Lapeer County Medical Care Facility

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to Intake Number 2661843. Based on observation, interview and record review, the facility failed to ensure supervision was provided during mealtime for two residents (#1 and 2), who had safe swallow instructions during meals, of four Residents reviewed for dining and assistance with meals. Findings include:On 11/13/25 at 12:15 PM, an observation was made of the dining room on the second floor during the lunchtime meal. The following observations were made:-Resident 1 (R1) was sitting in a Broda chair. The Broda chair is slightly reclined. There were two men working on the construction near the cabinets with yellow caution tape blocking the area. Resident 1 is positioned facing the construction area. -Resident 2 (R2) was positioned at a table with two other residents with her back towards the construction area and facing the outer wall. -At 12:32 PM, lunch trays are passed on the 2nd floor dining area. The hot food is served onto plates on the other side of the kitchenette area and not 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 call lights were within reach and responded to in a timely manner for 11 residents (R3, R16, R22, R36, R46, R52, R61, R63, R80, R116, R138) and a confidential group of residents, resulting in long call light wait times, delayed assistance and call lights not being accessible. Findings include: Resident #16 R16 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include hypertension, gastro-esophageal reflux disease and atherosclerotic heart disease. R16 has a brief interview for mental status (BIMS) score of 15, indicating they are cognitively intact. On 02/19/25 at 10:16AM, an interview was conducted with R16. R16 was asked if the facility staff answers her call light in a timely manner. R16 stated the staff can be slow to answer call lights, it's especially slow during meal pass times and when they are picking up trays. R16 stated that she has waited 3hrs one time. R16 was asked if they have ever had any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to update and reviews care plans for psychotropic meds, pain, skin care and respiratory care for 4 Residents (R#3, R#32, R#47, & R#90) of 5 sampled residents reviewed for care plans. Findings include: Resident #3 (R3) General According to the Electronic Medical Record reviewed on 2/19/2025 at 2:00 PM, R3 was [AGE] years old who was admitted to the facility on [DATE] with a diagnosis of Alzeihmers Disease (late onset), Carcinoma of the situ of skin and scalp, and neck, Squamous cell cardinoma of the skin of scalp and neck and Chronic Kidney Disease Stage 3 in addition to other diagnoses. R3 has a Brief Interview of Mental Status (BIMS) Score of 08/15 assessed on 12/4/2024. A Score of 08-12 on the BIMS indicates moderate cognition impairment. A score of 0-7 points suggests severe cognitive impairment and a scor of 13-15bpoints suggests that cognition is intact. R3, according to the Minimum Data Set (MDS) assessment dated [DATE] is dependent 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 provide a safe and monitored environment to prevent falls and injuries for 4 Residents (# 21, #103, #126, #127) of 13 residents reviewed for falls, resulting in residents having multiple falls and Resident's #'s 126 and #127 sustaining large bruises on their faces. Findings Include: Resident #21 Accidents A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #21 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Alzheimer's dementia, History of a stroke, heart disease, hypertension, , orthostatic hypotension, history of repeated falls, anxiety, kidney disease, and arthritis. The MDS assessment dated [DATE] revealed the resident had severe cognitive loss with a Brief Interview for Mental Status/BIMS score of 3/15 and the resident was dependent for most care. On 2/18/2025 at 11:18 AM, Resident #21 was observed sitting in the day room for an activity. A record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain a consistently operational call light system affecting three residents (Resident #46, Resident #63 and Resident #74) and a resident census of 158, resulting in extended call light times, unmet needs, and inconsistent tablet operability. Finding include: FACILITY On 02/19/25 at 02:18PM, an interview was conducted