Medilodge of Capital Area

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, the facility failed to update/revise individualized, person-centered care plans to reflect the changing care needs for 1 resident (R5) of 23 residents reviewed for care plans, resulting in the potential for unmet care needs. Findings include: Resident #5: Observation on 8/4/2025 during the initial screen process of the healthcare survey revealed Resident #5 to be located in the 300-unit hall resting in bed. Resident #5 had a perimeter mattress and bilateral fall mats placed at bedside. Resident #5 was able to make eye contact, although could not respond appropriately to surveyor questions. Record review of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed an elderly resident with severe impaired cognitive ability of a Brief Interview of Mental status (BIMs) score of 1 out of 15. Medical diagnosis included dementia, anxiety and depression. Record review of Resident #5's care plans pages 1-42 noted on page 36 a care plan of: Resident resides on secure care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 activity of daily living skills were maintained for one of five residents reviewed (Resident #74). Findings include:Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed R74 scored 12 out of 15 (cognitively intact) on the Brief Interview for Mental Status. Review of R74's care plan dated 6/24/25 revealed he required one person assist for hygiene, there was no documentation in R74's clinical record that reflected refused or was resistant to care. On 08/04/2025 at 11:14 AM, during the initial screening process Resident #74 was observed in dining/former therapy room, hair was observed greasy and not combed, mustache was very long and went into his mouth. R74 was observed wearing blue jogging pants with food and debris on them. On 08/05/2025 9:17 AM observed sitting at side of bed, wearing same soiled blue jogging pants as they day prior, R74's hair was observed messy and greasy, the same observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the development of facility-acquired pressure ulcer injuries for one resident (R5) of three residents reviewed, resulting in facility-acquired (in-house) development of pressure ulcer/injuries, pain, discomfort, and likelihood for prolonged illness or hospitalization. Findings include: Resident #5:Record review of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed an elderly resident with severe impaired cognitive ability of a Brief Interview of Mental status (BIMs) score of 1 out of 15. Medical diagnosis included dementia, anxiety and depression. Section M: Skin noted a stage II pressure ulcer upon re-entry to the facility.Observation on 08/05/2025 at 9:19 AM of Resident #5 was lying in bed on her back. Resident was noted to have a small green positioning wedge device pushed off the bed and on the floor. Record review of Resident #5's 'Skin/Wound' assessments revealed on 5/16/2025 a Right Gluteal 100% epithelial measuring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 MI00151282 Based on observation, interview, and record review the facility failed to serve food at the preferred temperature for two resident (#2, #4) of three resident reviewed for food palpability resulting in dissatisfaction during meals. Findings Included: Resident #2 (R2): Review of the medical record revealed R2 was admitted to the facility 12/13/2024 with diagnoses that included kidney failure, acute cystitis (inflammation of the bladder), dissection of thoracic aorta, chronic ischemic heart disease, hyperkalemia (high potassium level), muscle weakness, anemia (low red blood count), post-traumatic stress disorder (PTSD), mood disorder, depression, and myalgia (muscle pain). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/21/2025, revealed R2 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 04/08/2025 at 08:20 a.m. R2 was observed walking from his bathroom back to his bed. R2 explained that he has not had a hot meal since he was admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 MI00151282 Based on observation, interview, and record review the facility failed to provide food preferences for one Residents (#2) of three sampled Residents resulting in frustration and an unpleasant dining experience. Findings Included: Resident #2 (R2): Review of the medical record revealed R2 was admitted to the facility 12/13/2024 with diagnoses that included kidney failure, acute cystitis (inflammation of the bladder), dissection of thoracic aorta, chronic ischemic heart disease, hyperkalemia (high potassium level), muscle weakness, anemia (low red blood count), post-traumatic stress disorder (PTSD), mood disorder, depression, and myalgia (muscle pain). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/21/2025, revealed R2 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 04/08/2025 at 08:20 a.m. R2 was observed walking from his bathroom back to his bed. R2 explained that he had issues with getting the food items that were listed on his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 #MI00150230 Based on observation, interview and record review, the facility failed to follow Physician's Orders for medications for one Residents (Resident #10) of 4 reviewed for physician orders. Findings include: Review of the medical record reflected R10 was admitted to the facility on [DATE], with diagnoses that included type two diabetes and cirrhosis of the liver. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/14/25, reflected R10 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R10 no longer resided in the facility. Review of the physician orders revealed an order initiated on 1/26/25 for Lactulose oral solution 10 grams (GM)/15 milliliters (ML) to be administers three times a day. Review of the Physician orders revealed an order initiated on 1/24/25 for Glimepiride Oral tablet 2 milligrams (mg) to be administered one time a day and an order for Isosorbide Dinitrate oral tablet 10…

