Roosevelt Park Nursing and Rehabilitation Communit

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to submit and ensure an accurate and timely Minimum Data Set (MDS) for 1 Resident (R11) of 4 residents reviewed for Resident Assessments.Findings: R11A review of R11's Face Sheet, dated [DATE], revealed the resident admitted to the facility on [DATE] and expired on [DATE]. R11's Face Sheet revealed they had multiple diagnoses that included Alzheimer's disease, anxiety disorder, spinal stenosis, Chronic Obstructive Pulmonary Disease and Squamous Cell Carcinoma on skin of scalp and neck. Review of R11's progress notes revealed he expired on [DATE]. During an interview on [DATE] at 12:25 PM, MDS Coordinator P revealed they had not completed a Discharge MDS for this resident and the last MDS completed was his admission MDS on [DATE]. During an interview on [DATE] at 12:33 PM, Regional Nurse A revealed that [Name of MDS Coordinator] was unsure of the MDS procedure for discharge/death of a resident. Regional Nurse A stated she was now aware that R11 had not…

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

Based on interview and record review, the facility failed to address Pre-admission Screening/Annual Resident Review (PASARR) in a timely manner for 1 Resident (R35) out of 17 reviewed.Findings include:Review of Social Service Policy & Procedure for Pre-admission admission PROCESS reviewed Date 01/25, revealed, Social Services we'll review each potential resident's Sycho social and behavioral needs and Pre-admission Assessment and Annual Resident Review (PASARR) as available from the referral Source prior to determining appropriateness of placement. Procedure: . 2. Social Services will ensure that the referring party obtains a Level 2 PASARR screening, when indicated. 3. Social services will determine the needed facility services and programs to meet the potential resident's psychosocial and behavioral needs based upon pre-admission assessment and PASARR information.Review of facilities form CMS-802 Matrix for Providers failed to reflect residents that required a PASARR Level II.R35Review of R35's Electronic Medical Record (EMR) on 3/31/26 at 9:34 AM revealed PASARR Level I 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 daily care for one (R14) of one resident reviewed for cares of a dependent resident. Findings include:Review of a Face Sheet revealed R14 originally admitted to the facility on [DATE] and had pertinent diagnoses of hemiplegia and hemiparesis (one-sided weakness), vascular dementia, and blindness in right eye. Review of the Care Plan revealed R14 is severely cognitively impaired. During an observation on 3/30/26 at 9:49 AM, R14 was lying in bed, and his hands appeared to be contracted. Hand splints were observed sitting across the room on a table. In an interview on 3/30/26 at 12:31 PM, the Guardian of R14 reported concerns of not having a care conference in a long time to review R14's care. The Guardian reported concerns of R14 not being provided oral care. The Guardian reported she had concerns of R14 being in bed all day and not attending activities. R14 liked religious activities like singing gospel songs and church activities.…

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 oxygen tubing was dated for 1 (R20) and the oxygen concentrator filter was clean for 1 (R14), of 2 residents reviewed for respiratory devices.Findings include: R20 A review of R20's Face Sheet, dated 3/31/26, revealed resident admitted to the facility on [DATE] with diagnosis that included Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, and Interstitial Pulmonary Disease. An observation on 03/30/2026 at 10:19 AM, revealed R20 was receiving 4.5 L of oxygen via nasal canula. The oxygen tubing was observed to be undated. An observation on 3/31/2026 at 08:26, revealed R20 was in her wheelchair receiving oxygen via nasal cannula. The oxygen tubing was observed to be undated. Review of physician orders reflected, Oxygen tubing to be changed weekly and dated. Clean oxygen filter weekly. Once A Day on Sun 01/02/2024 - Open Ended. During an interview on 03/31/2026 at 11:51 AM, Regional Nurse A stated, Oxygen tubing 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 timely notify necessary parties, provide support and follow-up for 1 Resident (R27) out of 3 Residents having a psychosocial adjustment difficulty causing delay in care, services and the potential for further psychosocial, mental, and potential physical harm. Findings include:R27A review of R27's Face Sheet, dated 4/1/26, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. R27's Face Sheet further revealed they had multiple diagnoses that included chronic diastolic (congestive) heart failure, macular degeneration, paroxysmal atrial fibrillation, muscle weakness, need for assistance with personal care and chronic kidney disease.A review of R27's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 2/19/26, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 14 which revealed R27 was cognitively intact.Review of R27's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly label medications in 1 of 1 medication carts inspected (West Medication Cart). Findings include: During an observation on 03/20/26 at 2:29 PM, the medication cart was inspected with Licensed Practical Nurse (LPN) S. The following observations and interviews were made: - An albuterol sulfate HFA box had 37D (a room number) written on it. However, the box and the inhaler did not have any pharmacy labels (they had been torn off) or identifying information that would indicate who the inhaler belonged to if it should become separated from the box and/or an open/discard date on the inhaler. LPN S stated she did not know who the inhaler belonged to (whether it was the resident in room [ROOM NUMBER]D or a resident that had previously been in that room). - A fluticasone propionate 50 mcg nasal spray had 16 (a room number) written on the box. However, the box and the nasal spray did not have any pharmacy labels or identifying information…

