Medilodge of Montrose Inc

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that physical restraints were not used for one resident (Resident #69) of one resident reviewed, resulting in the use of a seatbelt restraint without an assessment for its use and an evaluation of its appropriateness. Findings include:Resident #69:On 1/27/26 at 3:34 PM, Resident #69 was observed sitting in their room in an electric motorized wheelchair. A seat belt was in place across the Resident's abdomen. An interview was completed at this time. When queried if they were able to undo their seat belt by themselves, Resident #69 replied, No. With further inquiry, Resident #69 stated, I used to be able to, but I can't anymore. Record review revealed Resident #69 was most recently readmitted to the facility on [DATE] with diagnoses which included chronic pain, anxiety, and muscular dystrophy (genetic disorder with progressive weakening and wasting of the muscles). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed…

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 update care plan interventions for two residents (Resident #55, Resident #124) of 22 residents reviewed, resulting in the likelihood for missed interventions in treatment and unmet needs. Findings include:Resident #55:In an interview on 01/27/2026 at 11:17 AM, Resident #55 stated that he has had a urinary catheter for years and basically takes care of it himself. He is on antibiotic for an irritated skin at the suprapubic site. He denied Urinary Tract Infection at this time but has had them in the past. The resident could not recall the facility staff education on catheter care provided to him. Observation on 01/27/2026 at 11:21 AM of Resident #55 was seated up in a wheelchair in his room and showed the surveyor his right catheter leg bag he puts on himself. Resident #55 was observed to be moving throughout the hallways in wheelchair self-propelling, will monitor the catheter hanging on his right leg throughout survey. Observation on 01/28/2026 at 9:54 AM of Resident #55 was Observed urinary catheter leg bag…

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 the provision of services to maintain grooming and hygiene for one resident (Resident # 1) of two residents reviewed. Findings include:Resident #1: On 1/28/26 at 8:43 AM, Resident #1 was observed in their room. The Resident was in bed, positioned on their back. The Resident was unshaven and had an unkempt appearance with uncombed and chunks of unknown substances on their shirt. When spoke to, Resident #1 made eye contact and shook their head yes or no in response to questions. When asked if staff had assisted them to get cleaned up, Resident #1 shook their head no. Record review revealed Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), epilepsy, gastrostomy (surgical procedure where an opening is created through the abdominal wall to the stomach, anxiety, traumatic brain injury, and dementia. Review of the Minimum Data…

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 1) Address a hunger strike for Resident #57, 2) Assess and monitor a new skin alteration for Resident #99, and 3) Ensure a quality of care of assessment and monitoring per professional standards for Resident #124, resulting in a lack of care coordination, documentation and assessments. Findings include: Resident #124: Record review of Resident #124's progress notes dated 1/19/2026 at 4:06 PM noted the resident returned from hospital and an assessment was completed. Record review of Resident #124's vital signs, dated 1/19/2026 at 3:32 PM, noted a forehead temperature of 101.3 degrees F. Record review of Resident #124's Medication Administration Record (MAR) noted that on 1/20/2026, an antibiotic Meropenem intravenous 1 gram every 8 hours for sepsis. Record review of Resident #124's readmission Minimum Data Set (MDS), dated [DATE], noted a female with Brief Interview of Mental Status (BIMS) score of 13 out of 15, cognitively intact. Active…

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 follow standards of practice by failing to assess and monitor the removal site of a gastrostomy tube (GT) site and monitor pain for one resident (Resident #124) of 3 residents reviewed for tube feeding in a sample of 22 residents. Finding include:Resident #124:Peg Tube Removal:In an observation and interview on 01/27/2026 at 9:49 AM, Resident #124 was lying in bed. She stated that she has a belly tube and the IV in her right arm. Resident #124 showed the state surveyor her right upper arm and abdominal gastrointestinal tube site. Observation revealed no split sponge gauze dressing noted to the site.In an interview on 01/28/2026 at 3:50 PM, Resident #124 was seated up in Wheelchair in the hallway and was so happy she got her belly tube out. She went to the doctor, and they took out her feeding/peg tube. She is so happy and tells everyone about it. Record review of the facility 'Nutritional Management' policy, dated 7/1/2025, revealed the facility provides care and services to each resident to ensure the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for storage and cleaning of respiratory equipment for one resident (Resident #1) of three residents reviewed, resulting in a lack of cleaning and appropriate storage of nebulizer (machine which converts liquid into fine mist for administrator of medications directly into the lungs through respiration) equipment. Findings include:Resident #1: On 1/28/26 at 8:43 AM, Resident #1 was observed in their room in bed. When spoke to, Resident #1 would make eye contact and shook their head yes or no in response to questions. A nebulizer machine was observed on the dresser beside the Resident's bed. A nebulizer administration mask was sitting next to the machine on the dresser in a clear bag. The nebulizer mask was connected in the bag and visible fluid was present in the medication administration chamber. An oxygen concentrator was present with nasal canula tubing connected. The nasal cannula…

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 2688354 and 2689940.Based on observation, interview and record review the facility failed to ensure timely reporting, notification, comprehensive assessment and continued post-fall monitoring for one resident (Resident #2) following an unwitnessed fall of one resident reviewed for safety and accidents. Findings include:Resident #2 (R2):A record review for Resident 2's (R2) quarterly Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental status (BIMs) score of 99 that indicated severe cognitive impairment and indicated a need for comprehensive assistance and specialized care approaches. Further record review of R2's medical record revealed medical diagnoses that included: dysphagia following cerebral infarction (stroke), aphasia following cerebral infarction, type 2 diabetes mellitus, seizures, contracture bilateral knees, Hemiplegia (one sided paralysis or weakness) and hemiparesis (one sided muscle weakness) following cerebral infarction affecting left…

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 2614165, 2646780, 2646846, and 2674790.Based on observation, interview, and record review, the facility failed to protect residents' rights to be free from sexual abuse and physical abuse by other residents for three residents. Findings include: Review of Facility Reported Incident (FRI) documentation revealed a facility Certified Nursing Assistant (CNA) alleged on 8/18/25, they observed Resident #114 with their hand down Resident #105's shirt while sitting in the dining area. On 11/20/25 at 8:40 AM, Resident #105 was observed sitting at a table in the central/dining area of the unit in front of a TV. When asked questions, Resident #105 made eye contact but did not provide any verbal response. Tears were observed in Resident #105's eyes and they were making gasping noises as though crying. Two other residents, including Resident #114, and CNA H were sitting at the table. CNA H was queried regarding Resident #105 including their tearful, sad facial expression and inability…

