Maple Valley Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the assessment of respiratory status prior to the administration of an inhaled medication and according to professional standards for one Resident (#18) of five resident reviewed for medication administration. Findings include: Resident #18 (R18) Review of the Minimum Data Set (MDS) assessment, dated 12/20/2024, revealed R18 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD). R18 was assessed as cognitively intact. On 4/10/2025 at 7:51 a.m., during an observation, R18 approached the medication cart where Licensed Practical Nurse (LPN) B was reviewing resident medication needs for the morning. R18 reported feeling short of breath to LPN B and requested to use her inhaler. LPN B was observed removing an albuterol (short-acting inhaled medication used to open the airway, commonly called rescue inhalers) inhaler from the medication cart to administer to R18. LPN B administered…

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 residents' code status was communicated and readily available for staff in the event of an emergency for three Residents (R17, R12, and R16) of six residents reviewed for advanced directives. Findings include: Resident #17 (R17) R17 was admitted to the facility on [DATE] with a primary medical diagnosis of Huntington's Disease. R17 was deemed totally incapacitated and had a court-appointed guardian. A document titled Out of Hospital Do-Not-Resuscitate [DNR] Order was signed by R17's guardian, physician, and two witnesses on [DATE]. The document read, in part: .In the event of an emergency or critical situation where a decision about immediate medical intervention is required, appropriate clinical decisions will be made in light of the directive below that you have signed and dated . No Resuscitation. Illnesses will be treated aggressively, including hospitalization if indicated, but in the event of cardiac or respiratory arrest, CPR 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.

Based on interview and record review, the facility failed to ensure laboratory results were obtained and reviewed to monitor for adverse effects of anti-psychotic medications for one Resident (#4) of five residents reviewed. Findings include: Resident #4 (R4) Review of the Minimum Data Set (MDS) assessment, dated 1/19/2025, revealed R4 was admitted to facility on 4/18/2016 and had diagnoses including dementia, seizure disorder and schizophrenia. R4 was rated as having severe cognitive impairment. Review of R4's active medication orders revealed the following: Clozapine oral tablet 100 MG [milligram], give 1 tablet by mouth in the morning related to paranoid schizophrenia. Order date: 12/01/2023. Clozapine oral tablet 100 MG, give 3 tablets by mouth at bedtime related to paranoid schizophrenia. Order date: 12/01/2023. Further review of R4's electronic medical record (EMR) revealed the following active physician's order for laboratory testing, dated 11/4/2024: CBC with diff [complete blood count with differential] q [every] 30 days. The EMR for R4 revealed the most recent laboratory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that Medication Regimen Reviews (MRR's) and pharmacy recommendations were reviewed timely for one Resident (R18) out of five residents reviewed for MRR's. This deficient practice resulted in the potential for unnecessary medications or inappropriate durations of treatments. Findings include: Resident #18 (R18) A review of R18's medical record revealed they admitted to the facility on [DATE] with medical diagnoses including diabetes mellitus type II, bipolar disorder, and anxiety. A review of their 12/20/24 Minimum Data Set (MDS) assessment revealed they scored 15/15 on the Brief Interview for Mental Status (BIMS) assessment, indicating intact cognition. A review of a Pharmacy Consultation Report dated 10/24/24 revealed in part, (R18) Consider adding lab draws for A1C and Magnesium levels .Physician agrees and signed on 11/5/24. Review of R18's Medications and Treatment Administration Records and progress notes, dated October through December…

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 MI00151466. Based on observation, interview and record review, the facility failed to ensure the safe administration of medications for one Resident (#10) of six reviewed, resulting in a significant error when R10 was administered another resident's medications, leading to lethargy and confusion. Findings include: Resident #10 (R10) Review of the Minimum Data Set (MDS) assessment, dated 1/22/2025, revealed R10 was admitted to the facility on [DATE] and had diagnoses including hypertension, diabetes, stroke, and depression. R10 was assessed as cognitively intact and independent with most ADLs (activities of daily living) and ambulation. On 4/8/2025 at 3:06 p.m., R10 was observed standing at the sink in her room washing her hands, unassisted. R10 walked unassisted to her bed and sat down. During an interview at the time of the observation, R10 was asked about care in the facility, including medication management. R10 reported an occasion when she was administered another resident's…

