Majestic Care of Livonia

This citation pertains to Intake MI00148803. On 12/08/24 between 8:40 AM-9:15 AM, during an initial tour of the kitchen, the following items were observed: In the walk-in cooler, there was a pan of soup dated 11/26-12/3, an opened undated bag of breaded chicken, an undated bag of whole ham, an undated bag of sliced ham, an opened undated package of hot dogs, an undated pan of tomato sauce, a crate of fat free half pints of milk dated 12/7. In the Traulsen reach-in cooler, there was an opened undated 1 gallon container of Italian dressing, a 1 gallon container of sweet and sour sauce dated 9/13/24-10/13/24, a 1 gallon opened, undated container of BBQ sauce. On 12/8/24 at 12:05 PM, when queried about the opened, undated items, Dietary Manager I provided no explanation. According to the 2017 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41…

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 one resident (R86) of one resident reviewed, was referred to with dignity regarding potentially deogatory language. Findings Include: A review of the record for R86 revealed an order entered by Licensed Practical Nurse (LPN) B dated 03/07/24 which documented, Assist feeder for all meals. The record further documented R86 was admitted into the facility 02/27/24. A review of the Minimum Data Set (MDS) assessment dated [DATE] documented, severely impaired cognition and substantial/maximal assistance for Activities of Daily Living. On 12/09/24 at 1:20 PM, LPN B was queried about the order and reported the order using the word feeder was not appropriate and should have read 'assist with all meals' or 'one to one assist with all meals'. On 12/10/24 at 11:52 AM, the Director of Nursing (DON) confirmed the term 'feeder' should not have been used. A review of the policy titled, Dignity dated 01/02/24 revealed, It is the practice of this facility to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a care plan was updated to reflect fall interventions for one sampled resident (R10) of three reviewed for accidents. Findings include: On 12/08/24 at 9:10 AM, R10 was observed to sit on the side of their bed. R10 right eye was observed with a discolored ring around the lower part of the eye. R10 was asked about the bruise on their eye. R10 explained they fell out of bed while they were asleep. R10 explained they hit their face on the night stand and landed face down on the floor. The environment around R10's bed was observed with some clutter. R10 was asked if the facility put things in place to try and prevent them from falling out of bed again. R10 said they didn't think so. A review of R10's incident and accident reports noted three falls: on 07/1/24, 11/09/24 and 11/12/24, all three were due to self transfer. On 12/10/24 at 12:25 PM, the Director of Nursing (DON) was asked if after each fall there was a review of the falls along 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 This citation has two deficient practice statements. Deficient Practice Statement #1: Based on observation, interview, and record review, the facility failed to provide showers for one (R8) of four residents reviewed for hygiene. Findings include: On 12/08/24 at 9:16 AM, R8 was observed in bed and appeared not to be dressed or cleaned up for the morning. R8 was asked about daily care and any related concerns and reported they hadn't had a shower in over a month. R8 reported when they ask staff about having a shower they are told their shower days are on Monday and Thursday, but on those days nobody offers a shower or they are told it can't be done for some other reason. Review of the facility record for R8 revealed an original admission date of 09/10/22 diagnoses included Cardiac Arrest and Heart Failure. R8's Care Plan dated 11/27/24 indicated R8 was incontinent, non-ambulatory, and required assistance with bathing. Review of the electronic medical record (EMR) and paper shower sheets from 11/03/24 to 11/25/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two deficient practices. Deficient Practice Statement #1: Based on observation, interview, and record review, the facility failed to ensure lower extremity lymphedema wraps (elestic bandage wrap applied to reduce swelling) were applied for one (R72) of four residents reviewed for care. Findings include: On 12/08/24 at 10:02 AM, R72 reported their legs hadn't been wrapped for edema for the past two days. R72's legs were visible, and no wraps were in place. Review of R72's facility record revealed an admission date of 07/29/22 with diagnoses included Heart Failure and Bilateral Lower Extremity Swelling. A physician order dated 12/3/24 documented: Wrap bilateral lower extremities with (name of elastic bandage) wrap daily and remove at HS (bedtime). Related to Lymphedema. On 12/09/24 at 1:20 PM, R72 was interviewed in their room. Their legs were visible and not wrapped. They were asked if their legs were ever wrapped yesterday or earlier today and they stated No. R72 reported they were concerned…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to apply hand splints for one resident (R38) out of five residents reviewed for mobility and range of motion. Findings include: On 12/08/24 at 8:55 AM, 10:14 AM, and at 11:31 AM, 1:14 PM, and 3:53 PM, R38 was observed lying in bed on their back sleeping with the head of the bed slightly elevated wearing a hospital gown. R38s hands appeared contracted. A hand splint was observed on the night stand. On 12/09/24 at 8:55 AM, R38 was observed lying their back in bed wearing a hospital gown with the head of the bed slightly elevated. The hand splint was observed in the same place on the night stand as previously observed. On 12/09/24 from 12:09 PM until 12/09/24 12:37 R38 was observed in their wheelchair in the dining room wearing a hand splint on their left hand and was observed eating with difficulty. A splint was not observed on their right hand. On 12/10/24 at 8:44 AM R38 was observed lying in bed on their back in bed with the head of the bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two deficient practice statements. Deficient practice #1. Based on observation, interview, and record review, the facility failed to provide tube feeding (TF-feeding supplied through a tube into the stomach) and hydration for one resident (R346) out of three residents reviewed for tube feeding. Findings include: On 12/09/24 at 09:50 AM, 10:12 AM, 11:27 AM, and 3:54 PM, R346 was observed lying in bed. R346's TF bottle contained 400ml (milliliters) and was dated 12/8/24. The TF and water flush was not connected to R346 and was not infusing. On 12/10/24 at 08:51 AM R346 was observed being pushed back to their room in a wheelchair by an unidentified staff member. R346's TF bottle was still dated 12/8/24, still contained 400ml, and was still not infusing. A review of R346's medical record revealed they were admitted to the facility on [DATE] with the following diagnosis: Acute and Chronic respiratory failure with hypoxia (low oxygen level); dysphagia (difficulty swallowing), unspecified; legal…