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 2648479. Based on interview and record review, the facility failed to implement and operationalize policies and procedures to ensure comprehensive discharge planning and a safe discharge home for one resident (Resident #110) of three residents reviewed for transfer/discharge. Findings include:Review of intake documentation, dated as received 10/15/25, revealed a concern that Resident #110 was discharged from the facility without coordination of care for resumption of care with home services including transportation for dialysis, necessary Durable Medical Equipment (DME)/supplies, and training to family care givers. On 11/19/25 at 1:56 PM, an interview was completed with Agency on Aging Witness FF. When queried regarding Resident #110's discharge from the facility, Witness FF revealed the Resident had been discharged on 10/14/25 without any coordination of care and/or agreed upon notification to the local Agency on Aging, no DME equipment, no training to the Resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake Numbers 2591663, 2612086, and 2665756.Based on observation, interview and record review, the facility failed to provide urinary incontinence care per professional standards of practice for two residents (#102, #112), Findings include: Record review of R112 Minimum Data Set/MDS dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 0 out of 15, severe cognitive impairment; It was further noted due to R112 diagnoses of aphasia (impaired verbal and/or comprehensions of verbal communication) she is unable to answer questions. Medical diagnoses included: dysphagia (impaired understanding and/or formulation of verbal communication) following cerebral infarction; aphasia; diabetes type II; seizures; acute kidney failure; chronic kidney disease (impaired renal function); contracture bilateral knees (impaired musculoskeletal status). On 11/20/2025 at 2:30PM, an observation of R112's room and bathroom was made, R112 was not present. On 11/20/2025 at 08:25AM, 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 Number 2585749.Based on interview and record review, the facility failed to obtain a physician's order for urinary catheter per professional standards of practice for one resident (Resident #106), resulting in the potential for bladder injury, prolonged illness, and an indwelling catheter being left in place with no physician's order.Findings include:Resident #106:Record review of Resident #106's Minimum Data Set (MDS) dated [DATE] revealed that the resident had an indwelling urinary catheter. Medical diagnosis included: Atrial fibrillation, heart failure, renal insufficiency, wound infection, respiratory failure, cellulitis of lower limb, and lymphedema. Record review of Resident #106's 'Nursing admission Evaluation' assessment dated [DATE] revealed an indwelling catheter with clear yellow urine. Record review of Resident #106's physician order recap report for the month of January 2025 revealed that there was no physician's order for a urinary Cather ordered.Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to Intake#: 2569658Based on observation, interview and record review, the facility failed to develop and implement interventions, including monitoring and supervision, to prevent resident-to-resident abuse involving 2 residents of 4 residents reviewed for abuse, including Resident #1 who grabbed Resident #2's hand and placed it on his pants over his genitals, resulting in the potential for additional instances of abusive behavior towards other residents. A review of the Face Sheet indicated Resident #1 was admitted to the facility on [DATE] with diagnoses: History of a stroke, difficulty talking, COPD, history of falls, depression, hypertension, Dementia, arthritis, and GERD.A review of the Face Sheet indicated Resident #2 was admitted to the facility on [DATE] an readmitted on [DATE] with diagnoses: Dementia, diabetes, chronic kidney disease, depression, hypertension, and anxiety.A review of a Facility Reported Incident/FRI revealed on 7/9/2025 Resident #1 was observed by a Staff member,…

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#: 2566178Based on observation, interview and record review, the facility failed to provide medications, and a right knee X-ray as ordered for one resident (#3) of three reviewed for medications and treatments, resulting in Resident #3 experiencing pain, nausea and delayed treatment. A record review of the Face sheet indicated Resident #3 was admitted to the facility on [DATE] with diagnoses: recent back surgery, neuropathy, anxiety, GERD, hypotension, history of a stroke, weakness, anemia, chronic kidney disease, and depression. On 7/31/2025 at 10: 37 AM, Resident #3 was observed lying in bed awake and alert. He said he had not received his medications for a couple of days after admission and was having pain and nausea. He said he was now receiving his medications but was upset that it took so long. The resident said his right knee had been causing him pain and he said without his pain medication, he felt nauseous. In addition, he was not receiving the medication that he normally…

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 #2577143.Based on observation, interview and record review, the facility failed to obtain timely dental services for one resident (Resident #4), who fell and injured their mouth area of one resident reviewed for dental care.A review of Resident #4 medical record revealed an admission into the facility on 6/26/25 with diagnoses that included diabetes, end stage renal disease, difficulty in walking and muscle weakness. A review of the Resident's Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 15/15 that indicated the Resident was cognitively intact and the Resident needed setup or clean-up assistance with oral hygiene and substantial/maximal assistance with toileting hygiene, bathing, lower body dressing and needed partial/moderate assistance with transfers. On 7/31/25 at 1:46 PM, an observation was made of Resident #4 sitting in his room on the bed. The Resident was dressed and had a phone that he was talking on but stopped when surveyor approached. The Resident answered questions and engaged in conversation. 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 Numbers 1205063 and 1205084.Based on observations, interview and record review, the facility failed to ensure that call lights were answered timely and assist with care needs, snacks, and incontinence care in a timely manner for four residents (6, 7, 14, and 18) of eight residents reviewed for call light responses, a Confidential Resident and a Confidential Group of Residents. Findings include: Resident Council: FACILITY According to the group of confidential residents, as of July 1, 2025, during the Resident Council (RC) meeting held between 1:30 PM and 2:30 PM, 15 of 15 Resident Council attendees opted to remain anonymous and asked to keep their identities confidential. One confidential resident stated that the issues brought up by the council do not get resolved and said, Some issues do not go anywhere. All 15 of 15 residents in the confidential group expressed that the call light response time was too long. During the RC Meeting, some residents indicated that grievance forms…

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 numbers: 1205082 and 1205084. Based on interview and record review, the facility failed to provide prompt efforts to resolve complaints pertaining to prolonged call light response time, food palatability, bedtime (HS) snack distribution, Weekend Manager on Duty (MOD) availability and accessibility for residents, staff attitude in providing quality of care, availability and assistance and to ensure the process to address grievances was understood for confidential group of 15 residents, resulting in unresolved grievances and potential for further frustration. Findings include: Resident CouncilFACILITYAccording to the group of confidential residents, as of July 1, 2025, during the Resident Council meeting held between 1:30 PM and 2:30 PM, they revealed that the Resident Council meets once a month. They requested to remain anonymous and to keep their identities confidential. One confidential resident stated that the issues brought up by the council do not get resolved and said, Some issues do not go anywhere. Some concerns are not followed up on, and no…

