Optalis Health & Rehabilitation of Muskegon

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor care to potentially prevent sepsis/hospitalization for one (R1) and failed to assess and monitor moisture associated skin damage (MASD) for one (R4) of two residents reviewed for quality of care.Findings include:Resident #1 (R1)Review of a Face Sheet revealed R1 originally admitted to the facility on [DATE] with pertinent diagnoses of a displaced fracture of the right femur (thigh bone), emphysema, and mental disorder. On 9/28/25 R1 received new diagnoses of sepsis and pneumonia. During an observation on 1/12/26 at 10:00 AM, R1 was lying in bed and did not want to talk at this time. Review of an Incident Report for R1 dated 8/21/25 at 11:18 AM revealed: Incident Description: Another staff member Alerted this nurse that resident was in need of assistance. Writer entered to observe resident sitting on floor in front of radiator. Resident Description: I tried to use the urinal standing up and just lost my balance. The resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide care and services according to professional standards to prevent the development and/or worsening of pressure injuries for 3 residents (R23, R54 and R90) out of 5 residents reviewed for pressure injuries. R23 Review of R23's admission record dated 1/13/26 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Pressure-induced deep tissue damage of sacral region, Alzheimer's disease, and muscle wasting. R23 was not her own responsible party. Review of R23's Skin – Total Body Eval -V2 dated 12/17/26 and signed by Unit Manager (UM) I revealed, Right thigh rear – possible pressure – unable to determine will require RN (Registered Nurse) assessment or eval by wound nurse for definitive etiology 5.6 x 4.8 x 0.2 (islands of epithelial present within these measurements). Left thigh (rear) – possible pressure – unable to determine will require RN assessment or eval by wound nurse for…

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

Based on observation, interview, and record review, the facility failed to ensure proper positioning/support for one (R56) of 3 residents reviewed for positioning.Findings include: Review of a Face Sheet revealed R56 had pertinent diagnoses of hemiplegia and hemiparesis (one sided weakness) affecting the left side and chronic kidney disease. During an observation on 1/12/26 at 10:20 AM, R56 was observed transporting down the hall in a wheelchair with her left arm flaccid and not supported.During an observation on 1/13/26 at approximately 11:00 AM, R56 was observed in bed without support for her left arm. R56 was then transferred to a wheelchair in anticipation of an appointment. R56's arm was not supported and hanging down in her lap as she was transported out of the facility. Review of the Care Plan for R56 revealed: ADL (activities of daily living) self-care deficit related to physical limitations. No goals documented. Interventions included: LUE (left upper extremity) Sling on when seated in (wheelchair) or standing/ambulating as resident will allow, initiated 10/30/25.In an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent falls for 1 (R1) of 2 residents reviewed for falls, and unsafe self-administration of medications left at the bedside for 2 (R13 and R27), of 2 residents observed with medications at the bedside.Findings include:Review of R13's admission record dated 1/14/26 revealed R13 was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: acute kidney failure, muscle wasting, unsteadiness on feet, bipolar disorder, and chronic pain syndrome. R13 was her own responsible party. During the medication pass observation on 1/13/26 at 8:00 AM, R13 had a bottle of nasal spray (Nasal Relief Oxymetazoline HCL 0.55 %) on her bedside table. R13 said she had been taking this nasal spray since admission and was assessed to be independent taking it. R13 said she takes it daily around 1:00 pm but denied reporting to any nurse she had been taking the nasal spray. R13 denied being set up with any secure storage for 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 ensure ordered supplements were provided to one resident with significant weight loss (R19) out of 2 residents reviewed for nutrition and hydration. Review of an admission Record reflected R19 admitted to the facility on [DATE] with diagnoses that included severe protein-calorie malnutrition, nutritional deficiency, unspecified and dysphagia (difficulty swallowing). Review of a Care Plan initiated 7/25/2025 reflected R19 was at risk for repeated alteration in skin integrity related to . poor nutritional intake due to dysphagia. An intervention for this focus area of the care plan was to provide diet and supplements per physician order. The Care Plan also indicated R19 required assistance with ADLs (activities for daily living) that included needing set up assistance for eating. Review of a Care Plan initiated on 7/7/2025 reflected (R19) is at unavoidable nutritional risk related to atrial fibrillation (abnormally fast pulse), CHF…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess and monitor ongoing irritation and drainage of a PEG tube (Percutaneous Endoscopic Gastrostomy tube) insertion site for one (R20) of 2 residents reviewed for tube feedings. Findings include:Resident #20 (R20)Review of a Progress note dated 1/6/26 for R20 revealed: Resident red and irritated around peg site, cleansed (with) normal saline and applied skin guard cream and split sponge. Review of a Skin assessment dated [DATE] for R20 revealed no skin concerns.During an observation and an interview on 1/13/26 at 10:52 AM, Licensed Practical Nurse (LPN) V was questioned about the condition of R20's PEG tube (Percutaneous Endoscopic Gastrostomy tubes). At this time LPN V went to change the split gauze covering the abdominal insertion site and the PEG tube bumper (base of the PEG tube before its inserted). The gauze had some reddish clear drainage, and the insertion site was red (about a nickel sized area) and crusted with some clear…