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 1 of 17 sampled residents (R9). Findings include: A review of R9's Face Sheet, dated [DATE], revealed R9 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R9's Face Sheet revealed they had multiple diagnoses that included bipolar disorder, mild cognitive impairment, cognitive communication deficit, obsessive-compulsive disorder (OCD), depression, and dementia with psychotic disturbance. A review of R9's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 4 which revealed R9 was severely cognitively impaired. A review of R9's electronic medical record (EMR), dated [DATE] to [DATE], revealed R9 had Letters of Guardianship (a court document appointing a guardian to a resident who is unable to make medical decisions) 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 This citation pertains to intake # 2614154Based on interview and record review, the facility failed to prevent misappropriation of residents narcotic medication for 2 residents (Resident #1 and #2) and monitor and investigate the potential/ongoing misappropriation of resident narcotic medication for 4 residents (Resident #2, #3, #4, and #6) out of 7 residents reviewed for the misappropriation of narcotics, resulting in the diversion of narcotic medications and the potential for ongoing diversion of narcotic medications. Findings:Resident #1 (R1)Review of an admission Record revealed R1 was a [AGE] year-old male, admitted to the facility on [DATE].Review of R1's Order Summary dated 3/3/22 revealed, Norco (hydrocodone-acetaminophen) tablet; 10-325 mg; amt: 1; oral Three Times A Day; 07:00 AM, 01:00 PM, 07:00 PM.Review of R1's Controlled Substances Proof of Use sheet in the column Quantity Remaining revealed:*On 8/22/25 at 7:20 AM there were 19 tabs of Norco remaining.*On 8/22/25 at 11:42 AM (the next entry) there…

