Aria Nursing and Rehabilitation

Based on observations, interviews, and record reviews, the facility failed to: (1) maintain 2 of 3 outdoor waste receptacles, and (2) clean the outdoor waste receptacle concrete pad surface affecting 83 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and pest attraction/harborage. Findings include: On 05/12/25 at 09:13 A.M., An initial tour of the food service was conducted with Dietary Director (DD) E. The following item was noted: On 05/12/25 at 10:40 A.M., The outdoor waste receptacle concrete pad was observed with accumulated dirt and debris (paper products, plastic bottles, plastic milk crate, wooden pallet, etc.). 1 of 4 receptacle plastic lids were also observed missing. 1 of 4 receptacle slider panels were additionally observed broken. The damaged slider panel contained a hole measuring approximately 6-inches-wide by 6-inches-long. (DD) E indicated she would place a work order into TELS as soon as possible. On 05/15/25 at 10:00 A.M., Record review of the Policy/Procedure entitled: Housekeeping Services dated 02/28/2025 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.

Based on observation, interview, and record review the facility failed to inform one resident (46) of five residents' benefits, risks, and alternatives for the prescribing of psychotropic medication. Findings Included: Resident #46 (R46) Review of the medical record revealed R46 was admitted to the facility 10/12/2024 with diagnoses chronic kidney disease, muscle weakness, atrial fibrillation, thoracic aorta aneurysm, congestive heart failure (CHF), gastro-esophageal reflux disease, sleep disorder, restless leg syndrome, depression, anxiety, chronic pain, mitral valve insufficiency, anemia (low red blood cells count), osteoarthritis, history of myocardial infarction (heart attack), peripheral vascular disease (PVD), chronic obstructive pulmonary disease (COPD), bipolar disorder, and hyperlipidemia (high fat content in blood). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/27/2025, revealed R46 had a Brief Interview of Mental Status (BIMS) of 12 (moderate cognitive impairment) out of 15. Review of R46's medical record demonstrated a 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.

Based on interview and record review, the facility failed to act promptly on grievances reported in resident council meetings and provided responses to grievances in 6 of 9 residents, as reported during a confidential resident council interview, in a total sample of 18 residents and a total census of 83 residents, resulting in unresolved resident concerns, frustration and decreased quality of life. Findings include: A record review of the past six months of resident council meeting minutes revealed concerns/grievances that were not addressed and resolved. Complaints go from month to month with a lack of documentation to reflect that the problem was resolved. This writer reviewed grievances from January 2025 to the current time of survey. Grievance forms were not filled out completely to reflect the complaint/grievance was resolved and did not have the residents' signature to show they are happy with the outcome. Review of the facilities Grievance Policy called Care Program last updated 06/11/2024. .If a resident, a resident's representative, or another interested person 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure three out of five residents (Resident #46, 53, and 69) reviewed for unnecessary medications had proper documentation. Findings Included: Resident #69 (R69): Per the facility face sheet R69 was admitted to the facility on [DATE]. Diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, major depression disorder, and anxiety dated 11/7/2024. Review of a progress note dated 11/9/24, for Psychological Services PSYCHOSOCIAL EVALUATION Supportive Care, revealed an initial evaluation was conducted on 11/9/2024, and revealed a documented diagnosis of, unspecified dementia without behavioral disturbance The mental health exam revealed R69 did not have delusions, hallucinations, behaviors, she was alert to herself, and oriented. The exam did not have any findings that R69 had psychotic features. Review of a Physician's order dated 11/8/2024, revealed R69 was ordered to receive Risperidone 0.5 mg one tablet one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one (Resident #17) of two residents reviewed for care plans, had a comprehensive care plan that was revised for resident care needs, resulting in the potential for additional falls and care needs not being met. Findings Include; Resident #17 (R17) Review of the medical record reflected R17 was an initial admission to the facility on [DATE], readmitted on [DATE] and on 05/10/202. Diagnoses of repeated falls, diabetes, left hip pain, bi-polar and dementia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/08/2025 revealed R17 had a Brief Interview of Mental Status (BIMS) of 13 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R17 requires assistance with personal care and uses a walker or wheelchair as an assistive device. Record reviews revealed R17 had eight falls in the last six months. 