Optalis Health and Rehabilitation of Kingsford

Based on observation, interview, and record review the facility failed to appropriately maintain and store respiratory equipment in a sanitary manner for one (Resident #31) of one resident reviewed for respiratory care. All times are in Eastern Daylight Time (EDT) unless otherwise noted.Findings include:Resident #31 (R31)Review of R31's electronic medical record (EMR) revealed initial admission to the facility on 1/7/25 with diagnoses including dementia, respiratory failure, depression, and heart failure. On 6/24/25 at 2:17 PM, an observation was made of R31 lying in their room in their bed. R31 was wearing a nasal cannula (soft plastic tubing to deliver oxygen to the nose) delivering oxygen from a concentrator at two liters and had a humidifier connected that was empty and not dated. R31 had a nebulizer lying on their bed with condensation and a small amount of medication in the cup.On 6/24/25 at 2:20 PM, an interview was conducted with R31 who was asked if the staff rinse out their nebulizer and replied, The nurse just comes in and puts the medication in it and turns it on 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.

All times are in Eastern Daylight Time (EDT) unless otherwise noted.Based on observation, interview, and record review the facility failed to appropriately maintain and store respiratory equipment in a sanitary manner for one (Resident #31) of one resident reviewed for respiratory care. All times are in Eastern Daylight Time (EDT) unless otherwise notedFindings include:Based on observation, interview, and record review the facility failed to appropriately assess one (Resident #60) out of three residents reviewed for pain management. Findings include:Resident #60 (R60) On 6/24/25 at 2:37 PM, an observation and interview were conducted with R60 in their room. R60 was asked if they had any pain and R60 responded, Yes, normally at night and I take aspirin at night because of the pain from my recent shingles. R60 stated that she keeps the medication in her purse that her daughter brought in for her. R60 then showed this surveyor the medications that they had in their purse which contained acetaminophen 500 mg (milligrams), a stool softener, and a laxative. R60 then stated that she could…