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 implement a system to prevent, recognize, and control the onset and spread of infection among staff and residents. Findings: Per the CDC, a norovirus outbreak is defined as an occurrence of two or more similar illnesses resulting from a common exposure that is either suspected or laboratory-confirmed to be caused by norovirus . Exclude ill personnel from work for a minimum of 48 hours after the resolution of symptoms. Resident #20 (R20) Review of an admission Record revealed R20 was a [AGE] year-old female, admitted to the facility on [DATE]. Review of the Resident Infection Control Log revealed that R20 began having gastrointestinal symptoms on 2/24/25 with a positive result of norovirus on 2/28/25. Review of the Employee Infection Control Log revealed: *On 2/23/25 a Certified Nursing Assistant exhibited gastrointestinal symptoms with aches/pain, nausea, and vomiting. There was no order for culture to confirm a norovirus diagnosis. Last symptom 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 call light placement within reach of two (Resident #26 and Resident #27) of two residents reviewed for accommodation of needs. Findings: Resident #26 Review of a Face Sheet revealed R26 was an [AGE] year old female, originally admitted to the facility on [DATE], with pertinent diagnoses of dementia and the need for assistance with personal care. During an observation on 06/03/25 at 9:30 AM, R26 laid in bed resting with her eyes closed and the call light hung between the foot of the bed and the wall, curled up into a knotted cord, out of sight and out of reach of the resident. During an observation on 06/04/25 at 7:49 AM, R26 laid in bed resting with her eyes open and the call light hung between the foot of the bed and the wall, curled up into a knotted cord, out of sight and out of reach of the resident. During an observation on 06/04/25 at 9:03 AM, R26 laid in bed with her eyes open, an uncovered and untouched breakfast tray sat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 4 of 13 residents (Resident #21, #24, #20, and #136), reviewed for the provision of nursing services. Findings: Resident #21 (R21) Review of an admission Record revealed R21 was an [AGE] year-old male, admitted to the facility on [DATE]. Review of R21's Order Summary dated 03/24/2025 revealed, metoprolol tartrate tablet; 25 mg; Amount to Administer: ONE; oral Twice A Day HOLD FOR SBP<125 (Systolic Blood Pressure [top number] less than 125) AND/OR HR <60 (heart rate less than 60). To be administered between 6:00 AM-10:00 AM and 6:00 PM-10:00 PM Review of R21's Pulse Summary revealed: *No heart rates assessed from 5/1/25-5/6/25 *No heart rates assessed from 5/9/25-5/12/25 *No heart rates assessed from 5/14/25-5/16/25 *No heart rates assessed from 5/18/25-5/23/25/5/25/25-5/26/25 *No heart rates assessed from 5/28/25-5/30/25 *No heart rates assessed in June Review of R21's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet resident needs for 3 of 13 residents (Resident #3, #5, and #10) and residents participating in resident council, reviewed for quality of care. Findings: Resident #3 (R3) Review of an admission Record revealed R3 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Need for assistance with personal care, muscle wasting and atrophy, and contractures. Review of a Minimum Data Set (MDS) assessment for R3, with a reference date of 2/25/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R3 was cognitively intact. During an interview on 06/03/25 at 11:04 AM, R3 reported that there was a significant staff shortage for 2nd shift resulting in long wait times for care. R3 reported at times there are only 2-3 CNAs (Certified Nursing Assistants) for the entire building. R3 reported it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to 1.) administer controlled medications and 2.) accurately document the administration of controlled drugs for 4 of 13 residents (Resident #14, #83, #7, and #20) reviewed for medication administration. Findings: Resident #14 (R14) Review of an admission Record revealed R14 was a [AGE] year-old female, admitted to the facility on [DATE]. Review of R14's Order Summary dated 05/21/2024 revealed, pregabalin (Lyrica) - Schedule V capsule; 100 mg; amt: 1 cap; oral Twice A Day. To be administered between 06:00 AM-10:00 AM and 06:00 PM-10:00 PM Review of R14's Controlled Substances Proof of Use form revealed: *On 5/19/25 R14's morning and evening dose of Lyrica was not dispensed. *On 5/20/25 R14's morning and evening dose of Lyrica was not dispensed. *On 5/21/25 R14's morning dose of Lyrica was not dispensed. Review of R14's May Medication Administration Record revealed all doses of Lyrica were administered on 5/19/25, 5/20/25, and 5/21/25. Review of R14's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer evening snacks for two (Resident #17 and Resident #5) of two residents, and to those residents that attend the monthly resident council meetings. Findings: Resident #17 (R17) Review of a Face Sheet revealed R17 was a [AGE] year old female, originally admitted to the facility on [DATE], with pertinent diagnoses of difficulty walking, the need for assistance with personal care, hearing loss, and a stroke. During an interview on 06/03/25 at 2:08 PM, R17 stated that she was not offered evening snacks. Review of the electronic health record (EHR) revealed R17 was not offered evening snacks from 01/01/25 to 06/03/25. Review of the facility form Meals and HS (evening) snack times reflected that evening snack time was designated at 7:30 PM. Resident #5 (R5) Review of an admission Record revealed R5 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Bipolar Disorder. Review of a Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain and clean a safe environment for all resident's that visited or utilized the activity room. Findings: During an observation on 06/05/25 at 7:49 AM, the cabinets under the sink in the activity room were not secured and contained one container of bleach wipes, two bottles of Clorox bleach spray, one plastic bottle with odor eliminator hand written on it, one bottle of glass cleaner, and one bottle of TB quat disinfectant. A sign hung under [NAME] the sink that read nothing can be stored under the sink. During the same observation, the two cupboard to the left of the sink were in disrepair. Particle boards were broken apart and covered with a black mildew looking substance. During an interview on 06/05/25 at 8:10 AM, Activity Director (AD) D indicated that maintenance and the administrator were aware that the cupboards needed to be repaired or replaced. It looks like mold in there. AD D also indicated that the maintenance director had indicated 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 Resident #10 (R10) Review of an admission Record revealed R10 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Cerebral Infarction (stroke), epilepsy, chronic pain syndrome, dysphagia (difficulty swallowing). Review of R10's Care Plan revealed: Problem Start Date: 06/10/2024 (R10) is unable to follow structured activity .Goal-(R10) will appear comfortable and satisfied with their daily facility activities/routine. (R10's) preferences will be honored to extent possible. Encourage (R10) to get up in his wheelchair daily and attend activities of interest . Approach Start Date: 06/10/2024 Assist (R10) with locating favorite TV show or channel as needed. Per sister (R10) will watch whatever is on the TV. He does enjoy sports mainly baseball and Westens (sic) . Approach Start Date: 06/10/2024 .Offer activities such as reading poetry or scripture, gentle hand massages, reminiscing/story telling, singing, listening to music, looking at photographs, etc. 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 interview and record review, the facility failed to adequately monitor and ensure residents were free from adverse drug reactions (extrapyramidal symptoms) for 2 of 13 residents (Resident #12 and #5) reviewed for psychotropic medication use. Findings: Review of the facility policy, Psychotropic Medication Use last reviewed 01/2025 revealed, .5. Residents who use psychotropic medications will have an Abnormal Involuntary Movement Scale performed on admission, quarterly, with a significant change in condition, change in antipsychotic medication and PRN (as needed) . Resident #12 (R12) Review of an admission Record revealed R12 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Bipolar Disorder and a traumatic brain injury. Review of R12's Order Summary dated 12/21/24 revealed, chlorpromazine ( typical antipsychotic used to treat psychotic disorders) tablet; 200 mg; amt: 0.5 tablets =100 mg; oral Special Instructions: Take 0.5mg (100 mg) total by mouth…

