The Orchards at Lapeer

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide Life Enrichment activities and care plan interventions for two residents (Resident #11, Resident 43) of two residents reviewed for activities, resulting in no activities provided. Findings include:Resident #43 On 3/02/2026, at 10:11 AM, Resident #43 was lying in their bed. The room was dark. The television (tv) was off. On 3/03/2026, at 8:55 AM, Resident #43 was sitting on their bed. The room was dark. The tv remained off. There was a tv remote on the over bed table. Resident #43 was asked if they wanted the tv on and Resident #43, shook their head yes. Moments later the resident closed their eyes and appeared to be resting. On 3/03/2026, at 9:10 AM, a record review of Resident #43's electronic medical record revealed an admission on [DATE] with diagnoses that included aphasia, mood disorder and stroke. Resident #43 required extensive assistance with activities of daily living and had severely impaired cognition.A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement interventions to prevent the development of a pressure injury for one resident (R29) of four residents reviewed, resulting in a blister developing and eventually opening. Findings include:Resident #29 (R29): R29 admitted to the facility on [DATE] with diagnoses that include hemiplegia affecting the left side, type 2 diabetes mellitus and hemiparesis following cerebral infarction. R29 has a brief interview for mental status (BIMS) score of 15, indicating she is cognitively intact. On 03/02/2026 at 12:45PM, an interview was conducted with R29. R29 was asked if she had any issues with her skin. R29 stated that she has a blister on her left heel that developed at the facility. R29 says she needs a new pair of heel boots, R29 feels the ones she has aren't in good shape anymore. Observation revealed two heel boots sitting on top of the closet in the room. On 03/03/2026 at 1:52PM, record review revealed a Braden Scale assessment 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 properly assess and identify the need for podiatry services for one resident (Resident #10) of 1 resident reviewed for foot care, resulting in resident frustration, the development of long, curved toenails, discomfort and delay in needed treatment. Findings include: Resident #10: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Diabetes, Chronic peripheral venous insufficiency, hypertension, and paranoid schizophrenia. The MDS assessment dated [DATE] indicated the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed assistance with lower body care including personal hygiene. On 3/02/2026 at 10:50 AM, Resident #10 was observed lying in bed awake. She said she had some problems with her feet and lifted her sheet to show her feet. Her toenails were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number 2679077. Based on observation, interview and record review, the facility failed to provide supervision for one resident (Resident #14) of three residents reviewed for accidents, resulting in a resident-to-resident altercation. Findings include: Resident #14 (R14): R14 admitted to the facility on [DATE] with diagnoses that include cognitive communication deficit, dementia, unspecified psychosis and paranoid personality disorder. On 03/02/2026 at 1:26PM, an interview was conducted with daughter GG of R14. Daughter GG was interviewed about the resident-to-resident altercation her mother had with another male resident. Daughter GG stated, my mom had only been here about two weeks at the time and another resident hit her. Daughter GG' stated my mom had wandered into his room, he was startled and he hit her. Daughter GG stated she was told that the resident that did it knew better, but it still happened. Daughter GG stated it would be very difficult to prevent these kinds 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 provide necessary care of an indwelling urinary catheter for 1 resident (Resident #45) of 2 residents reviewed for urinary catheters, resulting in a lack of documentation of catheter care and an observation of the resident's catheter lying flat on the floor. Findings Include: Urinary CatheterResident #45:A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: history of wound infection with multi-drug-resistant organisms, osteomyelitis (bone infection from a wound), sacral wound, respiratory failure, diabetes, and hypertension. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed some assistance with all care.On 3/02/2026 at 10:26 AM, Resident #45 was observed lying in bed in his room. An indwelling urinary…

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 residents received pain medication in a timely manner and as ordered for 1 resident (Resident #2) of 1 resident reviewed for pain management. Findings Include: Pain Management Resident #2:A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #2 was admitted to the facility on [DATE] with diagnoses: History of a stroke, Diabetes, hypothyroidism, hydronephrosis, urinary stents, history of digestive surgeries, GERD, chronic sinusitis, right foot drop, sacral pressure ulcer, history of urinary tract infections, bronchitis, and hypertension. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and needed assistance with some activities of daily living.On 3/02/2026 at 11:50 AM, Resident #2 was observed lying in bed. She said she was newer to the facility and stated, When I first got here, they didn't have my…

