Medilodge of Munising

Based on interview and record review, the facility failed to provide residents/responsible parties with written notifications of bed hold and transfer notifications and/or provide notification to the office of the state Ombudsman for facility initiated transfers, for three Residents (R9, R70, R1) of five residents reviewed for hospitalizations. Findings include: Resident #9R9 was transferred to the emergency department (ED) on 10/3/25, 10/18/25, and 12/17/25.The facility did not provide written notification of transfer to the resident/responsible party for the transfer on 10/18/28. There were no written notifications of bed hold issued when R9 was transferred to the ED on 10/18/25.The written notification of transfer dated 12/17/25 did not provide a reason for the transfer. The written notification of bed hold for the transfer on 12/17/25 did not have any boxes checked to indicate the choice of acceptance or declination of bed hold.The list of notifications to the Office of the State Long-Term Care (LTC) Ombudsman for the month of October 2025 did not include Ombudsman notification…

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 completion of a Level II PASARR (Pre-admission Screening/Annual Resident Review) for one Resident (#13) of one resident reviewed, resulting in the potential for lack of appropriate services for mental disorder [MD] or intellectual disability[ID]).Findings include:Resident #13 (R13)Review of the Minimum Data Set (MDS) assessment, dated 12/26/2025, revealed R13 was admitted to the facility on [DATE] and had active diagnoses including bipolar disorder, schizoaffective disorder, and dementia.Review of the electronic medical record (EMR) revealed a Level I PASARR (screening used to ascertain if a Level II PASARR evaluation and determination should be completed) was completed on 6/27/2025. Review of the Level I PASARR revealed the screening criteria listed yes to four of the six screening questions listed, including: a current diagnosis of mental illness and dementia; receiving treatment for mental illness and dementia; received one or more prescribed…

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, interviews, and record review, the facility failed to revise/updated resident person centered care plans for 1 Resident (#5) of 13 residents reviewed for care planning resulting in unnecessary administration of psychiatric medications for R5, the potential for administration of unnecessary medications without proper indication, and the potential for inadequate goods and services for residents to maintain their highest practicable physical, mental and psychosocial well-being.Findings include:Findings include:Resident #5 (R5)Review of an admission Record revealed R5, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Malignant neoplasm of the (large intestine) colon cancer. Review of a Minimum Data Set (MDS) assessment for R5 with a reference date of 10/22/25 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated R5 was cognitively intact.In an observation and interview on 1/5/2026 at 2:24 PM., R5 was observed in her room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide meaningful activities for one Resident (#74) of two residents reviewed for activities.Findings include:Resident #74 (R74)Review of Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE] with active diagnoses that included: Alzheimer's disease and non-Alzheimer's dementia. R74 scored a 3 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of severe cognitive impairment.During an observation on 1/5/26 at 1:35 p.m., R74 was sitting on the edge of her bed in the dark with no music or TV on in her room.Observations on 1/6/26 revealed the following:9:07 a.m., R74 was sitting on the side of the bed staring at the blank wall with no lights on in her room, no music playing, the tv was not turned on, and she did not have any activity or sensory items to interact with.9:48 a.m., R 74 continued to sit in the dark with no stimulation or interaction from staff.11:18 a.m., R74 sitting…

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 accurately document wounds, determine wound etiology, and adhere to physician's orders for bilateral lower extremity compression devices for one Resident (R51) of 18 residents reviewed for quality of care. Findings include:On 1/5/27 at 11:46 AM, Resident #51 (R51) was observed sitting in a wheelchair next to her bed with her feet directly on the floor. The lower calves and feet of R51 had a purple hue with evident edema (swelling caused by fluid trapped in the body tissue). R51 said, I can get bad swelling in my legs. I'm supposed to wear special stockings, but they haven't put them on in a while. R51 was unable to recall the last time staff had applied the special stockings. Review of the electronic medical record (EMR) for R51 revealed an admission date to the facility on 1/25/23 with a primary diagnosis of Diabetes. A Minimum Data Set (MDS) assessment dated [DATE] documented R51 did not refuse care or display behavioral symptoms. 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 discontinue an inhaled medication per pharmacy recommendations and physician order for one Resident (#85) failed to ensure non-pharmacological interventions were attempted prior to the administration of as needed pain medications for three Residents (#5, #85, #55) and failed to implement not pharmacological interventions prior to the start of an antipsychotic medication and utilize physician ordered as needed (PRN) anti-anxiety medications for one Resident (#5) of five Residents reviewed for unnecessary medications.Findings include:Resident #5 (R5) Review of an admission Record revealed R5, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Dementia. Review of a Minimum Data Set (MDS) assessment for R5 with a reference date of -10/22/25 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated R5 was cognitively intact. In an observation and interview on 1/5/2026 at 2:24 PM.,…

