Marshall Nursing and Rehabilitation Community

Based on observation, interview and record review, the facility failed to ensure the facility Activity Director met the criteria as a qualified activities professional in a current facility census of 46 residents.Upon observation of the main hallway of the facility on 09/02/25 it had a large board that was to post the Activities for the week. However, the board was blank and the Activity calendar was not posted until 09/04/2025. Review of the September activity Calendar offered activities 7 days a week, the latest activity held was 3:30 PM. Some of the titled Activities were Morning News, Church Packets Conversation ball. There were zero activities observed during the survey week of 9/02-09/08/25. On 09/08/2025 at 10:10am, during an interview with Nursing Home Administrator (NHA) A she reported being new to the facility and the suggested surveyor talk with Clinical Regional Director O because Activity Director/Certified Nursing Assistant Z now works as a CNA. On 9/08/2025 10:22 AM, during an interview with Clinical Regional Director O reported the facility had hired a new Activity…

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 conduct monthly pharmacy reviews for one resident (#5) of five resident reviewed for pharmacy services and the facility failed to implement/respond to pharmacy recommendations for four residents (#3, #5, #28, #46) of five residents reviewed for pharmacy services. Review of the medical record reflected R46 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included need for assistance with personal care. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/19/25, reflected R46 scored 12 out of 15 (moderately impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 9/9/25 at 1:30 PM, R46 was observed in her room. R46 was in bed and was pleasant and nicely groomed. Review of R46's medical record revealed a Pharmacist Drug Regimen Review for 6/2025, which revealed See report for any noted irregularities and/or recommendations. No copy of the pharmacy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program.Findings Include:Resident 104-1 (R104-1) Review of the medical record reflected that R104-1 was admitted to the facility on [DATE], hospitalized on [DATE] and was readmitted to the facility on [DATE]. Diagnoses of Displaced [NAME] fracture of left tibia, subsequent encounter for closed fracture with routine healing, need for assistance with personal care, Unsteadiness on feet. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE] revealed R104-1 had a Brief Interview of Mental Status (BIMS) of 15 (Cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R104-1 needed assistant with personal care. During a record review for a bed hold policy, transfer notice, discharge notice, there was not given nor documented that one was discussed for R104-1.…

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 and interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living. Findings Include:On 9/2/25 at 1:44 PM, observation of the Forest Unit spa room found three call lights in the room, two of the call lights had pull cords 18 to 28 inches off the ground and the third call light (in the far shower) did not have a pull cord at all. Further observation of the spa room found a nickel sized sticker on the shower wall with an image of a snowflake and three clean washcloths open and exposed on the rack in the first shower stall. On 9/2/25 at 1:58 PM, observation of the [NAME] Unit soiled utility room, found two boxes of gloves and two rolls of trash bags in the hand sink. Further observation found that the atmospheric vacuum breaker (AVB), in the over hopper faucet, was found to be leaking heavily when the faucet was turned on. On 9/2/25 at 2:00 PM,…

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 honor a resident's/guardian (#4) Advance Directives (a written statement of a resident's wishes regrading medical treatment) for DNR (Do not Resuscitate) of one residents reviewed. Findings Include:Resident #4(R4) Review of the medical record revealed R4 was admitted to the facility [DATE] with diagnoses that included cerebral palsy (a group of disorders that affect movement, muscle tone, and posture due to damage to the developing brain), hypertension, hyperlipidemia (high fat content in blood), epilepsy, contracture right elbow, contracture left elbow, contracture right hand, contracture left hand, gastro-esophageal reflux disease, dysphagia (difficulty swallowing), cognitive communication deficit, contracture right lower leg, contracture left lower leg, contracture right knee, contracture left knee, contracture right ankle, contracture left ankle, aphasia (language disorder that affects person's ability to speak) , anemia (low red blood…

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 notify the resident and/or resident's representative of the facility policy for bed hold and a written reason for the transfer, for one (Resident #50) and failed to provide notice of discharges and transfers, to the representative of the Office of the State Long-Term Care Ombudsman for two of two residents reviewed (Resident #50 and #52).Findings include: Resident #50 Review of the clinical record revealed R50 was admitted to the facility on [DATE] with a diagnosis of chronic kidney failure and heart failure. Further review of the clinical record revealed R50 was transferred to the hospital on [DATE] and did not return to the facility. There was no documentation in the clinical record to reflect R50 or his representative was provided in writing in a language they would understand explaining the reason for the transfer, no documentation that bed hold information was provided. Resident 52Review of the clinical record for Resident #52 (R52) revealed an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to submit a significant change Minimum Data Set (MDS) for one (Resident #13) out of 12 reviewed for significant change MDS. Findings include: Review of the medical record reflected Resident #13 (R13) was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included Aphasia, Pressure ulcer of right hip, pressure ulcer of left hip, vascular dementia, Quadriplegia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/27/2025, reflected R13 scored 4 out of 15 (severe impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 9/02/2025 at 1:46 PM, R13 was observed in bed sleeping. R13 did not respond to an interview request. Review of a Progress Note dated 03/12/2025 at 12:39 AM reflected resident [R13] left hip has open area on his old wound . Review of the Physician Orders revealed an order for wound care for R13's left hip was not ordered and implemented until…

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 accurately complete a Minimum Data Set (MDS) assessment for one resident (#25) of 12 residents reviewed for accurate assessments. Findings Included:Resident #25 (R25) Review of the medical record revealed R25 was admitted to the facility 08/27/2016 with diagnoses that included Parkinsonism (a group of neurological disorders that share similar symptoms to Parkinson's disease), seizures, disorders of psychological development, type 2 diabetes, anemia (low red blood cells), anxiety, bipolar disorder, hypothyroidism (low thyroid hormone), peripheral vascular disease (PVD), gastro-esophageal reflux disease, constipation, Parkinson's disease, malnutrition, dementia, and dysphagia (difficulty swallowing). Review of R25's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/18/2025 revealed a Brief Interview for Mental Status (BIMS) of 00 (severe impaired cognition) out of 15. On 09/02/2025 at 10:14 a.m. during observation and attempted interview R25 was observed sitting up in the hallway, in his…