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

All times are in Eastern Daylight Time (EDT) unless otherwise noted Based on observation, interview, and record review the facility failed to store medication in a secure and safe manner and ensure expired medication was disposed of in the active medication cart for three (Residents #33, Resident #57, and Resident #60) of 18 reviewed and one of two medication carts reviewed for medication storage.Findings include:Resident #33 (R33) Review of R33's medication administration record (MAR), dated June 2025, revealed a physician order for insulin glargine subcutaneous solution pen-injector 100 units/ml (milliliter), inject 14 units subcutaneously at bedtime for DMII (diabetes mellitus type 2), start date 3/10/25 at 1900 (7:00 PM), and administered on 6/24/25 at 7:00 PM. On 6/25/25 at 10:15 AM, a review of the medication cart for the South second floor end, revealed an insulin glargine subcutaneous solution pen-injector 100 units/ml with an opened date of 5/26/25 and an expiration date of 6/23/25 in the active medication cart. This insulin pen should have been discarded and was used 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 ensure medications were administered under nursing observation for one Resident (R6) of one resident reviewed for medication administration. This deficient practice resulted in the potential for delayed or non-administration of medications left unsupervised at bedside. Findings include: This deficiency pertains to Intake MI00152512. All times noted are Eastern Daylight Savings Time (EDST). Review of R6's Minimum Data Set (MDS) assessment, dated 1/16/25, revealed R6 was admitted to the facility on [DATE] with diagnoses that included: cancer, neurogenic bladder, anxiety disorder, depression, and unspecified mood disorder. R6 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. During an interview/observation on 4/30/25 at 11:28 a.m., R6 was observed lying in bed with a plastic cup of red and orange gummies on the overbed table in front of them. Licensed Practical Nurse (LPN) A entered the room,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 deficiency pertains to Intake MI00151603. Based on interview and record review, the facility failed to promptly resolve grievances for one Resident (R6) of three residents reviewed for grievances. This deficient practice resulted in resident frustration and dissatisfaction when missing personal items were not found or replaced. Findings include: All times noted are Eastern Daylight Savings Time (EDST). Review of R6's Minimum Data Set (MDS) assessment, dated 1/16/25, revealed R6 was admitted to the facility on [DATE] with diagnoses that included: cancer, neurogenic bladder, anxiety disorder, depression, and unspecified mood disorder. R6 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. During an interview on 4/30/25 at approximately 11:30 a.m., R6 reported the following items were missing and had not been located by the facility: a small pouch, mother's engagement and wedding rings, two mother's rings, a ring her brother made for her, a tennis bracelet, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a urinary nephrostomy drainage bag was maintained to prevent contact with contaminated surfaces or garbage for one Resident (R6) of one resident reviewed for catheter care. This deficient practice resulted in the increased risk of contamination of the urinary drainage bag and increased risk of urinary tract infection (UTI) for R6. Findings include: This deficiency pertains to Intake MI00152512. All times noted are Eastern Daylight Savings Time (EDST). During an interview and observation on 4/30.25 at 11:28 a.m., R6's nephrostomy urinary drainage bag was observed clipped to the bed linen on the right (exit) side of R6's bed, with the urinary drainage bag hanging down into R6's garbage can which contained various garbage items. No privacy/dignity cover was observed on the urinary drainage bag and the weight of the urine looked as though it continued to lower the bag into the garbage. When R6 was asked about the urinary drainage 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intakes: MI00151324, MI00151372. Based on observation, interview, and record review the facility failed to provide necessary care to assist two Residents (#3 & #4) of five residents reviewed for activities of daily living (ADLs)care. This deficient practice resulted in residents who appeared unkept, disheveled, and being left wet and soiled for extended periods of time and potential for embarrassment and humiliation based on the reasonable person comcept Findings include: Resident #3 (R3) Review of an admission Record revealed R3, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: hemiplegia-stroke affecting the left side. Review of a Minimum Data Set (MDS) assessment for R3, with a reference date of 3/6/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition was intact. Review of R3's Care Plan revealed: Focus: (R3) has an (Activity of Daily Living) ADL self-care performance deficit related to: historical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Intake #MI00149612 Based on interview and record review the facility failed to ensure the accuracy and confidentiality of resident records for one Resident (#9) of two residents reviewed for confidentiality of medical records, resulting in the release of incorrect resident information accompanying a deceased resident's remains to the funeral home. All times are in Eastern Standard Time. Findings include: Resident #6 (R6)/Resident #9 (R9) On [DATE], the facility transferred the body of R6 to the funeral home of choice with documentation that incorrectly identified