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 MI00148624. Based on interview and record review, the facility failed to provide interventions for a resident with PTSD (Post-Traumatic Stress Disorder) to address triggers for one Resident (R44) of one resident reviewed for trauma-informed care. Findings include: On 12/08/24 at 1:00 p.m., R44 reported they had been dealing with their PTSD and felt upset recently, as the facility had attempted to involuntarily discharge them on 11/29/24. R44 revealed their involuntary discharge form, dated 11/29/24, which showed they refused to sign the form. R44 reported they had not been made aware prior of any discharge plan, and this resulted in a traumatic reaction for them. R44 explained they became escalated when they learned about the discharge plan, as they were being discharged to a homeless shelter. R44 stated they had a home before being admitted to the facility, and had given up their apartment when they became a long-term care resident. R44 reported after the (State) Ombudsman…

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 biologicals were dated when opened in three of three medications carts reviewed. Findings include: On 12/08/24 at 4:23 PM, the A medication cart was observed with Licensed Practical Nurse (LPN) D: a glucose test strips container was not dated when opened. On 12/08/24 at 4:26 PM, the D medication cart was observed with LPN A: A vial of Lantus insulin was open and undated; A vial of Humalog insulin was open and undated; A container of glucose test strips was not dated when opened; and two latanoprost eye droppers were not dated when opened. On 12/09/24 at 9:07 AM, the C medication cart was observed with LPN C: a Humalog insulin vial was not dated when opened; three artificial tears eye dropper vials were not dated when opened; and the glucose test strips container was not dated when opened. On 12/10/24 at 11:52 AM, during and interview with the Director of Nursing (DON), the DON reported glucose test strips and insulin vials should be dated when opened and glucose strips were good for thirty days once…