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

This citation pertain to intake: MI00149478, MI00149576, and MI00149772 Based on observation, interview, and record review the facility failed to follow acceptable professional guidelines, by using PDI Sani-Cloth Germicidal Disposable Wipes while performing incontinent bowel care for one resident (#101) out of three residents reviewed. Findings Included: Resident #101 (R101) Review of the medical record reviewed R101 was admitted to the facility 07/17/2020 with diagnoses that included traumatic brain injury, schizoaffective disorder, dementia, hypertension, speech and language deficits, Parkinson's disease, gastro-esophageal reflux, dysphagia (difficulty swallowing), muscle spasm, and dysarthria (slurred speech). The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/02/2024, revealed a Brief Interview for Mental Status (BIMS) of 11 (moderate cognitive impairment) out of 15. During an interview on 02/10/2025 at 02:44 p.m. Certified Nurse Aide (CNA) D explained that on 01/06/2025 at 11:30 a.m. she had requested Staff Development Coordinator (SDC) I 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.

Based on observation, interview, and record review, the facility failed to maintain plumbing and refrigeration equipment, resulting in the potential for an increased risk of foodborne illness, affecting all residents that consume food from the kitchen. Findings include: On 6/25/24 at 9:58 AM, water was observed to be leaking from the in-line water filter provided for the coffee maker. At this time, water accumulation was observed on the floor. According to the 2017 FDA Food Code Section 5-205.15 System Maintained in Good Repair. A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; P and (B) Maintained in good repair. On 6/25/24 at 10:19 AM, the Arctic Air reach-in cooler was observed to be holding temperature at around 52 degrees Fahrenheit, read from the internal ambient air thermometer. At this time, Certified Dietary Manager (CDM) G stated that staff were just in the cooler and that the temperature hasn't dropped down yet since the door was open. Peanut butter jelly sandwiches, individually portioned salads, and meat and cheese sandwiches were observed in the cooler. 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.