the deceased as R9. The records sent included R9's face sheet with full name, date of birth , and medical history. Review of the Electronic Medical Record (EMR) for R6 and R9 revealed they were located in rooms on different hallways within the facility and their names did not begin with similar letters or sound the same. A phone interview on [DATE], at 3:49 PM, with Funeral Home Representative I revealed the the error was identified Representative I…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 MI00149149. Based on observation, interview, and record review, the facility failed to ensure appropriate and consistent assessment of a penile tear for one Resident (#2) of three residents reviewed for wound care, resulting in the potential for unidentified worsening of the wound and delay in treatment. Findings include: All times recorded in Eastern Standard Time (EST), unless otherwise noted. Review of the Minimum Data Set (MDS) assessment, dated 11/7/2024, revealed R2 was admitted to the facility on [DATE] and had diagnoses including obstructive uropathy, benign prostatic hyperplasia (enlargement), and dementia. Further review of the MDS assessment revealed R2 required substantial/maximal assist (helper does more than half the effort) for toileting hygiene and was dependent (helper does all the effort) for showering and bathing. R2 scored eight out of 15 on the Brief Interview for Mental Status (BIMS), indicating he had moderate cognitive impairment. Review of R2's Skin -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 MI00148886. Based on interview and record review, the facility failed to ensure consistent skin and risk assessments were completed according to professional standards of practice and facility policy, for one Resident (#7) at risk for pressure injuries of three resident reviewed, resulting in the potential for unidentified wounds and delay in treatment. Findings include: All times recorded in Eastern Standard Time (EST), unless otherwise noted. Resident #7 (R7) Review of the Minimum Data Set (MDS) assessment, dated 12/19/2024, revealed R7 was admitted to the facility on [DATE] and had diagnoses including Parkinson's Disease. Further review of the MDS assessment revealed R7 was at risk for the development of pressure injuries and required substantial/maximal assistance (helper does more than half of effort) for rolling left to right, sitting to lying and lying to sitting. R7 was dependent (helper does all the effort) for all transfers and had severe cognitive impairment. 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 This deficiency pertains to intake MI00148886. All times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on observation, interview, and record review, the facility failed to ensure a urinary catheter securement device was utilized, proper placement of a urinary collection bag, and timely drainage of urine from a urinary catheter collection bag for two Residents (R2 and R4) of three residents reviewed for catheters. Findings include: Resident #4 (R4) On 1/2/25 at 11:25 a.m., R4 was observed with a urinary catheter collection bag touching the floor next to his bed without a barrier beneath it. R4 said he had a catheter due to difficulty urinating and was scheduled to see the urologist. R4 was asked if they had a securement device to prevent pulling on the catheter. R4 said no securement device was in place. Certified Nurse Aide (CNA) A entered R4's room and was asked if R4 ever had a securement device for the urinary catheter tubing. CNA A said R4 had a securement device in place. CNA A picked up…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 MI00147496. Based on observation, interview and record review, the facility failed to ensure appropriate transfer using a mechanical lift for one Resident (#1) of three residents reviewed for accidents, resulting in Resident #1 sustaining a fall with subsequent left knee pain and the potential for serious injury. Findings include: All time recorded in Eastern Daylight Time (EDT), unless otherwise noted. Resident #1 (R1) According to the Minimum Data Set (MDS) assessment, dated 10/09/2024, R1 was admitted to the facility on [DATE] and had diagnoses including cervical disc disorder, morbid obesity and a history of falling. Further review of the MDS assessment revealed R1 was dependent on staff for all transfers and bed mobility. R1 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating R1 was cognitively intact. On 10/30/2024 at 12:05 p.m. R1 was observed in her room sitting in bed. R1's bed was observed to be in a high position, approximately three feet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 MI00 147221. Based on observation, interview and record review, the facility failed to ensure use of Enhanced Barrier Precautions (EBP, gown and glove use) during high-contact resident care activities, according to physician order and current professional guidelines, for one Resident (#2) of three residents reviewed for infection control, resulting in the potential for spread of multidrug-resistant organisms (MDROs) and infection. Findings include: All time recorded in Eastern Daylight Time (EDT), unless otherwise noted. According to the Minimum Data Set (MDS) assessment, dated 10/18/2024, R2 was admitted to the facility on [DATE] and had diagnoses including anal cancer, an open peri-anal surgical wound, colostomy, right and left nephrostomy, and neuromuscular dysfunction of the bladder with suprapubic catheter. Further review of the MDS assessment revealed R2 was dependent on staff for toileting hygiene and personal hygiene, including management of ostomies and catheters. 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.