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 food was served in a palatable (tasty), presentable manner for three Residents (R39, R45, and R246) of four residents reviewed for nutrition. Findings include: On 12/08/24 at 9:22 a.m., R246 stated they were a newer resident to the facility, admitted on [DATE] for rehabilitation. R246 reported the food did not taste good, and there was little variety. R246 explained the alternates also did not taste good. R246 clarified food was their main concern, as they could barely eat their meals which was upsetting to them. R246 appeared thin in stature and was seated in a manual wheelchair. On 12/08/24 at 10:05 a.m., R45 stated, The food is horrible, and the eggs taste like they are powdered. When asked about alternatives available, R45 reported, The alternates taste horrible, and clarified the bread was old and hard when sandwiches were requested. R45 reported they felt frustrated by this and had reported their concerns to staff. 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 non-allergenic food was provided for one Resident (R13) of one reviewed for food preferences. Findings include: On 12/10/24 at approximately 1:05 p.m., R13 reported they were served Shrimp [NAME] last night for dinner, which they were allergic to. R13 reported they believed it was Chicken [NAME] when the dinner was served. R13 reported they were chewing the meat and realized it was shrimp and spit it out immediately and asked a Certified Nurse Assistant (CNA) to call their nurse. R13 reported an aide was with them, CNA R, and their nurse, Licensed Practical Nurse (LPN) S, who gave them Benadryl (an antihistamine medication for an allergic reaction). R13 reported they had a reaction when their mouth and tongue felt tingling. Review of R13's meal ticket, on 12/10/24 at 1:10 p.m., which was on their lunch meal tray, revealed, (R13) .Allergies: .Seafood . in large, bold print, at the top of their meal ticket. Review of the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two deficient practice statments. Deficient practice #1. Based on observation, interview, and record review, the facility failed to implement transmission based precautions (TBP) for one resident (R346) out of one reviewed for infection control practices. Findings include: On 12/8/24 at 9:37 AM R346 was observed lying in bed. A sign was observed on R346's door revealed the following: CONTACT PRECAUTIONS EVERYONE MUST: clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. R346 explained the sign is there because they have an infection in their dialysis access site. A review of R346's medical record revealed they were admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00147513. Based on observation, interview, and record review, the facility failed to ensure a resident with a known pressure wound was repositioned timely for one resident (R704) of six reviewed for skin care management. Findings include: On 10/16/24 at 10:52 AM, wound care for R704 was observed with Licensed Practical Nurse (LPN) A and Certified Nurse Assistant (CNA) B. A pillow was removed from the side of R704 and placed at the top of the bed near R704's head. R704 was observed to have an open sacral pressure sore. The wound had a ruby colored base and drainage was noted on the dressing removed by LPN A. R704 was rolled side to side by the two staff during the care of the wound. Upon completion of the wound care the brief was changed and R704 was returned to a supine position on their backside around 11:15 AM. The head of the bed was raised to around twenty or thirty degrees and the pillow at the head was placed into R704's powered wheelchair. CNA B was asked about the…

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

This citation pertains to Intake MI00147416. Based on observation, interview, and record review, the facility failed to provide timely brief change, peri-care and bedding change for one (R705) of four residents reviewed for care concerns. Findings include: On 10/15/24 at 10:39 AM, R705 was interviewed while laying in bed. The incontinence pad under the resident was observed to be soaked with urine and there were clean linens and brief laying at the foot of the bed. Review of the facility record for R705 revealed an admission date of 01/26/22 with diagnoses including Alzheimer's Disease and Bilateral Lower Extremity Contracture. The Care Plan dated 09/05/24 identifies the focus area stating [R905] has episodes of incontinence of bladder and bowels and includes the goal statement [R905] will be maintained in as clean and dry and dignified a state as possible. The related interventions included Check routinely for incontinence and provide incontinence care as needed. On 10/15/24 at 11:59 AM, R905 was observed laying in bed. The incontinence pad had a large outer ring of dried urine and…

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

This citation pertains to Intake: MI00146915. Based on interview and record review, the facility failed to follow hospital discharge instructions and orders for one sampled resident (R701) of one resident reviewed for continuum of care. Findings include: A review of Intake MI00146915 revealed the following, Patient was admitted to the hospital, oncologist very concerned as pt (patient) did not follow up for oncology treatment post dc (discharge) to [nursing facility] .Pt was to follow up to establish care and treatment plan . Appears that this did not occur which could further put patient at risk due to lack of treatment and care . A review of R701's medical record revealed they were admitted into the facility on 8/1/24 with a diagnosis of Multiple Myeloma not having achieved remission. Further review revealed that the resident was cognitively intact, and required moderate to maximum assistance for Activities of Daily Living. Further review of R701's medical record revealed discharge instructions from the hospital: Follow up with [physician] Specialty: Medical Oncology, Internal…

