Medilodge of Marshall

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2741317. Based on observation, interview and record review, the facility failed to conduct root cause analysis and develop interventions to prevent falls for one (R1) of three reviewed for falls. Findings include:Review of the medical record reflected R1 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included hypothyroidism, low back pain and Alzheimer's. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/21/26, reflected R1 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R1 was always incontinent of bowel and bladder, and a trial of a urinary toileting program had not been attempted.On 5/21/26 at 11:23 AM, R1 was observed seated in a wheelchair, in the dining room, self-propelling with their feet. Non-skid socks were observed on both feet. Anti-rollback brakes were observed on the wheelchair.An Incident Report, for…

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 3013328 Based on observation and interview, the facility failed to ensure meals were served in a manner that maintained an appetizing appearance and palatability. Findings include:On 5/21/26 at 11:46 am a test tray was provided to the survey team. The stated lunch meal, per the facility provided menu, consisted of stuffed pepper casserole, buttered corn, and mocha fudge cake. The meal provided was observed to be stuffed pepper casserole, corn and not mocha fudge cake but rather a pistachio cake. The stuffed pepper casserole lacked an appetizing appearance, as it consisted primarily of rice and a meat sauce, and did not contain visible peppers. the casserole was tasted and determined to lack flavor. The corn lacked flavor as well. The meal served did not match the posted menu and overall deemed unappealing in appearance and palatability. In an interview on 5/21/26 at 2:19 pm, Resident #11 was interviewed regarding the lunch meal. Resident #11 rated the stuffed pepper casserole as nasty with no flavor.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake number 3013328 Based on observation, interview, and record review the facility failed to honor resident food preferences in one (Resident #12) out of three reviewed for food preferences. Findings include:Review of the medical record reflected Resident #12 (R12) was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/20/26, reflected R12 scored 9 out of 15 (moderate impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).On 5/20/26 at 11:13 am, R12 was observed in her room reviewing a stack of paperwork. R12 was groomed, appropriately dressed, and answered questions appropriately. R12 was sharing her frustration regarding dining staff not following her tray ticket, which lists her food dislikes. R12 showed me her tray ticket from her breakfast meal, which had a list of dislikes on it. One if the dislikes listed was pork. During 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 2728065.Based on observation, interview, and record review, the facility failed to administer medications as ordered for one (R2) of three reviewed.Findings include:Review of the medical record revealed R2 was admitted to the facility on [DATE] with diagnoses that included necrotizing fasciitis, major depressive disorder with anxiety, and type 2 diabetes. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/25 revealed R2 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 2/11/26 at 8:40 AM, R2 was observed sitting on the edge of their bed, eating breakfast. R2 reported they had concerns that their pain medications were occasionally administered late. Review of the Physician's Order dated 12/30/25 revealed an order for oxycodone (opioid pain medication) 10 milligrams (mg) every four hours. Review of the Medication Administration Record (MAR) revealed R2's oxycodone was scheduled to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: 2672585Based on observations/interviews/record review, the facility failed to protect the resident's (R2's) right to be free from verbal abuse and physical abuse by a resident.Findings Included:Resident #2 (R2)Review of the medical record revealed R2 was admitted to the facility 11/19/2024 with diagnoses that included pseudobulbar effect (a neurological condition causing sudden uncontrollable episodes of laughing or crying), cognitive impairment, severe intellectual disabilities (significant limitations in mental ability), bipolar disorder, social phobia, hypertension, gastro-esophageal reflux disease, depression, dysphagia, hypothyroidism (low thyroid hormone), obesity, and conversion disorder with seizures or convulsions (a condition where psychological stress or trauma manifest as real physical symptoms affecting movement). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/25/2025 that could not be completed because resident is rarely/never…

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: 2642660 Based on observation, interview, and record review the facility failed to ensure that Nursing staff followed professional standards for medication administration for one resident (#1) out of three residents reviewed for medication administration. Findings Included:Resident #1 (R1)Review of the medical record revealed R1 was admitted to the facility 02/19/2025 with diagnoses that included depression, thyroiditis (inflammation of the thyroid gland), gastro-esophageal reflux, osteoporosis (weak and brittle bones), dementia, hypercholesterolemia (high cholesterol), sleep apnea, insomnia, chronic pain, dysphagia, and (difficulty swallowing). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/25/2025, did not have a Brief Interview for Mental Status (BIMS) conducted.Resident #7 (R7) Review of the medical record revealed R7 was admitted to the facility 02/07/2025 with diagnoses that included chronic respiratory failure, type 2 diabetes,…