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: 1. Educate residents/resident representatives on the pneumonia vaccines currently available and recommended by the CDC for two residents (R10 and R72) of five residents reviewed for immunizations. 2. Administer a pneumococcal vaccination or document the clinical reasons for withholding the pneumococcal vaccination for one resident (R17) of five residents reviewed for immunizations. 3. Update vaccine consent forms and immunization policies with the pneumococcal vaccines (PCV15, PCV20 or PCV21) currently available and recommended by the Centers for Disease Control (CDC). Findings include: Resident #10 (R10) R10 was admitted to the facility on [DATE] with a primary diagnosis of diabetes with circulatory complications. A vaccination report from the [State] Care Improvement Registry (MCIR - State Agency Immunization Record) was reviewed on 4/10/25 and revealed R10 was overdue for pneumonia vaccination. The MCIR documented, in part: .Pneumococcal High Risk…

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 deficiency pertains to Intake MI00149589. Based on interview and record review, the facility failed to conduct regular skin assessments for one Resident (#1) of three residents reviewed for quality of care resulting in the potential for untreated skin conditions. Findings include: Resident #1 (R1) Review of R1's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including ischemic cardiomyopathy (a condition that reduces the heart's ability to pump blood due to decreased blood supply) and type two diabetes. Review of R1's most recent Minimum Data Set (MDS) assessment, dated 10/22/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. On 1/22/25 at 11:25 AM, a telephone interview was conducted with R1's Guardian [A] regarding the care she received at the facility. Guardian A stated R1 had consistent redness and irritation in her skin folds around her stomach and groin area. Guardian A stated the facility was not…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by failing to dispose of expired food in kitchen refrigerators. These deficient practices have the potential to result in food borne illness among any and all 23 residents of the facility. Findings include: On 4/22/24 at 10:00 a.m., the reach in refrigerator was observed to have six expired containers of juice. The six juice containers had expiration dates as far back as January 2024, February 2024, and March 2024. No container of juice had a received date labeled on top. During this observation, Kitchen Manager/Staff E stated that he had just went through the refrigerators for expired foods and must have missed these juices. The FDA Food Code 2017 states: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section,…

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 administer its policies, practices, and procedures in a manner that displayed effective and efficient use of its resources to ensure the achievement and maintenance of the highest practicable physical, mental, and psychosocial well-being for all 22 residents at the facility, as evidenced by the following: 1. The facility administration was not present during the delivery of an Immediate Jeopardy (IJ) regarding resident abuse on 4/22/24 at approximately 5:30 PM despite disclosure of the severity of the concern by state surveyors during an earlier meeting (at 2:54 PM). The IJ was delivered to the Director of Nursing (DON) who stated the Nursing Home Administrator (NHA) had already left the facility for the day (reference tag F600). 2. The facility administration failed to report and investigate an unauthorized leave of absence (LOA) from the facility resulting in a resident's (Resident #9's/R9) location being unknown for approximately 16 hours without required medical supplies and equipment, including…

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 Infection Preventionist (IP) completed specialized training in infection prevention and control. Findings include: On 4/23/24 at 3:10 PM, an interview was conducted with MDS Coordinator/Former IP O. MDS Coordinator/Former IP O indicated she served as the facility's IP from January 2023 through March 2024. MDS Coordinator/Former IP O stated she began the taking classes for the IP certification but never finished the training. MDS Coordinator/Former IP O stated she would further discuss her struggles with the IP certification process at the Infection Control (IC) meeting scheduled with this surveyor on 4/25/24 at 10:00 AM. On 4/25/24 at 9:55 AM, MDS Coordinator/Former IP O was observed storming out of her office with her jacket on and bags packed. MDS Coordinator/Former IP O stated, I have essentially been terminated on the spot. I will not be meeting with you at 10:00 AM for the IC meeting or answering any more questions. On 4/25/24 at 10:00 AM, an interview was conducted with Current IP B. Current IP B 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.