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

Based on observation, interview and record review, the facility failed to ensure a medication error rate at or below five percent (5%), with three errors out of 31 opportunities resulting in a medication error rate of 9.68%, affecting one Resident (#85) of four residents reviewed.Findings include:On 1/6/2025 at 7:42 a.m., Licensed Practical Nurse (LPN) M was observed preparing to administer R85's medications. LPN M began administration by handing R85 a Trelegy Ellipta 200 mcg (microgram) - 62.5 mcg - 25 mcg inhaler. R85 was observed attempting to slide the cover of the inhaler open but her hand slipped and she closed the inhaler at which time LPN M took the inhaler, slid open the lid to load a dose of the medication before handing it back to the Resident. R85 then held the mouthpiece against her lips, inhaled the medication and exhaled immediately following the inhalation of the medication.Immediately following administration of the Trelegy, LPN M handed R85 a medication cup with oral medications. R85 put the medications in her mouth followed by water and swallowed 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 This deficiency pertains to MI00153258 Based on observation, interview, and record review the facility failed to use the appropriately sized sling with the mechanical lift, and provide adequate supervision during a transfer to prevent injury for one Resident (#1) of two residents reviewed for accident/hazards. This deficient practice resulted harm when R1 incurred deep purple bruises on arms and leg, an injured toe, discomfort during transfers and risk of additional injury during transfer. Findings include: Resident #1 (R1) Review of the Minimum Data Set (MDS) assessment for R1, dated 6/22/25, revealed admission to the facility on [DATE], with diagnoses that included the following, in part: Debility, cardiorespiratory conditions, heart failure, peripheral vascular disease (PVD), anxiety, post traumatic stress disorder (PTSD), chronic obstructive pulmonary disease (COPD), and morbid obesity. R1 scored 13 of 15 on the Brief Interview for Mental Status (BIMS) assessment, reflective of intact cognition, and was her…

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 receipt and transcription of physician orders for immediate care upon admission of two Residents (R3 & R11) out of 9 residents reviewed for physician orders. This deficient practice resulted in lack of physician orders for necessary medications and treatments, and the potential for worsening of condition. Findings include: This deficiency pertains to Complaint Intake #MI00151891. Resident R3 Review of R3's Minimum Data Set (MDS) assessment, dated 3/2/25, revealed R3 was admitted to the facility on [DATE] with active diagnoses that included the following, in part: Alzheimer's disease, and visual loss. R3 had severely impaired cognition. During a telephone interview on 4/8/25 at 9:52 a.m., Complainant A reported the facility failed to provide necessary eye drop medications to R3 for approximately two weeks following their admission to the facility on [DATE]. Review of a pre-admission physician progress note for R3, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure denture care and timely incontinence care were provided for one Resident (R3) of seven residents reviewed for assistance with Activities of Daily Living (ADLs). This deficient practice resulted in R3's inability to use their dentures, per the care plan, and an extended time in a urine saturated brief. Findings include: This deficiency pertains to Complaint Intake #MI00151891, which alleged inappropriate hygiene/grooming and dental care. Review of R3's Minimum Data Set (MDS) assessment, dated 3/2/25, revealed R3 was admitted to the facility on [DATE] with active diagnoses that included the following, in part: Alzheimer's disease, non-Alzheimer's dementia, depression, visual loss, bilateral hearing loss and need for assistance with personal care. R3 had severely impaired cognition and was dependent upon staff for assistance with eating, wheelchair mobility, and incontinence care. During a telephone interview on 4/8/25 at 9:52 a.m.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide meaningful activities to promote psychosocial well-being for 1 resident (R3) of 4 residents reviewed for activities. This deficient practice resulted in social isolation for R3 who had both visual and bilateral hearing loss. Findings include: This deficiency pertains to Complaint Intake #MI00151891. Review of R3's Minimum Data Set (MDS) assessment, dated 3/2/25, revealed R3 was admitted to the facility on [DATE] with active diagnoses that included the following, in part: Alzheimer's disease, non-Alzheimer's dementia, depression, visual loss, and bilateral hearing loss. R3 had severely impaired cognition and was dependent upon staff for assistance with eating, wheelchair mobility, and incontinence care. During a telephone interview on 4/8/25 at 9:52 a.m., Complainant A expressed concern that R3 was left without human interaction for long periods of time and with the Resident's blindness and hearing loss she was left to sit without…

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 follow physician orders for wound care for two Residents #6 and #7 of eight residents reviewed for physician orders. This deficient practice resulted in the potential for infection, possible harm to intact skin, and a delay in healing. Findings include: Resident #6 (R6) Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 7/15/22, with active diagnoses that included peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the arms or legs) or peripheral arterial disease (a circulatory condition in which narrowed arteries reduce blood flow to the arms or legs) and heart failure. Further review of the MDS Section M revealed R6 had a venous/arterial ulcer (leg ulcer caused by impaired blood circulation). A review of Electronic Medical Record (EMR) on 4/8/25 revealed that a recommendation from a wound clinic on 9/24/24 read in part . apply primary dressing 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.

