The Laurels of Kent

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement comprehensive, person centered care plans for 4 residents (Resident #102, #103, #104 and #105) of 6 residents reviewed, resulting in unmet care needs and the potential for negative physical, mental and psychosocial outcomes. Findings include: Resident #102 Review of an admission Record revealed Resident #102 was originally admitted to the facility on [DATE] with pertinent diagnoses which included cognitive communication deficit and major depressive disorder. Review of the Facility Reported Incident (FRI) dated [DATE] revealed, On [DATE] at 10:00 PM, (Registered Nurse- RN) N observed (Resident #101) resident laying on (Resident #102's) bed with (Resident #2) in between (Resident #101) legs. (Resident #101) pants were off one leg and around her other ankle and (Resident #102) had his pajama and underpants down to his knees, his penis was not fully exposed. (Registered Nurse (RN) ) F immediately intervened and assisted (Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure dignified verbal interactions between staff and resident for 1 (Resident #9) of 4 residents reviewed for dignity and respect resulting in negative emotional feelings and the potential for decreased self-worth or self-esteem. Findings include: Resident #9: Review of Resident #9's medical diagnoses, print date 4/9/25, included diagnoses of down syndrome and unspecified dementia. Review of Resident #9's brief interview for mental status score, dated 3/26/25, was scored 2 which indicated severe cognitive impairment. During an observation on 4/9/25 at 8:47 AM, Resident #9 was seated in her wheelchair in her room and was observed calling out verbally, moaning, crying, and stated, Ow, it hurts. Housekeeping staff F entered Resident #9's room as this was happening. Staff F asked what resident #9 needed and Resident #9 was unable to clearly state a care need to Staff F. Staff F then stated, We're not just gonna (going to) sit and cry, told…

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 timely report an injury of unknown origin to the State Agency in 1 of 1 resident (Resident #94) reviewed for abuse, resulting in the potential for a delayed/incomplete investigation. Findings include: In an interview on 12/18/24 at 4:43 PM, Family Member L reported a concern involving a bruise on Resident #94's right inner thigh. Family Member L reported they noticed the bruise during a visit while Resident #94 was in the bathroom. Family Member L described the bruise as .huge . and reported when they asked the nurse what happened the facility had no explanation. Family Member L reported they were concerned that the large bruise to Resident #94's right inner thigh was not reported or investigated. Review of an admission Record revealed Resident #94 was a female, with pertinent diagnoses which included severe dementia with agitation, depression, anxiety, high blood pressure, heart disease, and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #94, with a reference date of 9/24/24, revealed a Brief…

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 thoroughly investigate an injury of unknown origin in 1 of 1 resident (Resident #94) reviewed for abuse, resulting in an incomplete facility investigation. Findings include: In an interview on 12/18/24 at 4:43 PM, Family Member L reported a concern involving a bruise on Resident #94's right inner thigh. Family Member L reported they noticed the bruise during a visit while Resident #94 was in the bathroom. Family Member L described the bruise as .huge . and reported when they asked the nurse what happened the facility had no explanation. Family Member L reported they were concerned that the large bruise to Resident #94's right inner thigh was not reported or investigated. Review of an admission Record revealed Resident #94 was a female, with pertinent diagnoses which included severe dementia with agitation, depression, anxiety, high blood pressure, heart disease, and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #94, with a reference date of 9/24/24, revealed a Brief Interview for Mental…