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: 2642660Based on observation, interview, and record review the facility failed to prevent significant medication errors for one resident (#1) out of three residents reviewed for medication errors. Findings Included:Resident #1 (R1)Review of the medical record revealed R1 was admitted to the facility 02/19/2025 with diagnoses that included depression, thyroiditis (inflammation of the thyroid gland), gastro-esophageal reflux, osteoporosis (weak and brittle bones), dementia, hypercholesterolemia (high cholesterol), sleep apnea, insomnia, chronic pain, dysphagia, and (difficulty swallowing). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/25/2025, did not have a Brief Interview for Mental Status (BIMS) conducted.Resident #7 (R7) Review of the medical record revealed R7 was admitted to the facility 02/07/2025 with diagnoses that included chronic respiratory failure, type 2 diabetes, depression, pain in right hip, post-traumatic stress disorder…

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 2595312.Based on observation, interview, and record review, the facility failed to ensure an abuse allegation was reported timely to the State Agency for one (R5) of five reviewed.Findings include: Review of the facility reported incident revealed R5's roommate (R4) alleged R5 was having sexual relations with another person .[R5] has a low BIMS [Brief Interview for Mental Status-a cognitive screening tool] and is unable to consent. As such if activity is occurring, it would be without consent.Review of the medical record revealed R4 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/23/25 revealed R4 scored 15 out of 15 (cognitively intact) on the BIMS. Review of the medical record revealed R5 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction. The MDS with an ARD of 5/9/25 revealed R5 scored 3 out of 15 (severe cognitive impairment on the BIMS. An observation on 8/20/25 at 1:05 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 This Citation pertains to Intake #1286451Based on observation, interview, and record review, the facility failed to report allegations of abuse to the State Agency for 6 (Resident #2, #3, #5, #9, #10, #11) of 8 reviewed, resulting in allegations of abuse that were not reported to the State Agency and the potential for further allegations of abuse to go unreported. Findings include:Resident #2 (R2)Review of the clinical record revealed Resident #2 (R2) was [AGE] years old and was admitted to the facility on [DATE], Review of the Minimum Data Set (MDS) with an Assessment Reference Date ARD) [DATE] reflected R2 scored 8 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). On [DATE] at 11:09am during an interview with CNA G when queried if she had witnessed abuse while employed at the facility, CNA G reported she had witnessed CNA I be verbally aggressive with R2 and say mean things to R2. When asked to elaborate, CNA G declined and stated God sees everything and will take care…

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 #1286451Based on interview and record review the facility failed to thoroughly investigate allegations of abuse for seven residents (#2, #3, #4, #5, #9, #10, and #11) of 8 reviewed for abuse.Findings include:Resident #2 (R2)Review of the clinical record revealed Resident #2 (R2) was [AGE] years old and was admitted to the facility on [DATE], Review of the Minimum Data Set (MDS) with an Assessment Reference Date ARD) [DATE] reflected R2 scored 8 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). On [DATE] at 11:09am during an interview with CNA G when queried if she had witnessed abuse while employed at the facility, CNA G reported she had witnessed CNA I be verbally aggressive with R2 and say mean things to R2. When asked to elaborate, CNA G declined and stated God sees everything and will take care of it. When queried if she had reported this to the facility abuse coordinator, she stated her Nurse did report it but nothing happens,…

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 #1286451Based on observations/interviews/record review, the facility failed to protect the resident's (Resident #1) right to be free from verbal abuse and physical abuse by Certified Nursing Assistant (CNA) IFindings include:Review of the clinical record revealed Resident #1 (R1) was under hospice care, review of the Minimum Data Set (MDS) dated [DATE] revealed R1 scored 12 out of 15 (cognitively intact) on the Brief Interview Mental Score. On 07/16/25 at 9:45am during a bedside interview, R1 was resting in bed, when queried about his care and treatment it was reported that there were no concerns with the exclusion of an incident that occurred about a year earlier that involved a Certified Nursing Assistant (CNA). R#1 reported to this surveyor he had been verbally and physically abused by a CNA that was employed at the facility but was unable to recall her name. R1 provided a physical description of (CNA) I. R1 reported about a year earlier CNA I was in his room and told him he…