11/27/24-R17 fell on the bathroom floor trying to get 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 citation pertains to intake #: MI00144444 Based on interview and record review the facility failed to ensure that medications were administered following the physician ordered parameters for 3 of 8 residents (Resident #7, #8, and #10), reviewed for medication administration, resulting in medication errors. Findings: Resident #7 (R7) Review of an admission Record revealed R7 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: heart disease and hypertension. Review of R7's Order Summary dated 5/9/24 revealed, Metoprolol Tartrate Oral Tablet 50 MG (Metoprolol Tartrate) Give 0.5 tablet by mouth two times a day for HTN (hypertension) Hold is SBP (systolic blood pressure/top number) < (less than) 120 mmHg, Pulse < 60. To be administered at 7:00 AM and 7:00 PM. Review of R7's July Medication Administration Record and Blood Pressure Summary revealed: *On 7/1/24 R7's blood pressure was 108/64 and the 7:00 PM metoprolol was administered. *On 7/4/24 R7's blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complaint intake MI00145033. Based on observation, interview, and record review the facility failed to prevent staff to resident abuse (#10) and investigation, immediately report allegations to the state agency and thoroughly investigate allegations resulting in the potential for continued abuse of residents. Findings Include. Resident #10 (R10) Review of the medical record reflected R10 was admitted to the facility on [DATE]. Diagnoses include Orthopedic aftercare following surgical amputation, Amputation of right foot, Osteomyelitis of both ankles and feet, difficulty walking, Peripheral Vascular Disease, Pain and Malaise. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/27/2024, revealed R10 had a Brief Interview of Mental Status (BIMS) of 15(cognitively intact) out of 15. Under section G0110, Activities of Daily Living (ADL) Assistance reveals R10 requires set up assistance for eating and partial to moderate assistance with bathing and getting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food product safely, maintain plumbing, and practice good hand hygiene, resulting in the potential increased risk of foodborne illness, affecting all residents that consume food from the kitchen. Findings include: On 4/2/24 at 9:00 AM, a tray of non-pasteurized shell eggs, located in the white reach-in cooler next to the cookline, was observed to be stored on a rack over ready-to-eat, individually portioned salad dressing cups. At this time, Dietary Staff DD stated that they were responsible for placing the eggs over the salad dressing cups and that was only their third day working there. Dietary Manager Q proceeded to moving the tray of eggs in the proper location. According to the 2017 FDA Food Code Section 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor . 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 observation and interview, the facility failed to maintain proper backflow protection, and store equipment in a safe manner, resulting in the potential for contamination of the potable water supply and contamination of care equipment, affecting all 92 residents in the facility. Finding include: On 4/3/24 at 1:25 PM, a hose spigot with the hose attached, located in the laundry room, was observed to not be provided with a backflow protection device (a device commonly used in plumbing to preclude the backflow of contaminants into the potable water supply. At this time, Maintenance Director EE stated they will acquire a backflow device for the hose. On 4/3/24 at 1:31 PM, a large box of single service bowls was observed to be stored on the floor in the Emergency Supply Room. At this time, Maintenance Director EE moved the box off of the floor. On 4/3/24 at 1:35 PM, an exterior hose spigot with the hose attached, located at the back loading bay, was observed to not be provided with a backflow protection device. On 4/3/24 at 2:00 PM, three boxes of gloves and one box of gowns were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 number MI00143255. Based on observation and record review, the facility failed to maintain the pest control program, resulting in pests throughout the building, affecting all 92 residents in the facility. Findings include: During an interview on 4/2/24 at 2:24 PM, Resident #67 stated that they consistently have ants on the floor in their room and uses their wheelchair to run over the ants and squish them. At this time, numerous live and dead ants were observed on the floor nearest to the window. Resident #67 continued to say that the facility has not addressed the ants in their room. On 4/2/24 at 2:29 PM, multiple ants were observed on the floor throughout room [ROOM NUMBER]. On 4/3/24 at 12:18 PM, multiple ants were observed on the floor at the cookline, feeding on food debris. At this time, food debris was observed on the floor at the cookline and under the preparation table across from the cookline. On 4/3/24 at 12:31 PM, an ant was observed on the floor in the 1st floor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 state Ombudsman and state agency contact information