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 showers were provided on a routine, regularly scheduled basis and as preferred for one resident, (Resident #6) of one reviewed.Findings include:Review of the clinical record, including the Minimum Data Set, dated [DATE] revealed Resident #6 (R6) was admitted to the facility with diagnoses that included major depression, obesity and dementia. R6 scored 12 out of 15 (moderated cognitive impairment) on the Brief Interview for Mental Status (BIMS). On 09/02/2025 at 10:10 AM, during an interview with R6 reported being displeased about not getting showers twice a week. R6 stated she was supposed to receive showers on the afternoon shift, but this does not happen consistently. Review of the R6's clinical record revealed R6 received 3 showers in April, (4/8, 4/15 and 4/29) 3 showers in May 2025 (5/2, 5/16, 5/27), 3 showers in June 2025 (6/3, 6/17, 6/20) and 5 in July (7/16, 7/18, 7/22, 7/25, 7/29). There was no evidence in the clinical…

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 initiate Cardiopulmonary Resuscitation efforts in a timely manner for one (Resident #51) of one reviewed. Findings include: Review of the medical record reflected R51 was admitted to the facility on [DATE], with diagnoses that included Chronic obstructive pulmonary disease and Respiratory failure. R51 expired at the facility. Review of the Electronic Medical Record revealed a Physician Order dated [DATE] which stated Full Code, Give CPR (Cardiopulmonary resuscitation). Review of R51's Electronic Medical Record reflected R51 expired at the facility, however, there was no documentation to describe the events that surrounded R51's change in condition and passing. In an interview on [DATE] at 2:23 PM, Licensed Practical Nurse (LPN) E confirmed she was working the night R51 had experienced a change in condition. LPN E reported that she was alerted to R51's condition when a staff member notified her that R51 was on the floor, positioned on his stomach. LPN E…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement pressure wound treatment orders in a timely manner for one (Resident #13) out of one reviewed for pressure wounds. Findings include: Review of the medical record reflected Resident #13 (R13) was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included Aphasia, Pressure ulcer of right hip, pressure ulcer of left hip, vascular dementia, Quadriplegia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/27/2025, reflected R13 scored 4 out of 15 (severe impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 9/02/2025 at 1:46 PM, R13 was observed in bed sleeping. R13 did not respond to an interview request. Review of a Progress Note dated 03/12/2025 at 12:39 AM reflected resident [R13] left hip has open area on his old wound . Review of the Physician Orders revealed an order for wound care for R13's left hip was not ordered and implemented until…

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 label medication with open dates in two of three medication carts reviewed and failed to record refrigerator temperatures for two or two medication refrigerators reviewed. Finding Included:On 09/08/2025 at 10:04 a.m. during inspection of [NAME] North medication cart, with Licensed Practical Nurse (LPN) W, it was observed that the following medication was open and did not have a date that they were opened recorded on the medication container: Trelegy 100mcg(micrograms)/62.5mcg/25mcg inhalers, and two Albuterol Sulfate inhalers 90mcg.During an interview on 09/08/2025 at 10:05 a.m. Licensed Practical Nurse (LPN) W explained that it was the facility practice to date all medication once it is open. LPN W could not explain why the identified medication above in [NAME] North medication cart did not have a date on the medication container when it was open. LPN W explained that she would be calling pharmacy to replace the inhalers that were 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 provide dental services for one resident (8) out of one resident's review for dental services. Findings Included:Resident #8(R8) Review of the medical record revealed R8 was admitted to the facility 12/31/2024 with diagnoses that included bipolar disorder, type 2 diabetes, hypertension, hyperlipidemia (high fat content in blood), gastro-esophageal reflux disease, restless leg syndrome, paranoid schizophrenia, chronic pain, anxiety, depression, and obesity. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/07/2025, demonstrated a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on R8 was observed lying in bed. R8 was observed edentulous (without teeth). R8 explained that she had dentures while she was at home but when she came to the facility, she did not have her dentures. R8 explained that she had informed someone that she would like her dentures, but she had not received any recent updates 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 offer the influenza immunization to one (Resident #13) out of 5 reviewed for immunizations. Findings include:Review of the medical record reflected Resident #13 (R13) was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included Aphasia, Pressure ulcer of right hip, pressure ulcer of left hip, vascular dementia, Quadriplegia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/27/2025, reflected R13 scored 4 out of 15 (severe impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 9/02/2025 at 1:46 PM, R13 was observed in bed sleeping. R13 did not respond to an interview request. During immunization record review, there was an absence of any offering of the influenza vaccine for 2024. In years prior, R13 had consented to and received the influenza vaccine. On 9/08/2025 at 12:08 PM, Regional Clinical Director O stated that she was unable to locate any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to offer the COVID-19 immunization to one (Resident #13) out of 5 reviewed for immunizations. Findings include: Review of the medical record reflected Resident #13 (R13) was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included Aphasia, Pressure ulcer of right hip, pressure ulcer of left hip, vascular dementia, Quadriplegia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/27/2025, reflected R13 scored 4 out of 15 (severe impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 9/02/2025 at 1:46 PM, R13 was observed in bed sleeping. R13 did not respond to an interview request. During immunization record review, there was an absence of any offering of the COVID-19 vaccine for 2024. In years prior, R13 had consented to and received the COVID-19 vaccine. On 9/08/2025 at 12:08 PM, Regional Clinical Director O stated that she was unable to locate any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake number 2580873.Based on interview and record review the facility failed to ensure for one out of three residents (Resident #2) Physician's orders were followed to ensure diagnostic testing was performed for proper treatment and prevent hospitalization.R2 no longer resided at the facility at the time of the investigation.Per the facility face sheet Resident #2 (R2) was admitted to the facility on [DATE]. R2 had a diagnosis of Personal history of urinary (tract) infections (UTI).Record review of R2's care plans dated 8/31/2023, revealed R2 received prophylactic (preventative) antibiotics due to chronic urinary tract infections.Review of a Nurse Practitioner progress note dated 5/20/2025, revealed documentation that R2 had increased confusion, and a urine sample would be obtained.On 5/20/2025 a Physician order was written to obtain a UA to rule out a UTI.Upon review of R2's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the month of May 2025,…

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 assess, monitor, follow physician orders and document on skin wounds for one (R101) of three residents reviewed for non-pressure skin conditions. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R101 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), peripheral vascular disease(decreased blood flow in legs), wound infection and diabetic. The MDS reflected R101 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required staff assist with bathing and supervision with dressing, ambulation, and transfers. Review of complaint received by the State Agency alleged the facility failed to provide adequate and appropriate interventions to prevent and care for wounds. Review of R101 Nursing Progress Note, dated 1/16/25, reflected, Resident arrived via ambulance with family…