This citation pertains to intake MI00147078. Based on observation, interview and record review, the facility failed to provide a meal and assistance for one resident (R13) of three residents reviewed for meal delivery and feeding assistance. This deficient practice resulted in the potential for clinical/nutritional compromise. Findings include: (All times are recorded in Eastern Daylight Time (EDT) unless otherwise noted.) On 9/25/24 at 10:16 AM, R13 was heard calling out in a loud voice as this surveyor passed by his room. Upon entering the room, R13 exclaimed, They refuse to get me breakfast. I need my breakfast. The Speech Language Pathologist (SLP) F was also in the hallway when the shouting occurred, and stated she would take care of R13's request for breakfast. When R13 was asked about his meal, he stated he did not know why he did not get breakfast and said he may have been sleeping when breakfast was being passed, but he asked for his tray from staff passing by and they refused to get it for him. He stated he needed assistance with his meals. During an interview on 9/25/24…

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

This citation pertains to intake MI00147078. Based on interview and record review the facility failed to provide timely pharmaceutical services, for one resident (R15) of three sampled residents reviewed for pharmacy services. This deficient practice resulted in missed doses of a prescribed medication with symptoms of sweating and shaking and the potential for worsened medical conditions. Findings include: (All times are recorded in Eastern Daylight Time (EDT) unless otherwise noted.) During an interview on 9/25/24 at 5:00 PM, R15 stated he was concerned he was not getting his needed medication. R15 said, When I came in here I did not get my Parkinson's medications. They are critical and time sensitive and they were not here when I got here. R15 explained it took a while for the medication to come. He stated,It took a while the next day too. R15 stated, I have only been here a week and they have messed up three times. He said counting the admission problem and then R15 stated, At 8:20 AM (CDT Central Daylight Time) this morning (9/25/24). I asked my CNA (Certified Nurse Aide) to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This intake pertains to MI00145231: Based on interview and record review, the facility failed to inform the Resident Representative of the grievance policy and procedure and promptly address all grievances for one Resident (R1) out of three residents reviewed for Resident Rights. This deficient practice resulted in grievances submitted by email, without inclusion in the facility grievance log, and a delay or omission of grievance response(s). Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. An abbreviated survey was conducted on 7/24/24 related to complaint allegations that the facility failed to provide staff assistance with personal hygiene and incontinence for R1. This included the failure of the facility to maintain an adequate stock on incontinence briefs (pull-up style) in the specific location (R1's top dresser drawer) for R1, as specified in R1's care plan, based on R1's Resident Representative request. Review of R1's Minimum Data Set (MDS) assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 intake pertains to MI00145231: Based on interview and record review, the facility failed to provide the appropriate treatment and services to maintain the ability to carry out activities of daily living for one Resident (R1) out of three residents reviewed for ADL care. This deficient practice resulted in inadequate grooming, dressing, personal hygiene, and toileting for R1. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. An abbreviated survey was conducted on 7/24/24 related to complaint allegations that the facility failed to provide staff assistance with personal hygiene and incontinence for R1. This included the failure of the facility to maintain an adequate stock of incontinence briefs (pull-up style) in the specific location (R1's top dresser drawer) for R1, as specified in R1's care plan based on R1's Resident Representative request. Review of R1's Minimum Data Set (MDS) assessment revealed R1 was admitted to the facility on [DATE], with active…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 MI00141835, MI00142802, and MI00142093. Based on observation, interview, and record review, the facility failed to provide adequate nursing staff to provide quality care and services. This deficient practice resulted in extended call light wait times with the potential for lack of care to meet resident's needs amongst any/all 73 residents. Findings include: (All times are in Eastern Daylight Time) A review of multiple complaints reported to the State Agency included allegations that there was not enough staff to consistently provide activities of daily living (ADL) including bathing, toileting, and oral care for residents, and not responding to call lights in a timely manner to provide appropriate care to meet resident's needs. Resident #53 (R53) On 5/19/24 at 2:15 PM, an interview with R53's resident representative (RR) was conducted. The RR stated R53 was not getting her soiled linens changed as needed when her call light was put on. R53 stated she felt embarrassed when 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 and interview, the facility failed to ensure the dietary department was provided with sufficient and properly trained staff to carry out the functions and duties of the nutritional services department. This deficient practice has the potential to result in inadequate nutrition for all 73 residents. Findings include: (All reported times are in EDT) On 5/19/24 at approximately 3:45 PM, an interview with Kitchen Manager (KM) A was conducted. It was learned KM A had not completed the Certified Dietary Manager's (CDM) course, nor had credentials in food service sanitation, i.e. ServeSafe or Certified Food Service Manager (CFM). KM A stated she had completed about one half of the CDM coursework. At approximately 4:40 PM an interview was conducted with Registered Dietitian (RD) E who stated his responsibility was for clinical assessments and interventions, and did not have any role in the kitchen functions. On 5/21/24 at approximately 8:15 AM, an interview was conducted with KM A and it was learned the facility had a corporate registered dietitian (F) who consulted via…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 On 5/20/24 at 12:48 PM, the lunch meals were observed to include mostaccioli, garlic bread, green beans, and fruited jello. The mostaccioli appeared to have no meat and had cottage cheese or ricotta cheese, but only four to five pearls of cottage cheese per serving visible. The recipe for the mostaccioli was requested to investigate the protein content of the mostaccioli entree. During the initial tour on 5/19/24 at 2:54 PM, Resident # 22 (R22) stated she had a healing below the knee amputation, and she needed to be fitted for a prosthesis. She said she knew she needed protein to continue with the healing process. However, she said, There is bad food here with very little protein. I have gained weight by eating crap here. She showed me protein supplements that she had ordered because the facility was not serving enough protein. The Electronic Medical Record (EMR) revealed a Minimum Data Set (MDS) assessment dated [DATE] listing the admission date for R22 as 8/26/23 with diagnoses including primary medical…

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

Based on observation, interview and record review the facility failed to follow menu recipes to ensure that the nutritional value of the items was met. This deficient practice has the potential to result in nutritional deficiencies to all 73 residents of the facility. Findings include: (All times reported in EDT) On 5/20/24 at approximately 12:45 PM, the noon meal was observed to be served. The main component was identified as Mostaccioli and was being served from the steam table. At this time an interview was conducted with KM A and asked if the Mostaccioli had any meat. KM A stated No. KM A then stated the protein source for the dish was sourced through the cheese. A review of the recipe for the Mostaccioli was conducted and learned that the dish required five pounds of cottage cheese for every 50 servings. On 5/21/24 at approximately 8:30 AM, an interview was conducted with [NAME] G, who had made the Mostaccioli the day before. [NAME] G stated that he had used about two and a half pounds of cottage cheese for the dish that was meant to serve the 73 residents. When asked if all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 diets as prescribed by a physician for one of three residents reviewed for therapeutic diets (Resident #25) in a sample of 18 Residents. This deficient practice resulted in the potential for health complications. Findings include: (All reported times are in Eastern Daylight Time.) On 5/19/24 at 3:23 PM, Resident # 25 (R25) was observed in her room sitting in her recliner, while the remainder of her lunch tray was positioned on the bedside table. The tray had 25% of the ham uneaten, 25% of the cheesy potatoes remained uneaten and 25% of the caramel bread pudding remained uneaten. The lunch diet slip read DIET: Menu 2 Gram Sodium Diet Order: Cardiac Regular Texture . R25 said the food is always the same. The Electronic Medical Record (EMR) face sheet revealed R25 was originally admitted to the facility on [DATE] with diagnoses including heart failure, muscle wasting, heart attack, atherosclerotic heart disease,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 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 any and all 73 residents. Findings include: (All times reported in EDT) On 5/20/24 at approximately 12:10 PM, [NAME] B was observed preparing the steam table with hot food, including a pan of Mostaccioli. [NAME] B was asked if the hot food was prepared to be served and if the temperature of the foods had been measured. [NAME] B responded yes. Using a Thermapen metal stem digital thermometer, the Mostaccioli was measured to have temperatures of 119°F, 122°F and 128°F. An interview with [NAME] B followed and was asked what temperature she had measured. [NAME] B replied she had measured 178°F. [NAME] B was requested to demonstrate the procedure used to measure the temperature of the Mostaccioli. [NAME] B , using a metal stem digital thermometer, placed it toward the back of the pan and pushed the stem down to within a half…