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, the facility failed to provide an updated daily staffing report, resulting in a four-day old staff list and the inaccessibility for residents, visitors and staff to what staff was working. Findings include. On 3/02/2026, at 9:05 AM, a record review of the DAILY STAFFING REPORT hanging on the wall in the main entry was conducted. The report was dated 2/26/2026

Based on observation, interview and record review, the facility failed to provide listed menu items to dining room residents, resulting in no bread offered for the lunch meal, and frustration voiced by a confidential resident group. Findings include.Confidential Group of Residents: On 3/2/26 a Confidential Group of Residents were together for a group meeting at approximately 3:00 PM. The Group consisted of seven Residents, all who were able to answer questions and six engaged in conversations and discussions. The group was asked about concerns with care received at the facility and the Group brought up concerns with menus not being followed. A Resident brought up the concern that menu items were substituted without letting the Residents know. Two Resident voiced they don't get a menu and that there used to be someone dedicated to do the menu with you but now they are gone. One Resident stated, The menu will say one thing and you don't get it. They replace it with something else, and gave an example that they were going to have scalloped potatoes, and we got mashed potatoes instead,…

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, the facility failed to explain arbitration agreements in a manner that could be understood for four residents (R2, R27, R42, R70) of four residents reviewed for arbitration agreements, resulting in confusion about the agreements that were signed and feelings of regret for signing the agreement. Findings include:On 03/04/2026 at 2:36PM, an interview was conducted with Social Worker (SW) AA. SW AA stated that he is responsible for getting admission paperwork completed at the facility, this includes completing arbitration agreements with the residents. SW AA was asked how long they have been responsible for getting admission contracts and arbitration agreements completed. SW AA stated they have been doing admission contracts and arbitration agreements since February 20, 2025. SW AA was asked how he explains arbitration agreements to the residents. SW AA' stated that they first ask the resident if they understand what arbitration is. SW AA then stated that whether they say yes or no, I still explain to the agreement to them. SW AA' stated, I explain that it is our…

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 2719390. Based on interview and record review the facility to ensure that 1) resident code status was correctly identified, 2) Emergency Medical Services were notified in a timely manner and 3) an AED (automated external defibrillator) was used during an emergent situation when Resident #3 was found not breathing and his heart had stopped. Findings Include: Resident #3: A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #3 indicated an admission to the facility on [DATE] with diagnoses: Metabolic encephalopathy, history of falls with fractures- left side ribs, COPD, heart disease, peripheral vascular disease/PVD, epilepsy, Dementia, kidney failure, anemia, and aphasia/difficulty speaking. The MDS assessment dated [DATE] revealed the resident had severe cognitive decline with a Brief Interview for Mental Status/BIMS score of 0/15 and the resident needed assistance with all care. On [DATE] at 1:50 PM, during an interview with the Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to Intake Numbers 2707758 & 2711787.Based on interview and record review, the facility failed to ensure breakfast was offered, prior to leaving for dialysis, for one resident (Resident #6) and Food Acceptance was consistently monitored for one resident (Resident #1) of 3 residents reviewed for food and nutrition. Findings Include: Resident #1 A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #1 was admitted to the facility on [DATE] with diagnoses: history of a stroke, cervical disc degeneration, history of falls, depression, anxiety, hypothyroidism and overactive bladder. The MDS assessment dated [DATE] revealed the resident had severe memory 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 titled, Change in Condition indicated Resident #1 had a change of condition on 12/11/2025 due to an excessive cough. On 12/27/2025 another Change of Condition evaluation…

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 appropriately clean and store reusable medical equipment, store blood specimens and needles, perform hand hygiene and wear Personal Protective Equipment (PPE) during resident care for four of four residents reviewed for infection control practices, resulting in cross-contamination. Findings include: On 3/18/25, at 1:19 PM, CNA E was observed assisting Resident #24 with their meal. The Resident in bed 1 dropped their pillow which was resting under their head. CNA E set Resident #24's fork down, picked up the pillow and placed back under the head of the resident in bed 1 without replacing the pillow case. CNA E sat back down and continued to feed Resident #24 without performing hand hygiene. On 3/18/25, at 3:25 PM, Upon entry into Resident #25's room, CNA E was observed placing a soiled brief into a clear plastic bag. CNA E was observed performing incontinence care for Resident #25. CNA E was not wearing a protective gown and CNA E's uniform…