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 controlled medications were properly labeled and stored per professional standards of practice for one residents (R104) and a medication cart in a current facility census of 45 residents. Findings Included: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R104 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease, pneumonia, weakness and depression. The MDS reflected R104 had a BIM (assessment tool) score of 14 which indicated her ability to make daily decisions was cognitively intact. Review of complaint received by the State Agency alleged the facility failed to appropriately store controlled medications. During an observation and interview on 5/28/25 at 8:23 a.m., Registered Nurse (RN) C unlocked the [NAME] 1 medication cart and controlled drawer. This surveyor observed nine unlabeled clear plastic bags including eight bags…

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 MI00149290 Based on observation and interview the facility failed to maintain documentation to indicate glucometer calibration was being performed potentially affecting all residents (17) who were diagnosed with diabetes with ordered monitoring resulting in the potential for inaccurate blood glucose readings and incorrect treatment. Findings include: On 2/11/25 at 1:09 PM Licensed Practical Nurse (LPN) C was interviewed regarding the process of blood glucose testing. LPN C was asked how she knows a machine is reading results accurately. LPN C responded by saying the glucometer is quality control tested by night shift every 24 hours. On 2/12/25 at 8:55 AM the glucometer calibration logbook was requested and the Assistant Director of Nursing (ADON) F searched for the book. On 2/12/25 at 9:05 AM the Director of Nursing (DON) B and Regional Nurse (RN) G were observed searching for the glucometer calibration logbook at the nurse's station, looking through the medication cart, the cupboards, the files. The logbook was not found. At the second nurse'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.

Based on observation, interview and record review the facility failed to maintain disinfection for glucometer's (blood glucose testing devices) affecting residents (R4, R5, R8, and R9) of 4 residents reviewed resulting in the potential for bacterial growth and transmission of pathogens. Findings include: On 2/11/25 at 11:45 AM during medication pass Licensed Practical Nurse (LPN) C was observed performing point-of-care (in resident room) blood glucose testing for R9 using a glucometer. LPN C placed the glucometer on the table without placing a barrier. LPN C was observed after blood glucose testing picking the glucometer up with a gloved hand and carrying it to the medication cart. No disinfection of the glucometer was done prior to leaving the room. LPN C then placed the glucometer on top of the medication cart, removed the gloves she was wearing, disposed of the gloves, and did not follow with sanitization of hands. Disinfection of the glucometer was also not performed. On 2/11/25 at 11:59 AM LPN C picked up the glucometer and walked to the dining table (in the common dining area)…

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 resident emergency transfer notifications were sent to the State Long-Term Care Ombudsman over the last for 41 residents, resulting in the potential for residents being inappropriately transferred or discharged . Findings Included: In an interview on 9/19/2024 at 9:15 AM, the State Long-Term Care Ombudsman R stated she had not received any copies of notifications of resident emergency transfers out of the facility for the last year, and stated she had inquired about them several times to the facility, but had not received any answer nor copies. On 9/19/2024 at 9:30 AM, the Regional Clinical Director (RCD) Q was requested to provide a list of all residents who were emergency transfers out of the facility over the last year, and also provide evidence that the Long-Term Care Ombudsman was provided with a copy of notifications of each resident's emergency transfer notice over the last year. On 9/19/2024 at 4:34 PM, (RCD) Q provided at list of residents over the last year who were emergency transfers out 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 Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 49 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies. Findings include: On 09/18/24 at 08:58 A.M., An initial tour of the food service was conducted with Dietary [NAME] M. The following items were noted: Packing shrink wrap was observed peeling and partially intact on both interior door surfaces of the Beverage-Air 2-Door Cooler (#1). Packing shrink wrap was observed peeling and partially intact on both exterior door surfaces of the BlueAir 2-Door Cooler (#2). The can opener assembly was observed soiled with accumulated and encrusted food residue. The Sharp microwave oven interior was observed soiled with accumulated and encrusted food residue. The Hobart stand mixer spindle gear cover and backsplash were observed soiled 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.

Based on observations, interviews, and record reviews, the facility failed to effectively maintain the outdoor waste receptacle effecting 49 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and pest attraction/harborage. Findings include: On 09/18/24 at 10:05 A.M., An environmental tour of the outdoor waste receptacle pad and container was conducted with Dietary Manager K. The following items were noted: The outdoor waste receptacle was observed missing the rear sliding door. The outdoor waste receptacle was observed with 1 of 2 swinging doors cracked and broken, increasing the likelihood for pest attraction/harborage. Dietary Manager K indicated she would contact the current waste removal company for necessary repairs as soon as possible. On 09/20/24 at 09:00 A.M., Record review of the Policy/Procedure entitled: Sanitizing Garbage Cans and Dumpsters dated 08/23 revealed under Policy: Garbage cans will be thoroughly cleaned and sanitized on a regular basis. Record review of the Policy/Procedure entitled: Sanitizing Garbage Cans 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 observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 49 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality. Findings include: On 09/18/24 at 04:44 P.M., An environmental tour of the facility Laundry Service was conducted with Director of Maintenance L. The following items were noted: Clean Laundry Room: The flooring surface was observed heavily soiled with accumulated and encrusted dust/dirt deposits. Soiled Laundry Room: The flooring surface was observed heavily soiled with accumulated and encrusted dust/dirt deposits. Director of Maintenance L indicated he would have housekeeping staff thoroughly clean and sanitize the flooring surfaces as soon as possible. Clean Laundry Storage Room: 2 of 2 overhead light plastic lens covers were observed soiled with dead insect carcasses. On 09/19/24 at 08:29 A.M., A common area environmental tour was conducted with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications/treatment carts remained secured in 2 of 3 medication/treatment carts reviewed, resulting in the potential unsafe access to medications. On 9/18/24 at 12:10 PM, two treatment carts located in the resident's dining room (North [NAME]) were observed to be unlocked. The cart drawers were opened revealing wound treatment supplies, including several prescribed topical medications. On 9/19/24 at 9:01 AM, the same treatment carts remained unlocked. On 9/19/24 at 10:24 AM, the same treatment carts remained unlocked. On 9/19/24 at 12:21 PM, one of the treatment carts was observed to be unlocked. The cart drawers were opened revealing wound treatment supplies, including several prescribed topical medications. On 9/19/24 at 3:11 PM, Regional Clinical Director Q observed the unlocked treatment cart, proceeded to lock it, and stated that the treatment carts should be locked. During an observation of medication administration 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 observations, interviews, and record reviews, the facility failed to provide palatable food products effecting 49 residents, resulting in the increased likelihood for resident decreased food acceptance and nutritional decline. Findings include: On 09/18/24 at 12:06 P.M., Resident #44 was observed seated at the table awaiting her lunch meal, within the Forest Dining Room. Resident #44 was also observed removing the meal tray upper insulation cover and stating: What the hell is this! referring to her lunch meal food products. On 09/18/24 at 12:10 P.M., Lunch meal food trays were observed leaving the food production kitchen, within an insulated transport cart. On 09/18/24 at 12:09 P.M., Lunch meal food trays were observed arriving to [NAME] (North) Dining Room. On 09/18/24 at 12:13 P.M., Food product temperatures were monitored utilizing a ThermoWorks Superfast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded for Resident #1's lunch meal: Burrito - 138.7…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective system to correct and monitor deficiencies for range of motion/mobility (F688) for two (Resident #31 and Resident #503), medication labeling/storage (F761), and environment (F921) that were identified on the previous survey dated 9/20/24, and ensure the facility was in compliance by the facility's alleged compliance date of 10/17/14. Findings include: F688: Review of Form CMS-2567 dated 9/20/24 revealed a completion date (alleged compliance date) of 10/17/24. The Plan of Correction for F688 revealed Element #2 Current residents who require splints have the potential to be affected. Current residents with splints have had care plan reviewed and current splint schedules updated and staff aware. Element #3 Nursing staff educated on ADL [activities of daily living] policy and splint application per plan of care. Staff education included where to find splinting schedules in plan of care and list of residents with splints…