Based on observation, interview, and record review, the facility failed to control pests in the kitchen and reduce harborage conditions, resulting in uncontrolled pests in the facility, affecting all residents in current facility census of 99 residents. Findings include: On 6/25/24 at 10:03 AM, a swarm of gnats were observed in the dry storage room, surrounding the bread rack, which is located directly next to a drainage pipe. At this time, Certified Dietary Manager (CDM) G stated that the pest control operator has provided them with floor and drain cleaner which is supposed to help with the gnats. On 6/25/24 at 10:15 AM, a swarm of gnats were observed flying around the grease trap by the three-compartment sink. On 6/25/24 at 11:35 AM, gnats were observed to be flying around the dish machine area. On 6/25/24 at 11:44 AM, a cart in the dining room was observed to be holding breakfast trays, while residents were in the dining room waiting for their lunch trays. The breakfast trays were observed to be attracting gnats, with multiple gnats observed on the leftover breakfast foods. 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, interview and record review the facility failed to ensure the Activities Director had minimum qualifications to perform the duties of the position effectively involving residents on the memory care unit with a current census of 20 residents. Findings include: On 06/25/24 at 10:03 AM during the initial tour of the facility's memory care unit, (census of 20) several residents were observed in bed. Nine residents were observed sitting in lounge/ TV area 7 of 9 residents were sleeping. No observed activity throughout the unit was in progress. On 06/26/24 at 12:48PM Eight residents were observed in day area, TV was on but residents were looking around and nodding off. On 06/27/24 at 09:09 AM, the day room area had the TV was on, 9 residents were present 4 were asleep and the other 5 residents were looking around the room. At 9:33 4 of the 6 residents continued to sleep the television was still on and none of the residents were watching it. The memory care Activity Calendar for 6/27/24 reflected a scheduled activity titled Coffee and Cocoa at 10:30 at 10:35am…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 at the preferred temperature for one resident (#57) and six residents (confidential resident group) and failed to provide condiments, food accuracy, preferred food palatability, preferred eating utensils, and preferred food items for six residents (confidential resident group) resulting in dissatisfaction during meals. Findings Included: Resident #57 (R57) Review of the medical record demonstrated that R57 was admitted [DATE] with diagnoses that included spinal stenosis, neoplasm (abnormal mass) related pain, malignant (cancer) neoplasm of the cervix, malignant neoplasm of bone, chronic obstructive pulmonary disease (CPOD), cognitive communication deficit, insomnia, mood disorder, depression, and back pain. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/30/2024, revealed R57 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. During 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 immediately report an injury of unknown origin for one out of six residents (Resident #25), resulting in the potential for further injuries of unknown origin to not be reported, and facility corrective action to not be taken. Findings Included: Per the facility face sheet R25 had been a resident at the facility since 11/16/2023 with a recent readmission on [DATE]. Review of an incident report dated 6/20/2024, revealed R25 was noted to have a small bruise that measured 0.5 inches by 0.5 inches on her forehead at her hairline. The report revealed R25 preferred to rest her head on the wall when standing in the bathroom while being changed. It was documented on the report, resident often leans forward and places head on wall. The report also revealed R25 was not able to give a description or stated what had happened that caused the bruising. The incident report did not describe the color of the bruise or the stage of healing the bruise was in.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a thorough investigation was conducted for one out of six residents (R25) sampled for alleged abuse resulting in the potential for abuse to occur, and necessary actions to not take place for resident protection. Findings Included: Per the facility face sheet R25 had been a resident at the facility since 11/16/2023 with a recent readmission on [DATE]. Review of an incident report dated 6/20/2024, revealed R25 was noted to have a small bruise that measured 0.5 inches by 0.5 inches on her forehead at her hairline. The report revealed R25 preferred to rest her head on the wall when standing in the bathroom while being changed. It was documented on the report, resident often leans forward and places head on wall. The report also revealed R25 was not able to give a description or stated what had happened that caused the bruising. The incident report did not describe the color of the bruise or the stage of healing the bruise was in.…