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 prompt nursing care and services were provided to assist 1 of 13 residents (Residents #10) reviewed for Activities of Daily Living (ADL) care. Findings: Resident #10 (R10) Review of an admission Record revealed R10 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Cerebral Infarction (stroke), epilepsy, chronic pain syndrome, dysphagia (difficulty swallowing). Review of R10's Care Plan revealed, Long Term Goal Target Date: 09/13/2025 (R10) will be clean/well-groomed daily and will participate in cares to his fullest ability. (R10's) preferences will be honored to the extent possible. Approach Start Date: 02/11/2025 Staff assist and encourage to get up in the broda chair daily. Approach Start Date: 07/02/2024 Status of mobility: up in recliner/broda Approach Start Date: 07/02/2024 Status of personal items: No teeth, needs oral care, up in broda chair. Has a peg tube. 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 provide preventative care, consistent with professional standards of practice, for 1 resident (Resident #10) out of 13 residents reviewed for the development of pressure injuries. Findings: Resident #10 (R10) Review of an admission Record revealed R10 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Cerebral Infarction (stroke), epilepsy, chronic pain syndrome, dysphagia (difficulty swallowing). Review of R10's Braden Scale for Prediction of Pressure Sore Risk dated 6/2/25 revealed a score of 12 indicating R10 was at High Risk for skin breakdown. During an observation and interview on 06/03/25 at 11:08 AM, R10 was in his broda chair (chair utilized for residents with limited mobility and can recline). R10 loudly exclaimed, I'm tired of hurting and you act like I'm not in pain. When asked where he was experiencing pain R10 stated, my nuts (scrotum). Family Member (FM) L reported R10 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 ensure interventions were in place to prevent the worsening of a contractures for 1 of 13 residents (Resident #10) reviewed for position, mobility, and splint use. Findings: Resident #10 (R10) Review of an admission Record revealed R10 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Cerebral Infarction (stroke), epilepsy, chronic pain syndrome, dysphagia (difficulty swallowing). During an interview on 06/04/25 at 10:54 AM, Family Member (FM) L reported that R10 was to have splints on his both of his hands during the day, but he had them in months and was unsure what had changed. Review of R10's Progress Note dated 10/30/2024 at 09:23 AM revealed, Per social services, (R10's) guardian emailed asking about hand rolls or splints for his hands. He does have some contractures noted to his hands. This nurse emailed therapy manager for OT (occupational therapy) eval. Order in (electronic…

