The Orchards at Niles

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00147923. Based on interview and record review, the facility failed to maintain complete and accurate medical records for 1 of 4 residents (Resident #202) reviewed for medical records, resulting in the lack of documentation pertaining to catheter care, test results, vital signs, and resident status, as it related to an impending UTI (urinary tract infection). Findings include: Review of an admission Record revealed Resident #202 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: urinary retention. In an interview on 11/13/24 at 1:51 PM, Licensed Practical Nurse (LPN) K reported that she had noticed on 11/10/24 that Resident #202 was not himself, was pale in color, not eating and drinking, had a large amount of sediment and blood in his urine, and was not using his typical sign language to communicate. LPN K reported that she had come across UA (Urinalysis:urine test) results that clearly indicated an infection, but were incomplete, so…

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 Quality Assessment and Assurance (QAA) meetings were held at least quarterly and the required individuals attended the meetings resulting in the potential for quality deficiencies not being identified or corrected. Findings include: Review of the Quality Assurance and Performance Improvement (QAPI) meeting sign in sheets revealed that the facility had QAPI meetings on 10/20/2023, 12/21/2023, 1/25/2024 and 8/29/2024. The Medical Director did not attend the QAPI meeting on 1/25/2024 and on 8/29/2024. There were no QAPI meetings from 1/25/2024 to 8/29/2024. During an interview on 9/12/2024 at 11:08 PM, Nursing Home Administrator (NHA) A stated that there wasn't a QAPI meeting since 1/25/2024 until 8/29/2024 but she had been meeting with each department head individually and goes over information for the month. Review of the Quality Assurance and Performance Improvement (QAPI) Policy with an implementation date of 3/2023 and a review date of 2/2024 revealed Policy Explanation and Compliance Guidelines: 1. The QAPI…

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

Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) completed specialized training in infection prevention and control, resulting in the potential for knowledge deficits pertaining to current infection prevention and control standards. Findings include: In an interview on 09/12/24 at 10:09 AM, Director of Nursing (DON) B reported that she was the facilities IP, and ran the infection control program for the facility, with the assistance of Unit Manager (UM) LL. DON B reported that she had completed all of the modules from the CDC (Center for Disease Control and Prevention) IP certification training program, but did not complete the post test. DON B reported that she did not have an IP certificate. DON B reported that the facility does not have anyone from corporate overseeing their infection control program, and that it had been DON B's sole responsibility. In an interview on 09/12/24 at 10:10 AM, UM LL reported that she had not completed the IP certification training, therefore was not a certified IP. In an interview on 09/12/24 at…

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 annual required abuse prevention education for all employees. This has the potential to affect all 79 residents residing in the facility at the time of the survey. Findings include: Review of Preventing The Abuse of Residents with Dementia or Alzheimer's Disease In The Long-Term Care Setting: A Systematic Review, Published by The National library of Medicine, 2019, revealed . there is an increasing rate of abuse in the long-term care setting, specifically for those individuals with either dementia or Alzheimer's. Common causes and risk factors leading to this abuse include poor training . In an interview on 09/11/24 at 11:06 AM, Certified Nursing Assistant (CNA) V reported (Vendor) training application was on a schedule to be completed. CNA V reported there was not much time at work to complete the trainings as would get pulled to the floor to work and/or they have their charting to do for the residents and it doesn't leave much time to complete the assigned trainings. CNA V reported they were able to access 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 provide consistent, meaningful and person-centered activities for 4 of 7 residents (Resident #16, #56, #60, #178) reviewed for activities provided by the facility, resulting in the potential for loss of interaction, joy, self-esteem, growth, sense of wellbeing, autonomy, connectedness, identity, creativity, independence, pleasure, and comfort. This has the potential to affect all 15 residents residing on the dementia care unit. Findings include: Review of Facility Assessment dated 8/6/24, revealed, .Activities: Assistant 4 FT .Activity Assistant- High School Diploma or GED, prior experience in a resident activities program in a health setting preferred, prior completion of a state-approved training course or willingness to complete such a course within 6 months of employment .Previous experience within a healthcare setting .Activities Management Administration 1 Experience with persons with dementia Previous experience within a healthcare…