Based on interview and record review, the facility failed to assess, reassess, obtain consent, and develop care plan interventions for one Residents (R5) of twelve sampled residents for care plan revision. Findings include: Resident #5 (R5) On 4/23/24 at 9:00 AM, an observation was made of R5 in her room sitting in her wheelchair. R5's bed had two side rails/mobility bars on the upper half of each side of her bed. On 4/23/24 at 9:05 AM, an interview was conducted with R5 and was asked if she had signed a consent for the mobility bars and replied, Not that I am aware. On 4/24/24 at 11:00 AM, R5 continued to have the two mobility bars in place. Review of R5's physician order, dated 2/22/23, read in part, .Please use mobility assist bars . Review of R5's Minimum Data Set (MDS) admission assessment, dated 2/23/23, lacked any indication of the use of a bed rail or mobility bar. R5's MDS quarterly assessment, dated 8/26/23 and 11/26/23, lacked any indication of the use of a bed rail or mobility bar. Review of R5's care plan, dated 3/6/23, read in part, .focus: Physical Mobility…

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 R6 A review of R6's EMR revealed admission to the facility on 3/11/19 with diagnosis including: dementia with other behavioral disturbance, type 2 diabetes, major depression disorder, bipolar disorder, stage 4 chronic kidney disease, and repeated falls. A review of R6's MRR's revealed that the pharmacist made recommendations on 9/21/23, 10/24/23, 12/27/23, and 2/26/24. The facility was unable to find the pharmacists recommendation and the physician's response by the survey exit date of 4/25/24. Based on interview and record review, the facility failed to ensure monthly regimen reviews (MRR's) were completed monthly and recommendations were reviewed by a physician and follow up for five Residents (R4, R6, R20, and R21) of four residents reviewed for MRR's. Findings include: Resident #20 (R20) A review of R20's EMR revealed admission to the facility on 4/4/23 with diagnosis including dementia, aphasia, and cerebral infarct. A review of R20's MRR's revealed the pharmacist made recommendations on 12/27/23 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.

Based on interview and record review, the facility failed to ensure the provision of resident rights training requirements for three of seven employees reviewed for resident rights training. Findings include: A review of staff education records and competencies on 4/25/24 revealed the following staff members had not completed the required resident rights training within the 12-month period: Nursing Home Administrator (NHA) - last completed 2/1/23 Registered Nurse (RN) B - last completed 2/1/23 Agency Certified Nurse Aide (CNA) F - had not completed any training. An interview was conducted with the Director of Nursing (DON) on 4/25/24 at 12:38 p.m. The DON stated that she was primarily responsible for annual training and competencies of the staff at the facility, and that the facility does training based on calendar year. The DON was asked about CNA F training as an agency staff to which she replied, She should have had training completed by the agency. When asked if CNA F had specific training completed for this facility, the DON stated No. Review of the facility's Resident Abuse,…

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 provision of infection control training for four of seven employees reviewed for infection control training. Findings include: A review of staff education records and competencies on 4/25/24 revealed the following staff members had not completed the required abuse, neglect and exploitation training and competency evaluation within the required 12- month period: Nursing Home Administrator (NHA): 8/29/24 (this date is in the future) Certified Nurse Aide (CNA) C - did not complete the Infection Control Annual Inservice Director of Nursing (DON) - did not complete the Infection Control Annual Inservice. A note provided by the facility stated that she was not working during class but has been the preventionist for years. No further documentation or certificate was provided by the survey exit date of 4/25/24. Agency CNA F - did not complete the Infection Control Annual Inservice

Based on observation, interview, and record review, the facility failed to ensure two Residents (R15 and R20) were free from physical restraints imposed for purposes of convenience, out of twelve residents sampled for review for restraints. This deficient practice resulted in restriction of freedom of movement and the potential for injury. Findings include: Resident #15 (R15) Review of R15's Minimal Data Set (MDS) assessment, dated 10/11/23, revealed R15 had diagnoses that included the following, in part: dementia, anemia, kidney disease, and constipation. R15 was dependent for eating, oral hygiene, toileting, bathing, and dressing. Section P of the MDS assessment revealed R15 did use a form of restraint daily marked as other alarm. Review of R15's complete electronic medical record (EMR) found no physical order, signed consent, or restraint assessment. R15's EMR, revealed, R15 was not their own responsible party and that R15 had a guardian listed as their responsible party. Review of R15's care plan, date revised 12/5/23, read in part, .Goal: Moderate fall risk R/T [related 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 an unauthorized leave of absence was reported timely to the facility administrator and State Agency (SA) for one Resident (#9) of 5 residents reviewed for accident and incident reporting. Findings include: Resident #9 (R9) Review of R9's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including Huntington's disease (a progressive, fatal genetic disorder that affects the brain and causes involuntary movements, cognitive decline, and emotional problems), aphasia (difficulty processing, using, and/or understanding language), dysphagia (difficulty or inability to swallow), contracture of unspecified hand (a permanent shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult), and alcohol abuse. Record review of R9's Minimum Data Set (MDS) assessment immediately preceding the unauthorized leave of absence (LOA) on 7/20/23, indicated R9 had severely impaired cognition -…