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 1286453Based on observation, interview, and record review the facility failed to provide scheduled bathing and complete nail care for one resident (R6) of three residents reviewed for activities of daily living. Findings include: Review of the medical record reflected R6 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included aphasia and cerebral infarction due to embolism. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4-8-25, reflected R6 was described as rarely/never understood.On 7/17/25 at 10:32 am, R6 was observed in bed. R6's fingernails and toenails were observed and noted to be excessively long. R6's hair was matted and R6 had an unpleasant odor.Review of the Activities of Daily Living Care Plan revealed R6 required staff assistance of one person for bathing and personal hygiene.Review of the MDS dated [DATE] revealed R6 was coded as dependent for shower/bathing.Review of the Task list revealed R6's showers…

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: MI00153167 Based on interview and record review the facility failed to provide Activities of Daily Living (toileting and incontinence care) for one dependent resident (#1) of 3 residents reviewed. Findings Included: Resident #1 (R1) Review of the medical record revealed R1 was admitted to the facility 05/07/2025 with diagnoses that included chronic obstructive pulmonary disease (COPD), hypertension, contusion of left lower leg, morbid obesity, pulmonary fibrosis (chronic lung disease that occurs when lung tissue around air sacs becomes damage and scared), acute bronchitis (inflammation of the lining of bronchial tubes), emphysema (chronic lung disease that progressively damages the alveoli, or tiny air sacs in the lungs), cardiac murmur, hyperlipidemia (high fat content in blood), peripheral vascular disease (PVD), gastro-esophageal reflux disease, anemia (low red blood cells), congestive heart disease (CHF), rheumatoid arthritis (body's immune system attacks it own tissue, typically in the hands and feet), obstructive sleep apnea, and spondylosis…

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: MI00153167 Based on interview and record review the facility failed to implement physician orders for the administration of pain medication for one resident (#1) of three residents reviewed. Findings Included: Resident #1 (R1) Review of the medical record revealed R1 was admitted to the facility 05/07/2025 with diagnoses that included chronic obstructive pulmonary disease (COPD), hypertension, contusion of left lower leg, morbid obesity, pulmonary fibrosis (chronic lung disease that occurs when lung tissue around air sacs becomes damage and scared), acute bronchitis (inflammation of the lining of bronchial tubes), emphysema (chronic lung disease that progressively damages the alveoli, or tiny air sacs in the lungs), cardiac murmur, hyperlipidemia (high fat content in blood), peripheral vascular disease (PVD), gastro-esophageal reflux disease, anemia (low red blood cells), congestive heart disease (CHF), rheumatoid arthritis (body's immune system attacks it own tissue, typically in the hands and feet), obstructive sleep apnea, and spondylosis…

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 assess and monitor pressure ulcers for one resident (#7) of three residents reviewed. Findings Included: Resident #7 (R7) Review of the medical record revealed R7 was admitted to the facility 02/24/2025 with diagnoses that included chronic obstructive pulmonary disease (COPD), repeated falls, enlarged prostate, pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder), adjustment disorder, dyspnea (difficult or labored breathing), dementia with agitation, constipation, hypertension, obstructive sleep apnea, and atherosclerotic heart disease (damage or disease of hearts major blood vessels). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/13/2025, revealed R7's Brief Interview of Mental Status (BIMS) was 7 (severe cognitive impairment) out of 15. Review of R7's medical record revealed a document entitled Skin and Wound Evaluation V7.0, completed 05/26/2025, revealed a deep tissue pressure injury (persistent non…

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 clean and maintain the physical plant effecting 91 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and potential cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies. Findings include: On 03/31/25 at 02:15 P.M., An environmental tour of the facility Laundry Service was conducted with Environmental Services Manager D. The following items were noted: Clean Laundry Room: The hand wash sink cold water supply valve was observed leaking water. Environmental Services Manager D indicated he would contact maintenance for necessary repairs as soon as possible. 3 of 3 overhead light assembly clear plastic protective lens covers were observed soiled with accumulated and encrusted dust/dirt deposits. Environmental Services Manager D indicated he would have maintenance thoroughly clean and sanitize the clear plastic protective lens covers as soon as possible. Soiled Laundry Room: 6 of 6 soiled laundry transport carts…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that grievances were promptly documented, investigated, tracked and resolved for one resident of one resident reviewed for grievances (Resident #52), resulting in anger, frustration and unresolved grievances. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R52 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included hypertension(high blood pressure), Guillain-Barre Syndrome with paraplegia, major depression and anxiety disorder. The MDS reflected R52 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact. During an observation on 3/31/25 at 2:55 PM, resident in Hall C, room [ROOM NUMBER] could be heard yelling out repeatedly, help me, help me, help me. with door closed. Observed resident in bed through small crack in closed door. Continued to observe with no staff response for greater than…

