Lake Woods Nursing & Rehabilitation Center

This citation refers to MI00147470. Based on observation, interview, and record review, the facility failed to secure 1 of 3 medication carts (Harbor Medication Cart), resulting in the potential for misappropriation of resident medications. Findings include: During an observation on 10/22/24 at 07:55 AM, the Harbor Medication Cart was left unlocked (the lock was in a pulled-out position and the red/orange dot- which would indicate the cart was unlocked- was clearly visible) and unattended in the hallway outside of a resident room. In addition, because the medication cart was left unlocked, the controlled substances that were stored in the medication cart were only under a single lock vs. the requirement that controlled substances are secured by a double lock system. There were not any staff within visual range of the medication cart. Residents were also observed in the hallway at the time of the observation. During the observation on 10/22/24 at 07:55 AM, Agency Registered Nurse (RN) A returned to the Harbor Medication Cart while the surveyor was writing down information for that…

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 refers to MI00147470. Based on observation, interview, and record review, the facility failed to safeguard the confidentiality of medical records for 1 of 83 facility residents (R9), resulting in the potential for unauthorized access to resident medical records and the potential for the loss of resident privacy and confidentiality of their personal health information. Findings include: During an observation on 10/22/24 at 7:55 AM, the computer screen on top of the Harbor Medication Cart was observed open to R9's electronic Medication Administration Record, (e-MAR). R9's personal and health identifying information (e.g., picture, name, room number, physician's name, and allergies) and medications were visible to anyone walking by the medication cart. No staff were visible within sight of the medication cart. During the observation on 10/22/24 at 7:55 AM, Agency Registered Nurse (RN) A returned to the Harbor Medication Cart while the surveyor was taking notes. RN A stated, uh oh and then proceeded to tell the surveyor the oncoming nurse was running late. RN A stated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #: MI00145370 Based on interviews and record review, the facility failed to protect a resident's (Resident #5) right to be free from physical abuse from another resident (Resident #4). Findings: Resident #4 (R4) Review of an admission Record revealed R4 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: dementia with agitation and behavioral disturbances and major depressive disorder. Review of a Minimum Data Set (MDS) assessment for R4, with a reference date of 4/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 7, out of a total possible score of 15, which indicated R4 was severely cognitively impaired. Review of R4's Care Plan revised 4/21/24 revealed, (R4) has the potential for psychosocial distress related to: anticipated dementia progression, expressing sadness / anger / empty feeling over lost roles and status. Wanderguard is in place due to unsafe wandering. Confusion and memory loss present. DX…

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 #: MI00146179 Based on observation, interview, and record review, the facility failed to ensure adequate supervision for 1 of 12 residents (Resident #1) reviewed for safety, resulting in R1 left unsupervised outside. Findings: During an observation on 08/15/2024 at 7:25 AM, the front entrance/main entrance of the facility had 2 sets of doors. The first set of doors was unlocked, the second set of doors required a code to enter. There was a doorbell attached to the wall. Resident #1 (R1) Review of an admission Record revealed R1 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: dementia, heart failure, and stage 4 kidney disease. Review of a Minimum Data Set (MDS) assessment for R1, with a reference date of 7/15/24 revealed a Brief Interview for Mental Status (BIMS) score of 6, out of a total possible score of 15, which indicated R1 was severely cognitively impaired. Review of R1's Assessment for Outdoor Independence dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00143643 and MI00144325. Based on observations, interviews and record review the facility failed to follow standards of care for 5 Residents (R20, R39, R78, R135, R136) out of 28 sampled residents, resulting in R39 not having her lower extremities assessed and evaluated by her physician, R78 not having his wounds treated as ordered, R20 potentially having a serious medication error and R135 and R136 not having a complete set of neurological assessments after a fall. R39 Review of R39's face sheet dated 5/20/24 revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included chronic kidney disease, stage 3, muscle weakness, weakness and need for assistance with personal care. R39 was her own responsible party. R39 was observed in bed on 5/13/24 at 1:28 PM. R48 complained of both ankles being swollen, she poked them with her finger and the skin dented in leaving a mark for a few seconds. R48 was concerned as to the reason and wanted…