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, monitor and treat 1 Resident's (R25) respiratory condition of 1 Resident reviewed for respiratory care.Findings included:Review of R25's admission record dated 1/14/26 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: muscle wasting and atrophy (waste away), burns involving 10-19% of body surface with 0% to 9% third degree burns and unsteady on feet. R25 was his own responsible party. R25 was observed in bed on 1/13/26 at 12:18 PM. R25's C-PAP machine was on his nightstand. R25 said he does normally use the machine when sleeping to help him breathe, but he can't use it every night. R25 said no one has assisted him with his CPAP or his breathing needs since admission.During an interview with Unit Manager (UM) I on 1/13/26 at 4:00 PM, UM I said R25's hospital discharge summary did indicate that he used a C-PAP machine. UM I said R25 was transferred to the facility on [DATE] but…

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 coordinate care consistent with the professional standards of practice by assessing and monitoring pre and post dialysis treatments, communicating and collaborating with the dialysis facility regarding care and medication reconciliation for one (R56) of 3 residents reviewed for dialysis. Findings include:Resident #56 (R56)Review of a Face Sheet revealed R56 admitted to the facility on [DATE] with pertinent diagnoses of end stage renal disease (ESRD), heart failure, and dependence on renal dialysis. During an interview on 1/12/26 at 10:18 AM, R56 reported she goes to dialysis on Tuesdays, Thursdays, and Saturdays. R56 reported she usually has high potassium and high phosphorus levels. R56 reported she did not recall if she takes a communication form to dialysis or brings any forms back after dialysis. Review of the Electronic Medical Record (EMR) for R56 revealed the last dialysis communication at the time of this survey was 12/30/25.…

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 offer and provide Influenza and Pneumococcal Immunizations to 1 Resident (R54) of 5 Residents sampled for Immunizations.Findings included:Review of R54's admission record dated 1/12/26 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: Hydrocephalus (fluid on the brain), Diabetes insipidus (disease which causes increase secretion response of the pituitary hormone resulting in increased diluted urine), dysphagia (difficulty swallowing) and communication deficit. R54 was not his own responsible party.Review of R54's electronic medical record revealed no request for consent for vaccinations, no orders for vaccinations and no vaccination records.During an interview with the facility Infection Preventionist (IP) A on 1/13/26 at 1:40 PM R 54's) Electronic Medical Record was reviewed. IP A said she did not review R54's vaccination records and get consent forms to his responsible party for vaccinations…

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 offer and provide a COVID-19 Vaccination to 1 Resident (R54) of 5 Residents sampled for COVID-19 Vaccinations.Based on interview and record review the facility failed to offer and provide a COVID-19 Vaccination to 1 Resident (R54) of 5 Residents sampled for COVID-19 Vaccinations.Findings included:Review of R54's admission record dated 1/12/26 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: Hydrocephalus (fluid on the brain), Diabetes insipidus (disease which causes increase secretion response of the pituitary hormone resulting in increased diluted urine), dysphagia (difficulty swallowing) and communication deficit. R54 was not his own responsible party.Review of R54's electronic medical record revealed no request for consent for COVID-19 vaccinations, no orders for COVID-19 vaccinations and no vaccination records were located.During an interview with the facility Infection Preventionist (IP) A on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to assess to determine if resident was appropriate for lone transfer in accordance with professional standards of care related to mental and physical conditions for one (Resident #1) of three residents reviewed for quality of care. Findings include:Resident #1 (R1)A review of R1's Electronic Medical Record (EMR) indicated that R9 was originally admitted to the facility on [DATE] with diagnosis including functional quadriplegia, chronic pain syndrome, morbid obesity, abnormalities of gait and mobility, weakness, spinal stenosis, and adjustment disorder with mixed anxiety and depressed mood. The EMR revealed a Brief Interview for Mental Status (BIMS) was performed on 9/25/25 where R1 scored a 10 out of 15, meaning R1 has moderate problems with thinking and memory.Therapy progress notes dated 8/20/25: Quarterly Therapy Screen Completed: Patient demonstrates minimal out of bed activity with deficits in mobility, strength, and ADLs. Patient…