with Certified Nursing Assistant (CNA) E. CNA E was asked how they know if there is a resident call light on. CNA E stated they have tablets in the halls that will show call lights that are on. CNA E was asked how reliable the tablets are. CNA E stated, sometimes the tablets will crash and I will reboot it. Sometimes it works and sometimes it doesn't. We have an app for our phones as well, but it drains my battery so I don't use it. There is a computer in the nurses station that has every call light that is on in the building. On 02/19/25 at 2:24PM, an interview was conducted with CNA F. CNA F was asked if there was any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to validate and update the care plan for DNR status for one resident (R#47) of 3 residents reviewed for advanced directives. Findings include: Resident #47 Advance Directives On 02/19/25 at 12:47 PM, R47's Advanced Directives in her clinical file was dated 11/1/2023. Resident #47 (R47) According to the review of Electronic Medical Records conducted on 2/20/25 at 2:45 PM, R47 was [AGE] years old and admitted to the facility on [DATE] with the diagnosis of Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side, vascular dementia with mood disturbances, and peripheral vascular disease in addition to other diagnoses. R47's son was the Durable Power of Attorney (DPOA) and emergency contact. R47's Brief Interview of Mental Status (BIMS), which was assessed on 12/25/24, revealed a score of 09/15. A score of 9 indicates moderate cognitive impairment. A score of 0-7 represents severe cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete a comprehensive care plan for one resident (R32) of four residents reviewed for unnecessary medications. Findings include: Resident #32 R32 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include, dementia, major depressive disorder, dysphagia and atrial fibrillation. R32 has a brief interview for mental status (BIMS) score of 3 indicating severe cognitive impairment. On 02/20/25 at 09:57AM, record review revealed that R32 admitted to the facility on [DATE] and there is a physician's order dated 09/10/24 for Venlafaxine (Effexor) HCl ER Tablet 150mg, give one tablet by mouth one time a day for depression. On 02/20/25 at 11:31AM, record review revealed that R32 has a care plan in place for Effexor for depression, however, Effexor was discontinued on 01/05/25. The psychotherapeutic medications care plan was initiated on 12/6/24, psychotherapeutic medication (Effexor) was initiated on 09/10/24. On 02/20/25 at 11:53AM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nail care was provided for two residents (#46 and #78) of five residents reviewed for Activities of Daily Living (ADL). Findings include: Resident #46: A review of Resident #46's medical record revealed a readmission into the facility on 7/28/22 with diagnoses that included chronic obstructive pulmonary disease, quadriplegia, heart disease, and contracture of unspecified joint. A review of the Minimum Data Set (MDS)assessment revealed the Resident had intact cognition and was dependent on staff for activities of daily living, mobility and transfers. On 2/18/25 at 12:27 PM, an interview was conducted with Resident #46 who answered questions and engaged in conversation. The Resident was observed to have limited mobility of her hands. The Resident's fingernails were long and there were a couple nails that had nail polish that was chipped or worn off from most of the nails. The Resident was asked about her fingernails, and she responded…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 coordination of Hospice Services for one resident (#151) reviewed for Hospice service. Findings Include: Resident #151: Hospice and End of Life A review of the Face sheet and MDS/Minimum Data Set assessment indicated Resident #151 was admitted to the facility on [DATE] with diagnoses: Seizures, history of falls with fractures: fourth cervical vertebra, nasal bones, maxilla, Dementia, anxiety, depression and hypertension. The resident wore a neck brace for the cervical fracture. A review of the physician orders indicated the resident was admitted to Hospice services on 1/21/2025 on admission. On 2/18/2025 at 12:17 PM, Resident #151 was observed sitting in a chair in his room watching TV. He was talkative and tried to answer question. He said he