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 resident choices were honored for one of four residents (Resident #26) reviewed for choices, resulting in feelings of frustration and distress. Findings include: R26 A review of R26's admission Record, dated 5/16/24, revealed R26 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, R26 had multiple diagnoses that included Chronic Obstructive Pulmonary Disease, Weakness, Dysphagia Oropharyngeal Phase, Muscle Weakness, Acquired Absence of Left Leg Above Knee, Diabetes mellitus due to underlying condition with diabetic polyneuropathy, and Phantom Limb Syndrome with Pain. During an interview on 05/14/24 at 11:20 AM, R26 was found in Bed 1 a few doors down from her assigned room. R26 revealed she was in here recouping from yesterday/last night. R26 stated that while she was in the dining room last night (5/13/24) the following incident occurred, my roommate (Name of R7) came into the dining room on her power…

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 MI00144325. Based on interview and record review, the facility failed to notify the responsible party after resident falls for 2 residents (Resident #135 and #58) of 2 residents reviewed for notification of changes, resulting in the physician and family/guardian not being notified of resident changes of condition and the potential for delayed medical intervention and care. Findings include: Resident #135 Review of an admission Record revealed Resident #135 admitted to the facility on [DATE] with pertinent diagnoses which included metabolic encephalopathy (brain function disturbances caused by chemical imbalance in the blood), unsteadiness on the feet, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #135, with a reference date of 4/23/2024 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #135 was moderately cognitively impaired. Review of Resident #135's Accident Report, 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 implement policies and procedures for ensuring the reporting of a resident-to-resident incident for 2 residents' (R7 & R26) out of 13 residents reviewed for abuse and neglect, resulting in the potential for ongoing abuse and/or neglect. Findings include: Review of the facility policy Abuse/Suspected Abuse; Crime Investigation & Reporting last revised February 2023 revealed, It is the policy of this facility to encourage and support all residents, covered individuals, and families, to report any suspected acts involving resident mistreatment, neglect, exploitation, abuse and crimes, misappropriation of resident property or injuries of unknown source. Allegations of abuse and crime are thoroughly investigated and properly reported in accordance with Federal Regulation including the Elder Justice Act. R26 A review of R26's admission Record, dated 5/16/24, revealed R26 was an [AGE] year-old resident admitted to the facility on [DATE]. In…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The following citation pertains to intake #MI00143643. Based on interview and record review, the facility failed to revise care plans for 2 residents (Resident #136 and #23) of 3 residents reviewed for care plan revision, resulting in Resident #136's care plan not being revised after a fall and Resident 23's care plan not being revised with the development and worsening of pressure ulcers. Findings include: Resident #136 Review of an admission Record revealed Resident #136 admitted to the facility on [DATE] with pertinent diagnoses which included heart failure, difficulty walking, and dementia. Review of a Minimum Data Set (MDS) assessment for Resident #136, with a reference date of 4/8/2024 revealed a Staff Assessment for Mental Status score of 3, which indicated Resident #136 was severely cognitively impaired. Review of Resident #136's Incident/Accident Checklist completed by Registered Nurse (RN) BB after Resident #136's fall on 3/15/2024 revealed .new fall care plan intervention in place . Review of 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 1 Resident (R78) with scheduled showers of 3 Residents reviewed for activities of daily living, resulting in R78 having feelings of frustration. Findings included: Review of R78's face sheet revealed the was an [AGE] year-old male that was admitted on [DATE] and had diagnoses that included: difficulty in walking, muscle weakness, and need for assistance with personal care. R78 was his own responsible party. On 5/13/24 at 11:14 AM, R78 was in his room sitting in his wheelchair. R78 was frustrated because he was scheduled for a shower on 5/11/24 and staff said they did not have time to give him a shower, but they would provide a shower on 5/12/24. R78 said he is to get a shower every Wednesday and Saturday evening. R78 again requested a shower on 5/12/24 and again staff said they did not have time to give him a shower. R78 said he had an outside medical appointment this week and really needed a shower before going to that medical…