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 safe and clean medical equipment (wheelchair) for one resident (#20) out of 15 residents reviewed. Findings Included: Resident #20 (R20) Review of the medical record revealed R20 was admitted to the facility 11/05/2019 with diagnoses that included Alzheimer's Disease, dysphagia (difficulty swallowing), need for assistance with person care, stage 3 kidney disease, insomnia, repeated falls, osteoarthritis (chronic disease causing breakdown of cartilage in bone joints), major depression, anxiety, epilepsy, anemia (low red blood cells), and hypothyroidism (low thyroid hormone). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/10/2024, demonstrated a Brief Interview for Mental Status (BIMS) of 2 (severe cognitive impairment) out of 15. During observation and attempted interview on 09/18/2024 at 10:58 a.m. R20 was observed sitting up in his wheelchair in the common area of the unit. R20 could not answer during attempted interview. R20's right sided wheelchair arm cushion…

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 complete accurate Minimum Date Set (MDS) assessments for 1 Resident (#33) (use of restraints) of 15 Residents reviewed for accurate MDS Assessments. Findings Included: Resident #33 (R33) Review of the medical record revealed R33 was admitted to the facility 01/17/2019 with diagnoses that included cerebral infarction (stroke), hemiparesis (difficulty moving one side of the body) of the left side, hemiplegia (paralysis one side of the body) of the left side, aphasia (difficulty speaking), dysphagia (difficulty swallowing), weakness, expressive language disorder, type 2 diabetes, contracture of the left knee, contracture of the left elbow, contracture, of the left hand, contracture of the left wrist, contracture of the left hand, hypertension, major depression, muscle spasm and chronic pain. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/07/2024, demonstrated a Brief Interview for Mental Status (BIMS) of 11 (moderate cognitive impairment) out of 15. During observation 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 observation, interview, and record review the facility failed to complete and provide a baseline care plan within 48 hours of admission for one Resident (#22) of 1 reviewed for baseline care plan development. Findings Included: Resident #22 (R22) Review of the medical record revealed R22 was admitted to the facility 09/09/2024 with diagnoses that included iron deficiency anemia (low red blood cells), end stage renal disease, depression, weakness, need for assistance with personal care, abnormalities with gait and mobility, heart failure, peripheral vascular disease (PVD), type 2 diabetes, dependence on renal dialysis, severe protein-calorie malnutrition, and atrial fibrillation. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/13/2024, demonstrated a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) of 15. During observation and interview on 09/18/2024 at 09:37 a.m. R22 was observed sitting in her wheelchair at the side of her bed. R22 explained that she did not have any knowledge or know any details regarding her plan…

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 hand, elbow, and knee splints were placed on and off as directed for one resident (Resident #31) out of one sample for mobility resulting in the potential for worsening of contractors. Findings Include: Per Resident #31's (R31) diagnoses list R31 had contractures of the right elbow, left elbow, right hand, left hand, right lower leg, left lower leg, right knee, left knee, right ankle, and left ankle. On 9/18/2024, at 10:53 AM, R31 was observed In bed with pillows under her knees lying flat on her back. Both of her arms and hands were observed to be contracted. Knee, hand and other splints were observed on a chair in the room. Inside R31's closet door was a posted note attached to the door that instructed to put both knee braces on R31 daily up to or less than 4 hours each time. No braces or splints were observed to be on R31 at the time. On 9/19/2024 at 11:35 AM R31 was observed in her bed, on her back, with pillows under her knees, and the braces/splints remained in the chair. On 9/19/2024 at 2:30 PM,…