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 # MI00147858 Based on interview and record review, the facility failed to follow professional standards and ensure 1 out of 3 residents (Resident #400) received a physician ordered medication to treat an infection and failed to obtain ordered labs and tests required to monitor the efficacy and safety of the medication. Findings: Resident #400 (R400) Review of an admission Record revealed R400 was a [AGE] year old male, originally admitted to the facility on [DATE]. R400 had 2 recent hospital admissions. The first from 07/05/24 to 08/21/24 and the second, that lead to the admission to the nursing facility, was from 08/26/24 to 08/31/24. During the first hospital admission, R400 was diagnosed with enterococcal meningitis (a fungal infection that effected the brain) and on 08/09/24 started on a medication called itraconazole. Review of an Infectious Disease hospital follow up note for R400, dated 08/26/24, reflected the following assessment .currently on treatment for cryptococcus…

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 prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: During a tour of the kitchen, at 10:05 AM on 10/28/24, it was observed that the hand wash sink, near the dish machine, was found to not have hot water coming out of the fixture. At this time a temperature of the hot water was taken with a rapid read thermometer and found to only reach 66F. Observation under the sink found a mixing valve with a water line also going to an eye wash station. At this time, an interview with Dietary Aide G found that hand sink doesn't seem to get hot. According to the 2017 FDA Food Code section 5-202.12 Handwashing Sink, Installation. (A) A HANDWASHING SINK shall be equipped to provide water at a temperature of at least 38oC (100oF) through a mixing valve or combination faucet. During a tour of the kitchen, at 10:08 AM on 10/28/24, observation of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living, affecting residents in the 300, 400 and 500 halls. Findings include: During a tour of the kitchen, at 10:30 AM on 10/28/24, it was observed that some non LED lights were missing their light shields over the preparation and serving area. During a tour of the facility, with Maintenance Director (MD) E, starting at 1:05 PM on 10/28/24, the following observations were made: A review of the 300 hall janitors closet found a Y valve connected to the spout of the janitors sink with both valves closed and the sink left on. This set up puts undue back pressure on the faucets internal vacuum breaker, of which it is not rated to handle. An interview with MD E found that they just got a new chemical dispense system and a vendor has been setting up these areas. A review of the 300 hall clean linen…