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

This citation pertains to Intake: MI00146528 Based on interview and record review, the facility failed to permit a resident to return to the facility after hospitalization for one resident (R901) of one reviewed for discharges. Findings include: A review of Intake: MI00146528 revealed the following, [R901] came to [local hospital] for evaluation, pt (patient) was cleared by physician and returned to [facility]. [Facility] indicated that they didn't receive clinical information, so they sent patient back to the Emergency Center. Staff called [facility] per pt., providing clinical clearance and they continued to refuse patient's return. The following day [hospital staff] contacted [facility administrator], he indicates that he cannot accept pt back as he doesn't have staff to care for patient. [Facility staff] sent clinical information to the building as requested. They requested a psychiatric evaluation, and this was conducted, this was sent to the facility as well, patient was cleared psychiatrically to return [facility administrator] continues to refuse to accept patient back to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00145985. Based on interview and record review, the facility failed to prevent the elopement of one resident (R700) of three reviewed for accidents and supervision. Findings include:: An incident and accident (I/A) report involving R700 was reviewed and revealed the following: Date: 7/25/24 23:22 (11:22 PM0 Incident Location: Outside. Incident Description: Nurse was informed by midnight staff that [R700] was not in [their] room or bed when [they] went to do rounds. Injuries Observed at Time of Incident: Injury Type: No injuries observed at time of incident. A progress note reviewed in R700's electronic medical record (EMR) revealed the following, 7/26/2024 00:49 (12:49 AM) Writer received call from charge nurse .stating that [R700] got out of the facility and an active code green (code used in potentially life threatening situations) was in place .Police [were] called. [R700] Returned to [the] facility with nurse, with no signs [or] symptoms of distress or injury. Further…

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

This citation pertains to Intake: MI00145599 Based on interview and record review, the facility failed to ensure the rights to self- determination were honored for Leave of Absences (LOAs) potentially affecting all 95 residents residing in the facility. Findings include: A review of Intake MI00145599 revealed the following,The administrator gave a copy of the letter given to residents restricting LOAs (Leave of Absence). Restrictions include times LOA are allowed, what activities that could result in restricting LOA, weather restrictions, residents must be accompanied by a community member during a LOA, and restrictions of resident personal items and activities residents cannot do in the community during a LOA. According to the letter, the letter was devised with input from the medial director, law enforcement, area businesses and members of the community . On 7/18/24 at 11:00 AM, an interview was completed with the Nursing Home Administrator (NHA) regarding restrictions related to LOAs. The NHA explained there had been conversations with law enforcement, local business owners and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation in part pertains to Intake: MI00145599 Based on interview and record review that facility failed to assist the Resident Council to meet for their monthly meetings consistently. Findings include: On 7/18/24 at 10:45 AM, a request for the last three months of resident council meeting minutes was requested from the Nursing Home Administrator (NHA). On 7/18/24 at 11:00 AM, the NHA explained that during a mock survey, he identified that their was a deficiency in resident council meetings and showed the surveyor a folder of documents that were identified as resident council meeting notes that were either incomplete and/or missing dates. A review of the facility's Resident Council policy revealed the following, Policy Statement The facility supports residents' desires to be involved and have input in the operation of the facility through the Resident Council .1. Policy Interpretation and Implementation. 1.The purpose of the Resident Council is to provide a forum for: a. Residents to have input in the…

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

This citation pertains to Intake MI00141614. Based on observation, interview, and record review, the facility failed to report an allegation of misappropriation of funds to the State Agency for one resident (R701) out of one reviewed for misappropriation of funds. Findings Include: On 2/22/2024 at 9:54 AM, an interview was conducted with R701. R701 was observed sitting in their wheelchair. R701 stated that back in December (2023) they were asleep, woke up and saw someone standing on the side of their bed. R701 stated that they thought they were just checking on them and went back to sleep. R701 stated that the next day they went to order some food and went in their wallet and $70 was missing. R701 stated that they reported it to the Nursing Home Administrator (NHA) and they were told that they would not be getting reimbursed. A review of the medical record revealed that R701 admitted into the facility on 5/22/2019 with the following diagnoses, Major Depressive Disorder and Multiple Sclerosis. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status…

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 MI00140504. Based on interview and record review, the facility failed to follow physician recommendations following a Gastrointestinal (GI) consult, and follow physician ordered parameters upon administration of a laxative for one resident (R901) of one reviewed for unnecessary medications, resulting in the potential for adverse drug consequences. Findings include: A review of R901's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Hypertension, Heart Failure, and a history of Colon Cancer. Further review of R901's medical record revealed that the resident was cognitively intact, and required extensive assistance for bed mobility, dressing and toilet use. Further review of R901's medical record revealed the following progress note: 9/21/2023 15:00 (3:00pm) MD/NP/PA (medical doctor/nurse practitioner/physician assistant) Progress Note. Late Entry: Note Text: Physician Orders. Date: September 21, 2023 Orders: Result of STAT…