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 investigate an incident of abuse/neglect for one Resident (#9) of two residents reviewed for abuse/neglect. Findings include: Resident #9 (R9) Review of R9's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including Huntington's disease (a progressive, fatal genetic disorder that affects the brain and causes involuntary movements, cognitive decline, and emotional problems), aphasia (difficulty processing, using, and/or understanding language), dysphagia (difficulty or inability to swallow), contracture of unspecified hand (a permanent shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult), and alcohol abuse. Record review of R9's Minimum Data Set (MDS) assessment immediately preceding the unauthorized leave of absence (LOA) on 7/20/23, indicated R9 had severely impaired cognition - unable to complete BIMS [Brief Interview for Mental Status]. R9 was admitted to hospice…

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 notify the resident in writing with the reason for a transfer out of the facility for two Residents (R18, R20) of three residents reviewed for transfers. This deficient practice resulted in limited knowledge of the treatment plan due to lack of written transfer or discharge notification to the resident/resident's representative. R18 A review of R18's Electronic Medical Record (EMR) revealed she was transferred to the hospital on 7/7/23. There was no written notification of transfer given to R18. R18 returned to the facility on 7/10/23. A request was made for the facility's transfer policy on 4/25/24. On 4/25/24 at approximately 11:20 a.m. an interview was conducted with Registered Nurse (RN)/Director of Nursing in Training A. RN A confirmed that the facility is not following their policy regarding transfer notification because they are such a small building, and they notify resident/resident representatives individually. Resident #20 (R20) A review of R20's EMR revealed he was transferred to the hospital on 6/19/23. There…

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 Resident #20 (R20) A review of R20's progress notes revealed the following: 6/19/23 06:55 (6:55 AM): Late Entry: .Right hip appears swollen, non tender to touch, skin color appears normal. When resident moves right leg he grimaces and says ouch. [facility Physician's name] notified .EMS [emergency medical services] called. Resident transferred to [local hospital name] for evaluation . Review of the Clinical Census report revealed R20 was hospitalized from [DATE]. R20 returned to the facility on 6/23/23. Review of R20's EMR revealed there was no Bed Hold Authorization form completed for the 6/19/23 transfer. Review of the facility's Attachment F-admission Contract Policy and Procedure for Bed Holds and readmission [Facility Name] revised on 1/1/2002 read, in part, [Facility Name] has formally adopted the following policy and procedure regarding the holding open of beds in the event of a resident's temporary absence from the facility. The purpose of this policy is to notify and inform residents of their rights 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 Based on interview and record review, the facility failed to submit a quarterly Minimal Data Set (MDS) assessment for one Resident (R15) of twelve residents sampled for timely of MDS assessments. Findings include: Review of R15's complete electronic medical record (EMR), revealed, R15 was originally admitted to the facility on [DATE], with her most recent admission date of 11/6/23. Review of R15's MDS assessment, dated 10/11/23, revealed R15 had diagnoses that included the following, in part: dementia, anemia, kidney disease, and constipation. R15 was dependent for eating, oral hygiene, toileting, bathing, and dressing. Section P of the MDS assessment revealed R15 did use a form of restraint daily marked as other alarm. Review of R15's MDS assessments, revealed, she was overdue to have a completed quarterly MDS assessment. R15's last MDS was on 10/11/23. MDS assessments are required every 90 days. No current MDS could be found and the facility could not provide an updated MDS for R15. On 4/25/24 at 9:30 AM, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Preadmission Screening (PAS)/Annual Resident Review (ARR) Mental Illness/Intellectual Disability/Related Conditions Identification (form DCH-3878) documents were reviewed, revised, and sent to the local state agency for review and/or evaluation for one Resident (R6) of one sampled resident reviewed for PASSARs. This deficient practice resulted in the potential for residents to be excluded from receiving necessary care and services appropriate to meet their mental health needs. Findings include: A review of R6's Electronic Medical Record (EMR) revealed admission to the facility on 3/11/19 with diagnoses including dementia with behavioral disturbance, depression disorder, and bipolar disorder. Review of her Annual Minimum Data Set (MDS) assessment dated [DATE] revealed she scored an 8/15 on the Brief Interview for Mental Status (BIMS) score, indicative of mild cognitive impairment. A review of R6's Preadmission Screening (PAS)/Annual 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 develop resident centered care plan based on the needs of one Resident (R21) of twelve sampled residents for development of resident centered care plans. Findings include: Resident #21 (R21) Review of R21's face sheet, revealed an original admission into the facility on [DATE] with medical diagnoses of the following, in part: depression, bipolar disorder, paraplegia, and pressure ulcers. On [DATE] at 10:40 AM, an interview was conducted with R21 in his room. R21 confirmed that the facility had been treating his wounds and the wounds were still currently open and undergoing treatments. During the interview an observation, no transmission-based precaution (TBP) signage was located outside of the room door for R21 to alert staff providing direct care that R21 was on enhanced barrier precautions (EBP) related to open wounds. Review of R21's physician order, dated [DATE], revealed the following, in part: attempt resuscitation/CPR…