Based on observation, interview, and record review the facility failed to provide nail care including toenail trimming for four Residents ( #3, #8, #9 and one Confidential Resident [CR]) of four residents reviewed for nail care. This deficient practice resulted in unnecessary pain, untrimmed toenails and the potential for injury. Findings include: Confidential Resident Review of CR diagnoses included: Peripheral vascular disease, or peripheral arterial disease. R6 scored a 15 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of intact cognition. During an interview on 4/8/25 at 9:55 a.m., CR reported the staff had trimmed her toenails about two weeks ago, but it had been almost a year since the last time her toenails had been trimmed. The nails were curved around the end of my toes, and I couldn't wear shoes anymore .when they finally cut them, it hurt my toes .when my socks even touched the end of my toes, I thought I would go right thru the ceiling . it hurt me. Resident #8 (R8) Review of R8's diagnoses included: diabetes mellitus, hypertension, and heart…

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. Securely store an insulin pen following use for 1 Resident ( #1), and 2. Secure 1 of 2 treatment carts reviewed for medication storage This deficient practice resulted in the potential misuse of resident medications and/or treatment supplies. Findings include: Resident #1 (R1) Review of an admission Record revealed R1, was originally admitted to the facility on [DATE] with pertinent diagnoses including: type 2 diabetes. Review of the Minimum Data Set (MDS) assessment for R1 with a reference date of 12/19/24 revealed a Brief Interview for Mental Status (BIMS) score of 00/15 which indicated R1 was severely cognitively impaired. On 1/29/25 at 12:50 PM., a pre-filled Lantus SoloStar Subcutaneous injectable pen with a marker date of 1/7/25, was observed laying on the bedside table of R1. The injectable pen had R1's name on it and approximately 150 units of insulin was observed remaining. Review of R1's Physicians Order dated 9/26/24…

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 #MI00149352. Based on observation, interview, and record review the facility failed to maintain equipment in good working order and failed to clean and sanitize resident equipment, resulting in an increased potential for spread of infections for residents utilizing equipment. Findings include: On 1/29/25 at 11:00 AM., 4 resident wheelchairs were observed in the bay side day room . All 4 wheelchairs were noted to be heavily soiled on the seat, arms, legs and overall components of the wheelchair. 1 motorized wheelchair was observed heavily soiled with food crumbs, dried spillage, and the seat cushion was noted to have holes in it. On 1/29/25 at 11:10 AM., a hoyer lift was observed outside of room [ROOM NUMBER]. The bag holding the sanitizing wipes was observed heavily soiled with dried crusted substances. The legs of the mechanical lift, and lift in general was observed with a heavy accumulation of dust and debris on it. In an interview on 1/29/25 at 1:45 PM., CNA H reported CNA…

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 #MI00149352. Based on interview and record review the facility failed to implement and follow their policy to ensure a safe and orderly discharge was provided for 1 Resident (#2) of 2 residents reviewed for discharge/transfers. This deficient practice resulted in an involuntary discharged into the community without sufficient preparation and orientation with the potential to disrupt the necessary care and services and the potential for homelessness. Findings include: Resident #2 (R2) Review of an admission Record revealed R2 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: type 2 diabetes. Review of a Minimum Data Set (MDS) assessment for R2 with a reference date of 12/17/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated R2 was cognitively intact. Review of a State Agency-Complaint Intake dated 1/7/2025 from Confidential Informant (CI) U revealed: CI U stated R2 left the faciity on [DATE] to travel 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 #MI00149718 Based on observation, interview and record review, the facility failed to remove expired foods from the mini-fridge for one Resident (#1) of one resident reviewed for storage of foods brought to residents by family and other visitors. This deficient practice resulted in the potential for expired food to be consumed and increasing the risk of food borne illness. Findings include: Resident #1 (R1) Review of an admission Record revealed R1, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: type 2 diabetes. Review of a Minimum Data Set (MDS) assessment for R1 with a reference date of 12/19/24 revealed a Brief Interview for Mental Status (BIMS) score of 00/15 which indicated R1 was severely cognitively impaired. On 1/29/25 at 12:50 PM., a personal mini refrigerator in R1's room was observed containing numerous food items which were expired including: (Brand Name) yogurt 4 pack expired 9/4/24, a block of [NAME] jack cheese expired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This deficiency pertains to Complaint Intake MI00146981. Based on observation, interview, and record review, the facility failed to provide sufficient staffing to address the care, needs, and safety of the entire facility population. This deficient practice resulted in unmet care needs and the potential for serious safety issues for all 65 residents of the facility. Findings include: Review of Complaint Intake MI00146981 submitted to the State Agency (SA) read, in part: Complainant is a staff member at [Facility Name]. Complainant states residents are being neglected by being left laying in wet and soiled beds, resident[s] are also not getting showers due to the facility not having enough staffing to keep up and handle the workload . Resident #42 (R42): Review of R42's electronic medical record (EMR) revealed initial admission to the facility on 7/15/22 with diagnoses including congestive heart failure and need for assistance with personal care. Review of R42's most recent Minimum Data Set (MDS) assessment,…

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

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 65 residents of the facility. Findings include: On 10/21/24 at approximately 12:20 PM during noon meal service, small bowl servings of potato salad were observed on a tray, at room temperature adjacent to the steam table serving line. The temperature of the potato salad was measured with a metal stem probe thermometer and found to be ranging from 46°F to 49°F. Eight small bowls of cottage cheese were observed being held next to the steam table waiting to be placed on residents' trays. The temperature of the cottage cheese was measured to be 47°F. Dietary [NAME] (DC) C was asked to take the temperature of the potato salad and cottage cheese with a facility thermometer. The potato salad was reported to be in the same range of 46-49°F and cottage cheese reported to be 45°F by [NAME] C. An interview with Kitchen…