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

Based on observation, interview and record review, the facility failed to maintain complete and accurate medical records for 2 (Resident #14 and #94) of 20 residents reviewed for medical records, resulting in an inaccurate reflection of personal hygiene acceptance, lack of nursing assessment documentation, and the potential for facility staff and providers not having all of the pertinent information to care for residents. Findings include: Resident #14 During an observation on 12/18/24 at 10:02 AM Resident #14 was lying in bed, his nails were very long, his facial hair was overgrown and the hair on his head was greasy and disheveled (messy). During an observation on 12/19/24 at 09:29 AM Resident #14 was lying in bed, his nails were long and dirty, and his facial hair had food substance in it. In an interview on 12/19/24 at 02:08 PM, Certified Nursing Assistant (CNA) I reported that Resident #14 refused grooming of his hair and nails, and did not like to be touched. CNA I reported that Resident #14 verbalized no when staff offer to assist with hair and nails. In an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00144277. Based on interview, and record review, the facility failed to provide adequate supervision and accurately implement the elopement policy in 3 of 5 residents (Resident #203, #208, & #209), reviewed for safety and monitoring, resulting in the potential for injury. Findings include: Review of the facility document Elopement Residents indicated 17 residents that were at risk for elopement and were currently wearing wanderguard bracelets. Resident #203, #208, and #209 were included on the list. Resident #203 Review of an admission Record revealed Resident #203 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: stroke and seizure disorder. Review of a Minimum Data Set (MDS) assessment for Resident #203, with a reference date of 4/11/24 revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #203 was cognitively impaired. Review of the Functional Abilities…

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.) provide appropriate and adequate tracheostomy care, 2.) maintain oxygen delivery rate, and 3.) maintain oxygen delivery equipment for infection control in 4 of 4 residents (Resident #50, Resident #24, Resident #10, and Resident #11) reviewed for respiratory care, resulting in the potential for breathing complications and respiratory infections. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R50 was in a persistent comatose state, unable to participate in his BIMS (Brief Interview Mental Status) was totally dependent on staff for all care needs including turning/positioning, with diagnoses that included anoxic brain injury (lack of oxygen to the brain) and quadriplegia. Review of R50's Order Summary -10/21/2023 apply 4 x 4 gauze under right side of patient's neck and under the foam trach ties to prevent pressure every shift for Trach (tracheostomy) foam ties pressure prevention -10/3/2023 suction trach as…

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.

R50 Review of R50's Order Summary -10/21/2023 apply 44 gauze under right side of patient's neck and under the foam trach ties to prevent pressure every shift for Trach (tracheostomy) foam ties pressure prevention -10/3/2023 suction trach as needed -10/20/2023 trach care to be performed. Change inner cannula using size 4 every shift Review of R50's Care Plan, 12/16/2022, the resident had a potential for difficulty breathing and risk for respiratory complications related to NPO (nothing by mouth) status, and aspiration risk (taking in foreign material into the lungs), tracheostomy (procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck via a tube), brain injury, with seizure risk. The goal was to display optimal breathing pattern daily/no labored breathing. To meet this goal, interventions to be implemented included, tracheostomy care per policy, provide good oral hygiene to prevent infection, PPE (personal protection equipment such as gloves) per protocol, observe for signs/symptoms including increased in sputum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure call lights were in reach for 1 (Resident #19) of 19 residents reviewed for call light placement, resulting in the inability to call for staff assistance, resident frustration, and unmet care needs. Findings include: Resident #19 Review of an admission Record revealed Resident #19 was originally admitted to the facility on [DATE] with pertinent diagnoses which included anxiety and history of falling. Review of a Minimum Data Set (MDS) assessment for Resident #19, with a reference date of 7/17/23, revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #19 was severely cognitively impaired. Review of the Functional Status with a reference date of 7/1/723, revealed that Resident #19 required extensive assistance of one person for dressing, toileting, and personal hygiene. Review of Resident #19's Care Plan revealed, (Resident #19) is at risk for fall related injury and falls R/T (related to): DX…