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 residents were treated in a respectful and dignified manner for a Confidential Group of residents, from a facility census of 54 residents, resulting in staff talking on personal cell phones while in the residents' rooms and while providing resident care. Findings Include: FACILITY Resident Council: On 3/19/2025 at 3:32 PM, during an interview with a Confidential Group of Residents, they said there was an issue with staff talking on their personal phones while providing care for the residents. The residents said some staff wear ear buds and the staff member will be talking to someone with the ear bud and the resident thinks they are talking to them. The residents' said they were embarrassed and upset when they were answering the staff member and were told, the staff member was not talking to them, they were talking to someone else on the ear bud. During the interview with the Confidential Group of Residents on 3/19/2025 at 3:32 PM, the residents said the staff will bring their personal phone in the residents'…

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 accurately code a pressure ulcer on the Minimum Data Set (MDS) for one resident (R44) of one resident reviewed for MDS accuracy. Findings include: Resident #44 (R44): R44 is [AGE] years old and admitted to the facility on [DATE] with diagnosis that include congestive heart failure, major depressive disorder, generalized anxiety disorder and metabolic encephalopathy. On 03/18/25 at 01:04 PM, record review of the CMS-802, resident matrix, revealed that R44 currently had an unstageable pressure ulcer that was facility acquired. The pressure ulcer is located on the right heel. On 03/19/25 at 02:52 PM an interview was conducted with the wound care nurse. Wound Care Nurse C was asked when did R44 acquire the right heel pressure wound. Wound Care Nurse C stated the wound started on 11/19/24, the wound started as a hematoma (a closed wound where blood collects) and then turned into what it is now. On 03/19/25 at 04:06 PM, record review of Section M (skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to revise care plans timely for two residents (R30, R44) of 12 residents reviewed for care plan revision, resulting in inaccurate care plans. Findings include: Resident #30 (R30): R30 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following a cerebral infarction affecting the left side, hypertension, history of pulmonary embolism and major depressive disorder. R30 has a brief interview for mental status score of 13, indicating they are cognitively intact. On [DATE] at 02:19 PM, record review revealed that R30 had a signed physician's order in place for Advanced Directives-Do Not Resuscitate (DNR), dated [DATE]. Further review of the record revealed a signed document for a DNR Code Status. On [DATE] at 02:25 PM, record review revealed a care plan with a focus that stated, I have chosen full resuscitation dated [DATE]. Interventions in the care plan revealed, If necessary, perform CPR, call…

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 MI00151174. Based on observation, interview and record review, the facility failed to ensure 1) Accurate orders for a feeding tube that was not being used, 2) Maintenance of the feeding tube including water flushes and 3) Care of the feeding tube insertion site to prevent redness and bleeding for 1 Resident (#38) of 2 residents reviewed for feeding tubes. Findings Include: Resident #38: Tube Feeding A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #38 was admitted to the facility on [DATE] with diagnoses: debility, feeding tube, depression, hypothyroidism, arthritis, and heart disease. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and needed some assistance with all care. On 3/18/2025 at 11:47 AM, Resident #38 was observed lying in bed. She said she had a feeding tube and showed her abdomen. There was a dressing dated 3/18/2025 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 Based on observation, interview and record review, the facility failed to follow standards of practice for assessment, monitoring and dressing changes of a PICC (Peripherally Inserted Central Catheter inserted into a vein for the administration of intravenous (IV) medication and fluids) for one resident (Resident #39), of one resident reviewed for intravenous therapy. Findings include: Resident #39: On 3/18/25 at 10:00 AM, an interview was conducted with Resident #39 who answered questions and conversed in conversation. The Resident was lying in bed. The Resident was asked about his PICC line and the resident pulled up his sleeve to expose the PICC line with a clear dressing over top. The dressing was observed to not have a date of when it was last changed. The Resident was asked and reported the dressing had been changed but was unsure of the date. A review of Resident #39's medical record revealed an admission into the facility on 2/22/25 with diagnoses that included infection and inflammatory reaction due 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 interview and record review, the facility failed to ensure the acquisition and administration of medications for two residents (Resident #34 and Resident #56) of eight residents reviewed for medication regimen review, resulting in seizures and hospitalization for Resident #34. Findings include: Resident #34: A review of Resident #34's medical record revealed an admission into the facility on 1/30/25 with diagnoses that included fracture of right clavicle and ribs and epilepsy. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) score of 6/15 that indicated severely impaired cognition. A review of Resident #34's medication orders and Medication Administration Record revealed the following: -For January 2025, the medication Fycompa 10mg, give 1 tablet by mouth at bedtime for seizures, was documented as not given on 1/30 and 1/31. Briviact 100mg, give 1 tablet by mouth every 12 hours for seizures, was documented as not given on 1/30 at 8pm, 1/31 at 8AM and 8PM. -For February 2025, the medication Fycompa 10 mg, give 1 tablet by…