was accessible, for nine out of 13 confidential residents in a group meeting, who did not know where the contact information was located. Findings Included: On 4/03/2024 at 11:03 AM, during group interviews, nine residents stated they did not know who the state Ombudsman was, how to contact the Ombudsman, nor did the nine residents know where the information was posted. The nine residents also stated they did not know where the posting was located for the contact information for the state agency. Observation on 4/3/2024 at 12:10 PM, of the third and second floors common areas, that included both the east and west sides, all dinning and activities rooms, and the chapel, revealed no postings for the state agency or Ombudsman contact information. During the same observation, the first floor was observed to have a large glass display case on the wall in the lobby area. A poster for the Ombudsman's main contact number was on the posting. The state…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 there was sufficient staffing, call lights were within reach, and call lights were answered promptly for 10 out of 13 confidential group interviews, and for two out of four residents (Resident #41 and 43). Findings Included: During a confidential group meeting on 4/03/2024 at 10:21 AM, one resident stated that staffing was so bad there were several times she would not receive staff assistant getting up out of bed and would miss the activities. The same confidential resident stated that about 4-5 times she did not receive staff assistance getting out of bed to attend activities and resident council, which resulted in her missing the activities and resident council meetings entirely. The resident stated it was due to not having enough staff. Another confidential resident stated he was told by staff they did not have enough time and were too busy to assist him to get up out of bed. Ten of the 13 confidential residents agreed that the…

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

Based on observation, interview, and record review, the facility failed to ensure opened medications were appropriately labeled and stored (R15, R41, R294, R297) in 3 of 5 medication carts reviewed for labeling and storage, resulting in the potential for decreased medication efficacy and adverse side effects. Findings include: On 4/4/24 at 7:56 AM, Two East Medication cart was reviewed in the presence of Licensed Practical Nurse (LPN) R. During the medication pass, two undated inhalers were observed after LPN R administered the inhalers. The name on the outside of the box reflected R297's name with no open date on the boxes or the actual inhalers themselves. LPN R confirmed the absence of opened dates on the inhalers and stated that the inhalers should have been dated when opened and was unsure of where the inhaler had come from or when it had been opened. Review of R297's medical record revealed an active order for Anoro Ellipta Inhalation Aerosol Powder 62.5-25 MCG/ACT and an active order for Fluticasone-Salmeterol 250-50 MCG/ACT Aerosol Powder. On 4/4/24 at 8:56 AM, Two East…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nutritionally adequate meals were served in accordance with dietary preferences, provided a repetitive breakfast menu, and failed to provide requested dietary items for one (Resident #287) of three reviewed and 10 of 13 residents that attended the Resident Council meeting, resulting in food preferences not being honored and the potential for unmet nutritional needs. Findings include: Resident #287 (R287) Review of the admission Record reflected R287 was admitted to the facility on [DATE] with diagnosis which included dependence on renal dialysis, end stage renal disease, heart failure, generalized anxiety disorder, type one diabetes mellitus, acquired absence of right leg below the knee, and muscle weakness. A Social Services Note dated 3/28/23 at 4:55 PM reflected R287's Brief Interview for Mental Status (BIMS) was scored 13 out of 15, indicating cognitively intact. R287's Care Plan indicated that he required supervision for assistance for most…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 serve food that was an appetizing temperature and provide a holiday meal for two (Resident #286 and #287) of three reviewed and 10 of 13 residents that attended the Resident Council meeting resulting in food complaints, the potential for unsafe food temperatures, and weight loss. Findings include: During on observation on 04/02/24 at 9:00 AM, the breakfast meal cart was delivered to the first-floor unit. Shortly after arrival, a family member approached the cart and a staff member opened the doors and handed the family member a breakfast tray for Resident #286. The staff member walked away from the cart, leaving the meal cart doors open. The doors on the meal cart were left open for 11 minutes while staff passed trays. In an observation on 04/02/24 at 12:38 PM, upon exit from a resident room the meal cart was observed on the first-floor unit. Staff was passing lunch trays and leaving the doors opened in between tray passes. On 4/2/24 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.