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 MI00139096. Based on observation, interview and record review the facility failed to ensure rooms were maintained free of lingering debris and odors and trash for five residents (R3, R39, R41, R55, and R77) and eight resident rooms (Rooms 5, 7, 9, 10, 11, and 17) from a total sample of 56 residents, resulting in resident dissatisfaction with their living conditions. Findings include: On Monday 10/02/23 at 8:58 AM, on the walk way to the front door of the facility the landscaped beds were observed with dissimilar weeds and stray grasses in with the plants. A urine odor was noted when the resident care area was entered from the lobby. The ceiling was damaged between rooms 7, 10 and 11 and was covered with clear plastic which had been taped to the ceiling. R41 On 10/02/23 at 9:28 AM, the room of Resident R41 was observed with peppermint candies strewn under the bed and baseboard heater behind the head of the bed. R41 reported they had dropped them on Saturday. R41 noted that it…

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

Based on observation, interview, and record review, the facility failed to maintain the kitchen in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 10/2/23 between 8:50 AM-10:20 AM, during an initial tour of the kitchen, the following items were observed: The hand sink in the dish machine room was blocked by a stack of boxes containing jugs of distilled water. The boxes were moved to the side, and the hot water temperature at the hand sink was measured to be 69 degrees Fahrenheit. The hot water at the hand sink located in the main kitchen was also tested, and was measured to be 86 degrees Fahrenheit. In addition, the hand sink in the main kitchen did not have any handwashing signage. According to the 2017 FDA Food Code section 5-202.12 Handwashing Sink Installation, 1. (A) A HANDWASHING SINK shall be equipped to provide water at a temperature of at least 38°C (100°F) through a mixing valve or combination faucet. Pf According to the 2017 FDA Food Code section 5-205.11 Using a Handwashing…

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

Based on observation, interview, and record review, the facility failed to maintain the exterior trash refuse area in a sanitary manner. This deficient practice had the potential to affect all residents, staff and visitors. Findings include: On 10/2/23 at 11:30 AM, the exterior trash refuse area was observed. There was a heavy accumulation of trash observed on the ground at the sides of both dumpsters, and in between the 2 dumpsters. A thick layer of trash bags, soiled adult briefs, milk cartons, straws, styrofoam cups, disposable plates and bowls, aluminum cans, disposable gloves, and flattened cardboard boxes littered the ground surrounding the dumpsters. On 10/2/23 at 11:45 AM, Dietary Manager N was queried about the cleaning of the exterior refuse area and stated that Maintenance was responsible for that area. Review of the facility's policy Dispose of Garbage and Refuse dated 08/2017 noted: All garbage and refuse will be collected and disposed of in a safe and efficient manner. Procedures: 1. The Dining Services Director coordinates with the Director of Maintenance to ensure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intakes MI00139498, MI00139958, and MI00139521. Based on observation, interview, and record review the facility failed to provide activities of daily living care (ADLs) to six residents (R4, R41, R46, R55, R91, and R96) of nine residents reviewed for ADL care, resulting in feelings of humiliation and dissatisfaction with care. Findings include: R96 On 10/3/23 at 9:15 AM, R96 was interviewed about their care at the facility and indicated that on 9/4/23 at around 2:45 PM, upon returning from a dialysis appointment and being assisted into bed, I told my staff that I needed to be assisted with toileting. I told my CNA (Certified Nurse Assistant) and they never came back to help me. My call light was on for two hours. I called the police and the officer came out, I was covered with feces and feces was all over the bed. The officer saw it. I felt humiliated and horrible. R96 indicated that they had experienced extend call light wait times for toileting in the past as well. On 10/3/23 at 9:22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake M100138667. Based on interview and record review, the facility failed to allow or document reason for one (R303) of three residents reviewed for discharges to return to the facility following hospitalization, resulting in R303 not being allowed to return to the facility, be provided an appropriate discharge or coordinate mental health and/or behavioral services. Findings include: Review of the facility record for R303 revealed an admission date of 03/27/03 with diagnoses that included Congestive Heart Failure, Chronic Kidney Disease and Schizoaffective Disorder-Bipolar Type. The Minimum Data Set (MDS) assessment dated [DATE] indicated that R303 required primarily Moderate/Maximum level assistance with activities of daily living and the Brief Interview for Mental Status (BIMS) score of 13/15 indicated intact cognition. Additional review of the facility record indicated that R303 had established a consistent pattern of aggressive and abusive behavior toward staff and other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise a fall prevention care plan after multiple falls, for one resident (R64) of six reviewed for accidents, resulting in multiple falls with major injures. Findings include: A review of R64's medical record noted the following falls, R64 2/01/23 unwitnessed fall, R64 found in bathroom with facial injuries and fractured right femur. 5/24/23 unwitnessed fall reported by R64 with no injuries. 8/01/23 unwitnessed fall reported by R64 in room, injuries fractured right forearm. 9/14/23 unwitnessed fall reported by R64 injuries facial bruises. 10/14/22 fall R64 sent to hospital with injuries. A review of R64's medical record revealed, an admission note related to the fall that occurred on 2/1/23. 2/6/2023 19:02 Orders - Administration Note Text: Patient arrived to facility via stretcher . Resident A & O x3 (alert and oriented to person, place and time). Able to make needs known. No acute distress noted. No s/s (signs symptoms) of SOB (short…