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 refers to MI00144528. Based on interview and record review, the facility failed to: 1) prevent an elopement for 1 of 1 resident (R73) reviewed for elopements and 2) failed to complete post-fall assessments on 1 of 3 residents (R58) reviewed for falls, resulting in R73 leaving the facility unbeknownst to staff, the potential for R73 sustaining serious injuries during the elopement, and the potential for staff not identifying a change in condition timely for R58 which could result in a serious physical outcome post-fall. Findings include: R73 A review of R73's admission Record, dated 5/15/24, revealed R73 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, R73 had multiple diagnoses that included Dementia and Alzheimer's Disease. A review of R73's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 4/15/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) assessment 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 Based on observation, interview, and record review, the facility failed to follow physician orders to clean and flush a catheter for 1 (R37) of 4 residents reviewed for catheter care and management. Findings include: R37 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R37 admitted to the facility on [DATE] with diagnosis of (but not limited to) bilateral below the knee amputations, traumatic brain injury, heart failure, and neuromuscular dysfunction of the bladder. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which represented R37 was cognitively intact. During an interview on 5/15/24 at 10:36 AM, R37 stated that staff were not changing his dressings to his back and suprapubic catheter like they were supposed to. R37 said he has a foul odor coming from one of them. During an observation and interview on 5/15/24 at approximately 10:50 AM, Licensed Practical Nurse (LPN) H was observed as she changed the suprapubic (SP) tube dressing. LPN H removed the old…

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 palatable food for 1 Resident (R48) of 28 sampled residents, resulting in the potential for poor nutrition and poor wound healing. Findings included: Review of R48's face sheet dated 5/20/24 revealed, she a [AGE] year-old female admitted on [DATE], she had diagnoses that included: pressure ulcer of left heel, unstageable, diabetes mellitus 2, lymphedema, pressure ulcer of right buttock, stage 2, non-pressure chronic ulcer of left calf, weakness, abnormalities of gait and mobility, and need for assistance with personal care. R48 was her own responsible party. During an interview with R48 on 05/13/24 at 1:41 PM R48 was very concerned the food being cold and not being able to eat food that was cold. R48 said she tells the staff, but they do not have time to reheat her food, so she just does not eat. R48 was observed in bed on 5/16/24 at 9:01 AM, R48's breakfast tray was in front of her and looked untouched but R48 said she had taken 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 reveiew, the facility failed ensure 1 resident (R64) of 1 Resident reviewed for therapy services, had follow up appointment related to medical equipment needed for physical therapy, resulting in pain and frustration with the use of the equipment. Findings included: Review of R64's ADL (activities of daily living) care plan revealed he was [AGE] years old and had diagnose that included encephalopathy (brain disease) and epilepsy (seizure disorder), Left above the knee amputation. No interventions for staff to assist him with his prothesis were located. Review of R64's discharge care plan revealed that on 9/19/23 his guardian agreed with a long term plan for nursing home care. During an interview with R64 on 5/13/24 at 12:52 PM he expressed frustration with the facility not assisting him to get adjustments completed on his prosthetic leg, he explained he stopped using it because it hurt. R64 said the therapist wanted him to keep the leg all day but it dug into his groin.…

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 refers to MI00142853 and the annual survey Based on interview and record review, the facility failed to maintain complete and accurate medical records for 3 of 29 (R5, R26, and R137) sampled residents, resulting in the potential for providers not having an accurate and complete picture of the resident's stay at the facility. Findings include: R137 A review of R137's admission Record, dated 5/14/23, revealed R137 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R137 had multiple diagnoses that included toxic encephalopathy (brain swelling caused by an infection or exposure to toxic substances), vascular dementia, depression, anxiety, and cognitive communication deficit. A review of the facility's investigative documentation for an incident on 2/8/24 revealed the following: - Facility investigation, undated, revealed a CNA (certified nursing assistant) staff member stopped by R62's and R137's room because she did not observe R62 in his bed where he had last been seen 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.