did not think he was receiving Hospice services. A review of the Care Plans identified a Hospice Care Plan dated initiated 2/3/2025 and revised 2/4/2025 with an intervention: Work…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review, the facility failed to assess and monitor pain levels and update a care plan for pain for one resident (Resident #3) with a diagnosis of Squamous Cell Carcinoma of the skin of scalp and neck requiring comfort in positing and wound care treatment of 3 residents reviewed for pain management. Findings include: Resident #3: Pain Management According to the Electronic Medical Record reviewed on 2/19/2025 at 2:00 PM, R3 was [AGE] years old who was admitted to the facility on [DATE] with a diagnosis of Alzheimer Disease (late onset), Carcinoma of the situ of skin and scalp, and neck, Squamous cell carcinoma of the skin of scalp and neck and Chronic Kidney Disease Stage 3 in addition to other diagnoses. R3 has a Brief Interview of Mental Status (BIMS) Score of 08/15 assessed on 12/4/2024. A Score of 08-12 on the BIMS indicates moderate cognition impairment. A score of 0-7 points suggests severe cognitive impairment and a score of 13-15 points suggests that cognition is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical staff received completed yearly Performance Evaluations and competencies for 2 of 2 nurses (N and O) and Performance Reviews for 2 of 2 Nurse Aides (L and M), Findings Include: FACILITY Sufficient and Competent Nurse Staffing: On 2/24/2025 at 9:11 AM, during a review of the Nurse and Nurse Aide competency reviews for Nurses N (Charge Nurse) and O and Certified Nursing Assistants L and M, it was identified there were no yearly Performance reviews. The nurses' yearly competencies had not been completed. Nurse N's competencies were last completed 1/26/2024: greater than 1 year prior. Nurse O's competencies were last completed 1/22/2024: greater than 1 year prior. On 2/25/2025 at 10:30 AM, Staff Education Nurse C was interviewed about the yearly clinical staff Performance reviews. He said the facility did not complete performance reviews to aid in determining staff training/competency needs for the nurses or nurse aides. Staff Educator Nurse C said the facility talked about completing yearly Performance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that medication had arrived timely to the facility and that medication was administered following physicians' orders and professional standards of care for one resident (Resident #358) of six residents reviewed for medication administration, resulting in Resident #358 not receiving the medication Renvela and Cholestyramine as ordered and the medication Cholestyramine given with other medications. Findings include: Renvela, sevelamer carbonate, a medication used to control phosphorus levels used in diagnosis of patients with chronic kidney disease that are on dialysis. Cholestyramine, a bile acid sequestrant medication that absorbs/combines with bile acids, excreted in the feces which leads to a decrease in low density lipoprotein plasma levels and decrease in serum cholesterol levels and is recommended to take other medication at least 1 hour before or 4 to 5 hours after taking cholestyramine. On 2/20/25 at 10:29 AM, an observation was made during medication administration of Resident #358 receiving…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure Infection Prevention and Control standards of practice were followed for 1) Personal Protection Equipment/PPE use during wound care for one resident (Resident #90) in Enhanced Barrier Precaution. Findings Include: Resident #90: A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #90 indicated an admission date of 3/12/2020 with diagnoses: Alzheimer's dementia, depression, arthritis, hypertension, heart disease, and anxiety. An unstageable pressure ulcer on the right heel was identified on 1/13/2025. The MDS assessment dated [DATE] identified the resident had severe cognitive loss with a Brief Interview for Mental Status/BIMS score of 5/15 and the resident needed assistance with all care. A review of the assessments for Resident #90 revealed she also had a wound on the outer base/hallux of her right great toe and on the top of the toe. On 2/21/2025 at 8:45 AM, wound care for Resident #90 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.