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

During this annual survey process the survey team identified an immediate jeopardy for pressure ulcers due to the facility's failure to identify, completely and accurately assess, appropriately treat and implement interventions to prevent facility-acquired pressure injuries and promote healing and prevent worsening of existing pressure injuries. When the NHA was asked if the QAPI committee had addressed skin and wound issues, she could not show any evidence of documentation demonstrating performance improvement activities in this area. The NHA reviewed the QAPI committee minutes and could only find a mention of Other injuries which she thought could include pressure ulcers. When asked for additional information, the NHA said the Director of Nursing (DON) would have that documentation, but the QAPI minutes did not contain an analysis of data tracking and trending or system improvements to prevent or heal pressure ulcers. The facility provided the policy Quality Assessment and Process Improvement which was dated as issued 10/15/2018 with no recent review dates and unsigned blank areas…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conduct and document an annual facility wide assessment resulting in the potential for inadequate knowledge of the facility population's needs and potential for inadequate resources to care for any and all 73 residents in the facility. Findings include: (All reported times are in Eastern Daylight Time) On 5/21/24 at 11:24 AM, the Nursing Home Administrator (NHA) was asked for a copy of the Facility Assessment. The NHA provided a Facility Assessment with the previous ownership of facility on it. During an interview on 5/21/24 at 11:40 AM, the NHA stated the facility assessment had been reviewed, signed 10/16/23, and was current. The owner of the facility was not current. Review of the Facility Assessment section titled Minimum Data Set (MDS) Resident Population Profile was dated 10/28/21-10/27/22 and the Patient Population was dated 10/2022 which did not reflect the current resident population. On 5/29/24 at 12:00 PM, during follow up interview the NHA and Regional Clinical Resource nurse stated they were waiting to update…

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

Based on interview and record review, the facility failed to implement and maintain an effective, comprehensive, data-driven Quality Assurance & Performance Improvement (QAPI) program to develop and implement appropriate plans of action to correct identified quality deficiencies. This deficient practice resulted in a system failure in the skin and wound program for prevention and healing of pressure ulcers, which had the potential to affect all 73 residents in the facility. Findings include: (All reported times are in Eastern Daylight Time.) During an interview on 5/29/24 at 7:27 AM, the Nursing Home Administrator (NHA) stated the QAPI committee met monthly with the goal of looking for department projects, systems that needed to be put in place, and what needed to be done to improve. The NHA indicated each department head participated and reported on issues included in their areas. The NHA gave an example of a process improvement plan stating, We are doing inventory sheets. Another area the NHA mentioned was infection control stating, We are getting the (infection) book together 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.

Based on interview and record review, the facility failed to ensure that a Quality Assurance and Performance Improvement (QAPI) program committee was composed of the required committee members. This deficient practice resulted in the potential for ineffective coordination of medical care and delayed resolution of facility issues placing all 73 residents of the facility at risk for quality care concerns. Findings include: (All reported times are in Eastern Daylight Time.) During an interview on 5/29/24 at 7:27 AM, the Nursing Home Administrator (NHA) stated the QAPI committee met monthly and indicated each department head participated and reported on issues included in their areas. The NHA reviewed the Quality Assurance and Performance Improvement Committee Meeting Attendance Record sign in sheets for the required members and identified the following: - On 5/9/23, the QAPI meeting included signatures of the NHA, the Director of Nursing/Infection Preventionist, (DON/IP), and 6 other members but did not include the Medical Director. - On 6/19/23, the QAPI meeting included signatures 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 observation and interview, the facility failed to maintain or ensure proper maintenance was provided on essential equipment in the kitchen. This deficient practice had the potential to result in equipment not being operational and contributing to unnecessary risks to staff and residents. Findings include: (All times reported in EDT) On 5/19/24 at approximately 2:30 PM, the floor under the three compartment sink and under the refrigerator near the south wall of the kitchen, were observed covered in water. An interview was conducted with [NAME] C at this time and it was learned the water was attributed to the drain from the three compartment sink overflowing. [NAME] C stated this has been an ongoing problem when the drains are opened from any of the compartments on the sink, the drain into the floor cannot handle the flow from even one of the sinks, individually. On 5/19/24 at approximately 4:45 PM, an interview was conducted with Kitchen Manager (KM) A regarding the water on the floor. KM A confirmed 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.