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 a 14-day stop date or document rationale for continuation of a PRN (as needed) psychotropic medication for one (R88) of three residents reviewed, resulting in unnecessary psychotropic medication use with the potential for adverse side effects. Findings include: Review of the facility record for R88 revealed an admission date of 07/29/22 with diagnoses that included Anxiety Disorder, Schizoaffective Disorder-Bipolar Type and Morbid Obesity. The Minimum Data Set (MDS) assessment dated [DATE] indicated R88 required primarily Maximum/Total level assistance with activities of daily living (ADLs). The Brief Interview for Mental Status (BIMS) score of 10/15 indicated Moderate cognitive impairment. On 10/03/23 at 11:01 AM, review of R88's physician orders revealed an order for ABH (Ativan-Benadryl-Haldol) gel every 4 hours as needed for anxiety ordered 03/17/23 with no 14-day stop date or end date and remaining currently classified as active. Review…

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 expired biologicals were discarded and opened bilogicals were dated and labeled with a resident identifier in three of four medication carts resulting in the potential for the decreased effectiveness of biologicals and medications. Findings include: On [DATE] at 8:24 AM, the A/B medication room was reviewed with Licensed Practical Nurse (LPN) C. The medication room refrigerator was observed to be at 28 degrees Fahrenheit. This was also documented as the last temperature recorded on the log sheet posted on the refridgerator. The refrigerator contained liquid nutrition supplement and insulin mediations. On [DATE] at 9:15 the A wing medication cart was reviewed with LPN A. Two unknown open insulin vials were discarded along with two open Novolog vials with expired date of [DATE]; two open Glargine insulin vials dated [DATE] and one open Lantus dated opened [DATE]. A Symbicort inhaler, a fluticasone inhaler, a Trelegy inhaler and a Anoro…

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

Based on observation, interview, and record review, the facility failed to maintain tube feeding poles and a tracheostomy (trach) cart surface in a sanitary manner, for two residents (R32 and R73), resulting in the potential for contamination of equipment. Findings include: R32 On 10/03/23 at 10:44 AM, R32's room was observed, with dried tube feeding formula along the pole and on the floor. On 10/03/23 at 11:45 AM, the room was observed in the same condition as above. On 10/04/23 at 11:06 AM, the room was observed in the same condition as above. R73 On 10/02/23 at 10:21 AM, R73's room was observed with dried tube feeding formula along the pole and on the floor. The cart that was observed to hold R73's trach care items and equipment was observed to be disorganized and unclean with debris on the shelves of the cart. On 10/03/23 at 10:15 AM, R73's room was observed in the same condition as 10/2/23. On 10/04/23 at 2:04 PM, the Director of Nursing (DON) was asked about the expectations of the staff to maintain a clean and sanitized condition in residents' room and explained, that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake M100134315. Based upon observation, interview and record review, the facility failed to maintain a clean, homelike environment for two (R801, R803) of three residents reviewed for environmental concerns, resulting in resident dissatisfaction with their living conditions. Findings include: R801 Review of the facility record for R801 revealed an admission date of 05/25/22 with diagnoses that included Congestive Heart Failure, Diabetes Mellitus and Asthma. The Minimum Data Set (MDS) assessment dated [DATE] indicated R801 required supervision to maximum assistance with self care and mobility tasks. The Brief Interview for Mental Status (BIMS) assessment score of 15/15 indicated intact cognition. On 8/23/23 at 12:24 PM, R801's bathroom was observed to have open cracks and lifting in the flooring adjacent to the toilet, exposing the sub-floor. The caulk around the base of the toilet was partially missing and lifting, exposing the base flooring. Multiple dark stains were present…

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.