Based on observation, interview and record review, the facility failed to ensure warm water availability in residents' rooms and that sink drainage was adequate for three residents (#23, #25 and #70), of a sample of 17 reviewed for environmental concerns. Findings include: On 2/19/25 at 10:12 AM, an observation was made in Resident #25's room of the Resident getting ready for a bed bath. CNA BB had left the room with a wash basin and returned a couple minutes later. When asked why the CNA had left the room to get water, the CNA reported that the sink in the room did not produce hot enough water to wash a resident up. The CNA state, It will get a little warm then go cooler, but not enough warm water when they are getting washed up. The hot water faucet was turned on and was lukewarm and the sink filled too much to keep it running. When asked about the poor drainage of the sink, the CNA stated, Most of the sinks down here, they don't drain fast enough. On 2/21/25 at 9:43 AM, an interview was conducted with Resident #70 who answered questions and engaged in conversation. The Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number MI00145825. Based on observation, interview and record review, the facility failed to properly apply restraints in a transportation van and operationalize facility policy for one resident (Resident #1) of three residents reviewed for incident and accidents resulting in the resident falling out of their rolling walker during transportation and getting assisted off the floor of the van before being assessed by a license nurse. Findings include: Resident #1: Resident #1 is [AGE] years old and was admitted to the facility on [DATE] with diagnoses that include chronic pain syndrome, chronic kidney disease, hyperlipidemia and depression. Resident #1 has a brief interview for mental status score of 15 indicating they are cognitively intact. On 07/30/24 at 10:25am, an interview was conducted with R1. R1 was observed with a bruise on their left cheek, sitting on the edge of the bed and in good spirits. R1 stated they have been receiving Cortisone injections for an ongoing right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Numbers MI00136997 and MI00139597. Based on observation, interview and record review, the facility failed to ensure dignified and respectful treatment for three residents (Resident #33, Resident #49, and Resident #106) reviewed and nine of nine Confidential Group Residents, resulting in Resident #106's indwelling urinary catheter drainage bag being exposed and not contained/covered, meals being served on aluminum foil, call lights not being answered in a timely manner, a lack of available staff, staff speaking to staff in a rude manner, and resident verbalizations of feeling unimportant and unvalued. Findings include: Resident #106: On 12/13/23 at 9:43 AM, Resident #106's room door was open. From the hallway, the Resident was observed laying in bed uncovered with their legs and brief exposed. An indwelling urinary catheter was present, and the drainage bag was uncovered and hooked on a walker positioned next to the bed. The Resident's eyes were closed and an overbed table with 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 ensure that care plan interventions were evaluated/revised for effectiveness and updated with changes/interventions for two resident (Residents #7, and Resident #403) of 27 residents reviewed for care plans, resulting in in the lack of care plan revision, implementation of appropriate interventions and the potential for unmet care needs relating to activities of daily living, weights and call bell use. Findings include: Resident #7: A review of Resident #7's medical record revealed an admission into the facility on [DATE] and readmission on [DATE], with diagnoses that included heart disease, asthma, urinary tract infection, anxiety disorder, schizophrenia, sepsis, dementia, and mood disorder. A review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 3/15 that indicated severely impaired cognition and needed substantial/maximal assistance with most activities of daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 coordinate care for four residents (Resident #7, Resident #127, Resident #134, and Resident #135) of four residents reviewed for changes in condition, resulting in a delay in treatment of skin infestation for Resident #127 and Resident #135 with the potential of worsening, itching, pain and infection; a delay in assessment and potential treatment of rectal pain for Resident #134, and a failure to assess and monitor a 10 pound weight gain in seven days for Resident #7 with the potential adverse health conditions to go undetected and untreated. Findings include: Resident #7: A review of Resident #7's medical record revealed an admission into the facility on 5/18/22 and readmission on [DATE], with diagnoses that included heart disease, asthma, urinary tract infection, anxiety disorder, schizophrenia, sepsis, dementia, and mood disorder. A review of the Minimum Data Set (MDS) assessment, dated 11/8/23, revealed a Brief Interview of Mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that licensed nurses (RN's-Registered Nurses and LPN's-Licensed Practical Nurses) received yearly evaluations/competencies to assure resident care and safety, and attain or maintain the highest practicable physical, mental and psychosocial wellbeing of residents in accordance with