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 employ a dietary manager with appropriate training and certifications to provide oversight of the kitchen increasing the potential for food service sanitation failures and food borne illness for all residents that consume food from the kitchen. Findings include: During the initial tour of the kitchen on 9/10/2024 at 9:30 AM, Dietary [NAME] (DC) H stated that they haven't had a dietary manager in the kitchen for over a month since the last dietary manager left. DC H said she wasn't sure when the Registered Dietitian (RD) comes in and if she monitors the kitchen when she is there. During an interview on 9/10/2024 at 4:58 PM, Nursing Home Administrator (NHA) A stated that she was aware that there isn't a manager in the kitchen and she tries to go back there to help but she is busy with her own job. During another interview on 9/11/2024 at 9:26 AM, NHA A stated that the RD comes in about 8 hours a month and doesn't monitor the kitchen when she is there.

Based on observation, interview and record review, the facility failed to ensure proper label and dating of foods in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings include: During the initial tour of the main kitchen on 9/10/2024 at 9:30 AM, the cook's reach in refrigerator was observed to have the following: bag of open cheese slices in a ziploc bag with no label and date shredded pork thawing on the middle rack on a cookie sheet with ready to eat food below it The dietary aide's reach in refrigerator was observed to have the following: 1 gallon open Vit D milk jug with no label and date 1 gallon open 2% milk jug with no label and date 1 8-ounce milk in cup, covered with plastic wrap on tray with no label or date During another tour of the kitchen on 9/11/2024 at 9:26 AM, the dietary aide's reach in refrigerator was observed to have the following: cranberry concentrate in a plastic container which was open and had a use by date of 8/14/2024 The main kitchen was observed to have the following: bread…

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

Based on interview and record review, the facility failed to ensure the provision of training for behavioral health care and services for 104 staff reviewed for behavioral health care training. This deficient practice had the potential to result in unmet behavioral health care needs and services for residents. Findings include: In an interview on 09/11/24 at 11:06 AM, Certified Nursing Assistant (CNA) V reported (Vendor) training application was on a schedule to be completed. CNA V reported there was not much time at work to complete the trainings as would get pulled to the floor to work and/or they have their charting to do for the residents and it doesn't leave much time to complete the assigned trainings. CNA V reported they were able to access the application at home and could complete the training at home and would submit a slip to the timekeeper to get paid for completion of the training. In an interview on 09/11/24 at 12:34 PM, Receptionist EEE reported she would run reports, employees needed certain classes to start work on the floor for any department. Receptionist EEE…

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 maintain the dignity of 1 (Resident #20) of 1 reviewed for dignity resulting in feelings of anger and frustration. Findings include: Resident #20 Review of an admission Record revealed Resident #20 had pertinent diagnoses which included: osteomyelitis (an infection in a bone) and end stage renal disease with dialysis (a condition when the kidneys no longer function, and dialysis- a procedure to filter the blood of the body when the kidneys no longer function). Review of a Minimum Data Set (MDS) assessment for Resident #20, with a reference date of 8/6/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #20 was cognitively intact. In an interview on 9/11/24 at 4:14 PM., Resident #20 reported he recently had asked to go to the hospital, and when Medical Director (MD) WW spoke with him (Resident #20) on the phone, MD 'WW's tone was short and curt when MD WW told Resident #20 he did not think he needed to go to the hospital and would not approve a transfer to the emergency 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.