This citation pertains to Intake MI000142093. Based on observation, interview, and record review, the facility failed to follow through with the grievance process initiated by resident representatives regarding resident care and by the resident council (10 members in attendance) related to snacks not being provided in the evenings. This deficient practice resulted in the residents and their representatives' grievances not being resolved or followed up on for those who filed grievances, with the potential for other grievances to go unanswered for any of the other residents at the facility. Findings include: (All reported times are in Eastern Daylight Time) During an interview on 5/19/24 at 3:08 PM, Resident #37's (R37) representatives voiced concerns the grievances they had filed were not addressed. R37's representatives had not been notified of action taken on their concerns. A grievance filed on 2/7/24 by R37's representatives read in part .not sure if this complaint will get to the right department/person because we have filed complaints in the past with different issues/concerns…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 include mandatory training outlining and informing their staff of the elements and goals of the facility's Quality Assurance and Performance Improvement (QAPI) program for 4 staff (identified as Staff N, P, R and Q) out of seven in-service training files reviewed for QAPI training. This deficient practice resulted in the potential for unmet resident care needs due to an ineffective performance improvement program. Findings include: All times are recorded in Eastern Daylight Time (EDT) unless otherwise noted. On 5/29/24, the employee records were reviewed to determine if individual staff had education on the facility's QAPI program. The computerized software education for QAPI was not found to be given to 4 of the 7 employees (identified as Staff N, P, R and Q) reviewed. During an interview on 5/29/24 at 10:50 AM, Housekeeping staff MM was asked about education on the facility's QAPI program. Staff MM stated, They give us papers to read and sign. We do not get to keep a copy of the papers. There are no classes when they give…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the appropriate care of indwelling, urinary catheter equipment for one Resident (R19) of three residents reviewed for catheter care, resulting in the potential for contamination of the equipment with infectious organisms and urinary tract infection. Findings include: All times recorded in Eastern Daylight Time (EDT), unless otherwise noted. R19 was admitted on [DATE] and had diagnoses including diabetes and urethritis (bacterial or viral infection causing swelling and irritation of the urinary tract). Review of R19's quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed he was dependent (helper does all the effort, resident does none of the effort to complete the activity) on staff for dressing, putting on/taking off footwear, and all mobility including rolling left to right, sitting to lying, lying to sitting, chair/bed-to-chair transfers and wheelchair mobility. Further review of the MDS assessment revealed R19…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respiratory status for residents receiving as needed respiratory medications and supplemental oxygen according to professional standards of practice for one Resident (R168) of one resident reviewed for respiratory care. Findings include: All times recorded in Eastern Daylight Time (EDT), unless otherwise noted. R168 was admitted on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and dependence on supplemental oxygen. An observation on 5/19/2024 at 2:11 p.m. revealed R168 lying in bed wearing a nasal cannula with tubing attached to a portable oxygen concentrator positioned on the floor next to the Resident's nightstand. The oxygen concentrator was running and set to deliver two liters (2L) of oxygen per minute. A nebulizer was observed to be sitting on top of R168's nightstand, with tubing, medication cup and mouthpiece attached. R168 reported he used the supplemental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the administration of an incorrect dose of insulin was documented and the attending physician notified for one Resident (R18) of two residents reviewed for insulin administration, resulting in the potential for uncontrolled glucose levels and future orders for insulin dosages adjusted based on incorrect documentation. Findings include: An observation on 5/22/2024 at 9:20 a.m. revealed Registered Nurse (RN) TT preparing to administer 36 units of Lantus Solostar 100 units/milliliter (ML) (long-acting insulin pen) into the back of R18's left upper arm. After cleansing R18's skin with an alcohol pad, RN TT proceeded to insert the needle into R18's upper arm by holding the insulin pen like a dart, with her thumb and fingers holding the pen near the lower end of the pen, just above where the needle attaches to the pen. Once the needle was embedded in R18's arm, RN TT walked her fingers up the pen to place her right thumb on the injection button at the opposite end of the pen from the needle. The pen, 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.