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 weights per policy in one of two residents reviewed for nutrition (Resident #26), resulting in the likelihood of inaccuracy of the individual's nutritional status. Findings include: Resident 26 (R26) A review of the medical record indicated that R26 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including sepsis, osteomyelitis, a sacral pressure ulcer, muscle weakness, and type 2 diabetes. The Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 8/16/24, reflected that R26 scored 8 out of 15 on the Brief Interview for Mental Status (BIMS), indicating cognitive impairment. On 9/18/24 at 9:19 AM, R26 was observed in his room, resting in bed. R26 was conversant, demonstrated a clear understanding of questions, and responded appropriately. R26 reported that he did not care for the taste of the food at the facility, stating that often times he would not consume any breakfast 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 observation, interview and record review, the facility failed to ensure proper storage, cleaning and labeling of oxygen/respiratory equipment for two Resident(R18 and R37), of two residents reviewed for oxygen and respiratory care, resulting in the likelihood for cross contamination, respiratory illnesses/disease and increased antibiotic usage. Findings include: Resident #18 (R18) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R18 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), chronic lung disease, diabetes mellitus, renal failure, heart failure, and heart disease. The MDS reflected R18 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for maximum assistance for transfers, dressing, bathing, dressing and required moderate assist with hygiene and oral care. During initial resident screening 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 provide ongoing communication and collaboration with the contracted dialysis facility regarding dialysis care for one resident (#29) of one resident reviewed resulting in ineffectively tracking weights and the potential for unmet care needs. Finding Include: Resident #29 (R29) Review of the medical record revealed R29 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included end stage renal disease and a binge eating disorder. Review of the Minimum Data Set revealed R29 received dialysis services. On 9/18/24 at 1:12 PM, R29 was observed in his room. R29 reported no concerns with his dialysis care, however, reported that sometimes the dialysis place doesn't send back the filled-out forms. Review of the Physician's Orders revealed an active order initiated on 08/07/2024 for a weekly weight. Review of the medical record revealed the following weights: 9/20/2024 7:06 AM Weight: 374 lbs (pounds)…

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

Based on observation, interview, and record review the facility failed to ensure that bed rails were assessed and measured to prevent possible entrapment for one Resident (#33) of one resident reviewed for Residents using bed rails. Findings Included: Resident #33 (R33) Review of the medical record revealed R33 was admitted to the facility 01/17/2019 with diagnoses that included cerebral infarction (stroke), hemiparesis (difficulty moving one side of the body) of the left side, hemiplegia (paralysis one side of the body) of the left side, aphasia (difficulty speaking), dysphagia (difficulty swallowing), weakness, expressive language disorder, type 2 diabetes, contracture of the left knee, contracture of the left elbow, contracture, of the left hand, contracture of the left wrist, contracture of the left hand, hypertension, major depression, muscle spasm and chronic pain. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/07/2024, demonstrated a Brief Interview for Mental Status (BIMS) of 11 (moderate cognitive impairment) out of 15. During…

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 a medication error rate less than 5% resulting in an error rate of 16%. Findings Included: During an observation on 9/19/2024 at 7:50 AM, of medication administration, Registered Nurse (RN) T was observed to put five pills into a medication cup that she had put a spoonful of pudding into. One of the pills RN T was observed to put in the medication cup was a Hyoscyamine 0.25 mg tablet (used for stomach issues). RN T was then observed to administered the pudding with all five of the pills into R38's mouth, and observed R38 to swallow the pudding and the pills. Review of R38's medication administration record revealed the order RN T administered for the Hyoscyamine 0.25 mg pill was ordered to be administered sublingual, meaning place under the tongue to dissolve, and not swallow. During an observation of medication administration (MAR) on 9/19/2024 at 8:00 AM, RN U was observed to administer R15's Flomax (used to treat enlarged prostate) 0.4 mg tablet to him while he sat in the dining at at table. RN U was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During observation and interview, the facility failed to provide alternative food choices for 3 Residents (#13, 26,41) resulting in the potential frustration of residents and a non-pleasurable dining experience. On 9/18/24 at 9:19 AM, Resident #26 (R26) was observed in his room, resting in bed. R26 was conversant, demonstrated a clear understanding of questions, and responded appropriately. R26 reported that he did not care for the taste of the food at the facility, stating that often times he would not consume any breakfast and would refuse a meal at least once a week. When asked if there was alternative food items available, R26 stated I think there's just a peanut butter and jelly sandwich. R26 stated that no one had ever discussed his food like and dislikes with him. On 9/18/24 at 10:08 AM, Resident #41 (R41) reported that the food at the facility was not good. R41 stated that if you don't like the food being offered, staff will provide her with the supplies to make her own peanut butter and jelly. R41 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 observation, interview, and record review the facility failed to coordinate hospice services for one resident (#38) out of one resident reviewed for coordination of hospice services resulting in the potential for care note being provided to resident receiving hospice services and the potential for residents not to be fully informed of hospice services provided. Findings Included: Resident #38 (R38) Review of the medical record revealed R38 was admitted to the facility 10/29/2021 with diagnoses that included pneumonia, frontotemporal neurocognitive disorder, dysphagia (difficulty swallowing), muscle weakness, need for assistance with personal care, dementia, anxiety, insomnia, depression, chronic obstructive pulmonary disease (COPD). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/30/2024, demonstrated a Brief Interview for Mental Status (BIMS) of 11(moderate cognitive impairment) of 15. Section 0-Special Treatments, Procedures, and Programs of the MDS, with the same ARD, demonstrated R38 had been receiving Hospice care while a 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.

This citation pertains to intakes: MI00145052, MI00145688 Based on observation, interview, and record review the facility failed to follow Enhanced Barrier Precautions (EBP), an infection control intervention designed to reduce transmission of multidrug-resistant organisms, for one Resident (#6) out of three resident reviewed for the appropriate use of infection control standards. Findings Included: Resident #6 (R6) Review of the medical record revealed R6 was admitted to the facility 10/04/2023 with diagnoses that included atrial fibrillation, malnutrition, open wound left great toe, osteomyelitis, urinary retention, abnormal gait and mobility, urinary tract infection, hypertension, gastro-esophageal reflux, constipation, chronic pain, benign prostatic hyperplasia (enlarged prostate), hyperlipemia (high fat content in blood), anorexia, tachycardia (fast heart rate), atherosclerotic heart disease (build up of fats, cholesterol, and other substances in and on artery walls), chronic obstructive pulmonary disease (COPD), asthma, and type 2 diabetes. The most recent Minimum Data Set…

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 MI00144513. Based on interview and record review, the facility failed to ensure background checks were completed prior to the start of employment for newly hired staff, with the potential to effect the 49 residents that resided in the facility at the time of the survey. Findings include: According to facility documents, Non-Certified Aide T had a hire date of 5/7/24. A background check was conducted 5/22/24. The background check for Non-Certified Aide T was conducted under the name of a different facility. According to facility documents, Certified Nurse Aide (CNA) KK had a hire date of 4/29/24. The background check for CNA KK was conducted under the name of a different facility. In an interview on 5/23/24 at 8:14 AM, Business Office Manager (BOM) AA reported she started an audit the day prior (5/22/24) and identified that Dietary Assistant U did not have a background check that she was able to locate. She verified that Dietary Assistant U started employment with the facility on 8/14/23. According to facility documents, Dietary Assistant U had a hire…