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, record review, and interview the facility failed to implement enhanced barrier precautions (EBP) for 1 of 3 residents reviewed for EBP. This deficient practice has the potential for development and transmission of Multidrug Resistant Organism (MDRO) infections. Findings Include: On 10/22/24, at 9:49 AM it was noted that there was no EBP outside of room [ROOM NUMBER] for bed A. Bed A was assigned to Resident 274 (R274). A review of records indicated R274 was admitted to the facility on [DATE], with diagnosis of cellulitis (skin infection) of right lower limb, lymphedema (swelling in the body due to build up of lymph fluid), chronic diastolic heart failure (heart is not able to pump enough blood to meet body's needs), paroxysmal atrial fibrillation (upper chambers of heart beat irregularly), morbid obesity (body mass index of 40 or higher), obstructive sleep apnea (throat muscles relax and narrow the airway during sleep, interrupting breathing) , essential hypertension (high blood pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a dignified existence regarding privacy during care by failure to knock on doors or request permission before entering resident's rooms as expressed by 8 Residents (R6, R19, R25, R42, R45, R55, R61, and R67) of 9 residents reviewed for dignity and respect. This deficient practice resulted in frustration, embarrassment, and lack of privacy. Findings include: On 10/21/24 at 3:35 PM, the Activity Director S agreed to set up a group meeting with oriented residents who would be interested in sharing their views of the facility. On 10/22/24 at 10:30 AM, a group meeting was held with the President of Resident Council and seven other interested residents. A record review revealed all residents present had a recent Brief Interview for Mental Statis (BIMS) score in the range of 13-15 indicating they were cognitively intact. During the meeting, an issue concerning dignity was voiced by seven of the eight residents present. R42 stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the Resident and Resident Representative in writing with the reason for a transfer out of the facility for four Residents (R124, R22, R29, R64) of four residents reviewed for transfers out of the facility. This deficient practice resulted in the potential for the Resident's Representatives to be uninformed regarding the Resident's conditions and location, as well as a potential for inappropriate discharge/transfers. Findings include: Resident 124 (R124) On 10/6/24, R124 was sent out to the hospital due to unresponsiveness and was returned/readmitted to the facility on [DATE]. On 10/20/2024, R124 was sent out to the hospital after discussion with the on-call physician. R124 was readmitted on the same day. A review of the Electronic Medical Record (EMR) for R124 revealed no written transfer notice. During an interview on 10/23/24 at 12:01 PM, the Nursing Home Administrator (NHA) and Regional Clinical Nurse (RN) N stated there currently was an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written notification of the bed-hold policy to residents or their representatives prior to hospital transfer for five residents (Resident #18, Resident #124, Resident #64, Resident #22, and Resident #29) including details of duration of the bed-hold and conditions of readmission. Findings include: During a review of Resident #18's (R18) medical record, it was noted there was not a bed-hold document listed in R18's clinical documentation for his transfers to the emergency department on 10/11/24, or 10/12/24. While conducting an interview on 10/23/24 at 10:17 AM, R18 stated he did not recall being educated on his bed being held when he was sent to the hospital. R18 stated he just assumed it would be there waiting for him, since he had been in the facility since December of 2023. During an interview conducted on 10/23/24 at 11:55 AM, the Director of Nursing (DON) and Regional Clinical Nurse N could not locate the notice of bed holds in R18's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, the facility failed to destroy discontinued schedule two medications in a timely manner for three medications carts reviewed of four medication carts for medication storage and used another resident's medication on a different resident. On [DATE] at 1:16 PM, an observation was made of Resident #22 (R22) in their room. R22 was asked if it was alright to look around for their wound care supplies and replied, Yeah, sure go right ahead. In R22's closet an observation was made of another residents acetic acid 1000 milliliters solution. R22 was asked if the facility staff was using the solution on them and replied, Yes, they use that on my lower legs when they wrap them. Review of R22's physician order, dated [DATE], read in part, Acetic Acid Irrigation Solution 0.25% .Apply to BLE (bilateral lower extremities) topically in the afternoon every Tue (Tuesday), Fri (Friday) for edematous state . On [DATE] at 1:30 PM, an interview was conducted with Licensed Practical Nurse…

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 dementia training was completed by four of four Certified Nursing Assistants (CNAs) reviewed for annual training requirements. This deficient practice resulted in the potential for unmet care needs and the potential to affect all residents with dementia in a current facility cenus of 65 residents. Findings include: Review of CNA in-service training logs were conducted for CNAs F, V, U, and E. The training transcripts of CNAs F, V, and U read: Dementia Care: Normal Aging vs. Alzheimer's/Dementia listed as incomplete with a due date of 9/30/24. CNA E's training transcript did not list any dementia training. On 10/24/24 at 10:53 AM, an interview was conducted with the Assistant Director of Nursing (ADON) I who stated there was no specific dementia training for nurse aides as it was included in a training course called, Challenging Behaviors. When asked about the course listed on the transcript titled, Dementia Care: Normal Aging vs. Alzheimer's/Dementia, ADON I stated he was unaware of the course and verified it was…