Based on observation and interview the facility failed to provide proper notification of a room change to 1 (Resident #20) of 1 resident reviewed for room change resulting in feelings of anger and frustration. Findings include: Resident #20 Review of an admission Record revealed Resident #20 had pertinent diagnoses which included: osteomyelitis (an infection in a bone) and end stage renal disease with dialysis (a condition when the kidneys no longer function, and dialysis- a procedure to filter the blood of the body when the kidneys no longer function). Review of a Minimum Data Set (MDS) assessment for Resident #20, with a reference date of 8/6/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #20 was cognitively intact. In an interview on 9/11/24 at 4:18 PM., Resident #20 reported he had been moved rooms after he complained to administration about a confrontation he had with his former roommate. Resident #20 reported he refused to move rooms when administration asked him to move rooms, but he still was the one that was moved. Resident…

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 updated and accurate advanced directive information was in place for 2 (Resident #12 & #60) of 3 residents reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers. Findings include: Resident #12 Review of Resident #12's current Code Status Order in the electronic medical record indicated, Full Code, with a linked advance directive document from 2019 indicating Full Code, including CPR (cardiopulmonary resuscitation/chest compressions). Review of Code Status binder at the nurses station on [DATE] at 3:11 PM revealed Resident #12 had a green sheet of paper, indicating full code, initiate CPR, and an Advance Directive document dated [DATE] indicating that Resident #12 did not want CPR (DNR) do not resuscitate). These documents…

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 #MI00146430. Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (corporal punishment) by staff in 1 (Resident #37) of 5 residents reviewed for abuse, when staff covered Resident #37's mouth and sprayed water in her face, to keep Resident #37 from being heard yelling during a shower. This deficient practice resulted in increased agitation and mental anguish. Findings include: Review of an admission Record revealed Resident #37 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia and alzheimer's disease. Review of a Minimum Data Set (MDS) assessment for Resident #37, with a reference date of 7/27/24 revealed a Brief Interview for Mental Status (BIMS) score of 7, out of a total possible score of 15, which indicated Resident #37 was cognitively impaired. Review of Resident #37's Care Plan revealed, .has a behavior problem such as combativeness, refusing care, verbal…

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 submit the investigation of an allegation to the State Agency for 1 resident (Resident #21) of 5 residents reviewed for abuse resulting in the potential for the allegation to not be thoroughly investigated and for the State Agency to not be notified of the status of the allegation. Findings include: Resident #21 (R21) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R21 admitted to the facility on [DATE] with diagnoses of bipolar disorder, type 2 diabetes, depression and anxiety. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R21 was cognitively intact (13 to 15 cognitively intact). Per the facility report to the State Agency on 6/20/2024, R21 alleged that someone stole a wad of ones and two fifties from his room and he called the police to file a report and notified facility staff. Nursing Home Administrator (NHA) A reported the allegation to the State Agency on 6/20/2024, the day it…

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 PASSAR (Preadmission Screening/Annual Resident Review, 3877) documentation and OBRA Level II (3878) exemption criteria were completed appropriately for 2 (Resident #39 and #60) of 3 residents, resulting in the potential for unmet behavioral health needs. Findings include: .Under the PASRR program, all persons seeking admission to a nursing facility who are seriously mentally ill and/or have an intellectual/developmental disability are required to be evaluated to determine whether the nursing facility is the most appropriate place for them to receive services and whether they require specialized behavioral/mental health services . https://www.michigan.gov/mdhhs/keep-mi-healthy/mentalhealth/mentalhealth/obra Resident #39: Review of an admission Record revealed Resident #39 was a male with pertinent diagnoses which included dementia, anxiety, psychotic disorder with delusions (severe mental disorders that cause abnormal thinking and perceptions), major depressive disorder, insomnia, and traumatic brain injury (brain…

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 assistance with activities of daily living (ADL) care was provided for 3 (Resident #16, #61, #178) of 4 residents reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for resident's dependent on staff for assistance. Findings include: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 50742-50744). Elsevier Health Sciences. Kindle Edition.Personal hygiene affects patient's comfort, safety, and well-being. Hygiene care included cleaning and grooming activities that maintain personal body cleanliness and appearance. Personal hygiene activities which as taking a bath or shower and brushing and flossing the teeth also promote comfort and relaxation foster a positive self-image, promote healthy skin, and help prevent infection and disease . Resident #16: Review of an admission Record revealed…