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

Based on observation, interview, and record review the facility failed to accurately complete a comprehensive assessment for one (Resident #254) of twenty residents reviewed resulting in the potential for unmet care needs. Finding Included: Resident #254 (R254) Review of the medical record demonstrated R254 was admitted to the facility 06/10/2024 with diagnoses that included Parkinson's Disease, type 2 diabetes, chronic obstructive pulmonary disease (COPD), Epilepsy (disorder of the brain characterized by repeated seizures), schizoaffective disorder, atrial fibrillation, anxiety, insomnia, dementia, hypertension, depression, anemia (low red blood cells), orthostatic hypotension, and stroke. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/16/2024, revealed R254 had a Brief Interview for Mental Status (BIMS) of 11 (moderate cognitive impairment) out of 15. Section M (skin conditions) of the MDS, with the same ARD, demonstrated that R254 did not have a pressure ulcer. During observation and interview on 06/25/2024 at 01:14 p.m. R254 was observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement resident care plans in two of 20 residents reviewed for care plans, resulting in the likelihood for the development of pressure ulcers and injuries (Resident #34) and a delay in dental care (Resident #36). Findings Include: Resident #34 (R34): R34's Minimum Data Set (MDS), with assessment reference date of 3/22/24 revealed she was admitted to the facility on [DATE], and her cognitive skills for daily decision making was severely impaired (never/rarely made decisions). The same MDS assessment revealed R34 was dependent in activities of daily living (ADL) care and, at the time of the assessment, had a facility acquired Stage 3 pressure ulcer (full tissue thickness loss; subcutaneous fat may be visible, but bone, tendon or muscle was not exposed; slough [devitalized tissue] may be present but does not obscure the depth of tissue loss; may include undermining [erosion under wound edges] and tunneling [passageways…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meaningful, diverse, and engaging activity program for one resident (#44) of one resident reviewed for activities. Findings include: Resident #44 (R44) Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected Resident # 44 (R44) was a admitted to the facility on [DATE] with diagnoses that included dementia and resided on the facility's secured memory care unit. R44 scored 00 on the Brief Interview for Mental Status indicating severe cognitive impairment. Review of R44's activity assessment dated [DATE] reflected R44 enjoys music, talk radio, walking and pet visits. The assessment reflected R44 had severe cognitive impairment and will make sounds but not normally words. Section 2 of the same assessments reflected materials would be provided as needed or requested. Section 4 of the assessment reflected R44 was cheerful, anxious/depressed and a passive observer. Review of R44's activity care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safely transfer Resident #34 with a mechanical lift, in one of four residents reviewed for accidents, resulting in a hematoma and bruises. Findings Include: Resident #34 (R34) On 6/27/24 at 8:35 AM R34 was observed lying in bed with her legs crossed at her knees. R34 had a raised bruise on the right side of her forehead. Resident Aide (RA) J and Certified Nurse Aide (CNA) I provided morning activities of daily living (ADL) care. Staff Development Registered Nurse (SDRN) C entered R34's room to perform a competency check-off for the mechanical lift transfer while surveyor was observing care. RA J placed a transfer sling with green binding under R34. RA J was guided by CNA I on how to don the sling and attach the sling to the mechanical lift transfer device (Maxi Lift). R34 was lifted from her bed in the sling without her head supported and her lower trunk was not fully supported in the sling. RA I and CNA J lowered R34 back to her bed,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to ensure their medication error rate was below 5% when three medication errors were observed from a total of 27 opportunities for one resident (Resident #81) of seven reviewed resulting in a medication error rate of 11.11%. Findings include: On 06/26/24 at 9:05 AM, Licensed Practical Nurse (LPN) K was observed preparing and administering medications to R81. LPN K administered Metoprolol (used to treat hypertension/high blood pressure) 25 milligrams (mg) , two Senna Plus (senna 8.6 mg (laxative) with docusate sodium 50 mg (stool softener)) , and 25 milliliters (mL) of ClearLax (Miralax/laxative). LPN K measured the ClearLax in a plastic pill cup. When asked how much was being administered, LPN K reported 25 milliliters (mL). R81 was admitted to the facility on [DATE] with diagnoses that included thoracic spine injuries. Review of R81's Physician's Order dated 6/6/24 revealed R81 was ordered to receive Metoprolol 25 mg half tablet (12.5 mg) twice 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 promptly schedule a dental referral, in one of one resident reviewed for dental care (Resident #36), resulting in continued pain and a delay meeting resident goals. Findings include: Resident #36 (R36) R36 was observed sitting in his bed on 6/26/24 at 8:27 AM and stated he had sores in his mouth, like blisters, that caused him pain. R36 complained that he was supposed to see another dentist but was not aware if an appointment had been scheduled. R36's MDS with ARD dated of 3/07/24, revealed he was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS, cognitive screener) score of 10 (08-12 Moderate Impairment). In review of R36's care plans on 6/26/24, there was no care plans regarding dental issues or oral care. R36's Dental visit notes dated 3/28/24 revealed R36 had the diagnoses of dementia, obstructive sleep apnea, and lung disease. R36 had generalized soreness in his mouth, including burning sensations.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adaptive equipment for one resident (#30) out of twenty residents, resulting the potential for decrease independence with preparing meals and eating. Findings Included: Resident #30 (R30) Review of the medical record demonstrated R30 was admitted to the facility 04/30/2024 with diagnoses that included osteomyelitis (inflammation of bone caused by infection) of left ankle an foot, type 2 diabetes, arthritis, myocardial infarction (hear attack), heart disease, uropathy (disease affecting urinary flow), absence right leg below knee, urinary retention, cognitive communication deficit, depression, atherosclerosis (build-up of fats, cholesterol in and on the artery walls), peripheral vascular disease (PVD), hypertension, hyperlipemia (high fat content in blood), insomnia, and stroke. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/05/2024, revealed R30 had Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During 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.