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.) notify a physician of a missed medication dose 2.) failed to enter physician order for a change in oxygen flow rate 3.) obtain a re-weight for a resident with potential nutritional concerns in 2 (Resident #11 and Resident Resident #73) of 19 residents reviewed for standards of practice, resulting in the potential for worsening of health conditions. Findings include: Resident #11 Review of an admission Record revealed Resident #11, was originally admitted to the facility on [DATE] with pertinent diagnoses which included vascular dementia and major depressive disorder. During an observation and interview on 10/23/23 at 8:07 AM, Licensed Practical Nurse (LPN) Q reported that Resident #11 had an order to receive acetaminophen (Tylenol) rectal suppository for a fever and discomfort. LPN Q reported that he would need to skip administering the Tylenol until he could find a staff member to assist him because Resident #11 was sitting up in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY `This citation pertains to intake: MI00139865 Based on observation, interview, and record review the facility failed to ensure PRN (as needed) oral care was performed for 1 of 19 resident (R50) reviewed for ADL (activities of daily living), resulting in dried oral secretions, dry cracked lips, and the potential of gum disease. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R50 was in a persistent comatose state, unable to participate in his BIMS (Brief Interview Mental Status) was totally dependent on staff for all care needs including turning/positioning, with diagnoses that included anoxic brain injury (lack of oxygen to the brain) and quadriplegia. Review of R50's Care Plan, revised 8/18/2023, the resident had ADL (activities-of-daily-living) Self-Care Performance Deficit and required total assistance with ADLs and mobility related to diagnoses of anoxic brain injury (complete lack of oxygen to the brain) and quadriplegia (paralyzed in all four limbs). The goal was to have ADL needs…

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: MI00139865 Based on observation, interview, and record review, the facility failed to implement and revise pressure ulcer interventions for 1 of 2 residents (R50) reviewed for skin integrity, resulting in the potential of an impaired skin integrity condition. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R50 was in a persistent comatose state, unable to participate in his BIMS (Brief Interview Mental Status) was totally dependent on staff for all care needs including turning/positioning, with diagnoses that included anoxic brain injury (lack of oxygen to the brain) and quadriplegia. Review of R50's Care Plan, revised 8/18/2023, reported the resident was at risk for impaired skin integrity/pressure injury related to diagnoses of quadriplegia and anoxic brain damage (lack of oxygen to the brain). The resident was dependent of staff for positioning/turning and had braces for contractures. The goal was to minimize risk to reduce likelihood of pressure…

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 safety precautions were in place and accurate in 1 of 1 residents (Resident #48) reviewed for safety, resulting in the potential for elopement. Findings include: Review of an admission Record revealed Resident #48 was a male with pertinent diagnoses which included dementia, impulse disorder, and psychotic disorder with delusions. Review of current Care Plan for Resident #48, revised on 9/1/2023, revealed the focus, .(Resident #48) is at risk for exit seeking. He has a history of attempts to leave facility unattended. (Resident #48) wears a wander guard on right front of wheelchair to ensure safety . with the intervention .Apply wander guard per order. Check placement, function and expiration date per facility protocol. Wander guard to: Left wrist .Distract resident when wandering into inappropriate areas by offering pleasant diversions, structured activities, food, conversation etc .Observe wandering behavior and attempted diversional interventions when wandering into inappropriate locations such as…

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 pre and post dialysis (procedure that removes excess water, solutes, and toxins from the blood in people whose kidneys cannot perform these functions) assessments were completed for 1 (Resident #42) of 1 resident reviewed for dialysis care, resulting in the potential of being unprepared for a potential decline in resident condition, due to the adverse effects from dialysis. Findings include: Resident #42 Review of an admission Record revealed Resident #42, was originally admitted to the facility on [DATE] with pertinent diagnoses which included end stage renal disease. Review of Resident #42's Dialysis Care Plan dated 7/27/22 revealed, (Resident #42) is at risk for complications R/T (related to) needs dialysis due to: ESRD (End Stage Renal Disease) with AV fistula (surgically created vascular access area for dialysis treatments) left upper arm (M,W,F) . Interventions: Do not draw blood or take B/P in left arm, Encourage resident to go for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure PRN (as needed) orders for psychotropic drugs were limited to 14 days and/or document the rationale in the resident's medical record and indicate the duration for the PRN order for 1 (Resident #29) of 6 residents reviewed for unnecessary medications, resulting in the prolonged use of psychotropic medication and the potential for residents to receive unnecessary psychotropic medications. Findings include: Review of an admission Record revealed Resident #29, was originally admitted to the facility on [DATE] with pertinent diagnoses which included major depressive disorder and schizophrenia. Review of Resident #29's Orders revealed, Misc Natural Products External Gel (Misc Natural Products) Apply to wrists topically every 6 hours as needed for Schizophrenia. Risperidone gel 0.25 mg/1 ml: apply 0.5 mL. Start Date: 07/09/2023. During an interview on 10/24/23 at 9:23 AM, Social Worker (SW) II reported that the Risperidone PRN gel was an active order…