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 complete accurate Minimum Data Set (MDS) assessments for one resident (#8) of 19 residents reviewed for MDS accuracy, resulting in inaccurate MDS assessments. Findings Included: Resident #8 (R8) Review of the medical record demonstrated R8 was admitted to the facility 02/23/2025 with diagnoses that included type 2 diabetes, hypertension, stage 3 kidney disease, vascular dementia, cognitive communication deficit, dysphagia (difficulty swallowing), cataract right eye, mood disorder, hallucinations, delusional disorder, anxiety, depression, chronic pain, gastro-esophageal reflux, and hyperlipidemia (high fat content in blood). Review of R8's Minimum Data set (MDS), with an Assessment Reference (ARD) of 02/28/2025, revealed R8 had a Brief Interview for Mental Status (BIMS) of 05 (severe cognitive impairment) out of 10. Review of section H-Medications of the MDS, with the same ARD, demonstrated that R8 had received one injection of insulin during the seven day look back period. Review of section H- Medications of the MDS, 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 implement comprehensive resident-centered care plans for one out of 19 residents (R7), resulting in unmet care needs and constant yelling out for help and increase frustration for all residents on hall C. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R7 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included hypertension(high blood pressure), heart failure, kidney failure, lung cancer, depression and anxiety disorder. The MDS reflected R7 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact. During an observation on 3/31/25 at 2:55 PM, R7 was laying in bed with door open small crack yelling, help me, help me, help me. R7 refused to speak with surveyor. R7 continued to yell out for over half an hour and no staff observed to enter room. Review of R7 care plans, dated 2/25/25, reflected, [named R7]…

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 meaningful, individualized, and engaging activities to one resident (#7) of one reviewed for activities. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R7 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included hypertension(high blood pressure), heart failure, kidney failure, depression and anxiety disorder. The MDS reflected R7 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact. During an observation on 3/31/25 at 2:55 PM, R7 was laying in bed with door open small crack yelling, help me, help me, help me. R7 refused to speak with surveyor. R7 continued to yell out for over half an hour and no staff observed to enter room. Review of R7 care plans, dated 2/25/25, reflected, [named R7] is at risk for altered activity patterns/pursuits related to anxiety, continuous oxygen, decline in…