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

Based on observation, interview and record review, the facility failed to maintain professional standards in response to a change of condition in 1 (Resident #202) of 19 residents reviewed for quality of care, when facility staff failed to ensure a physician was notified of Resident #202's abnormal blood work results, and continued monitoring of the resident's condition was documented, resulting in the potential for delay in treatment of anemia (lack of healthy oxygenated blood). Findings include: During an observation on 12/10/24 at 12:21 PM Resident #202 was lying in his bed, and his skin was observed very pale (loss of color from skin). Review of Resident #202's Progress Note dated 12/2/24 at 2:30 PM revealed, Seen by (Medical Doctor (MD) C) .new order for CBC (complete blood count), CMP (comprehensive metabolic profile) d/t (due to) possible anemia, res (resident) pale. There was no other documentation related to the resident status. Review of Resident #202's Bloodwork obtained on 12/5/24, indicated that the hemoglobin level (a protein containing iron that distributes oxygen 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 Based on observation, interview and record review, the facility failed to ensure residents received the necessary care and services to prevent the development of pressure ulcers in 1 (Resident #54) of 4 residents reviewed for pressure ulcers, resulting in not receiving preventative interventions and protective skin treatments per physician orders, based on a history of multiple pressure wounds, and the potential for the development of new pressure injuries. Findings include: Review of an admission Record revealed Resident #54 was originally admitted to the facility on [DATE]. Review of Resident #54's Care Plan revealed, .has actual skin issues r/t (related to) impaired physical mobility, spinal stenosis (immobility, generalized weakness. Open area to R (right) upper thigh and L (left) lower inner leg. Resolved. Date initiated: 09/15/23. Revision on: 09/05/24 .Interventions: .administer treatments as ordered and monitor effectiveness. Date initiated: 09/15/23 .Follow facility policies/protocols for 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 ensure 1. facility staff followed the care plan for transfer techniques for 1 (Resident #29) of 5 residents reviewed for falls, resulting in the potential for a fall, and/or an injury. Findings include: Resident #29 Review of an admission Record revealed Resident #29 had pertinent diagnoses which included: Dementia, abnormalities of gait (walking) and mobility, and lack of coordination. Review of a Minimum Data Set (MDS) assessment for Resident #29, with a reference date of 6/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 5/15 which indicated Resident #29 was severely cognitively impaired. On 9/10/24 at 10:27 AM., Certified Nurse Assistant (CNA) R was observed positioning Resident #29 into a seated position on the side of his bed, reaching under both of his arms, picking Resident #29 up and transferring him into his wheelchair that was positioned to the right of CNA R, next to Resident #29's bed, parked on top 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, interview, and record review, the 1. facility failed to develop person centered interventions and approaches for dementia care and implement a plan of care to engage and enrich the quality of life, 2. failed to provide qualified staff for dementia care for 1 (Resident #56) of 4 residents reviewed for dementia care, resulting in the potential for negatively affecting the residents' highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an admission Record revealed Resident #56 was a female with pertinent diagnoses which included dementia, anxiety, major depressive disorder, lack of coordination, muscle weakness, cognitive communication deficit ( (progressive degenerative brain disorder resulting in difficulty with thinking and how someone uses language) and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #56, with a reference date of 7/11/24, revealed Section F: Very important to the resident to: do…

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 failed to maintain complete and accurate medical records in 3 (Resident #13, Resident #69, and Resident #21) of 19 residents reviewed for complete and accurate medical records resulting in an incomplete and inaccurate documented information in the medical records. Findings include: Resident #13 Review of an admission Record revealed Resident #13 had pertinent diagnoses which included: Type 2 diabetes (a condition that occurs when the body cannot regulate blood sugar). Review of a Minimum Data Set (MDS) assessment for Resident #13, with a reference date of 6/12/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #13 was cognitively intact. On 9/11/24 at 9:31 AM., Registered Nurse (RN) JJ was observed administering Humalog (insulin) 20 units to Resident #13. In an interview on 9/11/24 at 9:35 AM., RN JJ reported that Resident #13 had an order for Novolog and had Humalog insulin available in the medication cart. RN JJ reported that the two insulins could be interchanged. Review of Physician…