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 perform a root cause analysis and implement meaningful interventions/preventative measures following a fall for 1 of 13 residents (Resident #10) reviewed for accidents and hazards. Findings: Resident #10 (R10) Review of an admission Record revealed R10 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Cerebral Infarction (stroke), epilepsy, chronic pain syndrome, dysphagia (difficulty swallowing). During an interview on 06/03/25 at 11:30 AM, Family Member (FM) L reported she had not been notified of the root cause of R10's fall. FM L reported she felt the fall was suspicious and had concerns with how it could have occurred. FM L reported she had been advocating for a curved (scoop) mattress because R10 would frequently push the bolster/wedges off of the bed. During an observation on 06/04/25 at 06:15 AM, R10 was in bed on his back with his knees up facing towards the window. The bolster/wedge 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 follow safety guidelines for two (Resident #83 and Resident #10) of two residents reviewed for tube feeding. Findings: Resident #83 (R83) Review of a Face Sheet revealed R83 was an [AGE] year old female, originally admitted to the facility on [DATE], with pertinent diagnoses of a recent pelvic fracture, stroke, and dependence on tube feeding for nutrition and hydration. During an observation on 06/03/25 at 8:57 AM, R83 laid flat in bed, the tube feed pump ran, and the resident received a bed bath from certified nurse aide (CNA) A. CNA A paused the tube feed at 9:09 AM, disconnected the tubing from the nasogastric tube (NG), capped the end of the NG tube, and laid the tubing from the pump uncapped, on the bedside table with the end of the tubing draped over the back of the bedside table. At 9:12 AM, CNA A reconnected the tubing for the tube feed to the NG tube without cleaning the ends of either tubing, and raised the head of the bed to 30…

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 sufficient pain management was provided for 1 of 13 residents (Resident #10) reviewed for pain management. Findings: Resident #10 (R10) Review of an admission Record revealed R10 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Cerebral Infarction (stroke), epilepsy, chronic pain syndrome, dysphagia (difficulty swallowing). During an observation and interview on 06/03/25 at 11:08 AM, R10 was in his broda chair (chair utilized for residents with limited mobility and can recline). R10 loudly exclaimed, I'm tired of hurting and you act like I'm not in pain. When asked where he was experiencing pain R10 stated, my nuts. Family Member (FM) L was present in his room and reported R10 had been complaining of increased pain and an increased frequency of pain, so tramadol was started but immediately discontinued. FM L reported that she had requested the use of a different pain…

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 implement the antibiotic stewardship program for 1(Resident #138) of 7 residents reviewed for antibiotic use. Findings: Resident #138 (R138) Review of an admission Record revealed R138 was a [AGE] year-old female, admitted to the facility on [DATE]. Review of R138's Order Summary revealed, cephalexin capsule; 500 mg; Amount to Administer: 1 capsule; oral Twice A Day Take 1 capsule twice a day for 7 days. From 04/05/2025 - 04/12/2025 Review of R138's McGeer's Criteria dated 4/6/25 revealed, .Criteria 1. MUST HAVE at least 1 of the following with no symptoms document (left unchecked) Criteria 1a. Acute dysuria or acute pain, swelling, or tenderness of the testes, epididymis, or prostate dysuria documented. Criteria 1b. Fever or leukocytosis (left unchecked indicating no fever or leukocytosis) Criteria 1c. In the absence of fever or leukocytosis, MUST HAVE 2 or more of the following with no symptoms document (left unchecked) Criteria 1d. Fever or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the influenza vaccine and pneumococcal vaccines were offered and administered for 3 of 5 residents (Resident #15, #10, and #24), reviewed for immunizations. Findings: Resident #15 (R15) Review of an admission Record revealed R15 was a [AGE] year-old female, admitted to the facility on [DATE]. Review of R15's Electronic Medical Record revealed no documentation of R15's last influenza immunization or pneumococcal immunization. There was no consent or other supporting documentation of the last time it was administered, offered, or declined. Resident #10 (R10) Review of an admission Record revealed R10 was a [AGE] year-old male, admitted to the facility on [DATE]. Review of R10's Electronic Medical Record revealed no documentation of R10's last influenza immunization or pneumococcal immunization. There was no consent or other supporting documentation of the last time it was administered, offered, or declined. Resident #24 (R24) Review of an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes #'s: MI00149655 and MI00149651 Based on interview and record review, the facility failed to 1.) prevent misappropriation of residents narcotic medication and drug diversion for 4 residents (Resident #8, #7, #3, and #4) and 2.) monitor and investigate the potential/ongoing misappropriation of resident narcotic medication for 3 residents (Resident #3, #4, and #5) out of 7 residents reviewed for the misappropriation of narcotics. Findings: INCIDENT #1 Resident #8 (R8) Review of an admission Record revealed R8 was a [AGE] year-old male, admitted to the facility on [DATE] and discharged on 1/20/25. Review of a Facility Reported Incident (FRI) revealed, .On 1/4/2025 at approximately 4:45p, the (Name of police department arrived at the facility to inform (name of facility) that during a routine traffic stop, (RN E) [Registered Nurse (RN) E] was found to have medications belonging to resident, (R8) . In the police report it was listed that (RN E) was found in the procession of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation refers to MI00147558. Based on interview and record review, the facility failed to maintain complete and accurate medical records for 2 of 4 residents (R2 and R4), resulting in the potential for providers not having an accurate and complete picture of the resident's stay at the facility. Findings include: R2 A review of R2's Face Sheet, dated 11/25/24, revealed R2 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, Resident 2's admission Record revealed multiple diagnoses that included delusional disorders, severe depression with psychotic symptoms, post-traumatic stress disorder (PTSD), and personality disorder. A review of R2's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 11/21/24, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 7 which revealed R2 was severely cognitively impaired. A review of the facility's investigation summary documentation (an internal…