This citation pertains to intakes MI00141709 and MI00142802. Based on observation, interview, and record review, the facility failed to ensure a medication error rate of 5% or less, with 3 medication errors observed of 35 opportunities, resulting in a medication error rate of 8.57%. Findings include: All times recorded in Easter Daylight Time (EDT), unless otherwise noted. An observation on 5/22/2024 at 9:59 a.m. revealed Registered Nurse (RN) TT preparing medications to be administered to Resident 19 (R19). RN TT pulled R19's packet of Keppra (anti-convulsant medication) 500 mg (milligram) tablets from the medication cart and place one tablet in a medication cup containing R19's other scheduled medications. After preparing all R19's scheduled, oral medication, RN TT was observed entering R19's room and assisted R19 with taking the medications. RN TT then performed a finger stick point of care blood glucose test with a result of 375 mg/dL (milligrams per deciliter). Immediately following the observation, RN TT was observed going back to the medication cart and prepared 38 units 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 intakes: MI00140557 and MI00140628 This requirement is not met as evidenced by: All times are reported in Eastern Standard time (EST) unless otherwise indicated. Based on observation, interview, and record review, the facility failed to provide properly sized incontinence briefs for four residents (R6, R7, R8, and R10 ) of four residents reviewed for adequate supplies. This deficient practice resulted in the potential for embarrassment, brief leakage, discomfort, and skin breakdown from residents wearing incorrectly sized briefs. Findings include: An interview was conducted on 11/21/23 at 7:10 a.m., with Certified Nurse Aide (CNA) D who stated they worked the night shift at the facility. During the interview CNA D stated the building was out of supplies all the time, and included briefs as being an area of concern. CNA D stated if residents run out of briefs the CNAs obtains briefs from other residents. During an interview on 11/21/23 at 7:30 a.m., CNA E revealed further concerns with 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.