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 1205063, 1205080 and 1205084.Based on observation, interview and record review, the facility failed to provide necessary assistance to honor residents' preferences, choices, or requests to maintain bathing, grooming, nail care and personal hygiene for 6 residents (Resident's #1, #3, #6, #7 #18 and #22) of 7 residents reviewed for Activities of Daily Living/ADL care, resulting in the loss of personal dignity and individuality.Facts and Findings include:Review of the face sheet, physician orders dated 5/26/2025 and Activities of daily living/ADL care plan initiated on 4/16/2025 revealed, Resident #1 was [AGE] years old, alert with a BIMS (cognitive assessment) of 15, admitted to the facility on [DATE] and dependent on staff for supervision and assist of 1 for ADL's including shaving. The resident's diagnosis included, heart disease, respiratory failure with hypoxia, mood disorder, Chronic lung disease, anxiety, and need for assistance with personal care, schizophrenia. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #1205063.Based on observation, interview and record review, the facility failed to maintain a consistently operational and accessible call light system affecting 5 residents (R7, R10, R11, R18 and R22), Residents residing in the100 hall, 200 hall, 300 hall, 400 and 500 halls, resulting in extended call light times and unmet needs. Findings include: Resident #7 A review of Resident #7’s medical record revealed an admission into the facility on 4/2/25 with diagnoses that included fracture of the lumbar vertebra, fall, dementia, vertigo, muscle weakness, and need for assistance with personal care. A review of the MDS revealed a BIMS score of 13/15 that indicated intact cognition and needed substantial/maximal assistance with bathing self, dependent on assistance with lower body dressing and toileting hygiene and needed partial/moderate assistance with upper body dressing, transfers and mobility. On 7/1/25 at 1:30 pm, an observation was made of Resident #7 lying in bed and a visitor…

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 #1205082.Based on interview and record review, the facility failed to protect a resident from abuse and neglect for one resident (R#14) when a nurse on midnight shift neglected to respond to the call light promptly, and did not provide nursing care during IV infusion while the resident's PICC (Peripherally Inserted Central Catheter) machine alarm was sounding for prolonged periods and wound care as needed of a total sample of 3 residents reviewed for abuse and neglect. Findings include:A review of the Facility's Incident Report dated 6/9/25 at 2:00 AM revealed that the resident (R14) alleges that the assigned nurse (Nurse U) neglected to ensure his IV meds were completed timely. The assigned nurse (Nurse U) was suspended, and an investigation was initiated. Further review of the Facility Incident Report, Concluded and wrote: That they cannot substantiate any abuse or neglect for the following reasons:Residents assigned to Nurse U were interviewed. They denied any issues 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.

This Citation pertains to Intake Number MI00153369. Based on observation, interview and record review, the facility falsified the completion of staffs' online education, which had the potential to affect a census of 112 residents residing in the facility. Findings Include: On 6/10/25 at 8:50 AM, an interview was conducted with Nurse B. When asked about education, the Nurse reported that they started a new education (online education) but could not get into the program and had not completed the education though the facility wanted to have it done. The Nurse reported having issues with getting in the system and had not completed the education. On 6/10/25 at 12:45 PM, an interview was conducted with CNA (Certified Nursing Assistant) I. When asked if they have had their education completed with the new online education, the CNA indicated she had not completed it. The CNA reported they could complete it at home but was unable to and stated, I have not done it yet. On 6/10/25 at 1:53 PM, an interview was conducted with CNA (Certified Nursing Assistant) T. When asked about the completion…

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 MI00153563. Based on observation, interview and record review, the facility failed to ensure infection control practices were followed and emergency equipment was available for residents with tracheostomy status for four residents (#14, #15, #16 and #17) of four residents reviewed for tracheostomy and oxygen care. Findings include: Resident #15: On 6/10/25 at 11:45 AM, an observation was made with the Director of Nursing (DON) of Resident #15 lying in bed in her room. The Resident did not respond when her name was called. The Resident's head of the bed was elevated and the Resident had oral secretions coming out of her mouth. The Resident had a tracheostomy, and a collar with oxygen. A review of the emergency equipment at the head of the bed revealed an obturator in a bag that was taped to the wall above the head of the bed. When asked where a replacement trach was in the resident's room, the DON was unsure, looked through supplies but did not find the emergency equipment.…

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 MI00153369 and MI00153563. Based on observation, interview and record review, the facility failed to ensure resident safety with a lack of timely documentation of Resident #13 exiting the building unattended by staff. The facility also failed to update and/or revise care planning to include exit-seeking behavior and ensure that staff signed out pagers that notify staff of the resident call system and door activation for one resident (Resident #13) of three residents reviewed for elopement. Findings include: Resident #13: A review of Resident #13's medical record revealed an admission into the facility on 1/22/25 with diagnoses that included dementia, metabolic encephalopathy, bipolar disorder, altered mental status, depression, adjustment disorder with anxiety, muscle weakness, unsteadiness on feet, restlessness and agitation. A review of the Resident's Minimum Data Set assessment dated [DATE], revealed a Brief Interview of Mental Status score of 00/15 that indicated…

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 MI00151406 and MI00151580. Based on observation, interview and record review, the facility failed to ensure that residents' rights and/or dignity were maintained by failing to answer residents' call lights in a timely manner, ensure that call lights were in reach, ensure that meals and/or snacks were provided and followed the residents' preferences, and provide adequate lighting in a resident's room for five residents (#2, #3, #6, #8, and #9) of five residents reviewed for food and call lights, resulting in long call light wait times, incontinence, and frustration. Findings include: Resident #2: A review of Resident #2's medical record revealed an admission into the facility on 7/19/22 and readmission on [DATE] with diagnoses that included Parkinson's disease, diabetes, unsteady on feet, muscle weakness, epilepsy and chronic obstructive pulmonary disease. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) score of 15/15…