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

Based on interview and record review, the facility failed to protect residents from verbal abuse for one resident (R61) of four residents reviewed for abuse. This deficient practice resulted in mental distress and anguish after a staff member suggested the resident end his life. Findings include: The medical record for R61 revealed an admission date of 9/13/24 with diagnoses which included spinal stenosis (bone deterioration resulting in pressure/pain to the spine), repeated falls, pressure ulcer of the sacral region and heel , diabetes (T2DM), heart failure (CHF), and kidney disease (CKD), The Minimum Data Set (MDS) assessment included a Brief Interview for Mental Status (BIMS) score of 15 of 15 indicating cognitively intact. On 10/22/24 at 7:59 AM, R61 was asked about his interactions with the staff and the care he had been receiving. R61 stated one nurse said, When I get your age and have your problems I am going out in the woods and end it. He said he understood he had many problems, but he was upset stating that for her to say that was inappropriate. He was able to describe 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 interview and record review the facility failed to report alleged abuse timely for two Residents (R61 and R124) out of four residents reviewed for abuse reporting to the State Agency (SA). This deficient practice resulted in the potential for ongoing abuse. Findings include: The medical record for R61 revealed an admission date of 9/13/24 with diagnoses which included spinal stenosis (bone deterioration resulting in pressure/pain to the spine), diabetes, heart failure, and kidney disease. The Minimum Data Set (MDS) assessment included a Brief Interview for Mental Status (BIMS) score of 15 of 15 indicating R61 was cognitively intact. On 10/22/24 at 7:59 AM, R61 was asked about his interactions with the staff and the care he had been receiving. R61 stated one nurse said, When I get your age and have your problems I am going out in the woods and end it. He said he understood he had many problems, but he was upset stating that for her to say that was inappropriate. He was able to describe the nurse and the circumstances and stated he had told several staff members of this…

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 two residents (Resident #18, Resident #274) of two residents reviewed for the clinical need for urinary catheterization (a tube placed into the bladder to facilitate bladder drainage), leading to inappropriate or potentially unnecessary catheter usage. Findings include: Resident #18 (R18) A review of R18's Electronic Medical Record (EMR) indicated diagnoses of complex regional pain syndrome (chronic condition that causes severe pain dis-proportionate to the injury), morbid obesity (body mass index of 40 or higher), essential hypertension (high blood pressure not caused by medical conditions), fibromyalgia (chronic condition that causes widespread pain, fatigue, and sleep issues), osteoarthritis (degenerative joint disease), irritable bowel syndrome (chronic digestive disorder of the large intestine), sarcopenia (muscle mass, strength, and performance compromised by age), muscle weakness, rheumatoid arthritis(autoimmune disease of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure ongoing assessment and monitoring for weight fluctuations for two Residents (R61 and R124) of four residents reviewed for nutritional needs. This deficient practice resulted in the potential for inaccurate assessments, continued weight loss or gain, and physical decline. Findings include: Resident 61 (R61) During an interview on 10/22/24 at 7:51 AM, R61 stated he was eating well but not always getting what I want. When asked about his weight R61 stated, They are not weighing me as much as the hospital did, and was unsure of his current weight. The medical record for R61 revealed an admission date of 9/13/24 with diagnoses which included pressure ulcer of the sacral region, diabetes (T2DM), heart failure (CHF), kidney disease (CKD), high blood pressure (HTN) and gastro-esophageal reflux disease (GERD). On 9/17/24 a Minimum Data Set (MDS) assessment was completed. Section K of this document revealed a weight for R61 as 175 pounds. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This deficient practice has two different DPS's. DPS A and DPS B. DPS A: Based on interview and record review the facility failed to obtain informed consent and obtain physician orders for psychotropic medication for Residents (R19 and R49) of four residents reviewed for unnecessary psychotropic medications. Resident #19 (R19) Review of the Minimum Data Set (MDS) assessment, dated 5/24/24, revealed R19 was admitted to the facility on [DATE] with a primary diagnosis of contact with and suspected exposure to Covid-19. On 10/23/24 at 4:36 PM, review of R19's electronic medical records (EMR) revealed R19 had a physician order for lorazepam 0.5 mg (milligram), give 0.5 mg by mouth every 8 hours as needed for anxiety related to generalized anxiety disorder for 2 weeks, start date 5/9/24 and stop date 5/23/24. Review of R19's EMR, physician order dated 7/18/24, revealed the following, lorazepam 0.5 mg, give 1 tablet by mouth every 24 hours as needed for anxiety and with an end date of 9/12/24. R19's order recap had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00147081 Based on interview and record review, the facility failed to ensure an accurate indication to administer a laxative prior to administering for one Resident (R901) of one resident reviewed for unnecessary medications. Findings include: The Complaint Intake Unit received an allegation of Resident #901 (R901) receiving a laxative on 9/23/24 despite having daily bowel movements. As a result, R901 experienced diarrhea and bowel incontinence when she could not get to the bathroom timely. R901 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R901 was always continent of bowel and bladder. The MDS coded R901 as requiring assistance from staff for transferring to the toilet and toileting hygiene. A bowel elimination tracking document in R901's medical record revealed R901 had a medium-sized bowel movement on 9/20/24 and an extra-large bowel movement on 9/21/24. No bowel incontinence or diarrhea was documented 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 deficiency pertains to Intake: MI00146075 Based on interview and record review, the facility failed to provide showers for one Resident (R5) of three residents reviewed for showers. Findings include: Resident #5 (R5) was admitted to the facility 7/8/24. R5's diagnoses included but were not limited to hemiplegia (paralysis on one side of the body) due to a stroke, urinary tract infection, dementia, cognitive communication deficit, and weakness. R5 was discharged from the facility on 7/25/24. The care plan was revised on 8/9/24, 15 days after R5 discharged from the facility, but did not include interventions for showering or bathing. An admission Minimum Data Set (MDS) assessment dated [DATE] documented R5 required moderate assistance from staff for showering and shower transfers. R5 was occasionally incontinent of bladder. The MDS did not code concerns with refusal or rejection of care, or behavioral difficulties. Certified Nursing Assistant (CNA) documentation revealed R5 was provided with one shower during…