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

Based on interview and record review the facility failed to ensure that four Certified Nurse Aides (CNA) )(N, P, Q, and R) and one Registered Nurse (RN) (O) had the required initial competency evaluations and one CNA Q annual competency evaluation, including demonstration in skills and techniques necessary to care for Residents resulting in the potential for staff to lack in the necessary training to adequately meet the needs of 49 Residents that currently reside at the facility. Findings Included: Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) N was hired 03/14/2024. CNA N's personnel records did not demonstrate any initial competency evaluation after date of hire. Record review of facility staff personnel records demonstrated Certified Aide (CNA) P was hired 11/06/2023. CNA P's personnel records did not demonstrate and initial competency evaluation after date of hire. Record review of facility staff personnel records demonstrated Certified Aide (CNA) Q was hired 02/08/2022. CNA Q's personnel records did not demonstrate an initial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide showers as ordered for two (Resident #6 and #7) of three reviewed. Findings include: Resident #6 (R6): Review of the medical record reflected R6 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included weakness and need for assistance with personal care. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/1/24, reflected R6 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 5/16/24 at approximately 10:56 AM, R6 was lying in bed. She reported she was supposed to have showers twice per week, on first shift. R6 reported for the past two to three months, she was getting one shower every two weeks, and staff did not attempt to make up missed showers. R6's medical record reflected a Physician's Order for bath/shower on Monday and Thursday. On 5/22/24 at 10:31 AM, an email was sent to Nursing Home Administrator…

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

Based on interview and record review the facility failed to ensure that one Certified Nursing Aide (CNA) (Q) of four CNA's reviewed received annual performance evaluations to adequately meet the needs of the 49 Residents that currently reside at the facility. Findings Included: Record review of facility staff personnel records demonstrated Certified Aide (CNA) Q was hired 02/08/2022. CNA Q's personnel records did not demonstrate an annual performance evaluation for 02/2023 or 02/2024. During an interview on 05/24/2024 at 02:13 p.m. Business Office Manager (BOM) M confirmed that Certified Nurse Aide (CNA) Q did not have an annual performance evaluation for 2/2023 or 2/2024. He explained that it is the expectation that all employees receive an annual performance evaluation in their annual month of hire. BOM M could not explain why CNA Q had not had annual performance evaluations completed.

Based on interview and record review the facility failed to ensure two Certified Nurse Aide (CNA) (N,P) out of five reviewed were trained in the facility expectation on caring for Residents which included effective communication, resident rights and facility responsibilities, abuse/neglect and exploitation, and infection prevention to adequately meet the needs of 49 Residents that currently reside at the facility. Findings Included: Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) N was hired 03/14/2024. Review of CNA N employee personnel filed did not demonstrate that any education had been completed since date of hire. Education was not present for effective communication, resident rights and facility responsibilities, abuse/neglect and exploitation, and infection prevention. Record review of facility staff personnel records demonstrated Certified Aide (CNA) P was hired 11/06/2023. Review of CNA P employee personnel filed did not demonstrate that any education had been completed since date of hire. Education was not present for effective…

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 meet the required 12-hour educational requirements for one Certified Nursing Aide (CNA) (Q) out of five CNA's reviewed to adequately meet the needs of the 49 Residents that currently reside at the facility. Findings Included: Record review of facility staff personnel records demonstrated Certified Aide (CNA) Q was hired 02/08/2022. CNA Q personnel records did not demonstrate that she had received 12 hours of in-service training. During an interview on 05/24/2024 at 02:13 p.m. Business Office Manager (BOM) M confirmed that Certified Nurse Aide Q personnel records did not contain 12 hours of in-service training. He explained that the 12 hours had been assigned but that none of those hours had been completed during her last year or employment. BOM M could not explain why the 12 hours assigned had not been completed.

Based on interview and record review the facility failed to ensure that two Certified Nursing Aides (N, P) out of five direct care staff had behavioral health training to adequately meet the needs of 49 Residents that currently reside at the facility. Findings Included: Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) N was hired 03/14/2024. Review of CNA N employee personnel filed did not demonstrate that any education had been completed since date of hire. Education was not present for behavioral health training. Record review of facility staff personnel records demonstrated Certified Aide (CNA) P was hired 11/06/2023. Record review of facility staff personnel records demonstrated Certified Aide (CNA) P was hired 11/06/2023. Review of CNA P employee personnel filed did not demonstrate that any education had been completed since date of hire. Education was not present for behavioral health training. During an interview on 05/24/2024 at 02:13 p.m. Business Office Manager (BOM) M confirmed that Certified Nursing Aide (CNA) N and P had 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.