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 MI00151746. Past Non-Compliance (PNC) was identified at the facility during investigation of the allegation and was accepted by the survey team upon exit from the facility for this citation. Following discussion with the State Manager, Past Non-Compliance was accepted with a Compliance Date of 3/24/2025. Based on interview and record review, the facility failed to immediately report to the Abuse Coordinator allegations of sexual abuse and report timely to the State Agency abuse allegations for one resident (#1) of four residents reviewed for abuse, resulting in a delay in the investigation and the potential lack of resident safety to go undetected and abuse to continue to occur. Findings include: Resident #1: A review of Resident #1's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included cerebral palsy, dysphasia, adult failure to thrive, hydrocephalus, dementia, anxiety disorder, and adjustment 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 Number MI00150467. Based on observation, interview and record review, the facility failed to ensure the provision and documentation of Activities of Daily Living (ADL) and hygiene care for five residents (701, 702, 703, 704, and 705) of five residents reviewed. Findings include: Review of intake documentation dated as received [DATE] revealed concerns of inadequate staffing and that residents are not getting the proper care they need . showers are not being done, and residents are not getting the proper grooming . Resident #701: Record review revealed Resident #701 was originally admitted to the facility on [DATE] and readmitted with [DATE] with diagnoses which included cerebral infarction (stroke) with resulting attention and concentration deficit, chronic respiratory failure, tracheostomy (surgically created opening in the front of the neck to the trachea to allow for breathing), gastrostomy (surgically created opening in the abdomen to the stomach to allow for introduction of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to Intake Number MI00150264. Based on observation interview and record review the facility failed to ensure an operational call light system in the short-term units of the facility (100, 200, 300, and 400 hallways). Findings include: Review of intake documentation detailed a concern that Call lights have been broken for a month and Care is not properly given due to the call lights being broken. The intake further detailed the pager call light notification is delayed and/or non-functional. During an observation of the central area of the short-term units of the facility (100, 200, 300, and 400 hallways) and nurses' station on [DATE] at 1:00 PM revealed no central call light monitoring screen/monitoring system. There were no visual light indicators outside of the rooms in the hallways. On [DATE] at 1:13 PM, an interview was completed with Registered Nurse (RN) I. When queried regarding the call light system, RN I revealed the facility used a pager system and there were no lights and/or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to Intake Number MI00150264. Based on interview and record review, the facility failed to ensure timely nursing assessment, response, and documentation for a change in condition for one resident (#705) three residents reviewed. Findings include: Resident #705: Review of intake documentation revealed concerns related to lack of appropriate care and Resident #705's subsequent death. Record review revealed Resident #705 was originally admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke) with resulting left sided hemiplegia and hemiparalysis (one sided paralysis), dysphagia (difficulty swallowing), and dysarthria (difficulty speaking), and gastrostomy (surgically created opening in the abdomen to allow for a feeding tube to be placed). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and was dependent upon staff for completion of all Activities of Daily Living (ADL's). Record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure tube feeding equipment was maintained, tube feeding supplies were labeled and dated, and enteral nutrition and care per physicians' orders were provided for four residents (#34, #35, #53, #90) out of five residents reviewed for enteral nutrition, resulting in undated solutions, unassessed skin, inaccurate volumes infused and dirty equipment. Findings include: Resident #90: On 12/04/24, at 8:35 AM, an observation along with Nurse J of Resident #90's alarming tube feeding pump and Glucerna 1.5 solution was conducted. Nurse J was asked if there was a date or time on the solution bottle and/or tubing and Nurse J shook their head no. Nurse J was asked what the total volume fed for solution and total volume fed for water flush was. Nurse J manipulated the pump to reveal total volume fed to be 1915 ml (milliliters) and the total flush to be 960 ml. The water flush bag was a liter volume capacity and appeared to be 100 % full. There 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: 1) Ensure that residents received oxygen as ordered for 4 residents (#'s 21, 24, 30 and 83) of 6 residents reviewed for oxygen use and; 2) Ensure proper management of oxygen and trach supplies for 2 residents (#'s 24 and 83) of 5 residents reviewed for Trachs, resulting in the potential for the lack of necessary oxygen therapy and contamination of supplies. Findings Include: Resident #21: On 12/05/2204 at 9:54 AM, Resident #21 was observed wheeling herself rapidly in her wheelchair past the nurses table near the 300 hall. Her face was red and she was breathing heavily. A staff member was walking with her and said she was looking for a nurse, because the resident's oxygen tank was empty. The resident was asked if she was having difficulty breathing and she shook her head Yes and stated, I need a new oxygen tank. The Assistant Director of Nursing/ADON, said she would get the resident a new oxygen tank. The resident said she was on the other…

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

Based on interview and record review, the facility failed to ensure that Licensed Nurses (RNs-Registered Nurses and LPNs-Licensed Practical Nurses) and Certified Nursing Assistants (CNA) received yearly competency evaluations to ensure competent and trained nursing staff to perform their duties to attain or maintain the wellbeing of residents, for six Nurses and CNAs of seven staff reviewed for evaluations, education and competencies, resulting in the potential nursing staff lacking necessary training and skills to adequately care for the needs of the residents residing in the facility of a census of 105. Findings include: On 12/5/24 at 12:43 PM, an interview was conducted with Human Resources (HR) Personnel U during the Sufficient and Competent Nurse Staffing task of the survey. The HR was asked for documentation for staff competency and evaluations with training/education based on the evaluation outcomes. LPN W's evaluations were reviewed with one completed in 2022. When asked for a more current competency evaluation, HR Personnel indicated she did not have one available for 2023…

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 post required, accurate, updated nurse staffing records and retain accurate data of the nurse staffing hours, resulting in the potential to affect all Residents residing in the facility of a census of 105, Resident representatives and visitors to be unable to determine nursing staff on duty. Findings include: On 12/5/24 at 11:51 AM, an interview was conducted with Scheduling Coordinator (SC) T to review nursing staffing hour postings. An observation of the posting for 12/5/24 did not have the RN (registered nurse) hours posted. The SC indicated that the posting must have been cut off when it printed and reported she will reprint the posting. The RN hours were confirmed. The posting for November 23, 2024, did not have RN posted hours. The DON confirmed that there was a RN on for the day. The SC was questioned about the daily posting of nursing staffing hours. The SC indicated that every day when she comes in, she would retrieve the posting and correct it if there were any changes during the night. When asked…

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 of medications in 4 of 4 medication carts reviewed, and ensure appropriate narcotic reconciliation, resulting in opened and undated multi-dose medications, the potential for unaccounted controlled substances and altered medication efficiency. Findings include: Medication Storage and Labeling: Observation and interview on 12/03/24 at 11:10 AM with Licensed Practical Nurse (LPN) A of the 300-hall medication cart review noted medication punch cards in the second drawer, the surveyor found 2 loose white tablets, marked with TV 2204 on back side of tables. LPN A stated that the night shift was to clean out the medication carts last night and placed the loose tablets in a drug buster located within the medication cart. Review of third drawer of the medication cart revealed nasal spray Fluticasone Propionate 50 mcg for the resident in room [ROOM NUMBER] was opened/used and not dated for when the multi-dose bottle was opened.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to update care plan interventions for 2 residents (#74, #75) of 22 sampled residents, resulting in the potential for resident care needs being not met/missed, prolonged illness or injury. Findings include: Resident #74: Record review of Resident #74's Minimum Data Set (MDS) assessment dated [DATE] revealed an elderly male resident with a Brief Interview of Mental status (BIMs) score of 3 out of 15, severe cognitive impairment. Medical diagnosis included: Atrial fibrillation, hypertension, gastroesophageal reflux disease, obstructive uropathy, diabetes, dementia, and depression. Section H: bowel & bladder revealed there was no urinary catheter in place. Observation and interview on 12/02/24 at 11:38 AM of Resident #74 revealed the bed to be in low position. Resident #74 was speaking about a dog in the house and to get it out. The surveyor attempted more questions, with no response. Observation of urinary catheter and tubing to be laying on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to follow physician's orders for monitoring blood pressure and heart rate parameters with administration of the medication Metoprolol (used to treat chest pain and hypertension (high blood pressure)) for one Resident (#34), of six reviewed for medication review, resulting in the potential for adverse drug consequences, lack of medication treatment effectiveness and medical conditions left untreated. Findings include: Resident #34: A review of Resident #34's medical record revealed an admission into the facility on [DATE] with diagnoses that included stroke, diabetes and essential (primary) hypertension. A review of Resident #34's Medication Administration Record revealed an order for Metoprolol Tartrate oral tablet 25 mg, give 0.5 tablet via PEG-Tube (Percutaneous endoscopic gastrostomy-a tube placed in the stomach to administer nutrition, fluids and medication) every morning and at bedtime for hypertension. Hold if SBP (systolic blood pressure) is less…