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 maintain complete and accurate medical records for 3 of 19 residents (Resident #54, #11 and #29) reviewed for comprehensive and accurate medical records, resulting in an inaccurate reflection of the resident's medical conditions and needs, and the potential for providers to not have an accurate picture of resident status and condition. Findings include: Resident #54 Review of an admission Record revealed Resident #54 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: cerebral infarction (stroke). In an interview on 10/24/23 at 08:51 AM, Licensed Practical Nurse (LPN) H reported that a Certified Nursing Assistant (CNA) had reported abnormal vital signs for Resident #54 on 10/16/23 around 6:45 PM, and LPN H rechecked the vital signs and got the same readings; Respirations 32, Pulse (heart rate) 114. LPN H reported that she sent a text message regarding the abnormal vital signs to the on-call provider and stated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to update a care plan to reflect current actual skin impairment for 1 resident (Resident #4) of 4 residents reviewed for accuracy of care plans, resulting in the potential for staff to provide care that was inconsistent with the needs of the resident. Findings include: Review of an admission Record revealed Resident #4 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and depression. Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 8/30/2023 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #4 was severely cognitively impaired. In an observation on 9/19/2023 in Resident #4's room at 3:33 PM, Resident #4 had a bordered foam dressing on her right foot dated 9/18/2023. Review of Resident #4's Wound Care Progress Note dated 9/18/2023 at 5:40 PM revealed #4's treatment recommendations for right foot…

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 obtain a physician order to reflect current wound treatment for 1 resident (Resident #4) of 4 residents reviewed for skin conditions, resulting in the potential for residents to have received inappropriate care and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an admission Record revealed Resident #4 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and depression. Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 8/30/2023 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #4 was severely cognitively impaired. Review of a list of facility residents with ordered skin treatments received from the facility on 9/19/2023 revealed Resident #4 had an order to apply skin prep to her right foot wound and leave…