Based on observation, interview, and record review, the facility failed to maintain clean and sanitary medical equipment at bedside for one Resident (R53) reviewed, resulting in the potential for the use of an unsanitary medical device. Findings: The Minimum Data Set (MDS) for R53 dated 3/25/24 Section K reflected R53 has a feeding tube. Section K also reflected R53 received 26 to 50% of the total calories received through the feeding tube. On 5/13/24 at 11:23 AM, R53 was asleep in bed. Observed on the night stand next to the bed was a graduated vessel and a large syringe used for the Resident's feeding tube. It was observed that the vessel was dated 3/30/24 and contained a sticky substance in the bottom of the vessel. The large syringe was not dated. An off-white substance, assume left-over nutritional material, remained at the bottom of the syringe barrel, and filled the tip of the syringe. This indicated that the undated syringe had not been cleaned after the last use. On 5/13/23 at 2:30 PM an interview was conducted with the Director of Nursing (DON) in the room of R53. The DON…

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

Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) completed specialized training in infection prevention and control, resulting in the potential for knowledge deficits pertaining to current infection prevention and control standards and infectious disease outbreaks. Findings include: According to the Centers for Medicare and Medicaid Services (CMS) Infection Prevention, Control & Immunizations pathway, dated April of 2024, the designated Infection Preventionist is required to complete specialized training in infection prevention and control prior to assuming the role of the Infection Preventionist. In an interview on 5/16/2024 at 1:02 PM, the Director of Nursing (DON) reported there was not currently an employee with specialized training in infection prevention. The DON reported Registered Nurse (RN) Unit Manager Z is the new facility IP and had been working on her IP certificate but had not yet completed her certificate. RN Unit Manager Z reported she took over as the IP a few months ago and had been working on her IP certificate…

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 MI00142132 Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent falls for 1 Resident (R6) of 3 residents reviewed for falls, resulting in R6 having multiple avoidable falls. Findings included: Review of R6's face sheet dated 2/22/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: encephalopathy (Brain disease), dementia, bipolar disorder, difficulty walking, weakness and chronic pain. R6 was not her own responsible party. Review of R6's care plan dated revision on 1/22/24 revealed, R6 is at increased risk for decreased functional mobility and ADL's (activities of daily living) related to increase risk for fatigue and weakness, decreased alertness, increased confusion, and muscle weakness, secondary to encephalopathy, increased difficulty handling complex tasks, decreased coordination and motor function, increased confusion and disorientation secondary 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 MI00142132 and MI00142485 Based on observations, interviews and record review, the facility failed to provide adequate pain relief, accurate assessment of pain, and pain medication as ordered to 2 Residents (R5 and R7), resulting in R5 and R7 experiencing unnecessary pain. Findings included: Review of R 5's face sheet dated 2/21/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: fractured left tibia (lower leg bone), abnormal gait (walking) and mobility, low back pain, and weakness. He was his own responsible party. Review of R5's care plan dated 1/4/24 revealed, R5 has a potential for alteration in comfort: fracture of left leg. Goal: R5 will have effective pain relief with interventions as evidence by verbal responses indicating relief; and/or no facial grimace, and no behavioral indication of discomfort. There was no indication of his long-term chronic pain and his expectation of effective pain relief. During and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00142132 Based on interview and record review the facility failed to accurately account for the dispensing of 4 Residents (R5, R7, R8, R9) narcotic medications of 4 Residents reviewed for narcotic medication use, resulting in the potential for overdose, missing doses, and drug diversion. Findings included: The facility provided a copy of Controlled Medication Storage, Security and Disposition dated 6/2006 with a revision dated of 12/2016 for review. The policy reflected, 12. Controlled medication accountability records are maintained in a separate binder for ease of access and auditing purposes . Review of R 5's face sheet dated 2/21/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: fractured left tibia (lower leg bone), abnormal gait (walking) and mobility, low back pain, and weakness. He was his own responsible party. Review of R5's care plan dated 1/4/24 revealed, R5 has a potential for alteration in comfort:…