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 assist with denture care and nail care for two Residents (#11 and 51) of seven residents reviewed for activities of daily living, resulting in fingernails long and jagged, denture cup with debris inside and the potential for embarrassment, skin injury and infection. Findings include: Resident #11: A review of Resident #11's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included stroke, hemiplegia and hemiparesis following stroke affecting right dominant side, dementia, anxiety disorder, depression and dysphagia following stroke. A review of the Minimum Data Set assessment dated [DATE] revealed the Resident had intact cognition and needed substantial/maximal assistance with activities of daily living. On 12/4/24 at 9:40 AM, an observation was made of Resident #11 in their room. The Resident was dressed and had on her personal jewelry and many bracelets on her wrists. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to 1. Coordinate and collaborate hospice service for Resident #83 to ensure comprehensive care and 2. Complete timely assessment and monitoring of skin and change bandages and sheets when visibly soiled for Resident #403. Findings Include: Resident #403: On 12/3/2024 during initial tour, Resident #403 was observed in bed resting, she stated she recently admitted to the facility after being septic and coding. She reported her fingers are black which is why they are bandaged and were last changed last night by facility staff. Resident #403's bilateral hands were bandaged but were completely saturated with brown colored drainage. There was a dressing on the right side of her neck dated 11/25 11:00 and another dressing on her right arm with no date. On 12/4/2024 at 9:15 AM, Resident #403 was observed visiting with her husband. When asking about the dressings that were on her right arm and chest the day prior. He expressed facility staff voiced 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 Based on interview and record review the facility failed to ensure thorough initial therapy assessment documentation, prevent a reduction in range of motion and the development of contracture for one resident (Resident #10) of one resident reviewed for limited range of motion. Findings Include: Resident #10: On 12/4/2024 at 11:05 AM, Resident #10 was observed resting in this in his room. He reported he has been at the facility for one year and therapy has not attempted to stand him up. He stated they informed him he would not be able to stand due to the outwardness of his feet. He reported he was walking at one point with a cane and now is not able too. On 12/4/2024 at approximately 11:45 AM, a review was conducted of Resident 10's medical records and it indicated he admitted to the facility on [DATE] with diagnoses that included, Peripheral Vascular Disease, Heart Disease, Kidney Disease, Adjustment Disorder, Hypertension and Mood Disorder. Further review of the records yielded the following: Progress Notes:…

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 necessary management and care of an indwelling urinary catheter for 2 residents (Resident #24, and Resident #74) and management of recurrent Urinary tract infection/UTI for one resident (Resident # 73) of 3 residents reviewed for urinary catheters, resulting in the potential for complications including infection and a decline in condition. Findings Include: Resident #24: Urinary Catheter or UTI On 12/03/2024 at 10:23 AM, Resident #24 was observed sleeping in bed. An indwelling urinary catheter (Foley catheter) bag was sitting on the floor bent over, not hanging freely; the catheter tubing had thick yellow urine with sediment and biofilm (a sticky grouping of bacteria) on the inside of the catheter walls. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: history of a stroke, diabetes, chronic kidney disease,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to respond to pharmacy recommendations for two (#8 and #9) residents of five residents reviewed for unnecessary medications. Findings Include: Resident #8: On 12/4/2024 at 10:45 AM, a review was completed of Resident #8's medical records and it revealed he admitted to the facility on [DATE] with diagnoses that included, Traumatic Brain Injury, Depression, Insomnia and Adjustment Disorder. On 12/05/24 at 12:15 PM, review was conducted of Resident #8's Medication Regime Review's (MRR) from November 2023- November 2024. It was found there were three recommendations from the pharmacist that the facility failed to respond too. The recommendations were requested from the facility (as they were not accessible in the medical record) and, the DON (Director of Nursing) stated they do not have the physical pharmacy recommendations prior to October 2024. She further explained she would have to call pharmacy to obtain them, and they would not have 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 observation, interview, and record review the facility failed to provide risk versus benefits and/or medication education to one resident (Resident #75) or resident/responsible party, resulting in Resident #75 to be administered a benzodiazepine medication without appropriate risk versus benefit analysis of the medication explained to the resident/responsible party and the increased potential for serious side effects and adverse reactions. Findings include: Resident #75: Record review of Resident #75's Minimum Data Set (MDS) dated [DATE] revealed a [AGE] year-old male resident with medical diagnosis of: Anemia, hypertension, renal insufficiency, diabetes, aphasia, stroke, dementia, hemiplegia, anxiety, depression, and manic depression. Resident #75 Brief Interview of Mental status (BIMs) score of 7 out of 15 cognitively impaired Observation and interview on 12/02/24 at 10:21 AM revealed Resident #75 to be in his room, seated in a wheelchair at the bedside. Surveyor attempted interview with Resident #75,…