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 care in a dignified manner for 2 residents (Resident #57 and Resident #73) out of 18 residents reviewed for quality care. Findings include: Resident #73 (R73) Review of an admission Record reflected R73 admitted to the facility with diagnoses that included non-traumatic intracerebral hemorrhage (stroke), hemiplegia and hemiparesis (partial or complete paralysis on one side of the body) following a stroke, difficulty walking, and dysphagia. Review of a Minimum Data Set (MDS) assessment dated [DATE] reflected R73 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 11/15. Review of a Care Plan revealed R73 has limited/impaired physical mobility and had an Activity for Daily Living (ADL) self-care performance deficit related to a stroke and right sided weakness. The plan of care indicated R73 needed two people to assist with showers and bathing, toilet use and transfers. 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 Based on observation, interview and record review, the facility failed to A) Develop, implement and evaluate the effectiveness of care planned interventions, B) Complete required assessments and follow-up after a fall, C) Accurately complete Minimum Data Set (MDS) assessments, and D) Track incidents and accidents as an aspect of Quality Assurance (QA) for 1 resident (Resident #69) out of 18 residents reviewed for quality care. Findings: Resident #69 (R69) Review of an admission Record reflected R69 admitted to the facility from the hospital following a stroke which resulted in hemiplegia and hemiparesis (loss of strength or paralysis on one side of the body) and high blood pressure. During an interview and observation on 10/29/2024 at 10:26 AM, R69 reported he had concerns related to understanding what level of function he could perform on his own. R69 was seated in a wheelchair when he reported that he took pride in making his own bed and transferring himself to the bathroom using a quad cane. R69 reported…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess and monitor a wound for 6 weeks for 1 Resident (R28) of 2 residents reviewed for pressure ulcers, resulting in the potential of R28's pressure ulcer to worsen due to missed assessments. Findings: Resident #28 Review of an admission Record revealed R28 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region, End Stage Renal Disease, Flaccid Hemiplegia Affecting Right Dominant Side, Colostomy, Disorganized Schizophrenia, and Anxiety Disorder. Review of a Minimum Data Set (MDS) assessment for R28, with a reference date of 8/15/24 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated R28 was moderately cognitively impaired. Further review of R28's MDS reflected she is at risk for pressure ulcers and currently had an Unhealed Pressure Ulcer. The record reflected she had 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure licensed staff carried out physician orders according to professional standards for the care of residents who receive enteral feeding for one resident (Resident #73), out of one resident reviewed for tube feeding from a total sample of 18 residents. Findings include: Resident #73 (R73) Review of an admission Record reflected R73 admitted to the facility with diagnoses that included non-traumatic intracerebral hemorrhage (stroke), hemiplegia and hemiparesis (partial or complete paralysis on one side of the body) following a stroke, difficulty walking, and dysphasia. Review of a Minimum Data Set (MDS) assessment dated [DATE] reflected R73 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 11/15. Review of physician orders on the October 2024 Medication Administration Record (MAR) reflect: Enteral Feed Order every shift related to DYSPHAGIA FOLLOWING UNSPECIFIED CEREBRAL VASCULAR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, the facility failed to maintain complete and accurate medical records for 2 of 18 sampled residents (R8 and R12), resulting in the potential for providers not having an accurate and complete picture of the resident's stay at the facility. Findings include: R8 A review of R8's admission Record, dated [DATE], revealed that R8 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R8's admission Record revealed they had multiple diagnoses that included anxiety, depression, obsessive compulsive disorder (OCD), schizophrenia, and post-traumatic stress disorder (PTSD). A review of R8's electronic medical record (EMR), dated [DATE] to [DATE], revealed the facility had completed a Pre-admission Screening and Resident Review (PASARR) Level I Screening on [DATE]. R8's PASARR Level I Screening indicated that a Level II Evaluation (a comprehensive evaluation that is conducted to confirm or rule out a serious mental illness, intellectual disability, or related conditions and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) according to facility policy for one resident (Resident #73) out of 18 residents reviewed for infection control from a total sample of 18 residents. Findings: Resident #73 (R73) Review of an admission Record reflected R73 admitted to the facility with diagnoses that included non-traumatic intracerebral hemorrhage (stroke), hemiplegia and hemiparesis (partial or complete paralysis on one side of the body) following a stroke, difficulty walking, and dysphagia. Review of a Minimum Data Set (MDS) assessment dated [DATE] reflected R73 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 11/15. During an interview on 10/30/24 at 9:40 AM, R73 said he did not know anything about a sign on his door indicating he was in Enhanced Barrier Precautions (EBP) and said staff do no wear a gown when providing direct care. Review of R73's October 2024 Treatment…

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 #MI00143516 Based on observation, interview, and record review, the facility failed to ensure effective hot water sanitization of resident dishes, utensils and facility cookware. Findings: Review of the 2017 Food Code reflected Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the warewashing (dishwashing) machine meet or exceed the required 71°C (160 degrees Fahrenheit (F)). On 7/24/24 an observation, interview, and record review were conducted of the operation of the facility dishwashing machine. Dietary Manager (DM) G initiated a wash and rinse cycle after placing a surface temperature measuring device called a puck into the machine. While the temperature gauge of the incoming hot water reflected 194 degrees F the puck revealed a dishware surface temperature of 149.5 F. A repeat test reflected a puck result of 155.6 degrees F. Review of the facility High Temperature Dish Machine Logs from May 2024 to date of July 2024 reflected consistent recorded Daily Puck Temp of less than 160 degrees…