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 meals per menu for four residents (Resident #1, Resident #17, Resident #24, Resident #26) of four residents reviewed during dining task, resulting in incomplete meals offered. Findings include: On 3/18/25, at 1:19 PM, Resident # 24 was in their room eating their lunch meal with the assistance of CNA E. There were two bowls; one with dry mashed potatoes and the other one had pureed tan food. CNA E was asked where the rice and vegetable were and CNA E offered, I think they pureed it all together with the chicken. There was no cake. CNA E was asked where the cake was and CNA E offered, he didn't get any cake. Resident #24 was unable to verbalize. On 3/19/25, at 9:00 AM, Resident #1 was resting in their bed with their eyes closed. Their breakfast meal was at their bedside. The meal consisted of two pieces of toast, 3 pieces of bacon and a cup of fluids. On 3/19/25, at 9:01 AM, a record review of the meal ticket on the tray revealed:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents were receiving fresh fluids at the bedside in a timely manner for one resident (Resident #11) of 18 residents reviewed including a Confidential Group of Residents, resulting in Residents having warm water with no ice. Findings Include: FACILITY A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #11 was admitted to the facility on [DATE] with diagnoses: Traumatic Brain Injury, Dementia, seizure disorder, schizophrenia and peripheral vascular disease. The resident needed some assistance with all care. On 3/19/2025 at 1:55 PM, several residents in the East hallway including Resident #11 did not have fresh water. Resident #11 had a Styrofoam cup on his bedside table dated 3/18/2025. The water was warm and there was no ice. The resident said he didn't know when the facility had provided the water. He said it was not fresh. On 3/19/2025 at 2:00 PM, the residents on the east hall were…

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

Based on observation, interview and record review, the facility failed to label, date and dispose of expired foods provided by the facility and label, date and dispose of residents' food brought in by outside sources, resulting in the potential for food borne illness. Findings include: On 03/18/25 at 09:00 AM, observations were made in the walk-in refrigerator and the walk-in freezer revealed: -a bag of frozen zucchini squash had no expiration date on it, no label was present on the bag with a received by or opened by date. -a can of french onion dip that had been opened, no open date or expiration date. -a package of hot dogs opened on 3/6/25 with no use by date. -a box of blueberries, a label on the box stated to use them by 3/13/25. -a box of tomatoes, a label on the box stated to use them by 3/11/25. -a box of celery, a label on the box stated to use them by 3/13/25. -a bag of onions, a label on the bag stated to use them by 1/21/25. These findings were verified with the dietary manager. On 03/18/25 at 09:45 AM, observations were made of the resident refrigerator/freezer that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to Intake Number MI00150900. Based on interview and record review, the facility failed to ensure that physician's orders were enacted for one resident (Resident #1) of 3 residents reviewed for a change of condition. Findings Include: Resident #1: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #1 was admitted to the facility on [DATE] with diagnoses: enlarged heart, anxiety, depression, Barrett's Esophagus, GERD and debility. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 14/15 and the resident needed some assistance with all care. A record review of the progress notes revealed Resident #1 was transferred to the hospital on [DATE] at 9:30 AM, with a change of condition related to low blood pressure 85/53, a rapid pulse rate 118 beats per minute, a rapid respiratory rate of 30 breaths per minute and very low oxygen saturation of 78% with use of oxygen via nasal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement comprehensive care plans for three residents (Resident #4, Resident #217, Resident #221) of 29 residents reviewed for comprehensive care plans resulting in the potential for unmet care needs, increased pain and pressure injury. Findings include: Resident #217 (R217): R217 was admitted to the facility on [DATE], is [AGE] years old and has diagnoses of weakness, anemia, hypertension, epilepsy and obstructive sleep apnea. On 04/30/24 at 11:01 AM, resident was observed laying in bed, nasal cannula in place and an oxygen concentrator beside the bed and functioning. R217 was asked if he is on oxygen all the time and R217 stated yes, even when they were at home prior to admission. On 04/30/24 at 02:59 PM, record review revealed that R217 did not have a care plan in place for the use of oxygen. On 04/30/24 at 03:00 PM, record review revealed a physicians order to start oxygen at 2L on 4/27/24. On 05/02/24 at 01:00 PM, 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 This Citation Pertains to Intake Numbers MI00137112, MI00139663, MI00140315, and MI00143170. Based on observation, interview and record review, the facility failed to ensure sufficient nursing staff to meet the needs of six residents (Resident #2, Resident #24, Resident #59, Resident #60, Resident #118 and Resident #167), of 11 residents reviewed for staffing, and a Confidential Group of Residents, potentially effecting all 62 residents who reside in the facility, resulting in staff verbalization of being unable to adequately provide timely care and/or supervision, residents' voicing frustration with long call light response times, a lack of supervision for residents' safety and the potential of unmet care needs. Findings include: Resident #2: On [DATE] at 2:46 PM, during the initial tour of the facility, Resident #2 was interviewed. The Resident was asked about concerns they had. The Resident reported not getting the help she needs to eat. The Resident indicated they would put the call light on and doesn't get…