Based on observation, interview, and record review the facility failed to ensure proper communication/documentation of Hospice services provided to one resident's responsible person (Resident #56) of one resident reviewed for Hospice services, resulting in a lack of coordination of comprehensive services and care provided. Findings Included: Resident #56 (R56) Review of the medical record demonstrated R56 was admitted to the facility 02/15/2024 with diagnoses that included dementia, traumatic subdural hemorrhage (brain bleed), type 2 diabetes, osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down), atrial fibrillation, urine retention, gastro-esophageal reflux, Alzheimer's Disease, depression, hyperlipidemia (high fat content blood), and hypertension. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/26/2024, revealed R56 had a Brief Interview for Mental Status (BIMS) of 00 (sever cognitive impairment) out 15. The same MDS demonstrated section O-Special, Treatments, Procedures, and Programs demonstrated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer pneumococcal immunizations in accordance with the Center for Disease Control and Prevention (CDC) recommendations for one resident (#25) of five residents reviewed resulting in the potential for server illness and complications from pneumococcal disease Findings Included: Resident #25 (R25) Review of the medical record demonstrated that R25 was admitted to the facility 11/18/2023 with diagnoses that included dementia, chronic kidney disease, anxiety, hyperlipidemia (high fat content in blood), sever protein-calorie malnutrition, hypertension, depression, muscle weakness, insomnia, irritable bowel syndrome, and spinal stenosis. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/25/2024, revealed R25 had a Brief Interview for Mental Status (BIMS) of 2 (severe cognitive impairment) out of 15. Review of R25's medical record demonstrated a date of birth of [DATE]. R25's medical record demonstrated that she had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation and record review the facility failed to honor residents rights for one resident #4 (R4) of one resident reviewed for resident rights resulting in increased anxiety, PTSD symptoms, decreased self-worth and psychosocial wellbeing. Findings Include; Resident #4 (R4) Review of the medical record revealed Resident #04 (R04) was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, acute kidney failure, pressure ulcer of sacral region, malignant neoplasm of connective and soft tissue, major depression, anxiety, post-traumatic stress disorder, acquired absence of left hip joint, absence of left leg, segmental and somatic dysfunction of upper extremity and polyneuropathy. According to Resident #04 (R04)'s Minimum Data Set (MDS) dated [DATE], revealed R04 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R04 requires 2 persons…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: MI00142444 Based on observation, interview, and record review the facility failed to obtain a timely urinary analysis for one resident (#7) of three residents reviewed for timely laboratory services. Findings Included: Resident #7 (R7) Review of the medical record revealed R7 was admitted to the facility 05/24/2023 with diagnoses that included sepsis, bacterial infections, type 2 diabetes, chronic obstructive pulmonary disease (COPD), pressure ulcer sacral region, malignant neoplasm (cancer) of connective and soft tissue, depression, anxiety, adjustment disorder, post-traumatic stress disorder (PTSD), hypertension, and urinary tract infection. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/20/2023, demonstrated a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. R7's MDS, with the same ARD, section H-Bowel and Bladder, demonstrated that she has an indwelling urinary catheter. During observation and interview on 02/13/2024 at 11:47 a.m. R7 was observed lying down in bed. Observed…

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

Based on interview and record review the facility failed to accurately record grievances for one resident (#1) out of three residents resulting in the potential for unresolved resident grievances. Findings Included: Resident #1 (R1) Review of the medical record revealed R1 was admitted to the facility 06/28/2023 with diagnoses that included infection following a surgical procedure, chronic obstructive pulmonary disease (COPD), asthma, ankylosis (abnormal stiffening and immobility of joints), right tibial (leg bone) tendinitis, adjustment disorder, anxiety, overactive bladder, chronic kidney disease, edema (swelling), ankle contracture (tissue tightening causing deformity), left tibial tendinitis, carpal tunnel syndrome of the left upper limb, and hypertension. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/03/2023, revealed R1 had a Brief Interview of Mental Status (BIM) of 15 (cognitively intact) out of 15. Section M-Skin Conditions of the MDS, with the same ARD, revealed that R1 had a surgical wound. R1 was discharged from the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, and record reviews, the facility failed to remove/discard expired ready-to-eat food products, effecting 81 residents that consume meals from the facility kitchen, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness. Findings include: On 04/24/23 at 08:40 AM, during the initial kitchen tour with facility cook S the first cooler container d a bag of sliced ham, the bag was opened and not dated, an open container of not labeled or dated contained 5 loose hot dogs, and a large zip lock bag was observed to have 8 sandwich size bags that contained 1/2 peanut butter and jelly sandwiches, none of the bags were labeled or dated. The second cooler contained a container of sliced cheese with a use by date of 4/23. There were 2 pitchers of liquid, one yellow one pinkish red, neither were labeled or dated. The freezer was observed to have a clear bag of meatballs 2.5 pounds was printed on the bag, but the bag was not labeled or dated. 5 packages of frozen waffles Freezer #5 in the row- 5 separate…