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 # MI00145822 Based on interview and record review, the facility failed to implement the mechanical lift transfer of one Resident (R105) in accordance with the facility policy. Findings: Review of the Electronic Medical Record (EMR) admission Record reflected R105 admitted to the facility 5/16/24 with diagnoses that included: Parkinson's Disease, Arthritis, and Anxiety. The Minimum Data Set (MDS) dated [DATE] reflected R105 was dependent on staff assistance for toilet use. Review of the facility five-day investigation reflected on 7/15/24, R105 had complained of a bruise to her left hand. The facility investigation reflected that on 7/14/25, R105 was transferred by a mechanical lift to and from the bathroom toilet by Certified Nurse Aide (CNA) D. The facility investigation reflected that R105 reported that CNA D was moving too fast, was in a hurry, and her left hand had been grabbed resulting in a bruise. This report reflected the Medical Provider, law enforcement, and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure proper storage of food and clean and sanitary supplies; 2. Clean food and non-food contact surfaces to sight and touch; 3. Properly store food product under refrigeration; and 4. Ensure proper instillation of an air gap on food contact equipment. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 74 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the kitchen, at 8:15 AM on 10/16/23, it was observed that two boxes of shell eggs were found stored on the middle shelf above cartons of milk. When asked if these eggs were appropriately stored, Dietary Manager H stated he will move the eggs to the bottom. During a tour of dining room one nourishment room, at 9:20 AM on 10/16/23, it was observed that paper towels and chemical containers were stored underneath the wastewater line of the sink. During a tour of dining…

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 monthly pharmacy drug regimen review recommendations were reviewed by the physician and/or acted upon in a timely manner for 3 of 5 residents reviewed (R23, R59, and R62), resulting in the potential for the physician not knowing of a pharmacy recommendation, the potential for a delay in implementing a pharmacy recommendation, and the potential for adverse effects from medications that the pharmacy identified as potential medication issues. Findings include: Resident #59 (R59) A review of R59's admission Record, dated 10/17/23, revealed R59 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R59's admission Record revealed multiple diagnoses that included depression and paraphilia (a mental disorder). A review of R59's MDS, dated [DATE], revealed a BIMS score of 11 which indicated R59 was moderately cognitively intact. A review of R59's pharmacy recommendation report, dated 12/12/22, revealed the pharmacist recommended…

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.

On 10/16/23 at 0:23 AM a review was conducted of the 400 Hall medication cart with Licensed Practical Nurse (LPN) L. Review of the top drawer of the 400 Hall medication cart revealed an in-use undated Humalog Quick pen for Resident #17 (R17). LPN L reported that insulin devices are to be dated when first placed in service. On 10/17/23 at 11:30 AM a review was conducted of the 300 Hall medication cart with LPN B. Review of the top drawer of this medication cart revealed an in-use vial of Lispro insulin for R40. The vial was dated 9/1. LPN B reported that insulin vials are to be dated when opened and are good for twenty-eight or thirty days. Further review of the top drawer of the medication cart revealed a Novolog insulin pen dated 9/15/23 also for R40. A Novolog insulin pen for R33 was observed to be undated. Review of the Doctor's Orders for R17, R33, and R40 reflected all Residents have current orders for insulin. Review of the Manufacturer's instructions for Humalog and Lispro insulin devices and vials reflect these be discarded after 28 days after first use even if it still has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a clean, sanitary, and comfortable environment in one soiled utility room (100 Hall), one shower room (200 Hall), one clean utility room (200 Hall), and four resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]), resulting in an unclean, unsanitary, and uncomfortable environment. Findings include: During an observation on 10/15/23 10:00 AM, the bathroom floor in room [ROOM NUMBER] was observed to have brownish black stain/soiling on the floor in front of toilet measuring approximately 29 inches by 29 inches. Stool and urine were observed on the toilet bowl rim and under the toilet seat. Urine and stool were also observed on the over-the-toilet chair seat. During an observation on 10/15/23 at 1:00 PM, dried bowel movement splash was observed on the toilet bowl (inner portion) and toilet seat, and accumulation of debris was observed on the underside of the toilet chair in the bathroom of room [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 interview and record review, the facility failed to coordinate with the appropriate, State-designated authority, to ensure that 1 of 2 residents (R33) reviewed received timely follow-up PASSAR II evaluations, resulting in the potential for a delay in care and services appropriate to their needs. Findings include: A review of R33's admission Record, dated 10/16/23, revealed R33 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R33's admission Record revealed multiple diagnoses that included mild intellectual disabilities. A review of R33's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 7/26/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R33 was cognitively intact. A review of R33's Preadmission Screening/Annual Resident Review (PASSAR), dated 3/29/22, revealed R33 was screened (Level 1 screening) and qualified for a comprehensive assessment (Level…