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 physician order for one Resident (R20) and failed to obtain a physician order for an emergency medication for one Resident (R21) of twelve sampled residents reviewed for physician orders. Findings include: Resident #20 (R20) Review of R20's MDS assessment, dated [DATE], revealed R20 had diagnoses that included the following, in part: dementia, aphasia, and cerebral infarct. Review of R20's physician order, dated [DATE], revealed an order for [NAME] Hose while seated during the day. On [DATE] at 4:10 PM, an observation was made of R20 sitting in a recliner chair in the residents' lounge and no [NAME] hose were observed worn on R20's lower legs. On [DATE] at 10:00 AM, an observation was made of R20 sitting in a recliner chair in the residents' lounge and no [NAME] hose were observed worn on R20's lower legs. On [DATE] at 1:20 PM, an interview was conducted with Registered Nurse (RN) K and was asked if he had seen R20's [NAME] hose…

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 provision of trauma-informed care to mitigate triggers that may cause re-traumatization for one Resident (R6) of one resident reviewed for trauma-informed care. Findings include: During an interview on 4/22/24 at approximately 11:45 am., R6 stated that her main concern was another male resident who constantly yells out. R6 stated that the sound scares her because she does not know when he is going to do it, even though he cannot help himself. Review of R6's Electronic Medical Record (EMR) revealed admission to the facility on 3/11/19 with diagnoses including: dementia with other behavioral disturbance, major depressive disorder, and bipolar disorder. Her 3/14/24 Minimum Data Set (MDS) assessment, revealed no history of trauma or post-traumatic stress disorder (PTSD), but was reflective in her Care Plan. R6 scored an 8/15 on the Brief Interview for Mental Status (BIMS) reflective of moderate cognitive impairment. Review of R6's Social Service Progress Notes dated 12/28/22 read, in part, .Resident was hospitalized…

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 appropriate assessment, measurements, and consent for bedrails was completed for one Resident (R5) of one resident reviewed for bedrails. Findings include: On 4/23/24 at 9:00 AM, an observation was made of R5 in her room sitting in her wheelchair. R5's bed had two side rails/mobility bars on the upper half of each side of her bed. On 4/23/24 at 9:05 AM, an interview was conducted with R5 and was asked if she had signed a consent for the mobility bars and replied, Not that I am aware. On 4/24/24 at 11:00 AM, R5 continued to have the two mobility bars in place. A review of the electronic medical record (EMR) revealed no evidence of a consent, gap measurements, or assessment. On 4/24/24 at 10:40 AM, an interview was conducted with the Director of Nursing (DON) was asked if a consent and assessment were required for the mobility bars and replied, Yes. The mobility bars are required to be care planned, assessed, and re-assessed quarterly, have a consent, and physician order. The DON was asked to provide 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 coordinate behavioral health services for one Resident (#4) of four residents reviewed for mood and behavior. Findings include: Resident #4 (R4) Review of R4's electronic medical record (EMR) revealed initial admission to the facility on 2/22/23 with diagnoses including recurrent major depressive disorder, dementia, and delusional disorders. Review of R4's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7, indicative of severe cognitive impairment. On 4/22/24 at 11:00 AM, R4 was observed sleeping in a dark room with the shades drawn. On 4/24/24 at 9:47 AM and 1:11 PM, resident was again observed sleeping in a dark room with the shades drawn. Review of consultation with [Community Mental Health Provider] dated 4/25/23 read, in part: .this consultation in being requested due to violent behaviors, slapping staff members, yelling, out of control since last Friday pm [evening], Patient…