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 proper labeling of medical supplies and eye drops, 2) Ensure that treatment carts contained dressing supplies, 3) Ensure that needles and prescription treatment medications were properly secured and 4) Ensure that narcotic medication was properly disposed of, in two of three medication carts, one of one medication rooms and two of two treatment carts reviewed for proper labeling of medications, storage and expired medication/supplies, resulting in the potential for a resident to receive medication or medical supplies with decreased efficacy, drug diversion, ingestion of medicated substances and inaccurate urinalysis results. Findings include: On [DATE] at 8:04 AM, an observation was made of the treatment cart in the Main Hall area that was not attended by a nurse, to be left unlocked and not secured. Nurse EE returned to the area. When queried about the unlocked treatment cart, the Nurse indicated the treatment cart should be…

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

On 04/30/24 at 04:32 PM, an interview with R44 was conducted about arbitration agreements at the facility. R44 was asked if they fully understood what an arbitration agreement was and if it was explained thoroughly to them before they signed it. R44 says they understand what arbitration agreements are and what they mean. R44 was asked if they knew that arbitration agreements were in every admission packet. R44 stated no and that most residents are not in the best shape (state of mind) when they come in to the facility and it should be explained better. R44 was asked if the arbitration agreement was thoroughly explained to them and R44 said no it wasn't. On 05/06/24 at 02:54 PM, an interview was conducted with R62. R62 was asked about the arbitration agreement they signed upon admission to the facility and if they understood what it was. R62 stated that they believed the arbitration agreement was about them having the right to refuse care. R62 was asked if the agreement was explained to them before they signed it. R62 stated that the arbitration agreement was not explained to them…

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 Transmission- Based Precautions (TBP), resulting in the potential for the spread of infection, which could cause serious illness. Findings Include: FACILITY Infection Control On [DATE] at 3:00 PM, during a tour of the facility with Infection Prevention and Control/IPC Nurse JJ, it was identified that several rooms with Enhance Barrier Precautions in place had expired hand sanitizer dated expired on 3/2024 and 11/2023 and one was empty. Also during the tour, the residents on the North Hall had clearly identified precautions in place with available Personal Protective Equipment/PPE, however on the East hall, some rooms with several residents sharing the room had Contact precautions on the door with no indication for which resident was in precautions. The signs did not clearly indicate the necessary PPE needed to care for the residents. For those residents needing…

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 a safe environment was maintained, with call lights accessible to residents and that an oxygen tank was stored properly for four residents (Resident #4, Resident #12, Resident #24, and Resident #44) of five residents reviewed for safe and sanitary environment and four residents reviewed for respiratory care, resulting in residents' feeling of frustration, the inability to call for assistance, and the potential for unmet care needs. Findings include: Resident #4: On 4/30/24 at 10:49 AM, a review of Resident #4's medical record revealed an admission into the facility on 2/18/22 with diagnoses that included delusional disorders, dementia, psychotic disorder, post-traumatic stress disorder (PTSD), and mood disorder. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status score of 6/15 that indicated severely impaired cognition, was independent in eating and toileting hygiene and needed…

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 an annual review for mental disorder, intellectual disability or a related condition was completed with Level II Evaluation documentation for one resident (Resident #4) of three residents reviewed for mental disorder screening, resulting in the potential for services and care planning of Level II determination and recommendations not being implemented and a lack of emotional or mental health needs not met. Findings include: Resident #4: On 4/30/24 at 10:49 AM, a review of Resident #4's medical record revealed an admission into the facility on 2/18/22 with diagnoses that included delusional disorders, dementia, psychotic disorder, post-traumatic stress disorder (PTSD), and mood disorder. A review of Resident #4's ARR (Annual Resident Review-Form DCH-3877), dated 4/19/23, revealed the Section II-Screening Criteria that indicated the person has a current diagnoses of Mental Illness and Dementia and received treatment for Mental Illness and Dementia, routinely received one or more prescribed antipsychotic or…

