM, SW II stated that she found an email of the last notice of transfers and discharges that she sent to the State Ombudsman which was dated November 2019. During an…

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

Based on interview and record review, the facility failed to ensure timely care and services to promote dignity in 1 (Resident #37) of 3 residents reviewed for dignity/respect, resulting in long call light wait times, delay in incontinence care, and the potential for feelings of diminished self-worth and frustration. Findings include: Resident #37 Review of a Resident Summary revealed Resident #37 was a male, with pertinent diagnoses which included: hemiplegia following cerebral infarction affecting left (left sided paralysis after a stroke), pain in left shoulder, and pain in right shoulder. Review of a Minimum Data Set (MDS) assessment for Resident #37, with a reference date of 7/20/24 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #37 was cognitively intact. Further review of said MDS revealed Resident #37 had a functional limitation in range of motion on one side for both upper extremity and lower extremity, that Resident #37 was frequently incontinent of bowel and bladder, and that Resident #37 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure call lights were in reach for 1 of 24 residents (Resident #10) reviewed for accommodation of needs, resulting in the inability to call for staff assistance and the potential for unmet care needs. Findings include: Resident #10 Review of an admission Record revealed Resident #10 was originally admitted to the facility on [DATE] with pertinent diagnoses which included osteoarthritis. Review of a Minimum Data Set (MDS) assessment for Resident #10, with a reference date of 7/4/24 revealed a Brief Interview for Mental Status (BIMS) score of 6/15 which indicated Resident #10 was severely cognitively impaired. Review of Resident #10's Care Plan revealed, .Communication: (Resident #10) is at risk for impaired communication related to change in environment .Interventions: .call light within reach. Date initiated: 11/30/23 . During an observation and interview on 8/27/24 at 12:18 PM, Resident #10 was lying in bed watching television.…

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

Based on observation, interview, and record review, the facility failed to ensure a clean and sanitary environment in 2 of 2 residents (Resident #53 & #54) reviewed for a clean, comfortable, homelike environment, resulting in soiled fans and the potential for respiratory complications. Findings include: Review of the policy/procedure High Profile Patient Room Cleaning, dated 2/1/22, revealed .High dust, beginning at the entranceway and working around the room in a circle. High dust horizontal surfaces above shoulder height starting opposite the restroom. Never dust above a patient/resident. High dust surfaces in the restroom .disinfect vertical surfaces including stains and spots from walls, light switches, door knobs and other relevant vertical surfaces . Resident #53 Review of a Profile Face Sheet revealed Resident #53 was a female, with pertinent diagnoses which included respiratory failure, heart failure, kidney disease, obstructive lung disease, vascular disease, high blood pressure, depression, and diabetes. In an observation on 8/27/24 at 11:41 AM, Resident #53 was in bed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff fully implemented the abuse policy and report allegations of neglect to the abuse coordinator in a timely manner for 1 (Resident #6) of 1 residents reviewed for abuse and neglect, resulting in the potential for continued violations involving neglect go unreported. Findings include: Review of an admission Record revealed Resident #6 was originally admitted to the facility on [DATE] with pertinent diagnoses which included parkisons disease. Review of Resident #6's Concern/Grievance form dated 8/27/24 revealed, Information about your concerns: On 8/27/24 (Resident #6) said that she was wet. The night aide came to change her at 6:10 PM. (Resident #6) was soaked and soiled. Her pants and her chair were soaked. The aide was so upset that she (Resident #6) had appeared to not had been changed at all during the day. She called (Licensed Practical Nurse Unit Manager (LPN-UM)) BB. This is not an isolated occurrence as her laundry is always soaked 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report allegations of neglect to the State Agency in a timely manner for 1 (Resident #6) of 1 residents reviewed for abuse and neglect, resulting in the potential for continued violations involving neglect going undetected, unreported, or without thorough investigation. Findings include: Resident #6 Review of an admission Record revealed Resident #6 was originally admitted to the facility on [DATE] with pertinent diagnoses which included parkisons disease. Review of Resident #6's Concern/Grievance form dated 8/27/24 revealed, Information about your concerns: On 8/27/24 (Resident #6) said that she was wet. The night aide came to change her at 6:10 PM. (Resident #6) was soaked and soiled. Her pants and her chair were soaked. The aide was so upset that she (Resident #6) had appeared to not had been changed at all during the day. She called (Licensed Practical Nurse Unit Manager (LPN-UM)) BB. This is not an isolated occurrence as her laundry is always…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement care plan interventions and orders for 2 (Resident # 50 and #43) of 18 Residents reviewed for care planning, resulting in a potential for unmet care needs. Findings include: Resident #50 Review of an admission Record revealed Resident #50 was originally admitted to the facility on [DATE] with pertinent diagnoses which included heart failure. Review of Resident #50's Care Plan revealed, . Nutritional Status: . Meal Assistance as needed. Date initiated: 6/27/23 . Review of Resident #50's Orders revealed, .Feeding Assistance with meals. Start date: 8/9/24 . During an observation on 8/28/24 at 12:35 PM, Resident #50 was sitting in the dining area with her lunch tray in front of her. Resident #50 was attempting to eat with a spoon. Resident #50 spilled all of the food contents from the spoon onto her lap several times. Resident #50 had several pieces of food on her shirt and pants. It was noted that there were no staff in the area to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess a change of skin condition in 1 of 5 residents (R43) reviewed for quality of care, resulting in a delay in assessment, treatment, pain, and the potential for worsening of condition and infection. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R43 was severely cognitively impaired with indication he was unable to complete his BIMS (Brief Interview Mental Status), required assistance with turning/positioning, and had diagnoses that included Alzheimer's disease, age-related physical debility, muscle weakness, cognitive communication deficit, and repeated falls. Review of R43's MDS dated [DATE], Section M-Skin Conditions revealed the resident was at risk for pressure ulcers with an unhealed stage 3 and skin tears. Treatments/interventions for both pressure ulcer and skin tears included pressure ulcer care, and application of nonsurgical dressings. Review of R43's Physician Orders, dated 1/28/2022, revealed,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow physician orders for use of oxygen for 1 (Resident #10) of 2 residents reviewed for respiratory care, resulting in inaccurate settings, irregular cleaning, and the potential for respiratory infection. Findings include: Resident #10 Review of an admission Record revealed Resident #10 was originally admitted to the facility on [DATE] with pertinent diagnoses which included pulmonary hypertension (high blood pressure that affects arteries in the lungs and in the heart). Review of Resident #10's Orders revealed, Change oxygen tubing weekly and label with date. Start date: 6/24/24 . Oxygen at 2 liters/minute per NC (nasal cannula) to keep sats (oxygen saturation) above 92% . During an observation on 8/27/24 at 12:18 PM, Resident #10 was lying in bed wearing her oxygen via nasal cannula. It was noted that Resident #10's oxygen was running at 3.5 liters/minute and the tubing on the oxygen tank was dated 8/19/24. During an observation on…