This deficiency pertains to MI00140557 and MI00140628. Based on interview and record review, the facility failed to ensure prompt resolution of grievances for seven Residents (R3, R6, R11, R12, R13, R14, and R15) of 15 samples residents reviewed. This deficient practice resulted in unaddressed resident grievances. Findings include: All times reported are in Eastern Standard Time (EST) unless otherwise indicated. During an interview on 11/21/23 at 8:30 a.m., the Nursing Home Administrator (NHA) was asked for a copy of the grievance policy. During an observation and interview on 11/21/23 at 12:30 p.m., the NHA provided a binder of resident grievance forms from facility residents. The NHA said some of the grievances had recently been addressed by the NHA, who had been employed by the facility for the last four days. Review of the facility Concern Forms 2023 binder, dates reviewed 9/1/23 through 9/30/23 revealed eight resident grievance forms from September 2023 that were incomplete. The NHA said many of the grievances were not completed because they involved missing clothing, and 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 dignified care for five Residents (Resident [R14] and four confidential group Residents [C2, C3, C4, and C6]), of seven residents reviewed for dignity. This deficient practice resulted in feelings of sadness and discouragement for R14, and feelings of frustration, unease, and anger for confidential group residents. Findings include: During an interview on 07/12/23 at 2:14 p.m., confidential interviewable group Residents were asked about dignified care interactions, with responses as follows: Resident C2: Reported they frequently heard staff talking about them and other residents care in the facility common areas, which angered them. Resident C2 stated: I have heard a lot of things I shouldn't have heard [about other residents' confidential medical status]. Resident C2 reported they were not consistently treated with dignity and respect and had privacy concerns. C2 confirmed this was an ongoing issue. Resident C3: Reported they heard staff talking about residents' private business in common areas, which concerned…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain informed consent for psychotropic medications for four Residents (#11, #18, #25, and #37) out of five residents reviewed for psychotropic medications. This deficient practice resulted in the lack of documentation for evaluation regarding use, and lack of communication/education to the resident/resident representatives for initiation and/or dose changes of psychotropic medications. Findings include: All time noted is Eastern Daylight Savings Time (EDST) unless otherwise noted. Resident #18 (R18) Review of R18's face sheet, printed on 7/14/23, revealed admission to the facility on 7/31/21 with medical diagnoses including dementia and major depressive disorder. R18's face sheet and medical records revealed a Durable Power of Attorney (DPOA) was activated and was not her own person. Review of R18's Minimum Data Set (MDS) assessment, dated 3/3/23, section C - cognition, revealed R18 was rated having long term and short-term memory loss…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and secure storage of medications in one of two medication rooms reviewed during the medication storage task. This deficient practice resulted in the potential for medication diversion. Findings include: All times are Eastern Daylight Savings Time (EDST) unless otherwise noted. During an observation on 7/12/2023 at 2:00 p.m., the 2nd floor medication room was observed in the presence of Registered Nurses (RN)/Unit Managers A and J. One of two bulk emergency back-up medication boxes (EKITS) were found with no security tab [green (unopened) or red (previously opened)] placed through the small holes in the box (one hole in the top cover, and one hole in the bottom portion of the box) to prevent the box from being opened without evidence of such. No EKIT Transfer Form was found in the unsecured, bulk, back-up medication box. A list of products in the EKIT was found on the box, and RN A and RN J verified the count of all medication in the unsecured EKIT. Review of documentation on the top and side 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 observation, interview, and record review, the facility failed to identify, obtain orders for treatment, and provide wound care according to professional standards of practice for one Resident (R267) of 17 residents reviewed for quality of care. This deficient practice had the potential for delayed or worsening of wound healing and infection. Findings include: All time noted is Eastern Daylight Savings Time (EDST) unless otherwise noted. On 7/11/23 at 3:10 PM, an observation was made of R267 lying in her bed in her bedroom. R267 was noted with a (brand name) dressing on her left elbow, beige in color, and measured 2 centimeters by 2 centimeters. R267's dressing did not have a date on it. R267 was asked how long the dressing had been in place and responded, Just shortly after I got here at the facility. It was placed a day or two later after I brushed it on my wheelchair arm. I am not sure what it looks like under there and no one has done anything with it since they put this bandage on. Review of R267'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 Based on observation, interview, and record review, the facility failed to prevent an avoidable accidental shoulder injury for one Resident (#60) of thirteen residents reviewed for accidents. This deficient practice resulted in Resident #60 reporting increased right shoulder pain, and feelings of frustration and unease related to the incident. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 5/4/23, revealed Resident #60 was admitted to the facility on [DATE], with diagnoses including cervical spinal cord injury, depression, and restless leg syndrome. Resident #60 required extensive two-person assistance with bed mobility, transfers, dressing, and toileting. Review of the Brief Interview for Mental Status (BIMS) assessment revealed Resident #60 had a score of 15/15, which showed Resident #60 was cognitively intact. The assessment revealed Resident #15 received scheduled and as needed pain medication. During an interview on 7/12/23 at 3:10 p.m., Resident #60 reported CNA O pulled them up…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate nutrition and monitoring of nutritional status for two Residents (#11 & #59) of three residents reviewed for nutritional status. This deficient practice resulted in wrong diets being provided and lack of appropriate monitoring and/or follow-up with significant weight changes. Findings include: All time noted is Eastern Daylight Savings Time (EDST) unless otherwise noted. Resident #11 (R11) A review of R11's electronic medical record revealed an admission date of 7/14/21 with diagnoses including unspecified dementia with psychotic disturbance, Vitamin B12 deficiency anemia, major depressive disorder, osteoporosis and schizoaffective disorder. R11's Physician Orders revealed a regular diet order with regular texture initiated on 6/8/23. The vital weight record indicated R11 weighed in the 150 - 157 pound range from 1/1/23 through 5/4/23. On 5/4/23 R11 weighed 152 pounds and the following week on 5/10/23 she weighed 132.7 pounds. This was calculated and identified as a 12% significant weight…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 #MI00136290. Based on observation, interview, and record review, the facility physician failed to review the total program of care, including skin/wound care treatments for one Resident (R33) of one resident reviewed for a facility acquired burn and subsequent wound. This deficient practice resulted in poor continuity of care, and the potential for inconsistent skin/wound care treatments for R33's. Findings include: All times are Eastern Daylight Savings Time (EDST) unless otherwise noted. During an interview on 7/11/23 at 3:12 p.m., R33 was observed sitting in a recliner chair in his room, wearing shorts. When asked about an accident with a cup of coffee, R33 stated, Oh my yes . It really hurt. Do you want to see it? R33 pulled down the shorts to uncover the lower abdomen and exposed a gauze pad secured with paper tape secured on the skin. R33 pulled the gauze slightly away from the skin on the lower abdomen which revealed a circular, open area, that appeared to have previously been a blister. There was a slight yellow discoloration around 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.

This deficient pertains to Intake #MI00131468. Based on interview and record review the facility failed to maintain a complete and accurate medical record for one Resident (R217) out of 15 sample residents reviewed. This deficient practice resulted in the failure to document a potential resident elopement from the facility. Findings include: All time noted is Eastern Daylight Savings Time (EDST) unless otherwise noted. During a telephone interview on 7/13/23 at 10:15 a.m., Confidential Witness G said R217 had eloped from the facility on 9/19/22. R217 walked across the street, accompanied by two facility staff members. The police were called, and two police officers arrived, along with Witness G and Family Member (FM) E. Witness G said R217 was sitting in a wheelchair near a local restaurant/bar, and when Witness G arrived, R217 jumped out of the wheelchair and into Witness G's van. R217 never returned to the facility following the supervised elopement from the facility on 9/19/22. Review of the discharge document My Transition Home 1 - V2 in the Electronic Medical Record (EMR)…

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