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

Based on observation, interview, and record review, the facility failed to; 1) maintain the physical plant and, 2) provide infection surveillance for 83 residents, resulting in the potential spread of harmful microorganisms and placing staff and other residents at potential risk of infection. Findings Included: During a tour of the facility laundry facility on 04/26/2023 at 08:46 a.m., with the Manager of Laundry and House Keeping O, it was observed that the two washing units were in the soiled section of the laundry room. Several containers of laundry solution was observed to be stored between one washing machine and a wall. Behind the containers it was observed that gypsum board had been removed from the wall and aluminum studs could be viewed. The gypsum board on the opposite side of the aluminum studs could be seen. A film of dark black substance and rust was visible on the aluminum studs. A film of dark black substance could be seen on the gypsum board on the other side of aluminum studs. A film of dark black substance could also be seen on the floor. The opening of the gypsum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 effectively clean and maintain the physical plant affecting 83 residents resulting in unsanitary conditions and the potential harborage of micro-organisms and the potential of decreased air quality. Findings Included: During a tour of the facility laundry facility on 04/26/2023 at 08:46 a.m., with the Manager of Laundry and House Keeping O, it was observed that the two washing units were in the soiled section of the laundry room. Behind the two washers, in an area approximately 6 feet by 12 feet, it was observed that the area contained old PVC (synthetic resin) pipe under the current washer drain. It was also observed that the floor was soiled and appeared to be un-uncleaned. A heating register was also observed to have a significant amount of what appeared to be rust on the register guard. An exhaust fan, which exited the building, was also observed to a significant amount of lint on the fan blades and around the inner guard of the unit. In an interview on 04/26/2023 at 08:46 a.m. with the Manager of Laundry…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 grievances were promptly investigated, and resolved for five of five Residents( resident #'s 15, 18, 33, 55 and 84) reviewed for grievances, resulting in anger and frustration. Findings include: Resident 55(R55) According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] , Resident # 55 (R55) was admitted to the facility on [DATE] with diagnoses that included spinal stenosis, anxiety. R55 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 04/24/23 at 10:17 AM, during a bedside interview with R55 it was reported every time Licensed Practical Nurse (LPN ) C was on duty misses dose of scheduled pain medication and medications with a physician ordered administration time of 8:00 am was frequently not administered until 11:00 am or later if LPN C was the assigned nurse. R55 stated the complaints have been verbalized on multiple occasions to management staff and have…