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 prevent the development of a pressure ulcer for one resident (#81) of one residents reviewed for the development of pressure ulcers. Findings Included: Resident #81 (R81) Review of the medical record revealed R81 was admitted to the facility 12/23/2024 with diagnoses that included fracture of left femur, repeated falls, dementia, nutritional deficiency, protein calorie malnutrition, urinary incontinence, and bilateral (right and left) hearing loss. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/29/2025, demonstrated a Brief Interview for Mental Status (BIMS) of 2 (severe cognitive impairment) out of 15. Review of section M- Skin Conditions, of the MDS with the same ARD, demonstrated that R81 did not have any pressure ulcers. During a telephone interview on 03/31/2025 R81's family member F explained that R81 had a pressure ulcer, that he had obtained at the hospital prior to his admission at the nursing facility. R81's family member F could not explain if the R81's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure professional standards for tracheostomy care including physician orders with the size of the tracheostomy for two Residents (#38, #87) of three residents review for respiratory care. Findings Included: Resident #87 (R87) Review of the medical record revealed R87 was admitted was admitted [DATE] with diagnoses that included stroke, respiratory failure, tracheostomy, dysphagia (difficulty swallowing), nutritional deficiency, cardiomyopathy (heart muscle disease), atrial fibrillation, ischemic cardiomyopathy (damaged heart muscle and heart can not pump effectively), asthma, hyperlipidemia (high fat content in blood), tricuspid (heart valve) insufficiency, and hypertension. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/20/2025, revealed R87 had a Brief Interview of Mental Status (BIMS) of 13 (intact cognition) out of 15. On 04/03/2025 at 10:19 a.m. during observation and interview, R87 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess a resident's expressions of distress, developed decreased social interaction, increased withdrawn, anger, and depressive behaviors, and reported possible cause of frustration for one residents (Residents #52) of two residents reviewed for psychosocial distress. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R52 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included hypertension(high blood pressure), Guillain-Barre Syndrome with paraplegia, major depression and anxiety disorder. The MDS reflected R52 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact. During an observation on 3/31/25 at 2:55 PM, Resident 7, who resided in Hall C could be heard yelling out repeatedly, help me, help me, help me. with door closed. R7 was observed in bed through small crack in closed door. Continued to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation is linked to intake MI00150346 Based on interview and record review the facility failed to ensure that a fall protection mat was at bedside (per care plan) to prevent injury from falls for 1 resident (R8) of 3 residents reviewed for falls. Findings include: On 3/5/25 record review revealed R8 was admitted [DATE] with pertinent diagnoses of pneumonia (a lung infection), emphysema (a long-term long condition that causes shortness of breath), paroxysmal atrial fibrillation (an irregular heartbeat), and arthropathy (a disease or disorder affecting the joints). According to documentation in a facility reported incident (FRI) with a filing date of 2/21/25, R8 was admitted with a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 14 indicating intact cognition. The FRI report also disclosed that upon admission R8 received a new terminal cancer diagnosis. R8 was in rehabilitation therapy for physical strengthening from the time of admission to discharge. According to further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an accurate account of controlled medications for one (R17) of four reviewed. Findings include: Review of the medical record revealed R17 was admitted to the facility on [DATE] with diagnoses that included dementia and major depressive disorder. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/12/25 revealed R17 did not have the Brief Interview for Mental Status (BIMS-cognitive screening tool) completed due to R17 rarely/never understood. Review of the Physician's Order dated 1/22/25 revealed an order for ABHR Cream (controlled drug) apply to skin topically every 12 hours as needed; 1 milliliter (mL) per application. Review of the Control Substance Record 30 grams of ABH gel was received on 1/21/25 and initialed by two nurses. The record indicated 1 mL was equal to 4 clicks. The first 1 mL dose signed out on the Control Substance Record was dated 1/23/25 at 9:00 PM. The amount remaining at that time was documented as 28…

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 knock prior to entering resident rooms and failed to ensure a resident was treated with respect and dignity for one (Resident #13) of three reviewed for dignity. Findings include: On 1/8/25 at 10:16 am, a staff member was observed entering a resident room without knocking. On 1/8/25 at 10:19 AM, a staff member was observed entering a resident room without knocking. On 1/8/25 at 12:34 PM, a staff member was observed entering a resident room without knocking. On 1/8/25 at approximately 12:45 PM, Resident 13 (R13) was observed at the dining room table without a lunch meal in front of her. Certified Nursing Assistant (CNA) P was observed entering the dining room and noticed R13 did not have a lunch. CNA P approached the dietary staff and requested a lunch tray for [resident first name whatever, whatever. In an interview on 1/9/25 at approximately 1:30 PM, R13 was observed in her room rummaging through her personal belongings. R13 was conversant, understood questions and answered appropriately. R13 stated that she…

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 an x-ray in a timely manner for 1 (Resident #8) of 3 reviewed for delay of care. Finding include: Review of the electronic medical record revealed R8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis which included hemiplegia and hemiparalysis following nontraumatic intracerebral hemorrhage affecting left non-dominant side (stroke causing weakness and/or paralysis on the left side of the body). Review of the Quarterly Minimum Data Set, dated [DATE], R8 scored a 13 out of 15 on the Brief interview for mental status indicated R13 was cognitively intact. In an observation on 1/8/25 at 1:32 pm, R8 was observed laying in bed watching television. R8 had a Geri-sleeve on his left wrist and arm. When queried about the Geri-sleeve, R8 stated that he had been dealing with some pain and swelling on his arm. R8 stated that he had an x-ray to his hand to rule out any injury, however, someone must have forgot 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 MI00147601 Based on interview and record review, the facility failed to develop a comprehensive care plan for 1 (R201) of 1 resident reviewed which would include interventions as safeguards against swallowing non-food items resulting in the potential for reoccurrence of the behavior. Findings include: On 11/13/24 at 10:15 AM R201 was observed in his wheelchair out in the main area of the facility talking and interacting with staff members. On 11/13/24 at 1:10 PM R201 during observation and interview was eating lunch in his room and said things were good. According to Electronic Medical Record (EMS) review R201 had an original admission date of 9/24/24 and a recent admission date of 11/6/24. R201 had pertinent diagnoses of Unspecified Intellectual Disabilities and Generalized Anxiety Disorder and Schizophrenia (a mental disorder characterized by delusions and disordered thinking). The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/24 revealed R201 scored 3…