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 sanitary conditions in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include: During an initial tour of the kitchen, starting at 9:03 AM on 7/1/24, it was observed that the top portion of the door seals of the two door Traulson freezer were found with an increased accumulation of crumb and dirt debris and shown to Dietary Supervisor (DS) G. During a revisit to the kitchen, at 8:02 AM on 7/2/24, it was observed that the top portion of the door seals of the two door Traulson freezer were found with an increased accumulation of crumb and dirt debris. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. During the initial tour of the kitchen, at 9:29 AM on 7/1/24, it was observed that the internal thermometer inside of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two Deficient Practice Statements (DPS) DPS 1: Based on interview and record review, the facility failed to 1) Implement a system to prevent, recognize, and control the onset and spread of infection among residents for 3 residents (Resident #33, Resident #37, and Resident #21) and 2) Investigate, document surveillance of, and implement preventative measures to address an outbreak of a respiratory illness among staff and residents. Findings include: Review of the [DATE] Resident Infection Control Log revealed 2 residents were listed due to the use of antibiotics. There was no other tracking related to residents with infectious symptoms. Review of the Electronic Health Record revealed 3 additional residents were identified as being prescribed antibiotics in the month of [DATE] and were not accounted for on the Resident Infection Control Log. Resident #33 (R33): Review of an admission Record revealed R33 was a [AGE] year-old male, admitted to the facility on [DATE]. Review of R33's Order Summary…

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 for all residents. Findings include: During a tour of the Utility Pantry, at 10:08 AM on 7/1/24, with Dietary Supervisor G and Dietitian F, it was observed that the cabinets were found to be deteriorating and falling apart from the base and underside of the unit. It was observed that water damage had occurred over time in the bottom of the cabinetry and had worn down surfaces. Further observation found a large hole in the wall behind a stainless-steel panel that was covering up plumbing between the ice machine and the cabinets. The stainless-steel cover did not seal the hole to minimize the entrance of pests. During a tour of the facility, with Maintenance Director (MD) E, starting at 11:28 AM on 7/1/24, it was observed that the storage room containing nursing and tube feeding supplies,…

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 accommodate the needs of 3 out of 3 residents reviewed ( Resident #10, Resident #4, and Resident #18) and several reported unmet needs at the Resident Council Meetings, when staff did not assist a resident to get out of bed throughout the day, did not consistently offer and pass out evening snacks or fresh water on each shift, and by not answering call lights in a timely manner. Findings: Resident #10 (R10): Review of a Face Sheet revealed R10 was [AGE] year old male, admitted to the facility on [DATE], with pertinent diagnoses of a stroke causing left sided weakness and paralysis and blindness in right eye. R10 requires assist from two staff persons to transfer out of bed. During an observation on 07/01/24 at 9:38 AM, R10 laid in bed with eyes open and TV on. During an observation on 07/01/24 at 12:40 PM, R10 laid in bed with eyes closed. R10 was uncovered, had a tee shirt pulled up over the umbilicus and wore only a brief. There were no…