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

Based on observation, interview, and record review, the facility failed to (1. ensure multi-dose insulin pens were dated upon opening in 1 of 3 medication carts; (2. label open multi-dose prescription eye drop with open date and resident name in 1 of 3 medication carts reviewed for labeling, dating and expiration of medications; (3. dispose of expired medications and/or medical supplies in 2 of 3 medication carts reviewed; and 4.) maintain secure treatment cart. This deficient practice resulted in the potential for administration of expired medications and decreased therapeutic effects of administered medications, the potential for cross contamination, and medication errors in a current facility census of 83. Findings include: During an observation and interview on 4/24/23 at 1:09 PM, Licensed Practical Nurse (LPN) C opened the 500B medication cart. One opened bottle of Folic Acid 400 mg with manufacturer expiration(manf. exp) date of 7/22, one open bottle of Vitamin D3 50000iu with manufacture expiration date 9/22 and one opened bottle of Allergy Relief Cetrizine Hyero 10mg with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the accuracy of 2 out of 18 residents (R72 and R16) Minimum Data Set (MDS) assessment, out of a total sample of 18, resulting in the potential for inaccurate assessment information, and resident care needs not being met. Findings included: Resident 72 (R72) Review of the medical record reflected R72 was an initial admission to the facility on [DATE]. Diagnoses of Alzheimer's disease, Chronic Viral Hepatitis C, unspecified mood disorder, symptoms of and signs involving cognitive functions and awareness, psychotic disorder with delusions due to known physiological condition, cognitive communication deficit and anxiety. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2023, revealed R72 had a Brief Interview of Mental Status (BIMS) of 00 (severely impaired) out of 15. Under section G0110, Activities of Daily Living (ADL) Assistance reveals R72 requires extensive assistance with care provided,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise care plans for 1 resident (resident #16) of 18 residents reviewed for care plans, resulting in the potential for mismanaged care and unmet nutritional goals for resident 16. Findings include: According to the clinical record, including the Minimum Data Set (MDS) dated [DATE], Resident # 16 (R16) was [AGE] year old and had resided at the facility for one year with diagnoses that included chronic obstructive pulmonary disease, morbid obesity and hypertension. R16 scored 15 out of 15 (cognitively intact) on the Brief interview for Mental Status (BIMS). Review of Registered Dietician (RD) E progress notes dated 2/20 and 2/21/23 reflected R16 weighed 378 pounds and verbalized to RD E that R16 had desired to lose weight. Review of R16's nutritional care plan dated 4/04/22 with a revision date of 3/13/23, did not identify morbid obesity as a problem, was not updated include a goal for weight loss or approaches on how the facility would…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide meaningful, individualized activities to 1 resident (R13) of 18 reviewed for activities, from a total sample of 18 residents, resulting in the potential for loneliness, boredom and feelings of lack of self-worth. Findings include: Resident 13 (R13) Review of the medical record reflected R13 was initially admitted to the facility on [DATE] and then admitted to hospice on 10/12/21. Diagnoses of Alzheimer's disease, peripheral vascular disease, muscle weakness, major depression and anxiety. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/20/2023, revealed R13 had a Brief Interview of Mental Status (BIMS) of 03 (severe impairment) out of 15. Under section G0110, Activities of Daily Living (ADL) Assistance reveals R13 requires extensive assistance to dependent with all care provided. Observation of activities listed on the white board for 04/25/23 revealed 10:30 Am coffee and cocoa, 1:30 pm movie,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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) follow Physician's Orders for medications for two Residents (R15 and R55) of 18 reviewed for physician orders; 2) ensure appropriate monitoring of blood glucose (sugar) levels for one Resident (R15) of one reviewed for assessment and monitoring; and 3) ensure insulin was administered according to Physician's Orders for one Resident (R15) reviewed for medications, resulting in medications not being administered according to Physician's Orders and/or manufacturer instructions, and lack of appropriate monitoring and management of diabetes. Findings include: Resident #15(R15) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R15 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), renal failure, diabetes with use of insulin, falls, depression and anxiety. The MDS reflected R15 had a BIM (assessment tool) score of 14 which indicated her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure two out of three residents (Resident #16 and 77) maintained an acceptable nutritional status and identifying potential causes for weight loss and gain resulting in the potential for further weight loss and/or gain. Findings Included: Resident #77 (R77): Per R77's electronic medical record (EMR) R77 was admitted to the facility on [DATE]. Diagnoses included open wounds to lower back, pelvis, left foot, and gangrene. In an interview on 4/24/2023 at 12:11 PM, R77 stated he had lost 40lbs (pounds) since he was admitted to the facility. During the interview with R77 a staff member entered his room to pick up his lunch tray. The staff member asked R77 if he was going to eat, and R77 said no he was not hungry. R77's food tray was observed during the interview which revealed R77 did not take one bite of his food. Review of R77's documented weights revealed that upon his admission on [DATE], R77 weighed 220 lbs., and on 04/13/2023, R77…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 was made aware and involved in significant weight losses and gains for one resident (R16) of 3 residents reviewed for nutritional status. This deficient practice resulted into R16's significant weight gains and losses going unevaluated and treated by the physician. Findings include: Resident #16 (R16) According to the clinical record, including the Minimum Data Set (MDS) dated [DATE], Resident # 16 (R16) was [AGE] year old and had resided at the facility for one year with diagnoses that included chronic obstructive pulmonary disease, morbid obesity and hypertension. R16 scored 15 out of 15 (cognitively intact) on the Brief interview for Mental Status (BIMS). Further review of the clinical record reflected section K of the MDS dated [DATE] was coded for significant weight loss (5% loss in one month or 10% loss in 6 months). Review of R16's medical record reflected, on 12/09/2022, the R16 weighed 346.8 pounds. On 01/05/2023, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician reviewed and acted upon identified medication regimen irregularities for one (Resident #16) of seven reviewed for unnecessary medications, resulting in the potential for unnecessary medications and adverse reactions. Findings include: According to the clinical record, including the Minimum Data Set (MDS) dated [DATE], Resident # 16 (R16) was [AGE] year old and had resided at the facility for one year with diagnoses that included chronic obstructive pulmonary disease, morbid obesity and hypertension. R 16 scored 15 out of 15 (cognitively intact) on the Brief interview for Mental Status (BIMS). Further review of the clinical record reflected the pharmacy reviewed R16's medication regimen and documented their recommendations the progress note in the electronic record reflected (see recommendation) further review of the clinical did not have the recommendations/ pharmacy report scanned in for the following dates: 6/14/22, 8/09/22,…