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 food preferences for a lunch for one resident (Resident #22) of fifteen residents reviewed during the dining task, resulting in consumption of food not liked with the likelihood of decreased nutritional intake. Findings include: Resident #22: On 12/03/24, at 12:15 PM, Resident #22 was sitting at a dining table with their lunch meal in front of them. Resident #22's meal ticket revealed dislikes that were on the plate. Resident #22 had mashed potatoes and gravy and what appeared to be carrots. The resident was asked if they liked masked potatoes and the resident stated, no, but I'll take what I can get. On 12/3/2024, at 3:30 PM, a record review of Resident #22's electronic medical record revealed an admission on [DATE] with diagnoses that included Dementia, Mood Disturbance and Anxiety. Resident #22 required extensive assistance with Activities of Daily Living (ADL's) and had severely impaired cognition. A review of the Focus (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 medication administration and clean reusable medical equipment for one resident (Resident #10) of six residents reviewed for medication administration task, resulting in the use of unsanitary equipment and the administration of dirty pills. Findings include: Resident #10: On 12/05/24, at 8:31 AM, During medication administration task, Nurse O prepared Resident #10's medications. Nurse O offered they needed to cut 2 of the larger pills for the resident. Nurse O placed a large tablet in the pill cutter which was soiled with a moderate amount of white residue. Nurse O placed the cut tablet in the medication cup with their bare hands. Nurse O then cut the second tablet and placed into the medication cup with their bare hands. Nurse O entered Resident #10's room and administered the medications to the resident. On 12/05/24, at 9:43 AM, Infection Control (IC) Nurse F was asked if residents oral medications should be touched with bare hands and IC Nurse F stated, no. IC Nurse F was alerted of the soiled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to: 1.) obtain laboratory results for the use of antibiotics prior to starting antibiotic therapy for two residents (#6 and #73); of three residents reviewed for antibiotic stewardship and initiate interventions to reduce antibiotic use, potentially effecting all residents, resulting in the potential for unnecessary medications, additional infections and resistant organisms. Findings Include: Resident #6: On 12/4/2024 at 11:00 AM, review was completed of Resident #6's medical record and it revealed he admitted to the facility on [DATE] with diagnoses that included, Parkinson's, Atrial Fibrillation, Major Depression and Kidney Disease. Further review of Resident #6's record revealed the following: November 2024 MAR (Medication Administration Record): Cephalexin Tablet 500 MG (milligram)- Given one tablet by mouth every morning and at bedtime for infection for 5 days per hospice. Possible UTI (urinary tract infection). Resident #6 received nine doses 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 Number MI00147080. Based on interview and record review, the facility failed to ensure one resident's (Resident #106) care plan (Impaired Hepatic Status) was implemented of 3 residents reviewed for care plans, resulting in the likelihood for exacerbated hepatic systems (increased abdominal girth, abdominal pain, fullness/discomfort, jaundice), pancreatic involvement (inflammation of pancreas) and hospitalization. Findings Include: Resident #106: Review of the Face Sheet, care plans dated 9/6/24, nursing and physician notes dated 9/5/24 through 9/13/24, revealed Resident #106 was [AGE] years old, alert, admitted to the facility on [DATE], and required assistance with activities of daily living (ADL's). The residents diagnosis included, gangrene of fingers, diabetes, chronic obstructive pulmonary disease, heart failure, atrial fibrillation, anemia, alcoholic cirrhosis of liver, chronic pancreatic, elevated liver transaminase levels and heart failure. The resident was transferred to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number MI00146098. Based on interviews and record review, the facility failed to ensure that one resident (Resident #101), who had a long history of mental illness (Bipolar Disorder, anxiety, attention deficit, and Borderline Personality with harm threats and physical aggression), of 3 residents reviewed for mental health services, obtained mental health services (including mental health medication review) while at the facility, resulting in a major psychotic episode with violent and aggressive behaviors towards staff, threats of harm to staff, with hospitalization. Findings Include: Resident #101: Review of the Face Sheet, behavioral charting, Minimum Data Set (MDS, resident assessment) dated 7/24, and progress notes, revealed Resident #101 was 30 years-old, admitted to the facility on [DATE] and discharged to the hospital on 8/2/24. The resident received psychotropic medications and had a known history of violence and harm to animals. The resident's diagnosis included, anxiety…

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 MI00145431. Based on interview and record review, the facility failed to implement policies and procedures to ensure a comprehensive and accurate assessment and documentation for one resident (Resident #205) of one resident reviewed, resulting in a lack of accurate, complete, and concise documentation and nursing assessment for a change in condition. Findings include: Resident #205: Review of intake documentation pertaining to Resident #205 revealed the Resident was transferred to the hospital from the facility where they tested positive for Legionnaires' (serious type of pneumonia caused by the Legionella bacteria). Record review revealed Resident #205 was admitted to the facility on [DATE] with diagnoses which included right ischium (one of three bones that form the hip bone) fracture, falls, diabetes mellitus, atrial fibrillation (irregular heart rhythm), and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident 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 This Citation pertains to Intake Number MI00145431. Based on observation, interview and record review, the facility failed to ensure medications were given timely and as ordered for one resident (Resident #201) of 3 residents reviewed for medications, from a census of 111 residents, resulting in Resident #201 receiving doses of medication too close together and too far apart, which could lead to adverse effects and decreased effectiveness of the medications. Findings Include: Resident #201 A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #201 was admitted to the facility on [DATE] with diagnoses: hydrocephalus, bipolar disorder, rheumatoid arthritis, anxiety, chronic pain syndrome, history of pulmonary embolism. The Director of Nursing was interviewed on 7/22/2024 at 2:40 PM, she was asked if Resident #201 was ever given her medications outside of the ordered timeframes. She said it had happened, but she wasn't sure of the exact circumstance. A request for copies 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 Number MI00136915. Based on interview and record review, the facility failed to ensure an environment free of abuse (verbal and physical) for four residents (Resident #117, Resident #118, Resident #119 and Resident #120), of 8 residents reviewed for abuse, resulting in verbalizations of anger, hostility, threats of violence, and physical and verbal abuse from Resident #102. Findings Include: Review of the facility admission packet given to all residents and/or Power of Attorneys at the time of admission (un-dated), stated Federal and/or State law gives you the right to remain at the center (the facility) once admitted , and not be transferred or discharged against your will, except for the following: The health and/or safety if the resident or other individuals in the center are endangered. Review of the electronic medical record and per interview done with the Director of Nursing/DON on 6/27/24 at approximately 2:00 PM, revealed that Resident #102 verbalized abusive behaviors…

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 MI00143098 Based on interview and record review the facility failed to treat one resident (Resident #111) of 3 residents reviewed for residents' rights with dignity resulting in Resident #111 having feelings of frustration and mental anguish. Findings include: Resident #111 (R111): Review of R111's face sheet dated 6/27/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: adjustment disorder with anxiety, heartburn, muscle weakness, shortness of breath and dependence on oxygen. R111 was her own responsible party. Review of R111's Interdisciplinary Progress Note dated 2/14/24 at 3:41 AM revealed a note written by the Director of Nursing (DON) This nurse has been in resident's room multiple times. The process of obtaining medications form the pharmacy has been explained to her each time. She continues to put her call light on asking for her alprazolam (antianxiety medication). She is demanding that a staff person…

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 MI00141964. Based on observations, interviews and record review the facility failed to implement standards of care and care planning for pressure relief and implement interventions to keep a pressure ulcer free from contamination for one resident (Resident #115) of 3 residents reviewed for pressure ulcers, resulting in Resident #115 having chronic wound contamination (urine and feces) and a lack of consistent pressure relief for 3 unstageable pressures and pressure ulcers worsening. Findings include: Resident #115 (R115): Review of R115's face sheet dated 6/27/24 revealed that he was a [AGE] year-old male, admitted to the facility on [DATE] and had diagnoses that included: chronic respiratory failure with hypoxia, cerebral infarction (brain injury), aphasia (language communication disorder), dependence on respirator, pressure ulcer of sacral region, unstageable. He was not his own responsible party. Review of R115's Activities of Daily Living (ADL) care plan dated 11/08/23…