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 provide ongoing clinical assessments (neurological assessments) for 1 (R203) of 1 resident reviewed for neurological assessments resulting in the potential for lack of recognition of brain injury. Findings include: Electronic Medical Record (EMR) review revealed that R203 admission date was [DATE]. R203 had pertinent diagnoses of Cerebral Atherosclerosis (a disease that occurs when the arteries in the brain become hard, thick, and narrow), Legal Blindness and Dementia (a group of symptoms affecting memory, thinking and social abilities). Further record review revealed a Visit Type: Acute note entered [DATE] by Nurse Practitioner (NP) E documenting a fall R203 had on [DATE] and stated in part, Spoke with nursing staff, note redness to right hand, right shoulder, and red mark on forehead. NP E documented that R203 was seen sleeping in bed. In the assessments and plans portion of the note NP E documented a plan to discuss care with hospice. Further review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00147874 Based on interview and record review the facility failed to reassess the respiratory status of 1 (R200) of 4 residents reviewed resulting in the potential for respiratory failure as cause of death. Findings include: According to Electronic Medical Record (EMR) review, R200 had an admission date of [DATE] and pertinent diagnoses of Obstructive Sleep Apnea (a sleep related breathing disorder) and Morbid Obesity. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed R201 scored 15 out of 15 indicating intact cognition on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). According to discharge paperwork from the hospital prior to R200's admission to the facility during hospital stay R200 was using a CPAP during sleep. (A CPAP is a machine that treats obstructive apnea). EMR review revealed a CPAP was not documented as being in use during the facility stay. According to documentation by Licensed Practical Nurse (LPN) K…

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 MI00146843. Based on interview and record review, the facility failed to ensure written notice was provided prior to room changes for four (Resident #2, #5, #6 and #11) of five reviewed. Findings include: Resident #2 (R2) Review of the medical record reflected R2 admitted to the facility on [DATE], with diagnoses that included dementia and anxiety disorder. According to the medical record, R2 had a room change on 8/21/24. The medical record did not reflect that written notice was provided to the responsible party prior to the room change. On 10/17/24 at 12:28 PM, Nursing Home Administrator (NHA) A reported R2's room change was related to a payor source change from Medicare to Medicaid. Resident #5 (R5) Review of the medical record reflected R5 admitted to the facility on [DATE], with diagnoses that included cerebral infarction (stroke). According to the medical record, R5 had a room change on 10/14/24. The medical record did not reflect that written notice was provided prior to…

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

This citation pertains to intakes MI00146687 and MI00146843. Based on observation, interview and record review, the facility failed to maintain cleanliness and repair of resident bathrooms. Findings include: On 10/17/24 at 9:06 AM, the bathroom shared by Resident #6 (R6), Resident #9 (R9) and Resident #11 (R11) was observed to have dried feces on the toilet seat riser and in the toilet bowl. On 10/17/24 at 12:12 PM, the bathroom shared by R6, R9 and R11 continued to be observed with dried feces on the toilet seat riser and in the toilet bowl. On 10/17/24 at 4:10 PM, the bathroom for room C-14 was observed to have a metal vent/register on the floor, which was bent and noted to be discolored with what appeared to be rust. On 10/18/24 at 9:19 AM, the bathroom shared by R6, R9 and R11 was observed to have feces on the toilet seat riser, on the inside of the toilet bowl and a small amount of feces in the toilet water. On 10/18/24 at 10:55AM during observation of the bathroom C9 it was noted there was an approximate 4 inch area on the lower wall of molding peeled away and open to an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake numbers MI00144590 and MI00144986. Based on interview and record review the facility failed to ensure for two out of three residents (Resident #1 and 3) accurate medical record documentation that reflected the care and services provided and the resident's condition. Findings Included: Resident #1 (R1) Review of R1's electronic medical record (EMR) revealed R1 had signed a Do Not Resuscitate (DNR) document and an Advanced Directive which revealed her wish to not receive resuscitation. Per R1's face sheet she was admitted to the facility on [DATE]. Review of R1's progress notes dated [DATE], revealed the Nurse Practitioner (NP) was notified via telehealth R1 was confused, short of breath, and pale in color. Review of another progress notes dated [DATE], documented by the same NP revealed R1 stated she did not feel right and wanted to go to the hospital. Vital signs were documented but there were no concerns, and R1 refused to wear her CPAP machine (worn on her mouth) at night.…