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

This deficiency pertains to Intake: MI00146243 Based on observation, interview, and record review, the facility failed to transcribe treatment orders and follow-up on wound clinic recommendations for one Resident (R5) of three residents reviewed for pressure injuries. Findings include: During an interview on 8/20/24 at 12:15 p.m., Resident #6 (R5) said, I have a sore that looks like a big hole. I got it a couple months ago. R5 said the wound became infected and he was sent to the hospital. R5 confirmed the wound developed at the facility. R5 said, It was getting better when they had the vacuum on it. The Electronic Medical Record (EMR) for R5 revealed the development of a stage 4 (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone) pressure injury (PI) on the sacrum on 3/4/24. A Wound VAC (Vacuum-Assisted Closure - negative pressure wound therapy) was used beginning on 5/22/24. R5 was transferred to the hospital on 7/29/24 and was admitted to the Intensive Care Unit (ICU) due to sepsis (a life-threatening…

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 MI00145314 and MI00145704 Based on observation, interview, and record review the facility failed to ensure adequate numbers of staff to meet the needs of four Residents (#1, #3, #7, and #11) of four residents sampled for sufficient staffing. This deficient practice resulted in the potential for a decline in resident quality of life and/or quality of care, not receiving medications timely, and unmet care needs for all seventy-seven residents. Findings include: Resident #11 (R11) Review of R11's Minimum Data Set (MDS) assessment, dated 7/1/24 revealed admission to the facility on 1/29/24, with active diagnoses that included: coronary artery disease, heart failure, hypertension, anxiety disorder, and depression. R11 scored a 15 of 15 on the Brief Interview of Mental Status (BIMS) assessment reflective of intact cognition. During an interview on 7/23/24 at 1:40 p.m., R11 stated I am on water pills twice a day .I turned my light on one night I waited and waited, and no one came . I peed 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.

This citation pertains to MI00145314 and MI00145704 Based on observation, interview, and record review, the facility failed to complete and post the daily nurse staffing information. This deficient practice resulted in the inability of residents and visitors to determine the number of staff available to provide resident care and had the potential to affect all 77 residents in the facility. Findings include: During an interview on 7/22/24 at 2:50 p.m., the Nursing Home Administrator ((NHA) was asked where the daily staffing posting was located. The NHA stated I don't know. During an observation on 7/22/24 at 3:15 p.m., the Regional Director of Clinical Services K was filling out the daily nursing staffing sheet for 7/22/24 and asked the staff at the nurses station to post the staffing sheet for 7/22/24 on the wall near the nurses station located near the entrance of the facility. A review of the direct care staffing hours (nursing staffing sheets) on 7/22/24 revealed no staffing information for day shift or afternoon shift on 7/13/24, 7/11/24, 6/23/24, 6/15/24, and 6/10/24. During 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 MI00145314 Based on observation, interview, and record review the facility failed to 1. Provide Personal Protective Equipment (PPE) that was readily available for staff 2. [NAME] PPE prior to entering a transmission-based precaution room. This deficient practice resulted in the potential for contamination and the spread of illness to residents and staff. Findings include: During an observation on 7/22/24 at approximately 12:45 p.m., the following resident rooms had signage regarding Transmission Based Precautions (TBP) related to active COVID-19 infection: 109, 110, 204, 206, 209, 210, and 214. During an observation on 7/22/24 at approximately 1:00 p.m., Licensed Practical Nurse (LPN) J entered a room of a resident on Transmission Based Precautions (TBP) with a gown, gloves, and a surgical mask. LPN J came out of the resident's room with the surgical mask around her ears and the mask pulled down under the chin. During an observation on 7/22/24 at 1:04 p.m., LPN J entered the same…