This citation pertains to intake number MI00142697. Based on interview and record review the facility failed to ensure one out of three residents (Resident #2) was free from abuse. Findings Included: In an interview on 3/12/2024 at 11:00 AM, Resident #2 (R2) stated that one time when she was being straight cathed (tube inserted into the bladder to drain urine then removed) and was exposed with her legs open in her bed, and upon a nurse leaving her room curtain and door were left open exposing her uncovered private area to anyone outside of her room. R2 said another nurse was holding her labia (flaps of skin on either side of the vagina) open during this time so she was not covered up. During the interview R2 began to cry and stated that she was humiliated, vulnerable, upset, scared, and felt threatened. R2 also stated that Registered Nurse (RN) O told her that she should have stayed home and had home care, and she was not to question her because she was the professional. R2 said that RN O told her there were no straight cath kits available so they would have to use her supply, 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 pertains to intake numbers MI00142630 and MI00142697. Based on observation, interview, and record review the facility failed to develop a comprehensive pressure ulcer care plan for two of three residents (Resident #1 & 2). Findings Included: Resident #1 (R1) Per the facility face sheet R1 was admitted to the facility on [DATE]. Diagnoses include right above the knee amputation and paraplegia. Review of a vascular (vein/artery system) Physician's (Patient Discharge Summary revealed R1 was admitted from the facility to the hospital 12/27/2024 for a right above the knee amputation. The summary revealed under discharge orders Additional Transfer Instructions, Wound site(s): left heel -Cleans wound with mild soap and water/saline, rinse well, pat dry -Apply Calcium Alginate to wound. (Cut to size.) -Cover with a mepilex border. -Change every other day Record review of a Vascular Surgery Office Note dated 2/7/2024, revealed .Patient (R1) states he has not had any wound care offered to his left heel since…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake Numbers MI00142729 and MI00142697 Based on observation, interview, and record review, the facility failed to 1) write a physician order for a laboratory (lab) test and document a resident assessment, rationale for lab test, and completion of the lab draw procedure for one resident (Resident #4) and 2) failed to administer medications as ordered by the physician, and maintain infection control prevention during catheterization for one resident (Resident #2) of 5 reviewed, resulting in residents not receiving care and treatment in accordance with professional practice and the potential for worsening medical conditions. Findings include: Resident #4 Review of the medical record revealed that Resident #4 (R4) was admitted to facility 12/15/23 with diagnoses including stage 4 pressure ulcer of right upper back, pressure-induced deep tissue damage of unspecified site, quadriplegia, contracture of right/left upper arm, moderate protein-calorie malnutrition, adult failure to thrive, 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 pertains to intake numbers MI000142729, MI00142630, & MI00143199. Based on observation, interview, and record review the facility failed to provide the necessary treatment and services for pressure ulcer for three out of three residents (Resident #1, 2, & 4) to promote healing and prevent infection. Findings Included: Resident #1 (R1) Per the facility face sheet R1 was admitted to the facility on [DATE]. Diagnoses include right above the knee amputation and paraplegia. Review of a vascular (vein/artery system) Physician's (Patient Discharge Summary revealed R1 was admitted from the facility to the hospital 12/27/2024 for a right above the knee amputation. The summary revealed under discharge orders Additional Transfer Instructions, Wound site(s): left heel -Cleans wound with mild soap and water/saline, rinse well, pat dry -Apply Calcium Alginate to wound. (Cut to size.) -Cover with a mepilex border. -Change every other day Record review of R1's physician orders dated 12/22/2023 through 3/13/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake numbers MI00138798 and MI00137463 Based on observation, interview and record review the facility failed to provide sufficient staffing to ensure resident needs were met timely for 2 (#3, #6) of 7 sampled residents resulting in unmet care needs and the potential for unmet care needs for all 53 residents residing in the facility. Findings include: Resident #3 Resident #3 (R3) was initially admitted to facility on [DATE] and readmitted on [DATE] with diagnoses including anoxic brain injury (damage due to a loss of oxygen flow to the brain), tracheostomy status, (an opening that surgeons make through the front of the neck and into the windpipe for breathing purposes), muscle weakness, and history of pneumonia. Review of the Progress Notes revealed that R3 had a guardian but was able to make needs known through the nodding of his head or use of a tablet. Review of a Minimum Data Set (MDS) dated [DATE] reflected that R3 deceased while at the facility. Review of a Progress Note dated…

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 # MI00137463 Based on observation and interview, the facility failed to maintain a functional, clutter free environment in the common areas potentially effecting all 53 residents, resulting in the likelihood of injury and an uncomfortable, nonhome-like environment. On 10/5/23 at 1:04 PM, the [NAME] unit was observed to contain 2 beds in the Dining/day room, multiple carts containing nursing equipment, a floor dryer on a table, wheelchairs and plastic bags containing clothing. Additionally, the [NAME] hallway contained multiple wheelchairs, Broda chairs (padded, reclining wheelchairs), 2 mechanical lifts, multiple walkers, wheelchair foot pedals on the floor, a pair of black shoes, a cardboard box, and a bundle of towels. On 10/5/23 at 2:15 PM, a resident was observed propelling down the [NAME] hallway in her wheelchair and struck one of the walkers that was in the hallway. In an interview on 10/9/23 at 11:39 AM, Maintenance Director M reported that the outdoor storage 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.

This citation pertains to Intake Number MI00136163 Based on interview and record review, the facility failed to provide an effective bowel management program for one (Resident #1) of three reviewed, resulting in the potential for constipation. Findings include: Review of the medical record revealed Resident #1 (R1) to the facility on 3/10/23 with diagnoses that included alcohol cirrhosis of liver, hepatic encephalopathy (the loss of brain function when a damaged liver doesn't remove toxins from the blood), and irritable bowel syndrome. R1 discharged from the facility on 3/20/23. Review of the Physician's Order dated 3/10/23 revealed Lactulose 10 gram/15 milliliters (g/mL) give 15 mL every 8 hours for hepatic encephalopathy. According to the Cleveland Clinic, treatment for hepatic encephalopathy includes Laxatives: Lactulose oral solution, a laxative made from lactose sugar, draws toxins into the colon. The laxative stimulates frequent bowel movements that help remove toxins from the body. (https://my.clevelandclinic.org/health/diseases/21220-hepatic-encephalopathy) Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00137735 and MI00137656 Based on observation, interview and record review, the facility failed to provide tracheostomy care and suctioning according to standards of practice for one (Resident #3) of three reviewed for tracheostomy care, resulting in the potential for respiratory distress and infection. Findings include: Resident #3 (R3) was initially admitted to facility on [DATE] and readmitted on [DATE] with diagnoses including anoxic brain injury (damage due to a loss of oxygen flow to the brain), tracheostomy status, (an opening that surgeons make through the front of the neck and into the windpipe for breathing purposes), muscle weakness, and history of pneumonia. Review of the Progress Notes revealed that R3 had a guardian but was able to make needs known through the nodding of his head or use of a tablet. Review of a Minimum Data Set (MDS) dated [DATE] reflected that R3 deceased while at the facility. Record Review of Hospital Discharge paperwork dated [DATE] revealed R3…

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 hand washing cleanser availability, maintain physical facility, and label chemical bottles, resulting in the potential biological and chemical contamination of food, affecting all residents that consume food from the kitchen. Findings include: On 8/2/23 at 9:41 AM, the hand sink soap dispenser was observed to not be provided with soap. On 8/2/23 at 9:43 AM, [NAME] M was observed to enter the kitchen and proceed to prep food without washing hands. During an interview on 8/2/23 at 1:15 PM, Nursing Home Administrator A was informed of staff not washing hands upon entering the kitchen and stated that dietary staff are new and still working on trainings. During an interview on 8/2/23 at 2:45 PM, Dietary Manager was queried on if [NAME] N has received training and stated that new staff are being trained as they go but have been told verbally to wash their hands. According to the 2017 FDA Food Code Section 6-301.11 Handwashing Cleanser, Availability. Each HANDWASHING SINK or group of 2 adjacent 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure resident medical records were secured and held confidential, when during medication administration the nurse walked out of the hall, away from the medication cart, and left laptop computer open, resulting in exposed resident medical information. Findings Included: Upon approaching Licensed Practical Nurse (LPN) F, who was performing medication administration, on 8/02/23 at 7:45 AM, LPN F became very upset, and stated that it was her first day by herself, and she was not comfortable being watched. LPN F stated that she was in the middle of pulling a resident's medications, and was not going to talk to the surveyor until she was done. LPN F stated she could not have someone observing her during medication administration, and also said she was not going to continue. During the same observation Director of Nursing (DON) B spoke with LPN F who was then observed to put the keys to the medication cart on top of the cart, and walk away from the cart…