Based on interview and record review, the facility failed to audit emergency carts, resulting in the potential for emergency carts to be ill-equipped to respond to emergency care, affecting residents on two halls in the facility. Findings include: On 4/2/24 a review of the 2 [NAME] Emergency Cart Checklist, notes that the last date the audit was completed was March 9th, 2024. A review of the 3 [NAME] Emergency Cart Checklist, notes the last date the audit was completed was January 11th, 2024. During an interview on 4/3/24 at approximately 3:30 PM, Director of Nursing B was queried on the emergency cart audits and stated that Nursing is responsible for completing the audit daily and that the Unit Manager is responsible for ensuring the audits are being done. A review of the facility's Emergency Cart Policy, reviewed 01/2023, it notes, . 5. It is the responsibility of nursing to visually verify each Emergency cart daily and document on ER cart audit form that a check has been completed. Checks are completed per audit form by verifying the number on the lock: If any items are not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two (Resident #23 and #68) of 19 reviewed. Findings include: Resident #23 (R23): Review of the medical record reflected R23 admitted to the facility 4/9/20 and readmitted [DATE], with diagnoses that included bipolar disorder and generalized anxiety disorder. The quarterly MDS, with an Assessment Reference Date (ARD) of 12/31/23, reflected R23 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R23's annual MDS, with an ARD of 4/17/23, was coded No for, A1500. Preadmission Screening and Resident Review (PASRR) .Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? A level II evaluation was noted in R23's medical record for 7/2022, reflecting a level II evaluation was needed again, by 7/20/23, if R23 remained in the nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure for three out of 19 residents (Resident #41, 43 and 287) a complete comprehensive care plan was in place and/or implemented. Findings Included: Resident #41 (R41): Per the facility face sheet R41 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Diagnoses included stroke. In an observation and interview on 4/02/2024 at 2:54 PM, R41 was observed in bed, and no drinking water was observed in R41's room. A sign was observed on wall which revealed Pudding Thick Liquids .) During the same observation and interview R41 asked if she could get some water. A staff member was informed of R41's request. At 3:00 PM a Styrofoam cup with a lid was observed to have been placed on a bedside table that was in the bed one area. R41 resided in bed 2. The cup was way out of reach for R41, the straw was laying next to the cup, the water was not pudding thick and had ice in it. On 4/02/2024 at 3:05 PM, R41 was heard to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to timely investigate a fall and revise a fall Care Plan for one (Resident #287) of 19 reviewed for Care Plans, resulting in an inaccurate Care Plan, identifying the effectiveness of implemented interventions, and the potential for more falls. Resident #287 (R287) Review of the admission Record reflected R287 was admitted to the facility on [DATE] with diagnosis which included dependence on renal dialysis, end stage renal disease, heart failure, generalized anxiety disorder, type one diabetes mellitus, acquired absence of right leg below the knee, and muscle weakness. A Social Services Note dated 3/28/23 at 4:55 PM reflected R287's Brief Interview for Mental Status (BIMS) was scored 13 out of 15, indicating cognitively intact. R287's Care Plan indicated that he required supervision for assistance for most Activities of Daily Living. In an observation and interview on 04/02/24 at 9:42 AM, R287 was seated on the side of the bed with his bedside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility failed to: 1) accurately assess, monitor, treat and prevent the development of pressure ulcers consistent with professional standards of practice to prevent avoidable pressure ulcers; and 2) implement care-planned and non-care-planned interventions for two Resident (R18 and R27) of three reviewed for pressure ulcers, resulting in facility acquired stage 3, and the increased likelihood for delayed wound healing and/or worsening of wounds and overall deterioration in health status. Findings include: Resident #27(R27) Review of the Face Sheet and Minimum Data Set (MDS) with ARD date 1/12/24, reflected R27 was a [AGE] year old male admitted to the facility on [DATE] related to mood disorder, left foot drop, osteoarthritis, anxiety, and depression. The MDS reflected R27 had a BIM (assessment tool) with score of 15 which reflected cognitively intact . Review of the facility Matrix, dated 4/02/24, reflected R27 had a facility acquired stage 3 pressure ulcer.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 # MI00143255 Based on interview and record review the facility failed to investigate falls and implement effective interventions to prevent falls for one (Resident #86) of three residents reviewed, resulting in the potential for falls and injury. Findings include: Resident #86 (R86) Review of the admission Record reflected R86 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnosis which included gastrostomy status (creation of an artificial external opening into the stomach for nutritional support), retention of urine, dementia with agitation and anxiety, need for assistance with personal care, delirium, and dysphagia (difficulty in swallowing food or liquid). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/7/23, reflected R86's Brief Interview for Mental Status (BIMS) was scored 4 out of 15, indicating severe cognitive impairment. The Care plan reflected that R86 did not walk, required extensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 insure that two residents (R56 and R63) were free from significant medications errors out of two residents reviewed for significant medication errors resulting in the potential for adverse physical reactions/outcomes to residents. Findings Included: Resident #56(R56) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R56 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included alcoholism, hypertension (high blood pressure), peripheral vascular disease, osteomyelitis bilateral ankles, orthopedic amputations bilateral feet related to recent gangrene infection(septicemia), and current smoker . The MDS reflected R56 a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact. The MDS reflected R56 had no behaviors including rejection of care. During an observation and interview on 04/02/24 at 10:20 AM, R56 was in the hall self…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dentures were received timely for one (Resident #68) of one reviewed for dental services. Findings include: Review of the medical record reflected Resident #68 (R68) admitted to the facility on [DATE], with diagnoses that included diabetes, dysphagia (difficulty swallowing) and history of transient ischemic attack (TIA) and cerebral infarction. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/16/24, reflected R68 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS was coded No in section L (Dental) for, A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) and F. Mouth or facial pain, discomfort or difficulty with chewing. The admission MDS, with an ARD of 9/14/23, reflected coding of No in section L (Dental) for, A. Broken or loosely fitting full or partial denture (chipped,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 offer influenza and pneumococcal immunizations per Centers for Disease Control and Prevention (CDC) recommendations for two (Resident #6 and Resident #56) of five reviewed. Findings include: Resident #6 (R6): Review of the medical record reflected R6 admitted to the facility on [DATE], with diagnoses that included cerebrovascular disease, chronic respiratory failure with hypoxia and diabetes. According to the medical record, R6 was his own responsible party and gave consent to receive the influenza vaccination on 12/15/23 and 12/19/23. R6's medical record did not reflect documentation of an influenza vaccination being given for the 2023/2024 influenza season. According to CDC, .Everyone 6 months and older in the United States, with rare exception, should get an influenza (flu) vaccine every season . (https://www.cdc.gov/flu/prevent/flushot.htm) Resident #56 (R56): Review of the medical record reflected R56 was [AGE] years old and admitted to 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 MI00140788 and MI00142060. Based on observation, interview and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment, in a census of 91 residents, resulting in the potential for transmission of infection, decreased air quality, odors, and accidents. Findings include: The shower room located on the third floor was observed on 1/31/23 at 2:41 PM, with overflowing garbage, and used gloves and paper towels on the floor. An office type chair with a fabric seat and back had a wet area on the seat. The toilet seat was soiled with smears of bowel. Hair was observed in the shower over the drain. The ceiling vent was covered heavily with dust that had accumulated and the vent was not pulling air from the room. Housekeeper K was interviewed on 1/31/24 at 2:50 PM and stated she worked from 8:00 AM to 4:00 PM and the shower room was cleaned once per day. Housekeeper K stated she had not cleaned the shower room on the third floor yet on 1/31/24. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00142060. Based on observation, interview and record review, the facility failed to ensure pharmacy procedures were in place for an extended leave of absence (LOA) for one (Resident #3) of one resident reviewed for LOA medication resulting in the resident not receiving medications for six days causing resident undue distress. Findings include: Resident #3 (R3) During an interview on 2/2/2024 at 10:34 AM R3 was sitting up in bed and stated that when she went LOA with her friend in December 2023, she had four days of medications and couldn't receive additional days of medications per request. R3 said that she went through a withdrawal when she did not take her scheduled medications per physician's orders. R3 said that her friend called the facility since she was concerned that R3 wasn't doing well and then took her to the emergency room. R3 reported that her friend was concerned that she was going through behavioral changes without medications. When asked how R3 felt at that time…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 evaluate and revise the care plan for one (#2) of two Residents reviewed for care plan revision, of a total sample of four, resulting in a lack of care plan evaluation, revision, and implementation of appropriate interventions, and the potential for unmet care needs. Findings include: Resident #2 (R2) Medical record revealed Resident #2 (R2) was admitted to the facility on [DATE] initially with diagnoses that included unspecified Dementia with severe mood disturbance, Dementia with severe agitation, Psychotic disorder with hallucinations due to known physiological condition and need for personal care. readmitted on [DATE] following a hospitalization for changes in mental status and returned with additional diagnosis of encephalopathy, sepsis, acute embolism and thrombosis of left distal lower extremity, urine retention, urinary tract infection, placement of a catheter, pleural effusion, and cardiomegaly. According to R2's Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 Registered Nurse (V) and 1 Certified Nursing Assistant (S) had the required annual competency evaluations in skills and techniques necessary to care for Residents, resulting in the potential for staff to lack the necessary training to adequately meet the needs of the 87 Residents that currently reside at the facility. Findings Included: In an interview and record review on 01/17/23 at 09:02 a.m. with the Nursing Home Administrator (NHA) A and the Director of Human Resources W employee personnel files were reviewed for the completion of competencies for the nursing department employees. The Director of Human Resources W was unable to locate the annual competency for Certified Nursing Assistant (CNA) S who's hire date as the facility was 06/19/2019. The Director of Human Resources W was unable to locate the annual competency for Registered Nurse (RN) V who's hire date at the facility was 12/17/2020. NHA A explained that it was the facility policy and practice that all competencies and employee evaluations be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide adequate medically related social services for 1 resident (R52) of 17 residents reviewed. Resulting in increased likelihood of resident overall psychosocial well being potentially affecting all 87 residents. Findings include: Resident #52(R52) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R52 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included atrial fibrilation(irregular heart beat), heart failure, chronic obstructive pulmonary disease, respiratory failure, weakness, anxiety and depression. The MDS reflected R52 had a BIM (assessment tool) score of 11 which indicated her ability to make daily decisions was moderately impaired, and she required one person physical assist with bed mobility, transfers, dressing, toileting, hygiene, ambulation, locomotion, and bathing. The MDS reflected R52 had and mood score of 16 which indicated moderately severe depression.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete, accurate and readily accessible resident medical records for five residents(R1, R14, R16, R52 and R68) of 19 reviewed for medical records, resulting in the likelihood for medication errors, missed treatments, incomplete discharge instructions, incomplete recap of stay and discharge summary, and overall incomplete medical records. Findings include: The clinical record must contain sufficient information to identify the resident; a record of the resident's assessments; the plan of care and services provided .and progress notes. According to Legal and Ethical Issues in Nursing, 4th Edition, ([NAME], G, 2006), a major responsibility of all health care providers is that they keep accurate and complete medical records. From a nursing perspective, the most important purpose of documentation is communication. The standards for record keeping attempt to ensure, patient identification, medical support for the selected diagnoses,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure skills- assessments were done before residents were allowed to administer their own medications for one of one residents (#19) resulting in the potential for incorrect dosing, missed medications and increased difficulty breathing. Findings include: A review of the facility's policy titled, Self-Administration of Medications, reviewed on 1/2020, reflected In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the interdepartmental team has determined that the practice would be safe for the resident and other residents of the facility and there is a physician's order to self-administer. A review of the medical record reflected Resident (R)19 was admitted to the facility on [DATE] for diagnoses including respiratory failure, emphysema, morbid obesity, heart failure and obstructive sleep apnea. A review of the Minimum Data Set (resident 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.

Based on observation, interview, and record the review the facility failed to ensure updated and accurate advance directive information (legal documents that allow a person to identify decisions about end-of-life care ahead of time) was in place for 1 (resident #68) out of 2 residents reviewed for advance directives, resulting in the potential for a residents preference for medical care to not be followed by the facility or other healthcare providers. Findings Include: Resident #68 (R68) Review of the medical record revealed R68 was admitted to the facility 12/21/2022 with diagnoses that included displaced fracture shaft of left clavicle, Alzheimer's disease, dementia, mood disorder (disease of thyroid with presence of nodules without biochemical abnormalities of the thyroid gland), anxiety disorder, nontoxic multinodular goiter, and atherosclerotic heart disease (buildup of cholesterol plaque in the walls of arteries). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/28/2022, revealed R68 had a Brief Interview for Mental Status (BIMS) of 99…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 grievance/concern forms were readily available to residents and visitors for all 87 residents living in the facility resulting in the potential for unreported concerns due to lack of anonymity and inability to access the grievance forms. Findings include: On 1/10/23 at 11:07 am resident council was held in the second floor activity/dining room. Fourteen residents were present. When I asked questions about grievance or concern forms. Residents agreed staff would complete the forms for them. No one knew if or where they were kept. On 1/10/23 at 12:15 pm I toured all four clinical areas and but failed to see grievance forms in public view. When asked, staff were unable to locate grievance forms behind the nurse's station. On 1/12/23 at 10:44 am, Nursing Home Administrator (NHA) A was advised of the findings. According to the facility procedure titled Grievance/Concern Procedural Guidelines, revised 1/2023, .5. Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 were not subjected to staff induced mental abuse and retaliation for two of six residents (#24, #76) assessed for abuse resulting in residents feeling worried, scared or upset and the potential for further abuse. Findings include: A review of medical records reflected R24 was admitted to the facility on [DATE] with diagnoses including diabetes, chronic renal failure, depression, anxiety, left below-the-knee amputation and gastroparesis. A review of the Minimum Data Set (MDS - resident assessment) dated 12/1/22 reflected R24 had normal cognitive function. A review of medical records reflected R76 was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, dysphagia (difficulty swallowing), history of alcohol abuse, stroke, pulmonary hypertension, depression and anxiety chronic renal failure, depression, anxiety, left below-the-knee amputation and gastroparesis. A review of the MDS dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to report an allegation of abuse to the State Agency (SA) for one (Resident #7) of six reviewed for abuse, resulting in an allegation of abuse not being reported to the SA and the potential for further allegations going unreported. Findings include: Review of the medical record reflected Resident #7 (R7) originally admitted to the facility on [DATE] and was readmitted [DATE], with diagnoses that included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation and diabetes. The Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/25/22, reflected R7 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R7 did not walk and performed most activities of daily living with extensive to total assistance of one to two or more people. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to thoroughly investigate an allegation of abuse for one (Resident #7) of six reviewed for abuse, resulting in an allegation of abuse not being thoroughly investigated and the potential for further allegations not being thoroughly investigated. Findings include: Review of the medical record reflected Resident #7 (R7) originally admitted to the facility on [DATE] and was readmitted [DATE], with diagnoses that included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation and diabetes. The Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/25/22, reflected R7 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R7 did not walk and performed most activities of daily living with extensive to total assistance of one to two or more people. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a written reason for transfer/discharge for one (Resident #7) of one reviewed for hospitalization, resulting in the potential for residents and/or their responsible party not being fully informed. Findings include: Review of the medical record reflected Resident #7 (R7) originally admitted to the facility on [DATE] and was readmitted [DATE], with diagnoses that included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation and diabetes. The Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/25/22, reflected R7 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R7 did not walk and performed most activities of daily living with extensive to total assistance of one to two or more people. During an observation and interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a bed hold policy for one (Resident #7) of one reviewed for hospitalization, resulting in the potential for residents and/or their responsible party not being fully informed of the facility's bed hold policy. Findings include: Review of the medical record reflected Resident #7 (R7) originally admitted to the facility on [DATE] and was readmitted [DATE], with diagnoses that included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation and diabetes. The Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/25/22, reflected R7 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R7 did not walk and performed most activities of daily living with extensive to total assistance of one to two or more people. During an observation 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 observation, interview, and record the review the facility failed to accurately code the Minimum Data Set (MDS) Assessment for 1 (Resident #45) of 19 reviewed for MDS Assessments, from a total sample of 19, resulting in the potential for inaccurate care plans and unmet care needs. Findings Include: Resident #45 (R45) Review of the medical record revealed R45 was admitted to the facility 04/20/2020 with diagnoses that included alcoholic cirrhosis of liver, type 2 diabetes, dementia, psychotic disorder with delusions, chronic obstructive pulmonary disease (COPD), chronic viral hepatitis C, tinea unguium (nail fungus), mood disorder, major depressive disorder, anxiety, anemia (low red blood cell count), nicotine dependence, cannabis use, and alcohol abuse. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/26/2022, revealed R45 had Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. Section O (special treatments, procedures, and programs) of the MDS with the same ARD revealed in subsection O0500 (restorative…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement comprehensive care plans for 1 (Resident #52) of 20 reviewed for comprehensive care planning, resulting in the potential for unmet care needs and services. Findings include: Resident #52(R52) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R52 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included atrial fibrilation(irregular heart beat), heart failure, chronic obstructive pulmonary disease, respiratory failure, weakness, anxiety and depression. The MDS reflected R52 had a BIM (assessment tool) score of 11 which indicated her ability to make daily decisions was moderately impaired, and she required one person physical assist with bed mobility, transfers, dressing, toileting, hygiene, ambulation, locomotion, and bathing. The MDS reflected R52 had and mood score of 16 which indicated moderately severe depression. During an observation and interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that care plans were revised for 2 residents (#25 and #55) out of 19 residents, resulting in the potential for resident unmet care needs. Finding Include: Resident #55 (R55) Review of the medical record revealed R55 was admitted to the facility 03/26/2019 with diagnoses that included hypertension, hyperlipidemia (high levels of fat in blood), depression, eczema (dermatitis), anemia (low number of red blood cells), hypo-osmolality (levels of electrolytes, proteins, and nutrients in the blood are lower than normal), hyponatremia (low levels of sodium in the blood), anxiety, seizures, morbid obesity, insomnia, cerebral infarction (stroke), type 2 diabetes, failure to thrive, injury of right achilles tendon, hirsutism (excessive hair growth), cognitive social and emotional deficit, eating disorder, pseudobulbar affect (involuntary laughing or crying), chronic obstructive pulmonary disease (COPD), asthma, Hemiplegia and Hemiparesis 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 Based on observation, interview and record review, the facility failed to effectively implement discharge planning for 1 of 4 residents (R52) reviewed for discharge planning according to resident specific goals. Resulting in frustration, findings include: Resident #52(R52) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R52 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included atrial fibrilation(irregular heart beat), heart failure, chronic obstructive pulmonary disease, respiratory failure, weakness, anxiety and depression. The MDS reflected R52 had a BIM (assessment tool) score of 11 which indicated her ability to make daily decisions was moderately impaired, and she required one person physical assist with bed mobility, transfers, dressing, toileting, hygiene, ambulation, locomotion, and bathing. The MDS reflected R52 had and mood score of 16 which indicated moderately severe depression. During an observation and interview on [DATE] at 3:20…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Activities of Daily Living (ADL) assistance to one (Resident #41) of two reviewed for ADLs, resulting in R41 not receiving the required supervision during care and the potential for injury. Findings include: Review of the medical record reflected Resident #41 (R41) admitted to the facility on [DATE], with diagnoses that included Crohn's disease, muscle weakness, osteomyelitis, anemia, and type two diabetes. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/13/22, reflected R41 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R41 required one-person physical assistance for ambulation and two-person physical assist for part of the bathing exercise. Review of the Care plan dated 12/8/2022 revealed R41 was at a risk for falls related to weakness and debilitation. R41 had a goal initiated on 12/8/2022 stating that R41 should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 coordination and follow-up related to hospital discharge medication orders (Kesimpta, a prescription medicine used to treat adults with relapsing forms of multiple sclerosis) and outside medical appointments for one residents (R1) of 19 residents reviewed for quality of care, resulting in verbalized complaints and delay in care and treatment. Findings include: Resident #1(R1) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R1 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included Multiple Sclerosis(MS) with quadriplegia and dysphasia, hypertension (high blood pressure), diabetes mellitus, legally blind, and generalized weakness. The MDS reflected R1 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required two person physical assist with bed mobility, transfers, dressing, toileting, hygiene,…

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

Based on observation, interview, and record review, the facility failed to identify use of unauthorized extension cord for 1 of 3 residents (R13) reviewed for accidents and hazards, resulting in the potential for accidents and injury. Findings include: During an observation on 1/09/23 at 3:50 PM an extension cord was noted extending from the wall across from the foot of the bed, across the walkway to under R13's bed(visual from hall door). The extension cord had 2 cords plugged into it with one being a cell phone charger. During an interview on 1/12/23 at 3:16 PM Facilities Director (FD) L reported residents not allowed have extension cords in facility and they do walking rounds daily to monitor for safety hazards. During a observation on 1/12/23 at 3:36 PM 2nd floor Unit Manager (UM) AA verified R13 moved rooms either 1/9/23 evening or 1/10/23 related to roommate conflicts and reported did not assist with the move. UM AA reported was not aware R13 had an extension cord in previous room that was in use and reported would verify not in use in new room. Housekeeping manager (HK) JJ…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician reviewed and acted upon identified medication regimen irregularities for one (Resident #14) of five reviewed for unnecessary medications, resulting in the potential for unnecessary medications and adverse reactions. Findings include: Review of the medical record reflected Resident #14 (R14) was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included unspecified dementia, auditory hallucinations, other hallucinations, dysthymic disorder, delusional disorders and major depressive disorder (recurrent, severe) with psychotic symptoms. The Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/9/22, reflected R14 scored seven out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R14 did not walk and performed many activities of daily living with extensive assistance of one 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 interview and record review, the facility failed to justify the use of antibiotics for one (Resident #44) of two reviewed for antibiotics, resulting in the potential for unnecessary medications and adverse side effects. Findings include: Review of an admission Record revealed Resident #44 (R44) admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness, bladder disorder, and hereditary spastic paraplegia. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/1/22, reflected R44 scored 15 of out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R44 did not walk and required extensive to total assistance of one to two or more people to perform most activities of daily living and had an indwelling catheter. Review of the Health Status Note dated 1/9/23 revealed, resident returned from appointment from [Clinic Name] Keflex 500 mg (milligrams) TID (three times a day) . A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to 1) ensure as needed psychotropic medications were not prescribed for longer than 14 days; and 2) justify an increase in antipsychotic medication for one (Resident #14) of five reviewed for unnecessary medications, resulting in the potential for unnecessary psychotropic medications and adverse reactions. Findings include: Review of the medical record reflected Resident #14 (R14) was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included unspecified dementia, auditory hallucinations, other hallucinations, dysthymic disorder, delusional disorders and major depressive disorder (recurrent, severe) with psychotic symptoms. The Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/9/22, reflected R14 scored seven out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R14 did not walk…

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