the facility assessment and residents' plans of care for five nurses of five nurses reviewed for education and competencies, affecting all 152 residents residing in the facility, resulting in the potential nursing staff lacking necessary training, skills, and competencies to adequately care for the needs of the residents residing in the facility. Findings include: On [DATE] at 4:12 PM, an interview was conducted with Inservice Director V. The Inservice Director was questioned regarding evaluations and competencies for the Nursing staff. The following Nurses were reviewed for yearly evaluations and competencies: LPN Z, RN Y, RN AA, RN BB, RN G, all of whom worked at 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 Number MI00141186. Based on interview and record review, the facility failed to inform and invite a resident and the resident's representative to regularly scheduled care conferences for one resident (Resident #403) of one resident reviewed for care conferences (meeting to discuss residents' plans of care), resulting in the resident and the residents' representatives being uninformed and not involved in their plan of care or able to make choices for care at the facility. Findings include: Resident #403: A review of Resident #403's medical record revealed an admission into the facility on [DATE] with diagnoses that included acute respiratory failure, spastic hemiplegia, diabetes, anxiety disorder, dementia, mood disorder, dysphagia after a stroke, and psychotic disorder with delusions. A review of the Minimum Data Set assessment, dated [DATE], revealed the Resident had moderately impaired cognition. According to the Progress notes in the medical record, the Resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate documentation, consent, assessment, a physician's order, evaluation, and re-evaluation of a restraint for one resident (Resident #33 [R33]) of two residents reviewed from a total sample of 27 residents, resulting in a resident confined in a Broda chair without a consent, evaluation for appropriateness, physician's order, and re-evaluation for appropriateness. Findings include: Resident #33 (R33): On 12/12/23 at 1:57 PM, R33 was observed in the dining room eating lunch assisted by CNA C. R33 was sitting in a semi-reclined position (approximately 110-120 degrees angle) on a Broda wheelchair (high back, reclining wheeled chair with rest base for both lower extremities). Although R33 was not moving a lot, R33 did not appear distressed or show any discomfort. CNA C when queried, explained why R33 was currently on this chair, and indicated it was because R33 had a tendency to slide down on the regular wheelchair. Although CNA…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement and operationalize policies and procedures to ensure completion of comprehensive investigations for injuries of unknown origin for one resident (Resident #64) of one resident reviewed resulting in a lack of completion and documentation of a thorough investigation to identify a cause of injury, lack of reporting to the State Agency, and the potential for further injury and unidentified abuse. Findings include: Resident #64: On 12/13/23 at 9:55 AM, Resident # 64 was observed sitting in the common dining/sitting room of the facility facing the window with their eyes closed. The Resident was sitting in a Rock N Go (high backed, reclining wheelchair with fabric style back, the ability to rock, and footrests) wheelchair. The back of the chair was in a locked in a recline position. The footrests of the chair were not elevated and Resident #64's lower extremities were dangling and did not reach the footrests. When spoke to, Resident #64 did not open…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a comprehensive person-centered care plan for two residents (Resident #27 and Resident #33) of two residents reviewed for care plans pertaining to the use of Broda chair R33 and use of supportive device for positioning R27's Right Upper Extremity (RUE) and Right Lower Extremity (RLE) from a total sample of 27 residents reviewed for care planning, resulting in not having an active and comprehensive care plan to ensure safety and appropriate care for positioning was followed and to ensure range of motion (ROM) was maintained and prevent further decline in functional abilities. Findings include: Resident #27 (R27): During the observation tour in the Dementia Unit Dining Area on 12/12/23 at 1:41 PM, R27 was observed eating lunch independently in the Dementia Unit dining area. R27 was observed sitting in the wheelchair, feeding herself using her left hand to hold the spoon while eating dessert. R27's right arm was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record, the facility failed to provide Activities of Daily Living (ADL) care per care plan for two residents (Resident #53 and Resident #128), resulting in unkept facial hair, long dirty nails, missed showers, unchanged clothing and dirty hair with the likelihood of decreased moods. Findings include: Resident #128: On 12/12/23, at 12:16 PM, Resident #128 was sitting in their room. They had red plaid pajama pants on with nothing else. Their nails were dirty, jagged, and approximately a quarter inch long. The had unkept facial hair. Resident #128 was asked if they needed any help with their nail care and Resident #128 stated, I guess they would help me if I asked. On 12/13/23, at 3:04 PM, Resident #128 was in their room sitting at their table. They had the same red plaid pajama pants. Resident #128 was asked if they needed anything and Resident #128 stated, nope. On 12/13/2023, at 2:00 PM, a record review of Resident #128's electronic medical record revealed an admission 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 oxygen tubing was stored appropriately and turn off wall-mounted oxygen while not in use for one resident (Resident #68), resulting in a cross-contamination of oxygen tubing and unsafe oxygen storage with the possibility of combustion causing a fire. Findings include: Resident #68: On 12/12/23, at 10:54 AM, Resident #68 was sitting in their wheelchair at their desk. The wall mounted inline oxygen was running at 2 liters. The oxygen tubing was draped dangling over the wall mount uncovered. The resident had oxygen hooked to a nasal cannula from a portable oxygen tank on their wheelchair. On 12/13/23, at 8:45 AM, Resident #68 was not in their room The wall mounted inline oxygen was running at 2 liters and the tubing was again draped over the wall mount uncovered. On 12/13/2023, at 11:00 AM, a record review of Resident #68's electronic medical record revealed an admission on [DATE] with diagnoses that included congestive heart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Vancomycin blood trough levels and hold IV (intravenous) antibiotic medication, Vancomycin, according to abnormal trough laboratory levels for one resident (Resident #7), of two residents reviewed for antibiotic medication administration, resulting in Resident #7 receiving IV Vancomycin when Vancomycin trough levels were high with the potential for adverse drug consequences and side effects of the medication. Findings include: Resident #7: A review of Resident #7's medical record revealed an admission into the facility on 5/18/22 and readmission on [DATE], with diagnoses that included heart disease, asthma, urinary tract infection, anxiety disorder, schizophrenia, sepsis, dementia, and mood disorder. A review of the Minimum Data Set (MDS) assessment, dated 11/8/23, revealed a Brief Interview of Mental Status (BIMS) score of 3/15 that indicated severely impaired cognition and needed substantial/maximal assistance with 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 ensure an as needed (PRN) antipsychotic medication had a 14-day stop date for one resident (Resident #74), resulting in the lack of physician follow up of the needed PRN antipsychotic medication with the likelihood of side effects going unnoticed. Findings include: Resident #74: On 12/12/23, at 11:05 AM, Resident #74 was lying in their bed. They complained they were bored and had worked on their puzzle all morning. On 12/12/23, at 2:30 PM, a record review of Resident #74's electronic medical record revealed an admission on [DATE] with diagnoses that included Diabetes Mellitus, Chronic Kidney Disease and Anxiety. Resident #74 had A review of the physician orders revealed Ativan Oral Tablet 0.5 MG (milligrams) . PRN Every 4 Hours . For Restlessness, anxiety . Start Date: 11/17/2023 End Date: Indefinite . A review of the Medication Administration Record (MAR) 11/1/203 - 11/30/2023 revealed Ativan Oral Tablet 0.5 MG (Lorazepam) Give 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.

Based on observation, interview and record review the facility 1) Failed to store and handle medications in accordance with acceptable pharmaceutical standards of practice for one of 2 medication rooms, 2) Failed to ensure that medication refrigerators were clean and temperatures outside of acceptable parameters were addressed, 3) Failed to ensure that controlled medications had administration orders, and 4) Failed to ensure that medications were stored according to professional standards of practice, including vaccinations, resulting in the potential for contamination of medications, incorrect administration of medications, a lack of therapeutic benefits necessary to promote healing for residents, increase the potential for adverse effects. Findings Include: FACILITY Medication Storage and Labeling On 12/15/23 at 8:38 AM, during a tour of the 2 north medication storage room with Nurse Q the following was observed: 1 refrigerator/fridge seal was broken around the inside door; about a 3 inch area was ripped. There was a dead fly in the bottom of the fridge. The refrigerator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely treatment and care for a contagious rash for two residents (Resident #127 and Resident #135), resulting in the potential worsening of symptoms, a decline in condition and spread of infection. Findings Include: Resident #127: A review of Resident #127 revealed an admission into the facility on 8/31/22 and re-admission on [DATE] with diagnoses that included stroke, dementia, heart disease, diabetes, psychotic disorder, mood disorder, Alzheimer's disease and atopic dermatitis. A review of the MDS dated [DATE], revealed the Resident had severely impaired cognition and needed substantial/maximal assistance with most ADL's. A review of Resident #127's progress notes included the following: -Dated 12/11/23 at 0800 AM, Skin/Wound note, Writer spoke with (Facility Doctor) yesterday morning regarding rash and (Dermatologist) coming to facility tonight. Writer received request to refer (Resident #127) back to (Dermatologist) as he was…

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