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. follow physician's orders and to perform a daily pressure ulcer dressing change; and (2. justify use of antipsychotic medication within the standards of practice for two resident (Resident #19 and # 21) from a total sample of 16 residents, resulting in the potential for infection, a wound to degrade and harm to intact skin and potential for unnecessary medication use with the increased potential for serious side effects and adverse reactions, and the inability to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence. Findings include: Resident #21 (R21) Review of the medical record revealed Resident #21 (R21) was admitted to the facility on [DATE] with diagnoses that included pressure ulcer of the sacral area, legal blindness, dorsalgia (pain in the upper back), obesity, weakness, restless leg syndrome and history of falls. According to Resident #21 (R21)'s Minimum Data Set (MDS) dated…

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 one out of one residents (R19), who had a Foley catheter (tube inserted into the bladder to drain urine), was appropriately assessed for the need to continue or discontinue the use of the catheter, resulting in the potential for complication and/or infections. Findings Include: Resident #19 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R19 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included encephalopathy, urinary retention, history of traumatic brain injury, hypertension (high blood pressure), diabetes mellitus, chronic obstructive pulmonary disease, schizophrenia, anxiety and depression. The MDS reflected R19 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required one person physical assist with locomotion on unit and set up assist with dressing, eating, toileting, hygiene, 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 observation, interview, and record review, the facility failed to collaborate with and obtain information from the dialysis center related to resident status during and post-dialysis treatment for one (Resident # 356) of one resident reviewed for dialysis, resulting in the potential for unmet post-dialysis care needs. Findings include: Review of the medical record revealed that Resident # 356 (R356) was admitted to facility 7/3/23 with diagnoses including acute kidney failure and dependence on renal dialysis. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/9/23 revealed that R356 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 9 (moderately impaired cognition). Section G of MDS revealed that R356 required one-person extensive assist with bed mobility and toilet use, two-person extensive assist with transfers, and was independent with eating after set up. Section O of same MDS revealed that R356 received dialysis treatment while a resident of the facility within the last 14 days. In an observation…

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 adequate monitoring and documentation of psychotropic medications for one residents (R19) reviewed for unnecessary medications, resulting in the potential for unnecessary medication use with the increased potential for serious side effects and adverse reactions, and the inability to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R19 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included encephalopathy, urinary retention, history of traumatic brain injury, hypertension (high blood pressure), diabetes mellitus, chronic obstructive pulmonary disease, schizophrenia, anxiety and depression. The MDS reflected R19 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required one person physical…

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 medication stored in two of four medication storage rooms were discarded at the time of the expiration date, resulting in the potential for the medications to cause complications and/or not be affective. Findings Included: During an observation on 8/02/2023 at 7:58 AM, with Director of Nursing (DON) B, of the 100 hall kitchen were medications were stored revealed the refrigerator contained 11 boxes of unopened influenza vaccinations that had and expiration date of 6/30/2023. During the same observation time, the 200 hall kitchen were medications were storage revealed the refrigerator contained two boxes of the influenza vaccination that also expired on 6/30/2023, and one box that contained five vials of the Covid19 vaccination that had an original expiration date of 9/22/2022, and an extended expiration date of 6/7/2023. In an interview on 8/2/2023, during the medication storage observation, DON B stated that the Unit Managers were supposed to check for expired medication in the medication storage…

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 two Residents (R21 and R40) of 16 reviewed for medical records, resulting in increased likelihood of medication error or missed treatments and the potential for an inaccurate reflection of resident conditions. Findings include: During an observation and interview on 8/02/23 at 1:01 PM, R40 was observed in bed. Staff Nurse O was observed changing R40 dressing located on both right and left hips with old dressings dated 7/31/23. Staff Nurse O verified removed dressings were dated 7/31/23 and R40 had orders for daily dressing changes. Review of R40 Treatment Administration Record, dated 8/1/23 through 8/2/23, reflected documentation to reflect staff completed R40 dressing treatments to both hips on 8/1/23. During an interview on 8/02/23 at 1:25 PM, DON B reported would expect to nurses to follow physician orders and document treatments after completed. Resident #21 (R21) Review of the medical record…

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 M100138094 Based on observation, interview, and record review, the facility failed to 1) adhere to infection control practices during medication administration observation; and 2) routinely adhere to proper contact precautions for one (Resident # 356) of one resident reviewed for transmission-based precautions, resulting in the potential for cross-contamination, spread of bacteria, and increased risk of infection. Findings include: Resident # 356 Review of the medical record revealed that Resident # 356 (R356) was admitted to facility 7/3/23 with diagnoses including acute kidney failure, dependence on renal dialysis, constipation, and adverse effect of other systemic antibiotics. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/9/23 revealed that R356 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 9 (moderately impaired cognition). Section G of MDS revealed that R356 required one-person extensive assist with bed mobility and toilet use, two-person extensive assist 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.

Based on observation, interview, and record review, the facility failed to monitor the antibiotic treatment course for one (Resident # 356) of one resident reviewed for antibiotic use, resulting in the potential for ineffective infection treatment and the return of or worsening of symptoms. Findings include: Review of the medical record revealed that Resident # 356 (R356) was admitted to facility 7/3/23 with diagnoses including acute kidney failure, dependence on renal dialysis, constipation, and adverse effect of other systemic antibiotics. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/9/23 revealed that R356 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 9 (moderately impaired cognition). Section G of the MDS revealed that R356 required one-person extensive assist with bed mobility and toilet use, two-person extensive assist with transfers, and was independent with eating after set up. Section H of same MDS revealed that R356 was frequently incontinent of bowel. In an observation and 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.