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 licensed personnel administered medications to 1 out of 12 Residents (Resident #12) reviewed for medication administration. Findings include: Resident #12 (R12) Review of R12's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including schizophrenia and chronic kidney disease. Review of R12's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicative of intact cognition. Review of R12's progress notes revealed the following entry on 12/27/23 at 19:17 [7:17 PM] by the Director of Nursing (DON): Miralax put in thickened liquid for another resident whose name is [same first name as R12]. Cena [Certified Nursing Assistant (CNA)] didn't realize it had medication in it and gave it to [R12]. [R12] drank it down fast before we could get it back. Review of Medication Related Incident Report revealed the following: Description 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 interview and record review, the facility failed to maintain accurate medical records for 1 of 12 residents (Resident #9) reviewed for medication administration. Findings include: Resident #9 (R9) Review of R9's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including Huntington's disease (a progressive, fatal genetic disorder that affects the brain and causes involuntary movements, cognitive decline, and emotional problems), aphasia (difficulty processing, using, and/or understanding language), dysphagia (difficulty or inability to swallow), contracture of unspecified hand (a permanent shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult), and alcohol abuse. Record review of R9's Minimum Data Set (MDS) on 7/20/23, indicated R9 was severely impaired cognition - unable to complete BIMS [Brief Interview for Mental Status]. Review of the Census list revealed R9 departed the facility on 9/18/23 at 6:07 PM for a leave 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 in implement enhanced barrier precautions (EBP) for one Resident (R21) of twelve sampled residents reviewed for infection control practices. Findings include: Resident #21 (R21) Review of R21's face sheet, revealed an original admission into the facility on [DATE] with medical diagnoses of the following, in part: depression, bipolar disorder, paraplegia, and pressure ulcers. Review of R21's Minimal Data Set (MDS) assessment, dated 11/28/23, revealed that R21 was cognitively intact. Review of R21's wound assessment, dated 11/22/23, revealed he had two wounds, one on his left lower leg and a second on his coccyx that he was admitted with. Review of R21's weekly wound assessment, dated 11/22/23 through 4/1/24, revealed R21's wounds were improving. On 4/22/24 at 10:40 AM, an interview was conducted with R21 in his room. R21 confirmed that the facility had been treating his wounds and the wounds were still currently open and undergoing…

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 an eligible resident was offered influenza vaccines as recommended by the Centers for Disease Control and Prevention (CDC) for 1 of 5 residents (Resident #20) reviewed for vaccination status. Findings Include: Resident #20 (R20) Review of R20's electronic medical record (EMR) revealed initial admission to the facility on 4/4/23 with diagnoses including cerebral infarction (stroke), dementia, and aphasia (difficulty processing, using, and/or understanding language). Review of 20's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicative of moderate cognitive impairment. Review of R20's vaccination history on the Michigan Care Improvement Registry (MICR), revealed the last dose of the seasonal influenza vaccine (Influenza IIVD) was administered on 10/30/20. The status for eligible vaccinations read, Seasonal Influenza DUE NOW. On 4/25/24 at 10:08 AM, an interview 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.

Based on interview and record review, the facility failed to maintain an effective abuse and dementia management training program for three out of seven staff members reviewed for annual training. Findings include: A review of staff education records and competencies on 4/25/24 revealed the following staff members had not completed the required abuse, neglect and exploitation training and competency evaluation within the required 12- month period: Abuse Training: Nursing Home Administrator (NHA) - last completed 2/1/23 Registered Nurse (RN) B - last completed 2/1/23 Agency Certified Nurse Aide (CNA) F had not completed the facility's abuse training program. Dementia Training: NHA: last completed 2/1/23 CNA F had not completed the facility's dementia training program. An interview was conducted with the Director of Nursing (DON) on 4/25/24 at 12:38 p.m. The DON stated that she was primarily responsible for annual training and competencies of the staff at the facility, and that the facility does training based on calendar year. The DON was asked about CNA F training as an agency staff…

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.