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 MI00143566. Based on interview and record review, the facility failed to ensure medications were administered as ordered for two (Resident #1 and Resident #3) of three reviewed. Findings include: Resident #1 (R1) Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses that included paraplegia, anxiety, and chronic pain. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/22/24 revealed R1 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), almost constantly had pain that affected sleep and interfered with therapy activities and day to day activities. Review of the Physician's Order dated 2/12/24 revealed an order for Oxycontin (controlled opiate pain medication) 20 milligrams (mg) two times a day for chronic pain. Review of the Medication Administration Record (MAR) revealed Oxycontin 20 mg was signed out as administered on 2/17/24 at 8:00 AM, however 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 MI00143566. Based on observation, interview, and record review the facility failed to maintain an accurate account of all controlled drugs for three (Resident #1, #2, #3) of three reviewed. Findings include: Resident #1 (R1) Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses that included paraplegia, anxiety, and chronic pain. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/22/24 revealed R1 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Physician's Order dated 2/23/24 revealed an order for lorazepam (Ativan/controlled anti-anxiety medication) 1 milligram (mg) three times a day for anxiety. Review of the Control Substance Record revealed a dose of lorazepam was signed out on 3/18/24 at 8:00 AM, which left one pill remaining. The next line reflected zero pills remaining, however, there was not date, time, or nurse signature for the…

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

Based on observation, interview, and record review, the facility failed to ensure proper label, dating and storage of foods occurred and dishwasher rinse temperatures were in the appropriate range with 82 residents consuming meals from the kitchen (1 resident receives nothing by mouth) resulting in increased risk of contaminated foods and the risk of food borne illness. Findings include: During an initial kitchen tour on 2/25/2024 at 8:52 AM, it was observed that the reach in freezer had ice buildup with chucks of ice on the bottom of the freezer. During another tour of the kitchen on 2/26/2024 at 10:03 AM with Dietary Director (DD) L, the following was observed in 2 different reach in refrigerators: 2 small containers of applesauce with a use by date of 2/25/2024 1 open white milk jug that didn't have a label that displayed an open and use by date 1 open chocolate milk jug that didn't have a label that displayed an open and use by date 3 strawberry purees in cups that didn't have a label that displayed a preparation and use by date During the tour on 2/26/2024 at 10:18 AM with DD L…

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 the attending physician documented in the medical record that identified medication review irregularities were reviewed, the action taken, and the rationale for no changes to the medications for five (Resident #7, #14, #18, #55, and #69) of five reviewed. Findings include: Resident #14 (R14) Review of the medical record revealed R14 admitted to the facility on [DATE] with diagnoses that included diabetes. Review of the Physician's Order dated 8/2/23 revealed an order for Lantus (insulin) 120 units subcutaneously (SQ) one time a day for diabetes. Review of R14's pharmacy Physician Recommendation dated 11/20/23 revealed The resident is receiving Lantus (Solostar Pen) 120 units SQ daily. The maximum amt [amount] per injection of the Lantus Solostar Pen is 80 units/dose. Review current orders and consider whether resident would be a candidate for twice daily dose of Lantus (ie 60 units SQ Q12H [every 12 hours]). There was no physician/prescriber…

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 the medication error rate was less than 5% when four medication errors were observed from a total of 27 opportunities for four residents (Resident #23, #49, #50, #179) of four reviewed for medication administration, resulting in a medication error rate of 14.81%. Findings include: Resident #49 (R49) Review of the Physician's Order dated 6/7/23 revealed an order for cyclosprine emulsion 0.05% (eye drops) instill one drop in left eye two times per day. An observation on 2/25/24 at 7:02 AM revealed Licensed Practical Nurse (LPN) C administered one drop in both of R49's eyes. When asked about why they gave the eye drops in both eyes, LPN C reported R49 had requested the medication be given in both eyes. LPN C reported they spoke with R49's eye doctor regarding the request, but the eye doctor wanted to see R49 before any changes were made. LPN C reported that appointment was scheduled for later that day. LPN C agreed the current order was to instill the cyclosporine in the left eye only. Resident #179…