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

During a tour of the facility, at 11:35 AM on 7/1/24, it was found that the hot water from the central spa hand sink was found to reach 123.9F when tested with a rapid read thermometer. An interview with Maintenance Director (MD) E, at 11:40 AM on 7/1/24, found that he takes hot water temperatures in the morning and there is multiple hot water systems in the building. One servicing the west end, one for the east end, and one for the kitchen. When asked what hot water system supplies the Central spa room, MD E stated it was the west end water heater. Observation of the water heater for the west end of the building, at 11:46 AM on 7/1/24, found that the water heater goes through a mixing valve before supplying care areas on the floor. At this time, the thermometer showed outgoing water at 120F and MD E adjusted the mixing valve to help lower the temperature. During a tour of the dining room, at 9:33 AM on 7/2/24, it was observed that the hot water to the sink was found to reach 126.8F with a rapid read thermometer. Observation under the sink found that it had a point of use mixing…

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 standards of practice for two residents (Resident #10 and Resident #25) receiving hydration and nutrition through a feeding tube. Findings include: Resident #10 (R10): Review of a Face Sheet revealed R10 was [AGE] year old male, admitted to the facility on [DATE], with pertinent diagnoses of a stroke causing left sided weakness and paralysis and blindness in right eye. R10 received all hydration and nutrition through a tube feeding. During an observation on 07/01/24 at 9:38 AM the syringe and plastic basin used to flush the tube feed were dated 06/24/24 and the plunger was stored inside the syringe and not separated out to dry properly. During an observation on 07/01/24 at 12:38 PM, R10's tube feed hung with a kangaroo flush bag that did not have the resident's name, a date or time indicating when it was started, nor the ordered rate. Review of the facility policy Tube Feeding last reviewed 01/2024 revealed: formula and flush bags…

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.) Properly store medications in 1 of 2 medication carts and in 1 of 2 medication storage rooms and 2.) Ensure that a resident's medications were securely stored in a medication cart for one resident (Resident #18). Findings include: During an observation and interview on [DATE] at 10:30 AM, Licensed Practical Nurse (LPN) A had a medication cart at the end of the hallway with 7 open bottles of artificial tears in the carts, 5 of the bottles were opened with no dates indicating when they were opened, one bottle had an opened date of [DATE] and the other bottle had an opened dated of [DATE]. Two bottles of Moisture Eye drops, 1 bottle of Fluconazole nasal spray, 1 bottle of Azelastine nasal spray, a bottle of liquid Famotidine which was opened, and 2 bottles of Dorzolamide eye drops, with no opened dates or proper labeling on the bottles were located inside the medication cart. Also located inside the cart was a large spray bottle with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to offer additional food preferences, and alternative or optional food choices for two residents (Resident #4 and Resident #18) of six residents interviewed. Findings include: An interview with Dietary Supervisor (DS) G at 11:58 AM on 7/1/24, found that menus are posted on the hallway and changed everyday. When asked what options are available for meal service, DS G stated there is a main entree option and the alternate menu for residents to choose from. When asked how residents make choices about what they would like, DS G stated that residents usually tell a nursing staff member who would relay that to the kitchen. When asked if facility staff takes regular orders from residents, DS G stated the kitchen would go by the residents preferences, likes, and dislikes, unless the resident tells us otherwise. A review of the Alternate Meal Choices menu posted outside of the dinning room stated Please let the kitchen know by 11 AM for lunch and 2 PM for Dinner.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the activated medical and financial Durable Power of Attorney (DPOA) was accurately recorded in the medical record for 1 of 6 residents (Resident #24) reviewed for advance directives, resulting in the potential for inappropriate delegation of resident rights to a person not formally authorized to make decisions on behalf of the resident. Findings include: Resident #24 (R24): Review of an admission Record revealed R24 was an [AGE] year-old female, admitted to the facility on [DATE]. Family Member (FM) L was listed as R24's POA (Power of Attorney)-Health Care and Primary Financial Contact. Review of R24's Advance Directive documentation revealed that R24 had been deemed incompetent by 2 physicians and R24's Designated POA's for medical and financial decisions were granted authority to make all financial and medical decisions on behalf of R24. Review of R24's Durable Power of Attorney for Financial Matters documentation revealed FM N was…