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

Based on interview and record review, the facility failed to 1. provide documentation of an adequate indication for medication use, 2. educate the resident/guardian on the intended or actual benefit versus potential risk(s) or adverse consequences associated with the selected medication, and 3. identify, care plan, and implement non-pharmacological interventions for 1 (Resident #57) of 5 residents reviewed for unnecessary medications, resulting in the potential for unmet psychosocial needs and the resident to have received an unnecessary medication. Findings include: Resident #57 Review of a Resident Summary revealed Resident #57 was a female, with pertinent diagnoses which included: anxiety disorder, unspecified. Review of a Physician's Order for Resident #57 revealed, Order Date 02/15/24, Start Date 3/01/24 Zoloft 25 mg (milligram) tablet (Sertraline) - 1 tablet By Mouth Every Day for anxiety Review of Resident #57's current Care Plan revealed a focus of (Resident #57) has a mood state problem related to Anxiety and the entirety of care planned interventions for this focus which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident foods brought in from outside sources in one resident personal refirgerator (Resident #53) and one of four shared resident refrigerators. 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 in the facility. Findings Include: An interview with Director of Dining Services (DDS) N at 10:18 AM on 8/27/24, regarding the four bistro areas of the facility, found that kitchen staff stock the bistro kitchen refrigeration units once a day and that housekeeping staff should clean the bistro once a day. When asked who takes care of resident food from outside sources, DDS N stated that nursing staff takes care of the labeling and dating of that product and it goes in the separate resident fridge which each bistro has. During a tour of the Heirloom Garden Bistro, at 11:18 AM on 8/27/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed to ensure proper hand hygiene was performed during brief change and wound dressing change, resulting in the potential for bacterial harborage, cross contamination, and the spread of disease to a vulnerable population. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R43 was severely cognitively impaired with indication he was unable to complete his BIMS (Brief Interview Mental Status), required assistance with turning / positioning, brief changes, and had diagnoses that included Alzheimer's disease, age-related physical debility, muscle weakness, and cognitive communication deficit. Review of R43's MDS dated [DATE], Section M-Skin Conditions revealed the resident had an unhealed stage 3 pressure ulcer and skin tears. Treatments/interventions for both pressure ulcer and skin tears included wound care, and application of nonsurgical dressings. Review of R43's Physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were screened for eligibility to receive pneumococcal vaccinations and receive vaccination if eligible for 1 (Resident #2 ) of 5 residents reviewed for vaccinations, resulting in the potential of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia. Findings include: Resident #2 Review of an admission Record revealed Resident #2 was originally admitted to the facility on [DATE] with pertinent diagnoses which included hypertensive heart disease with heart failure. Review of Resident 2's Immunization Record revealed that Resident # 2 had not received the Pneumococcal vaccine. Review of Resident #2's Vaccine History and Consent form dated 10/2/22 revealed that Resident #2 wished to receive the CDC recommended Pneumococcal vaccine . During an interview on 8/28/24 at 1:00 PM, Infection Preventionist (IP) EE reported that Resident #2 was currently due and eligible for an updated Pneumococcal vaccine. IP EE…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure COVID-19 immunizations were offered to 3 of 5 residents (Resident #2, #50 and #53) reviewed for COVID-19 immunizations, resulting in an increased risk for infection, and the potential spread of COVID-19 infection to other residents, staff, and visitors. Findings include: Resident #2 Review of an admission Record revealed Resident #2 was originally admitted to the facility on [DATE] with pertinent diagnoses which included hypertensive heart disease with heart failure. Review of Resident #2 Immunization Record revealed that Resident #2 had not received a Covid-19 vaccine. Review of Resident #2's Vaccine History and Consent form dated 10/2/22 revealed that Resident # 2 had wished to receive the Covid-19 vaccination During an interview on 8/28/24 at 1:00 PM, Infection Preventionist (IP) EE reported that Resident #2 was currently due and eligible for an updated Covid-19 vaccine. IP EE reported that the facility had missed assessing and administering…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate a fall and review and revise the care plan for 1 (Resident #103) of 4 residents reviewed for accidents/hazards, resulting in the potential for additional falls and injury. Findings include: Review of an admission Record revealed Resident #103 was a male, originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnoses which included: history of falling, muscle weakness, long term use of anticoagulants, and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). Review of Resident #103's Interdisciplinary Note dated 12/24/23 at 11:39 AM revealed, Patient up to wheelchair this morning for breakfast. Observed on the floor with face down on the floor and hands on the side. Resident states, I don't know whats wrong. Alert and oriented x3. Denies pain at time of fall. Skin tears noted to face, arms and right lower extremity. Resident able to move extremities.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00138567 and MI00139004. Based on interview and record review, the facility failed to: 1.) ensure residents received consistent and comprehensive skin/wound assessments, 2.) ensure physician orders for skin treatments were implemented, and 3.) perform STAT (immediate) blood work as ordered for 1 of 3 residents (Resident #101), reviewed for quality of care, resulting in the lack of assessment, monitoring, and documentation and the potential for the worsening of a medical condition and the delay in treatment. Findings include: Review of a Face Sheet revealed Resident #101 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and unsteadiness on feet. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 7/11/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15, which indicated Resident #101 was cognitively intact. Review of the Functional…