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 MI00145704 and MI00145755 Based on interview and record review, the facility failed to investigate the root cause of injuries to three Residents (#5, #3, and #4) of three residents reviewed for resident safety/falls. Findings include: Resident #5 (R5) Review of R5's Minimum Data Set (MDS) assessment dated [DATE], revealed an admission to the facility on 8/16/22, with active diagnoses that included: cancer, anemia, hypertension, and renal insufficiency/renal failure/end stage renal disease. R5 scored a 2 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of severe cognitive impairment. Review of R5's Incident report dated 6/29/24 revealed that R5 was found lying on her back on the bathroom floor in front of the toilet R5 was unable to give a description of incident. R5 was sent to the emergency room (ER) for x-ray of left hip/pelvis. The result of the x-ray revealed a left trochanter (hip) fracture. During an interview on 7/23/24 at 3:30 p.m., the Director 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 MI00145723 Based on observation, interview and record review, the facility failed to provide adequate medically-related social services to one Resident #2 (R2) of one resident reviewed for social services care. This deficient practice resulted in the potential for psychosocial decline. Findings include: Resident #2 (R2) Review of R2's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 5/31/24, with active diagnoses that included: multiple sclerosis, depression, legal blindness, and neurogenic bladder. R2's MDS assessment revealed R2 is understood and understands and has clear comprehension. Review of a Facility Reported Incident revealed on 7/9/24 at 9:50 a.m., R2 was yelled at and cursed at by another resident when he was looking for his room. During an interview on 7/23/24 at 9:38 a.m., R2 revealed I was pretty upset when it happened .I was pretty worried about what could happen to me .the staff talked to me about it initially, but they haven't…

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 assess a change in condition for one Resident (R2) of three residents reviewed for a change in condition. Findings include: Resident 2 (R2) A review of R2 Minimum Data Set (MDS) assessment, dated 3/9/24, revealed admission to the facility on 3/5/24 with active diagnoses that included: hereditary and idiopathic neuropathy, anxiety disorder, major depressive disorder, chronic pain, repeated falls, muscle weakness, and compression fracture of lumbar vertebra. R2 scored a 15 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. During an interview on 5/28/24 at approximately 11:00 a.m., R2 said the event happened around the 6th of May . I came into the building from outside, I was shaking uncontrollably and leaning up against the wall, it was so scary, I have never felt that way before, and something could have happened to me I have never been refused medical care before, but the nurse would not help me. Certified Nursing Assistant (CNA) D saw me and came to help me. CNA D went 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.

Based on observation and interview, the facility failed to maintain two refrigerators used for the storage of food in two nourishment rooms, in a safe and sanitary operating condition. This deficient practice has the potential to result food spoilage or injury to staff using the damaged doors, and had the potential to impact all 64 residents. Findings include: On 10/25/23 at approximately 8:14 AM observations were made in the facility's two nourishment rooms, each located behind the respective nurses' station (100/400 and 200/300 halls). The refrigerator in the 200/300 nourishment room was observed to have a door which was completely deteriorated at the bottom edge, the metal was rusted and swinging freely in the air when opened. Additionally, the crisper drawers were missing and had been substituted with plastic resident bedside wash basins. Other cracks and broken plastic was observed on the door and shelving. The refrigerator in the nourishment room behind the 100/400 nurses' station was observed to have a door which was deteriorated at the bottom, as well as cracked and broken…

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 a dignified dining experience for six Residents (R7, R10, R20, R28, R46, & R49) of 12 residents reviewed for dining. This deficient practice resulted in staff standing over residents while feeding them, lack of adequate feeding assistance & supervision resulting in food spillage and undignified care interactions. Findings include: Review of R7's Minimum Data Set (MDS) assessment, dated 7/22/23, revealed admission to the facility on 4/1/22. R7 required maximal assistance with feeding. The Brief Interview for Mental Status (BIMS) assessment revealed R7 was unable to participate, demonstrating severe cognitive impairment. Review of R10's MDS assessment, dated 7/18/23, revealed admission to the facility on 4/13/23. R10 was independent with eating. The BIMS assessment revealed a score of 2/15, which showed severe cognitive impairment. Review of R20's MDS assessment, dated 9/30/23, revealed admission to the facility on 4/29/21. R20…

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

Based on interview, and record review, the facility failed to complete a performance review of each nurse aide at least once every 12 months. This deficient practice resulted in the potential for inadequate resident care and unmet resident care needs for all 64 residents living in the facility. Findings include: On 10/27/23 at 8:50 AM, staffing records were reviewed with Human Resources Staff V. No annual evaluations were found for Certified Nurse Aides P, R, S, or T. During an interview on 10/27/23 at 9:49 AM, the Director of Nursing (DON) and the Regional Director of Clinical Services L confirmed the facility had not been completing annual evaluations. The DON stated, it's been a while since there have been yearly evaluations. During an interview on 10/27/23 at approximately 10:00 AM, the Nursing Home Administrator (NHA) stated the facility had not done annual performance reviews since he had begun his role approximately a year and a half ago. It was a system that was not in place and had not been implemented. On 10/27/23 at approximately 10:30 AM, Regional Administrative…