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

Based on observation, interview, and record review the facility failed to ensure a medication error rate less than five percent when 13 medication errors were observed from a total of 27 opportunities for two resident (R8 and R18) of seven residents observed during medication administration, resulting in a medication error rate of 48.15%. Findings include: During medication pass task observation, interview and record review on 4/25/23 at 1:51 PM, Unit Manager X reported was not the nurse assigned to the 200 hall medication cart but was asked by management a few minutes prior to assist Licensed Practical Nurse (LPN) F. UM X reported LPN F was nurse on 200 hall and half of 300 hall today from 6:30 a.m. to 7:00 p.m. and was currently working on 300 hall and had no knowledge of any emergencies that day that would have delayed scheduled medication pass. UM X unlocked the 200 hall medication cart and prepared 13 medication two supplements for R8 that included: -allopurinal 100mg one tablet -vitamin c 500mg 2 tablets -aspirin 81mg 1 tablet -bumex 1mg 2 tablets -vitamin D 1000iu 1 tablet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor medication administration to ensure medications were administered timely and according to professional standards of practice in 2 of 18 residents reviewed for medications (Resident #2 & #244), resulting in the potential to cause resident discomfort (Resident #2) and the potential to jeopardize health (Resident #2 & #244). Findings include: Resident #2 (R2) R2 was observed sitting in a wheelchair in the activity room [ROOM NUMBER]/25/23 at 12:21 PM. R2's Minimum Data Set (MDS) dated [DATE] revealed she admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score of 15 (13-15 Cognitively Intact), required extensive assistance for personal hygiene, and was admitted with a Stage 3 pressure ulcer (full thickness tissue loss), high blood pressure, diabetes mellitus, multiple sclerosis (causes nerve dysfunction), and pulmonary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observation, interview, and record review the facility failed to provide influenza vaccinations to two residents (#77, #84) out of five residents reviewed for influenza vaccination resulting in the exposure of serious illness to the residents. Findings Included: Resident #77 (R77) Review of the medical record revealed R77 was admitted to the facility 01/13/2023 with diagnoses that included Fournier gangrene (bacterial infection of scrotum, penis, or perineum), type 2 diabetes, wound to left foot, gout (increase of uric acid in bone joints), wound to lower back, congestive heart disease (CHF), lymphedema (swelling of body caused by abnormal accumulation of lymph), dementia, and hypertension. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/19/2023, revealed R77 had a Brief Interview for Mental Status (BIMS) of 15 (intact cognition) out of 15. During observation and interview on 04/26/2023 at 08:32 a.m. R77 was observed lying in bed. R77 explained that he had not received the influenza vaccination at the facility but that he was interested…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observation, interview, and record review the facility failed to provide Covid-19 vaccinations to two residents (#15, #84) out of five residents reviewed for Covid-19 vaccination resulting in the exposure of serious illness to the residents. Findings Included: Resident #15 (R15) Review of the medical record revealed R15 was admitted to the facility 03/14/2023 with diagnoses that included type 2 diabetes, chronic kidney disease, hyperlipidemia (high fat content in the blood), anxiety, and depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/20/2023, revealed R15 had a Brief Interview for Mental Status (BIMS) of 14 (intact cognition) out of 15. During observation and interview on 04/26/2023 at 08:35 a.m. R15 was observed sitting on the side of her bed. She explained that she was not offered a Covid-19 immunization when she was admitted to the facility. R15 explained that she was interested in the Covid-19 immunization and had been offered it yesterday. She also explained that a nurse had told her that she was going to get 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.