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

Based on interview and record review, the facility failed to provide Advance Beneficiary Notices (ABN) and the Notice of Medicare Non-Coverage (NOMNC) for 3 Residents (Resident #12, Resident #19, Resident #40) of 3 residents reviewed for notifications. Findings include: On 7/1/24 during entrance conference a request was made for a list of residents who were discharged from a Medicare covered Part A stay with benefit days remaining in the past 6 months. On 7/1/24 at 2:10 PM, an email correspondence was sent the Nursing Home Administrator (NHA) to provide the ABN and NOMNC notifications for three residents (R12, R19, and R40) who were chosen from the list provided. In an interview on 7/1/24 at 3:22 PM, the NHA and Social Worker (SW) C reported they did not have an ABN or NOMNC for the residents selected. Review of a Policy Provided by the facility revealed: Purpose: To abide by the Social Security Act and protect beneficiaries and [Facility] from unexpected liability for charges associated with claims that Medicare does not pay, and for the purpose of informing the Medicare…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents who required an antibiotic were prescribed the appropriate antibiotic for 3 of 6 residents (Resident #142, Resident #143, and Resident #144) reviewed for antibiotic use, resulting in inappropriate antibiotic utilization and the potential for antibiotic resistance. Findings: Resident #142 (R142): Review of an admission Record revealed R142 was an [AGE] year-old female, admitted to the facility on [DATE]. Review of R142's Order Summary revealed Cipro (ciprofloxacin hcl) tablet; 500 mg; and 250 mg; (Total of 750mg) Twice A Day. Start Date 03/27/2024 - 04/08/2024 Review of R142's Electronic Health Record revealed no culture and sensitivity report (to ensure the antibiotic ordered was effective in treating the bacteria). Resident #143 (R143): Review of an admission Record revealed R143 was a [AGE] year-old male, admitted to the facility on [DATE]. Review of R143's Order Summary revealed, cephalexin (Keflex) 500 mg tablet Four Times 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 interview and record review, the facility failed to ensure that a qualified Infection Preventionist worked at least part-time at the facility, was provided sufficient time to perform the Infection Preventionist role, and was present to properly assess, implement, and manage the Infection Prevention and Control Program. Findings include: Review of the Facility Assessment last reviewed May 2024 revealed the following the Director of Nursing was listed as the Infection Control Preventionist. .3.11. Roosevelt Park Nursing & Rehabilitation Community evaluates the infection prevention and control program to include effective systems for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement, that follow accepted national standards. Our infection Control Preventionist maintains a tracking and surveillance for all potential infectious and communicable diseases by infection and unit. Decisions are made regarding…

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 MI000136571 and MI000138546 Based on interview and record review, the facility failed to ensure all allegations of abuse and neglect were reported to the administrator immediately for 2 residents (Resident #25 and Resident #39) resulting in delayed reporting to other officials and the state agency and the potential for serious physical and psychosocial harm from ongoing abuse and neglect. Findings: Review of the facility Abuse Prevention Program Policy & Procedure revised on 6/2023 detailed the requirement to report allegations of abuse Immediately. Further review of the Abuse Prevention Program Policy & Procedure indicated Characteristics-Increase Risk of Abuse include but are not limited to Unsympathetic or negative attitudes toward residents; Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects; Resistive to care and services .Facility staff will report to their supervisor of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI000136571 and MI000138546 Based on interview and record review the facility failed to ensure 2 residents (Resident #25 and Resident #39) were protected from ongoing abuse, neglect and/or mistreatment, conduct thorough investigations into alleged abuse, neglect and/or mistreatment and take appropriate corrective actions in response to the findings of the investigations. Findings: Review of the facility Abuse Prevention Program Policy & Procedure revised on 6/2023 defined Abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the depravation of an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psycho-social well-being. Instances of abuse of all residents, irrespective of any mental or physical conditions, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse,…

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.