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 updated and accurate advance directive information was in place for two residents (Resident #14 and Resident #183) of two reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time). Findings include: Resident #14 (R14) Review of the medical record revealed R14 admitted to the facility on [DATE] with diagnoses that included dementia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed R14 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R14's medical record profile revealed he was a full code (wanted cardiopulmonary resuscitation). Review of the Do-Not-Resuscitate (DNR) order revealed R14 signed on [DATE] that he did not want resuscitation attempted. Review of R14's care plan revised [DATE] revealed R14 wished to be a full code at that time. On [DATE] at…

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 communicate, develop, and implement a coordinated plan of care for Hospice Services for one (#183) of one residents reviewed for Hospice services, resulting in uncoordinated care planning. Findings include: Review of the medical record revealed Resident #183 (R183) was initially admitted to the facility on [DATE] and admitted on hospice on 02/16/24 with diagnoses that included pancreatic cancer, liver cancer and Dementia. According to Resident #183 (R183)'s Minimum Data Set (MDS) dated [DATE], revealed R183 scored 06 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. During an interview on 02/26/24 at 11:01 AM, Licensed Practical Nurse (LPN) M and LPN E both stated hospice CNAs comes in daily, and nurses come in weekly from both hospice organizations. LPN E stated hospice keeps binders behind the nurses station with all the residents information in it. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to justify the continued use of medications for two (Resident #18 and Resident #55) of five reviewed. Findings include: Resident #55 (R55) Review of the medical record revealed R55 admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, dementia with anxiety, depression, and chronic pain syndrome. Review of the Physician's Order dated 10/30/23 revealed an order for ascorbic acid (vitamin C) 250 milligrams (mg) one time a day for supplement. Review of the Physician's Order dated 10/30/23 revealed an order for zinc 50 mg one time a day for supplement. Review of R55's pharmacy Physician Recommendations dated 11/20/23 revealed This hospice resident is receiving the vitamin supplements Zinc and Ascorbic Acid. Evaluation of continued benefit and need for continued supplementation is needed. The orders may have been initiated to aid in wound healing or to help improve dietary intake which no longer apply at this time. Please evaluate…

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 justify the use of PRN (as needed) psychotropic and antipsychotic medications for three (Resident #18, #55, and #69) of five reviewed. Findings include: Resident #55 (R55) Review of the medical record revealed R55 admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, dementia with anxiety, depression, and chronic pain syndrome. Review of R55's pharmacy Physician Recommendations dated 11/20/23 revealed the following recommendations: 1) Lorazepam [Ativan] 0.5 mg [milligrams] every 4 hours as needed (PRN) started on 10/26/23. PRN psychotropic orders are to be written for no more than 14 days. If PRN psychotropic orders are deemed necessary beyond this time, clinical rationale and a specific duration need to be provided by the prescriber. Unfortunately there are no exclusions for hospice residents in the regulations. The Physician/Prescriber Response revealed other was checked with the typed comment Hospice to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to obtain a dental appointment for one resident (#60) of one reviewed for dental services. Findings include: Review of the medical record revealed Resident #60 (R60) was initially admitted to the facility on [DATE] with diagnoses that included severe obesity, disc degeneration in the lumbar region, osteoarthritis, polyneuropathy, and pain in the right leg. According to Resident #60 (R60)'s Minimum Data Set (MDS) dated [DATE], revealed R60 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. Record review revealed R60 had a dental visit on 12/12/23 through Health Drive Dental Group at the facility. At that appointment R60 complained of only having 3 teeth left and wanted to have them pulled so she could get dentures or implants. Recommendation from Health Drive Dental Group was for extraction of remaining 3 teeth. During an interview on 02/26/24 at 02:03 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 This Citation Pertains To Intake #MI00141092 and MI00140644 Based on interview and record review the facility failed to ensure allegations of abuse were identified, investigated, and reported for two out of five residents (Resident #4 and #5) resulting in the potential for resident abuse that is not identified, investigated, and reported. Findings Included: Resident #5 (R5): Per the facility face sheet R5 was admitted to the facility on [DATE], however was discharged on 11/11/2023. Review of an audio conversation between R5's roommate, Administrator A, and Director of Nursing (DON) B dated 11/4/2023 at 2:00 PM, revealed R5's roommate told Administrator A, and DON B that R5 would cry out for Jesus to help him and have mercy on him. R5's roommate stated in the audio that a staff member (did not know name) yelled from the hallway for R5 to shut up. On 12/12/2023 around 2:00 PM, Administrator A was requested to provide the facility's investigation into the allegations of verbal abuse. Administrator A stated that she…

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.