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

Based on observation, interview, and record review the facility failed to: 1. Clean food and non-food contact surfaces to sight and touch; 2. Datemark and discard potentially hazardous foods; 3. Have an irreversible measuring indicator to ensure proper working order of the dish machine; 4. Maintain plumbing in good repair; 5. Properly store CO2 containers; and 6. Ensure proper cooling of potentially hazardous foods. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 73 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the kitchen, at 9:48 AM on 7/10/23, with Food and Nutritional Services Director (FNSD) I, it was observed that black debris was evident on gaskets of the four door traulson cooler. During the initial tour of the kitchen, at 9:50 AM on 7/10/23, it was observed that the delfield preparation cooler was found with increased amounts of debris in the top of the gaskets. During the initial tour of the kitchen, at 10:10 AM on 7/10/23, observation of the bulk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 # MI00128996, # MI00135026, & # MI00136953. Based on observation, interview, and record review, the facility failed to ensure sufficient staff to meet resident needs for 5 (Resident #10, Resident #282, Resident #8, Resident #88, and Resident #182) of 18 residents reviewed for staffing, resulting in long call light wait times, residents being left wet and soiled, and the potential for unmet needs for all residents of the facility. Findings include: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 1589-1592). Elsevier Health Sciences. Kindle Edition.Time management, therapeutic communication, patient education, and compassionate implementation of bedside skills are just a few of the essential skills you need. It is important for your patients to leave the health care setting with a positive image of nursing and a feeling that they received quality care. Your patients should never feel rushed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that resident medications were labeled and stored securely in 4 of 10 residents (Residents #33, #38, #59, & #51) reviewed for medication administration, and 1 of 5 medication carts reviewed for labeling and secure medication storage, resulting in the potential for decreased efficacy of and/or adverse reactions to medications, and the potential for residents, visitors, and/or staff to have unauthorized access to medications. Findings include: Resident #33 Review of an admission Record revealed Resident #33, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Schizophrenia. Review of a Minimum Data Set (MDS) assessment for Resident #33, with a reference date of 4/21/23 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #33 was cognitively intact. During an observation on 7/10/23 at 10:19 AM, noted an unlabeled medication cup which contained clear-colored…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Deficiency Practice Statements, A and B. Deficiency Practice Statement A Based on observation, interview, and record review, the facility failed to practice effective infection control techniques for 1 of 10 residents (Resident #333) reviewed for infection control during medication administration, resulting in the potential spread of infection when improper hand hygiene techniques were not performed during a Peripherally Inserted Central Catheter (PICC) line flush. Findings include: Resident #333 Review of an admission Record revealed Resident #333, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Surgical replacement of the hip. Review of a Physician Order revealed: Intermittent flush mid line: 5 mls Normal saline before and after medications & - 5 mls intravenous every day for maintenance. During an observation on 7/12/23 at 08:45 AM, in Resident #333's room, Agency Licensed Practical Nurse (LPN) II entered the room, then exited the room to find 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 provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) detailing estimated charges for continued services in 2 of 3 residents (Resident #4 & #28) reviewed for timely provision of notifications, resulting in the potential for residents/resident representatives to be unaware of changes in regard to financial liability. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) information related to Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) forms, page last updated 12/1/21, revealed .Skilled Nursing Facilities (SNFs) must issue a notice to Original Medicare (fee for service - FFS) beneficiaries in order to transfer potential financial liability before the SNF provides .an item or service that is usually paid for by Medicare, but may not be paid for in this particular instance because it is not medically reasonable and necessary, or .custodial care .For Part A items and services: SNFs use 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 # MI00130678. Based on interview, and record review, the facility failed to protect the residents right to be free fom staff to resident verbal and mental abuse and mistreatment for 3 (Resident #82, #10, and #333) of 18 sampled residents reviewed for abuse and dignity, resulting in residents feeling uncomfortable and anxious around the staff and the likelihood of feelings of embarrassment, humiliation and dehumanization. Findings include: Review of the medical record revealed that Resident #82 was admitted to the facility on [DATE] with pertinent diagnoses that included: muscle weakness, anxiety disorder, adult failure to thrive and chronic inflammatory demyelinating polyneuritis (neurological disorder causing progressive weakness). Review of the Facility Reported Incident received by the State Agency on 8/8/22 revealed that on 8/01/22, Resident #82 verbalized feeling emotionally abused by Certified Nursing Assistant (CENA) QQ and that she had seen CENA QQ badgering/intimidating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 # MI00136953. Based on observation, interview, and record review, the facility failed to provide bathing/showers per identified resident needs and preferences for 2 residents (R8 and R88) of 17 residents reviewed for ADL (Activities of Daily Living) care, resulting in psychosocial sadness, and the potential of poor hygiene, skin irritation and breakdown. Findings include: R8 According to the Minimum Data Set (MDS) dated [DATE], R8 scored 12/15 (moderately cognitively impaired) on her BIMS (Brief Interview Mental Status), with diagnoses including Parkinson's disease and anxiety. These diagnoses along with impairment in both her legs and occasionally incontinent of bowel and bladder, required R8 to receive extensive physical assistance from one person for turning/positioning in bed, transfers, and mobility on the units. To use the toilet, R8 required two-person physical assistance. Observed on 7/10/2023 at 10:12 AM R8 had outside of her room in the hall a transmission-based…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to identify PTSD (Post Traumatic Stress Disorder) triggers and implement interventions to mitigate triggers for 1 of 18 residents (Resident # 283) reviewed for trauma informed care, resulting in the potential risk of re-traumatization. Findings include: A review of a Face Sheet revealed Resident #283 was admitted to the facility on [DATE] with pertinent diagnoses that included: depression, encephalopathy, seizure disorder, suicidal tendency. In an interview on 7/10/23 at 1:50pm, Resident #283 reported feeling depressed, had thoughts of suicide prior to this admission and had lifelong history of trauma including abusive relationships and the violent loss of a child. Resident #283 reported she felt anxious about being at the facility. In an interview on 7/10/23 at 3:01pm, Director of Nursing (DON) B reported Resident #283 had a lifelong history of trauma, some of which centered around a crime committed against Resident #283's child, that the legal…

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