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 MI00143607. A complaint was filed with the State Agency that alleged the facility was not providing adequate tracheostomy (surgical opening into the windpipe to allow air to flow in and out) care. Based on observation, interview, and record review, the facility failed to assure that staff maintained infection control prevention ((sterile technique), while performing tracheostomy suctioning for one resident (Resident #122) of one resident reviewed for tracheostomy care, leading to the likelihood for increased risk of respiratory infection. Findings include: Resident #122 (R122): On 7/2/24, A clinical record review revealed R122 was admitted to the facility on [DATE] with diagnoses that included: hypertension, heart failure, kidney disease, left cerebellar stroke, dysphagia (difficulty swallowing food or liquid) required a PEG tube (percutaneous endoscopic gastrostomy, surgical procedure inserting a tube into the stomach to provide nutrition), chronic respiratory failure…

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 MI00142145 Based on observation, interview and record the facility failed to ensure that nurses were competent to administer medications for 1 resident (Resident #1) of 5 residents reviewed for medication administration resulting in medication errors, adverse effects from medications, and transfer to the hospital. Findings Include: Resident #1: A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #1 indicated the resident was admitted to the facility on [DATE] with diagnoses: history of a stroke, arthritis, hypertension atrial fibrillation, weakness, anemia, anxiety, and depression. The MDS assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating full cognitive abilities. On 1/24/2024 at 11:00 AM, Resident #1 was interviewed. He said he recently went to the hospital because, They gave me the wrong pills. It made me dizzy. On 1/24/2024 at 11:10 AM, Nurse Practitioner (NP) F 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 1) maintain equipment and properly use single-service items, 2) provide date labels, 3) ensure equipment was clean and dried properly, and 4) properly use gloves, resulting in the potential contmination of food product, increasing the risk of foodborne illness, affecting all residents that consume food from the kitchen. Findings include: On 11/8/23 at 10:12 AM, the atmospheric vacuum breaker (AVB) (a device commonly used in plumbing to prevent backflow of contaminants into the domestic water supply), provided for the dish machine, was observed to be leaking water out of the atmospheric port, indicating the AVB seal is not sealing properly. On 11/8/23 at 10:22 AM, a working spray container, located in the garbage room, was observed to not be provided with a label to identify the contents for safe use. According to the 2017 FDA Food Code Section 7-102.11 Common Name. Working containers used for storing POISONOUS OR TOXIC MATERIALS such as cleaners and SANITIZERS taken from bulk supplies shall be clearly 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 Resident #77: A review of Resident #77's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included stroke, dysphagia, diabetes, seizures, anxiety, muscle weakness, and dementia. A review of the Minimum Data Set assessment, dated 10//11/23, revealed the moderately impaired cognition and needed setup assistance with eating, moderate assistance with shower/bathing, and lower body dressing. On 11/7/23 at 1:42 PM, an observation was made of Resident #77 sitting in her wheelchair, dressed. Prior to entering the room, a sign on the door indicated that a Resident was on transmission-based precaution (TBP) for contact precautions. There were two residents that resided in the room, the sign did not indicate which resident was in TBP. The sign indicated that prior to entering the room, gown and gloves were to be put on. On 11/8/23 at 11:40 AM, an observation was made of Resident #77 being assisted by the CNA to get into the bathroom. The CNA does not don gloves…

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 dignity by failing to answer residents' call lights in a timely manner and ensure an adequate supply of linen for two residents (Resident #31, Resident #47) of 10 residents from the confidential Resident Group meeting, and residents observed during initial tour of the facility, of 23 residents reviewed for dignity and respect, resulting in frustration, anger and the potential of unmet care needs. Findings include: Resident #31: A review of Resident #31's medical record revealed an admission into the facility on 1/26/23 with diagnoses that included Lupus, gastrostomy, arthritis, heart failure, pressure ulcer of sacral region, Bell's Palsy, chronic pain, dementia, depression, and anxiety. A review of the Minimum Data Set, dated [DATE], assessment revealed severely impaired cognition and needed extensive assistance with activities of daily living. On 11/7/23 at 11:55 AM, an observation was made of Resident #31 lying in bed. 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 review and revise care plans with resident changes to ensure that interventions necessary for care and services were provided for 5 residents (Resident #16, Resident # 31, Resident #41, Resident #43, and Resident #239) of 27 residents reviewed for care plans, resulting in the potential for unmet care needs. Findings Include: Resident #16: Care Planning On 11/07/23 at 2:56 PM, Resident #16 was observed lying in bed in her room, visiting with her son. She said she was at the facility for antibiotic treatment for an ongoing infection related to prior back surgery. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #16 was admitted to the facility on [DATE] with diagnoses: Discitis, osteomyelitis (bone infection), psoas muscle abscess, acute cystitis with hematuria, diabetes, chronic kidney disease, sacral pressure ulcer, back pain, neuropathy, arthritis, hypertension, anxiety and depression. The MDS…

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.) Ensure sanitary storage of respiratory equipment for 4 residents (#23, #41, #43, and #47)), 2.) Ensure humidification for Resident #43's CPAP machine and 3.) Ensure appropriate assessment, monitoring and management of a tracheostomy tube for one resident (#41) of 4 residents reviewed for respiratory care, resulting in the potential for exposure to infectious organisms for residents (#23, #41, #43 and #47), the potential for a dry airway during CPAP treatment for Resident #43, and the potential for the lack of ability to safely maintain the airway for Resident #41. Findings Include: Resident #41: Respiratory Care A record review of the MDS assessment and Face sheet for Resident #41 indicated admission to the facility on 6/13/2023 and readmission on [DATE] with diagnoses: Dementia, history of a stroke, tracheostomy, hypertension, hypothyroidism, diabetes, anxiety, dysphagia, gastrostomy tube, and sacral pressure ulcer stage 4. The MDS…