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 fresh water and a call light were accessible for one physically and cognitively impaired Resident (R25) resulting in thirst, inability to request assistance, anxiety, and the potential for all facility residents to not be monitored or assisted with activities of daily living. Findings: Review of the Minimum Data Set (MDS) dated [DATE] reflected R25 admitted to the facility 11/18/22 and had current diagnoses that included: Neurological Disorders, Renal Insufficiency, Dementia, and Anxiety. The MDS reflected a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R25 was cognitively impaired. Review of this MDS Section G (Functional Status) revealed that R25 required the assistance of two staff members for bed mobility and transfers and required set-up help for eating and drinking. On 10/15/23 at 3:24 PM, R25 was observed supine in her bed. R25 stated I need water, repeating I'm so thirsty. R25 reported 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an Activities program was implemented to meet the interests and needs for two Residents (R475 and R47) resulting in a lack of life enrichment and the potential for social isolation and boredom for these and all facility residents. Findings: Review of the medical record reflected R475 admitted to the facility 8/1/2003 with pertinent diagnoses that included Traumatic Brain Injury (TBI), Dementia, Anxiety and Depression. Review of the Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R475 was cognitively impaired. Section B of this MDS reflected R475 is usually understood and understands. Review of the Care Plan reflected that R475 is dependent for meeting emotional, intellectual, physical, and social needs with a Goal that The resident will attend/participate in activities of choice multiple times weekly . Interventions include . 1:1(one on one) bedside/in…

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

Based on observation the facility failed to discard expired tube feeding supplements. These conditions resulted in an increased risk for contaminated foods and an increased risk of food borne illness for individuals who are prescribed these specific supplements. Findings include: During a tour of the facility, with Regional Housekeeping Manager I, at 11:07 AM on 10/16/23, it was observed that the facility storage closet on the 300 hall was found with boxes of expired tube feeding medications. Observation of the storage room found the following expired tube feeding supplies stored on the bottom shelf of an open wire rack: three bottles of Osmolite with a best by date of 1APR2022, one box (six to a box) of Osmolite with a best by date of 1JAN2023, one box of Osmolite with a best by date of 1FEB2023, one box of Osmolite with a best by date of 1MAR2023, one box of Osmolite with a best by date of 1JUN2023, one box of Nepro with a best by date of 1APR2022, two boxes of Nepro with best by dates of 1AUG2023, one box of Nepro with a best by date of 1SEP2023.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure oxygen tubing was changed for one Resident (R21) resulting in the potential for infection and failure to follow facility protocol and the potential for all facility residents that use oxygen devices to not have them properly maintained. Findings: Review of the medical record reflected R21 was admitted [DATE] with pertinent diagnoses that include Respiratory Failure and Chronic Obstructive Pulmonary Disease. During an observation conducted 10/15/23 at 10:44 AM, R21 was observed lying in bed with the resident receiving oxygen via nasal cannula tubing. R21's nasal cannula tubing was observed attached to his oxygen concentrator and the tubing was dated 10/08/23. Review of R21's Physician orders reflected, Oxygen Equipment Management 6/6/23 at 16:54 --change out, date & label all tubing/bags/set ups .clean filter and wipe down machine every night shift every Sun for cleaning routine. During an observation on 10/16/23 at 8:33 AM, R21 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% for 2 of 5 residents (R44 and R59) observed for medication administration, resulting in a medication error rate of 6.8% (2 errors from 29 opportunities). Findings include: A review of R59's admission Record, dated 10/17/23, revealed R59 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R59's admission Record revealed multiple diagnoses that included diabetes. During an observation on 10/16/23 at 07:50 AM, Licensed Practical Nurse (LPN) B administered multiple medications to R59, including 20 units of Humalog (insulin lispro- a short-acting insulin) from an insulin pen. Prior to the administration of the Humalog to R59, LPN B did not prime the insulin needle on the Humalog insulin pen to ensure there was not any air in the needle. LPN B just dialed in 20 (20 units) on the pen and administered the insulin. During an interview on 10/17/23 at 08:29 AM, LPN C stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate medical records for 4 residents (R21, R33, R59, and R62), resulting in incomplete and inaccurate medical records and the potential for providers not having an accurate and complete picture of the resident's stay at the facility. Findings include: Resident #33 (R33) A review of R33's admission Record, dated 10/16/23, revealed R33 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R33's admission Record revealed multiple diagnoses that included mild intellectual disabilities. A review of R33's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 7/26/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R33 was cognitively intact. A review of R33's Pharmacist Medication Regimen Review forms, dated 8/1/22 to 10/17/23, revealed the pharmacist had prepared a report for any noted…

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.