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

Based on observation, interview, and record review, the facility failed to maintain medication storage room free of expired medications and securely store medications, for one of two medication rooms and two of three medication carts reviewed for medication storage. This deficient practice resulted in the potential for administration of medications with reduced intended effect. Findings include: On 10/25/23 at 9:00 AM, an inspection was conducted on the 100 Hall medication cart. In the second drawer beneath the medication cards an observation was made of one loose fluoxetine 20 mg (milligram) capsule and two small white half tabs (unable to be identified). On 10/25/23 at 9:20 AM, an inspection was conducted on the 200 Hall medication cart with Licensed Practical Nurse (LPN) D. In the second drawer beneath the medication cards an observation was made of one loose hydroxyzine 25 mg capsule. LPN D confirmed that no loose pills should be kept in the medication carts and should be stored accordingly. On 10/25/23 at 9:40 AM, an inspection was conducted in the 200/300 medication storage…

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

This citation is Related to: Intake ID: MI00138873 & MI00139037 Based on observation and interview the facility failed to provide a sanitary and functional environment for residents, staff and visitors as evidenced by: 1. The presence of mold in two shower stalls used by staff to provide showers to residents. 2. Deteriorating walls surrounding a housekeeping floor sink. 3. Broken plastic light fixture shield over a shower enclosure. This deficient practice has the potential to result in the spread of fungus spores and contribute to respiratory irritation/complications to residents and staff using the shower area. Findings include: 1. On 10/25/23 at approximately 9:32 AM observations were made in the 200 hall and 300 hall shower rooms, in response to complaints. Both shower rooms were constructed with ceramic tiled shower stalls, and included the half walls and floor. Along the wall/floor juncture, black colored mold like material was observed on the white caulking. At approximately 10:00 AM an interview with Maintenance Director MD A was conducted, and was asked if he had received…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation is related to: Intake ID: MI00138630, MI138719 & MI00139905 Based on interview and record review, the facility failed to provide timely showers and toileting assistance for three Residents (R43, R44 and C1) of 17 Residents reviewed for activities of daily living (ADL's) including showers and toileting. This deficient practice resulted in resident dissatisfaction, embarrassment, and the potential for poor hygiene,and uncleanliness. Findings include: On 8/10/23, an anonymous complaint was received by the State Agency (SA) with additional information provided 9/27/23, noting a lack of basic care including showers and failure to provide timely assistance to the toilet. On 8/11/23, an anonymous complaint was received by the SA with further information reported on 9/7/23, that Residents aren't being showered regularly, and Residents aren't being provided with toileting asst.(assistance) in a timely manner. During a confidential interview on 10/24/23 at 3:49 PM, family member W stated the facility did not…

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

Based on interview and record review, the facility failed to implement an effective bowel management program for one Resident (R16) of one resident reviewed for bowel management. This deficient practice resulted in the potential for a bowel related complications including impaction, obstruction and other bowel related issues. Findings include: Resident #16 (R16) Review of R16's face sheet, printed on 10/24/23, revealed an original admission date of 4/5/2019, with medical diagnoses including dementia, anxiety, epilepsy, cerebral infraction (stroke), and aphasia (loss of ability to understand or express speech). On 10/27/23 at 9:03 AM, a review of R16's, task list for bowel elimination description, dated 9/27/23 through 10/26/23, revealed the following: a.) No bowel movement between 9/29/23 - 10/4/23 = six days with no medication intervention, no progress notes, no assessments, and no communication to the doctor. b.) No bowel movement between 10/14/23 - 10/18/23 = five days with no medication intervention, no progress notes, no assessments, and no communication to the doctor. c.) 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.

Based on observation, interview, and record review, the facility failed to provide pressure ulcer care per standards of practice for one Resident (R7) of one resident reviewed for wound care/pressure ulcers. This deficient practice resulted in the potential for poor wound healing, infection, and worsening of pressure ulcers. Findings include: Resident #7 (R7) Review of face sheet, date printed 10/24/23, revealed an original admission to the facility on 1/14/22, with medical diagnoses including spastic quadriplegic cerebral palsy (a form of cerebral palsy that affects both arms and legs and often the torso and face), intellectual disability, need for assistance with personal care, and neuromuscular dysfunction of bladder. Review of R7's Braden Scale for predicting pressure sore risk, dated 10/20/23, revealed completely limited sensory perception, and a score of 10 which indicated high risk. Review of R7's skin and wound assessment, dated 10/17/23, revealed a pressure ulcer stage 2 that developed on 10/17/23, measured 1.31 cm (centimeters) x 2.45 cm, and was noted to be in-house…

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

Based on observation, interview, and record review, the facility failed to maintain a medication administration error rate less than 5%, for 4 of 25 medication administrations. This deficient practice resulted in a medication administration error rate of 16.00%, with the potential for medical complications related to resident medication treatments for various conditions. Findings include: On 10/26/23 at 9:30 AM, a medication administration was observed with Licensed Practical Nurse (LPN) G. The following was observed: LPN G was observed preparing two insulin pens for Resident #37 (R37). LPN G opened her cart and grabbed an insulin glargine (long acting insulin) pen, removed the cap, placed a needle on the end of the pen, and primed with 2 units holding the pen horizontal. LPN G then grabbed the liraglutide (type 2 diabetes/obesity medication) pen, removed the cap, and placed a needle on the end of the pen and primed with 2 units holding the pen horizontal. LPN G failed to clean the end of the pens with an alcohol swab prior to placing the needles on the end of the pens, and failed…

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.