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 baseline care plan within 72 hours from admission for one resident (Resident #221) of 29 residents reviewed for baseline care plans, resulting in the potential for unmet care needs and social isolation. Findings include: Resident #221 (R221): R221 was admitted to the facility on [DATE], is [AGE] years old and has diagnoses of hypertension, dementia, Alzheimer's disease and rheumatoid arthritis. On 04/29/24 at 10:30 AM, R221 was observed sleeping in bed, dressed appropriately in pajamas, their hair was messy and there was a smell of urine noted in the room. On 04/30/24 at 09:59 AM , R221 was observed in bed eating breakfast, wearing appropriate clothing, their hair was messy and there was a smell of urine in the room. On 04/30/24 at 10:16 AM, a Wanderguard was observed on the right foot of R221. R221 was interviewed about why they have the Wanderguard on their foot. R221 stated they were unaware of why they have 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 MI00143170. Based on observation, interview and record review, the facility failed to review and revise care plans with resident changes to ensure interventions necessary for care and services were provided for one resident (Resident # 56) of 29 residents reviewed for care plans, resulting in the potential for unmet care needs. Findings Include: Resident #56: Accidents On 4/29/2024 at 12:15 PM during a tour of the facility, Resident #56 was observed lying in bed, alert and talkative. Her bed was in a very low position near the floor. Her lunch tray was present and sitting on the bedside table, which was positioned much higher than the resident's height in the bed. Resident #56 was observed attempting to roll over in bed to reach her tray that was on the bedside table. She couldn't reach it and continued to lean over and reach up in an attempt to reach the tray. A staff member was notified in the hallway that the resident needed assistance. A record review of the Face sheet…

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 interventions were in place to prevent facility-acquired pressure ulcers for one resident (Resident # 56) of four residents reviewed for pressure ulcers, resulting in Resident #56 developing two facility-acquired pressure ulcers. Findings Include: Resident #56: Pressure Ulcer/Injury On 4/29/2024 at 12:15 PM during a tour of the facility, Resident #56 was observed lying in bed, alert and talkative. Her bed was in a very low position near the floor. The resident was asked if she had any wounds and said yes and pointed at her feet. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #56 was admitted to the facility on [DATE] with diagnoses: heart failure, diabetes, atrial fibrillation, hypertension, depression, arthritis, obesity and history of falls. The MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 2/15. A record review of the progress notes…

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 maintenance and removal of a Percutaneuous Endoscopic Gastrostomy (PEG) Tube for one resident (Resident #59) of one resident reviewed for PEG Tubes, resulting in unmet care needs and feelings of hopelessness. Findings include: Resident #59 (R59): R59 is [AGE] years old, was admitted to the facility on [DATE] with diagnoses of Guillain-Barre syndrome, acute respiratory failure, dysphagia, heart failure and hypertension. On 04/29/24 at 02:07 PM, R59 was observed laying in bed, watching TV, eating snacks and drinking a pop. R59 was asked about their PEG Tube and if there were any plans for removal since they were on a regular diet now and not utilizing it. R59 stated that the tube was supposed to come out but that someone in the facility dropped the ball and no one scheduled transportation for the appointment for removal. R59 stated that now it might be June before the PEG tube is removed. R59 was asked how long they had been…

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 proper communication and documentation of hospice services for two residents (Resident #38, Resident #221) of three residents reviewed for hospice services, resulting in the absence of progress notes, assessments and care plans in the medical record. Findings include: Resident #221 (R221): R221 was admitted to the facility on [DATE], is [AGE] years old and has diagnoses of hypertension, dementia, Alzheimer's disease and rheumatoid arthritis. R221 is receiving hospice services as of 03/15/24. On 04/30/24 at 09:59 AM , R221 was observed in bed eating breakfast, wearing appropriate clothing, their hair was messy and there was a smell of urine in the room. R221 was asked if they were on hospice services at the facility. R221 replied yes and continued to eat breakfast R221 was asked if anyone from the hospice company came to visit them. R221 replied that they believe people from hospice come to visit them but they are unsure when they…

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.