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 MI00142132 Based on observation, interview, and record review, the facility failed to ensure 1 of 3 medication carts were under double lock for controlled substances and accounted for each shift change by 2 nurses. Findings include: The facility provided a copy of Controlled Medication Storage, Security and Disposition dated 6/2006 with a revision dated of 12/2016 for review. The policy reflected, 3. Medications listed in Schedules II, III, IV, and V are stored under double lock separated from other medications .The medication nurse on duty maintains possession of the key to the controlled medication storage areas and assumes responsibility for controlled substance key custody throughout the duration of their shift .6. A physical inventory of controlled medication is conducted by two licensed nurses and is documented on the controlled substance accountability record at each shift changes or whenever there is an exchange of keys between off-going and on-coming licensed nurses . During an observation and interview on 2/22/24 at approximately 11:30 AM,…

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 MI00142132 and MI00142485 Based on observations, interview and record review, the facility failed to treat 2 Residents (R5 and R7) of two reviewed with dignity, resulting in pain and feelings of frustration. Findings included: Review of R5's face sheet dated 2/21/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: fractured left tibia (lower leg bone), abnormal gait (walking) and mobility, low back pain, and weakness. He was his own responsible party. Review of R5's Brief Interview of Mental Status (BIMS) dated 1/8/24 revealed he scored 14/15 (normal cognition). During and observation/interview on 2/21/24 at 8:19 AM, R5 was up in his wheelchair moving about independently in his wheelchair. R5 was asked about his care. R5 was visibly upset and reported he was glad to be going home today. He reported he did not always receive his pain medications and when they did provide it, they did not provide it timely. He reported he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This intake pertains to intake number MI00136899, MI00138532 and MI00138627. Based on observations, interviews, and record review the facility failed to assess, monitor and treat 2 Residents' (R2 and R12) medical needs, resulting in R2 not being adequately assessed for fluid retention and requiring hospitalization/treatment for fluid retention and R12 not being provided post-surgical care as directed by her surgeon. Findings include: R2 Review of R2's face sheet dated, 9/8/23 revealed she was an [AGE] year-old female admitted on [DATE] and last admission was on 2/16/23. She had diagnoses that included, chronic respiratory failure with hypoxia, diabetes mellitus, muscle weakness, dysphagia (difficult swallowing), morbid (severe) obesity, chronic diastolic (congestive) heart failure, and chronic kidney disease, stage 3. She was her own responsibility party. Review of R2's electronic medical record (EMR) revealed the following weights were recorded. 1/10/23 296.6 pounds, 2/16/23 254.4 pounds, 2/17/23 288.6, 3/10/23…