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 medication was not left in a resident's room or on the floor, properly label open containers of medication and treatments, dispose of expired medical supplies, maintain a clean medication cart from loose tablets for three of four medication carts, one treatment cart and one medication room reviewed for storage and labeling of medication and supplies, resulting in the lack of a clean space to store and prepare medications, and the potential for drug diversion, residents to receive medication with altered potency and efficacy and medical procedures completed with outdated supplies. Findings include: On [DATE] at 8:32 AM, an observation was conducted with Nurse J of the 500 Hall medication cart. An observation was made of Wixela inhalation medication, opened, and not dated, Fluticasone inhaler opened and not dated with an open date. When asked about the medication not dated with an open date, Nurse J indicated the medication should 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 Based on interview and record review, the facility failed to ensure that Code Status was assessed, documented and accessible in the medical record prior to obtaining a physician's order for Code Status for 2 residents (Resident #288 and Resident #289) of 3 residents reviewed for Advance Directives, resulting in the potential for the resident's lack of informed knowledge related to options for code status and miscommunication of code status which could lead to a lack of appropriate interventions for care. Findings Include: Resident #288: Advance Directives A record review of the Face sheet indicated that Resident #288 was admitted to the facility on [DATE] with diagnoses: Fracture left femur, arthritis, hypertension, atrial fibrillation, cardiac pacemaker, GERD, and anxiety. A record review of the electronic medical record Face sheet on 11/08/23 at 9:38 AM, indicated the resident was a Full code. Further review of the assessments, progress notes and scanned documents indicated there was no assessment or note 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a person-centered baseline care plan to guide the care provided to one resident (Resident #288) of 27 residents reviewed for care plans, resulting in the failure to provide instructions to the staff for effective and person -centered care to promote well-being and provide pain management for Resident #288. Findings Include: Resident #288: Pain Management A record review of the Face sheet indicated that Resident #288 was admitted to the facility on [DATE] with diagnoses: Fracture left femur, arthritis, hypertension, atrial fibrillation, cardiac pacemaker, GERD, and anxiety. On 11/07/23 at 11:26 AM, Resident #288 was moaning and stated, Pain is my main problem. She said she cries from the pain and was very frustrated. Resident #288 said she was new to the facility and it was her 3rd day there. She said she had broken her left femur and had Norco 1 tablet about every 4 hours for pain, but she had to ask for it 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 provide assistance with grooming/removal of facial hair for one resident (Resident #43) and ensure preference of showering with assistance of bathing activity for two residents (Resident #31 and Resident #339) of three residents reviewed for Activities of Daily Living (ADL) care, resulting in unmet care needs, mustache hair with food debris while eating, and the potential for body odor, embarrassment and diminished feeling of self-worth and dignity. Findings include: Resident #31: A review of Resident #31's medical record revealed an admission into the facility on 1/26/23 with diagnoses that included Lupus, gastrostomy, arthritis, heart failure, pressure ulcer of sacral region, Bell's Palsy, chronic pain, dementia, depression, and anxiety. A review of the Minimum Data Set (MDS) dated [DATE], assessment revealed severely impaired cognition and needed extensive assistance with activities of daily living. On 11/7/23 at 11:59 AM, an interview…

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 cross contamination of pests (flies) on an open foot wound and food for one resident (Resident #74), resulting in cross contamination of food items and wounds, frustration and with the likelihood of infection or maggot infestation. Findings include: Resident #74: On 11/07/23, at 10:24 AM, Resident #74 was resting in their bed. Their feet appeared to have a gross amount of dried skin and dried medicine with no bandages. Their left great toe base had an area approximately 1 centimeter (cm) by 1 cm that was yellow and draining. There was a black fly flying around and had landed on their left foot wound. Resident #74 was asked if the fly was bothersome and Resident #74 stated, yes it lands on my face and then I have to roll over to get it to fly away. On 11/07/23, at 11:44 AM, an observation along with CNA S of Resident #74's open feet wounds and the fly landing on them was conducted. CNA S was asked if they often see flies in the room or on their feet wounds and CNA S stated, normally his feet are wrapped…

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 and monitor, ensure that the head of bed was elevated and provide Percutaneous Gastrostomy (PEG) tube feeding timely for one resident (Resident #438), resulting in the head of bed below 30 degrees, undated dressing to the PEG site, with the likelihood of complications such as aspiration and a clogged PEG tube. Findings include: Resident #438: On 11/07/23, at 2:52 PM, Resident #438 was resting in bed. Their tube feeding solution was hooked up and running. The angle of the bed appears to be lower than 30 degrees incline. Unit Manager (UM) B entered the room. The measuring tool hooked to the bed read 20 degrees and UM B raised the head of the bed to reach a 30 degree incline. On 11/08/23, at 9:16 AM, a record review of Resident #438's electronic medical record revealed an admission on [DATE] with diagnoses that included attention to Gastrostomy, Dysphagia and Epilepsy. A review of the physician orders revealed ENTERAL FEED . Start Date…

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 five medications timely for one resident (Resident #438), resulting in five missed evening medications with the likelihood of an increase or relapse in symptoms. Findings include: Resident #438: On 11/08/23, at 9:16 AM, a record review of Resident #438's electronic medical record revealed an admission on [DATE] with diagnoses that included attention to Gastrostomy, Dysphagia and Epilepsy. A review of the Discharge Instructions, Orders and Medications sent from the hospital revealed the following medications should have been given on 11/6/2023: risperidone (risperidone 1 mg (milligrams) . Next Dose: tonight atorvastatin (atorvastatin 40 mg . Next Dose: tonight lithium (lithium 150 mg . Next Dose: tonight/PM propranolol (propranolol 10 mg . Next Dose: today PM benztropine (benztropine 0.5 mg . Next Dose: today PM A review of the Medication Administration Record (MAR) for 11/12023 - 11/30/2023 revealed Resident #438 did not receive the medications…

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 a medication error rate of less than 5%, when 3 medication errors were observed from a total of 26 opportunities, for one resident (Resident #44) of 5 residents observed for medication administration, resulting in an error rate of 11.54%. Findings Include: FACILITY Medication Administration Resident #44: On 11/7/2023 at 9:25 AM during the Entrance Conference with the Director of Nursing/DON, she said the Medication Administration times for residents was divided into morning/AM (6:00 AM to 10:00 AM) and evening/HS 6:00 PM to 10:00 PM or at specific times if the medication was ordered with specific administration instructions. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #44 was admitted to the facility on [DATE] with diagnoses: Diabetes mellitus, kidney disease, renal dialysis, bipolar depression, history of falls, neuropathy. The resident had full cognitive abilities with a Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prevent significant medication errors for 1 resident (Resident #44) of 6 residents reviewed for medication errors, resulting in medications being administered to the resident's hours after they were due for Resident #44 leading to the potential for mistreatment of the resident's medical conditions, serious side effects, adverse effects and a decline in condition. Findings Include: FACILITY Medication Administration Resident #44: On 11/7/2023 at 9:25 AM during the Entrance Conference with the Director of Nursing/DON, she said the Medication Administration times for residents was divided into morning/AM (6:00 AM to 10:00 AM) and evening/HS 6:00 PM to 10:00 PM or at specific times if the medication had specific administration instructions. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #44 was admitted to the facility on [DATE] with diagnoses: Diabetes mellitus, kidney disease, renal dialysis,…

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.