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 MI00139243 and MI00139388. Based on interview and record review, the facility failed to identify, monitor and treat a skin condition for 1 (Resident #1) of 4 residents reviewed for skin treatment, resulting in lack of assessment, monitoring, and documentation and the potential for worsening of the condition and delay of treatment. Findings include: Review of an admission Record revealed Resident #1 admitted to the facility on [DATE] with pertinent diagnoses which included epilepsy, dementia, and cerebral palsy. Review of a Minimum Data Set (MDS) assessment for Resident #1, with a reference date of 7/19/2023 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated Resident #1 was moderately cognitively impaired. In a telephone interview on 9/18/2023 at 2:56 PM, Guardian of Resident #1 Q reported Resident #1 went to the local hospital emergency department on 8/20/2023 after having a seizure and falling at the facility 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: MI00133188, MI00136070, & MI00137867 Based on interview and record review, the facility failed to assure a registered nurse was on duty for eight consecutive hours a day seven days a week, resulting in the potential for a decrease in the quality of care for all residents residing in the facility. Findings include: Review of the Timecard Report for the period of 8/4/23 to 9/4/23 revealed there was no RN coverage providing direct resident care (zero hours logged) on 8/8/23, 8/17/23, 8/18/23, 8/25/23, and 8/31/23. In an interview on 09/06/23 at 3:35 PM, Regional Clinical Coordinator (RCC) C reported the facility was aware they don't have the needed staffing in the building. RCC C reported as the Director of Nursing she had a process in place to ensure the facility had RN covered for the minimum of 8 hours for a 24 hour period of time. RCC C' reported when the staffing was reported to CMS (Centers for Medicare and Medicaid) it would tell those days when there was not registered nurse coverage.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00133188, MI00136070, & MI00137867 Based on observation, interview, and record review, the facility failed to ensure adequate nurse staffing to promote the physical, mental, and psychosocial well-being in 4 of 9 sampled residents (Resident #100, #103, #107, & #108) reviewed for staffing, resulting in unmet care needs and the potential for physical and psychosocial harm for all residents in the facility. Findings include: Review of Resident Census and Conditions of Residents (CMS Form 672) submitted for review on 9/5/2023 indicated a census of 86 residents, revealed there were 83 residents were either an Assist of One or Two Staff or Dependent on staff for bathing; 66 residents were either an Assist of One or Two Staff or Dependent on staff for dressing; 52 residents were either an Assist of One or Two Staff or Dependent on staff for transferring; and 65 residents were an Assist of One or Two Staff for toilet use; 14 residents were either an Assist of One or Two Staff 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 This citation pertains to Intake: MI00133188 & MI00136070 Based on interview and record review, the facility failed to ensure a resident was consistently provided with showers/bathing for 2 of 9 residents (Resident #103 and #108) and 1 of 1 residents (Resident #107) with eating assistance reviewed for activities of daily living, resulting in unmet personal hygiene needs and the potential for weight loss. Findings include: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 50742-50744). Elsevier Health Sciences. Kindle Edition.Personal hygiene affects patient's comfort, safety, and well-being. Hygiene care included cleaning and grooming activities that maintain personal body cleanliness and appearance. Personal hygiene activities which as taking a bath or shower and brushing and flossing the teeth also promote comfort and relaxation foster a positive self-image, promote healthy skin, and help prevent infection and disease .…

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 utilize wheelchair footrests for safe wheelchair transport in 2 of 2 residents (Resident #105 & Resident #106) reviewed for accidents and hazards, resulting in the potential for falls and injury. Findings include: Review of Mosby's Textbook for Long-Term Care Nursing Assistants - E-Book by [NAME] A. [NAME], 6th Edition 2013 titled 'Wheelchair Safety revealed .Make sure the person's feet are on the footplates (foot pedals/rests) before moving the chair. The person's feet must not touch or drag on the floor when the chair is moving . Resident #105: Review of an admission Record revealed Resident #105 was a female with pertinent diagnoses which included stroke, osteoarthritis of right hip, paralysis affecting left side, vascular dementia with agitation, and seizure. Review of current Care Plan for Resident #105, revised on 11/03/2022, revealed the focus, .(Resident #105) is at risk for decline in cognition and has impaired cognitive function…

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: MI00133188 & MI00136070 Based on observation, interview, and record review, the facility failed to thoroughly assess and provide care per the standards of care for an indwelling catheter in 1 (Resident #103) of 3 residents reviewed for indwelling catheter care, resulting in the potential of a urinary tract infection. Findings include: Review of an admission Record revealed Resident #103 was a male with pertinent diagnoses which included dementia, anxiety, chronic kidney disease, proteus mirabilis (bacterium causing bacteremia (bacteria in the bloodstream) and sepsis (a life threatening complication of an infection), kidney stones, and history of recurrent UTIs (urinary tract infections). Review of current Care Plan for Resident #103, revised on 3/31/2022, revealed the focus, .(Resident #103) is at risk for urinary tract infection and catheter-related trauma: has foley catheter .(Resident #103) has tendency to touch his catheter with hands . with the intervention .Change catheter tubing per facility policy .Observe/record/report to physician for s/sx…

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.