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 intake pertains to intake MI00138532, MI00138627 and MI00138674 Based on observations, interviews, and record reviews, the facility failed to provide adequate nursing staffing to meet 1 Resident's (R12) care needs resulting in R12 not receiving timely incontinence care and other care in a timely manner. Findings include: Review of R12's face sheet dated 9/6/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and she had diagnoses that included: paraplegia (loss of movement in her legs), muscle weakness, and rheumatoid arthritis. R12 was her own responsible party. Review of R12's care plan revealed she had a care plan for impaired functional mobility and activities of daily living dated initiated 6/28/21 and a revision on 9/7/23. Interventions included: total assistance with bathing, bed mobility assist of 2 people, dressing assist of 2 people, eating requires physical assistance of one person in her room, elimination: wears incontinence products, may place liner in brief check 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 and record review, the facility failed to maintain proper infection control practices in the facility, potentially affecting all facility residents, resulting in improper wearing of personal protective equipment (face masks), R8's catheter bag being left on the bare floor, an unclean shower room, and the potential for the spread of illness and/or disease. Findings include: During an observation on 04/26/23 at 02:15 PM, Licensed Practical Nurse (LPN) C was observed at the medication cart across the hall from the Shore Nurse's Station with her surgical mask positioned below her nose, but covering her mouth. During an observation on 04/26/23 at 02:20 PM, certified nursing assistant (CNA) D was observed coming out of a resident room on the Harbor unit after providing care. CNA D had her surgical mask positioned below her nose, but covering her mouth. During an observation on 04/26/23 at 02:20 PM, CNA E was observed walking down the hallway on the Terrace unit with her surgical mask positioned…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain ongoing communication with the dialysis facility for one resident (R71), resulting in the facility not consistently communicating information to the dialysis center prior to R71's treatments. Findings include: A review of R71's admission Record, dated 4/26/23, revealed R71 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R71's admission Record revealed multiple diagnoses that included end stage renal disease, diabetes, and dependence on renal dialysis. A review of R71's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 2/28/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 12 which revealed R71 was cognitively intact. During an interview on 04/25/23 at 10:45 AM, R71 stated the facility does not always fill out a communication sheet and send it with him when he goes to the dialysis center for his treatments. 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 ensure that one resident (R51) reviewed for personal hygiene care received necessary nail care, resulting in a dependent resident not receiving timely and appropriate personal care to maintain comfort and hygiene. Findings include: Review of face sheet dated 4/27/23 revealed R51 initially admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included congestive heart failure, muscle weakness, traumatic brain injury, immobility syndrome (paraplegic), and paraplegia. R51 was their own responsible party and their most recent BIMS (Brief interview for Mental Status) assessment dated [DATE] revealed a score of 15/15, indicating the resident was cognitively intact. On 04/25/23 at approximately 12:45 PM an interview was completed with R51 in their room. R51 admitted that he declines showers and wound changes at times, but stated he had not gotten help with cutting his fingernails after asking multiple…

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 timely physician response to pharmacy recommendations for one sampled resident (R8) out of five residents with drug regimen reviews, resulting in unnecessary and unmonitored medication use. Findings include: Resident #8 Review of R8's face sheet dated 4/27/23 revealed she initially admitted to the facility on [DATE] with diagnoses that included: Fracture of femur, dementia, repeated falls, bipolar disorder and retention of urine. R8 was not her own responsible party. Review of R8's Pharmacist Medication Review dated 4/4/23 revealed a recommendation: This resident has an order for olanzapine (Zyprexa) 7.7 mg po HS (antipsychotic medication) and Trazadone 50 mg po HS (antidepressant medication). Both are due for a gdr (gradual dose reduction) consideration at this time. Recommendations: Please evaluate if resident is a candidate for a gdr at this time. CMS requires that antipsychotics used to manage behavior or stabilize mood be evaluated…

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 1 of 5 residents (R54) was offered the influenza vaccine during influenza season, resulting in R54 or their responsible party not being given the option to receive or decline the vaccine. Findings include: A review of R54's admission Record, dated 4/27/23, revealed R54 was an [AGE] year-old resident admitted to the facility on [DATE] and re-admitted on [DATE]. In addition, R54's admission Record revealed multiple diagnoses that included a cerebral infarction (brain bleed), dementia, and depression. In addition, R54's admission Record revealed she had an activated power of attorney for health care decisions. A review of R54's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 1/24/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 5 which revealed R54 was severely cognitively impaired. A review of R54's electronic medical record revealed 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.