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 use of personal protective equipment during care was used for residents in enhanced barrier precautions (EBP) in 2 (Resident #29 and Resident #41) of 2 reviewed for enhanced barrier precautions care resulting in the potential for the introduction of and/or the spread of infection. Findings include: Resident #29 Review of Physician Order Summary for Resident #29 revealed .Enhanced barrier Precautions due to open wound . started 7/17/2024 . Review of Care plan for Resident #29 revealed .Focus .wound management .date initiated on 7/17/24 . Interventions .enhanced barrier precautions due to open area toe . On 9/10/24 at 10:27 AM., observed signage on the door to Resident #29's room indicated that the room including a resident in enhanced barrier precautions. Certified Nurse Assistant (CNA) R was observed assisting Resident #29 to complete a transfer from his bed to his wheelchair. CNA R was not wearing a gown during care. In an interview on 9/10/24 at 10:30 AM., CNA R reported she had worked at the…

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

Based on interview and record review, the facility failed to ensure residents who were eligible for recommended Pneumococcal vaccines were offered the vaccinations in a timely manner for 2 residents (Resident #5& #14) out of 5 residents reviewed for immunizations resulting in the potential for developing vaccine preventable disease. Findings include: Resident #5 Review of Resident #5's Immunization Record revealed historical vaccines prior to admission including, Pneumococcal PPSV23 received on 3/2/23, and PCV (Prevnar) 13 received on 11/9/15. In an interview on 09/12/24 at 10:09 AM, Director of Nursing (DON) B reported that Resident #5 was over the age of 65, admitted to the facility in February 2024, and was eligible for additional doses of Pneumococcal vaccination (PCV15 or PCV20). DON B reported that the facility would order the vaccine to be administered. DON B reported that there was not education, consent, and/or declination documentation in the resident's record. Resident #14 Review of Resident #14's Immunization Record revealed one historical dose of Pneumococcal PPSV23…

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 maintain documentation related to staff COVID-19 vaccination to include, that staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine, that staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine, and maintain a record of current vaccination status of facility staff. Findings include: In an interview on 09/12/24 at 10:09 AM, Director of Nursing (DON) B reported regarding facility staff COVID-19 vaccinations, that the vaccination is available for staff to receive. DON B reported that she did not maintain documentation of the vaccination being offered, and/or declined by facility staff. In an interview on 09/12/24 at 02:13 PM, Nursing Home Administrator (NHA) A reported that she was not aware that they needed to keep records of educating, offering, or track status of the facility staff's COVID-19 vaccination status.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00145073, MI00143691 Based on observation, interview, and record review, the facility failed to ensure clean and sanitary environment, resulting in the potential for cross contamination, infections, and bacterial harborage. Findings include: During an observation on 6/20/24 at 10:58 AM, room [ROOM NUMBER] had dried material spilled on the floor midway through the room. During an observation on 6/20/24 at 12:54 PM, outside of room [ROOM NUMBER] on the wall there was dried liquid material running down the wall. There were chunks of dirt, like dried mud in a boot tread and scattered dirt/paper/debris on the floor outside of room [ROOM NUMBER]. During an observation on 6/20/24 at 12:57 PM on the floor outside of room [ROOM NUMBER] there were pieces of straw paperand scattered dirt/debris. In front of the nurse's station, there was various dirt and debris scattered on the floor in front of it. The hallway had scattered locations of dirt/debris/pieces of straw paper scattered from…

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: MI00145073. Based on observation, interview, and record review the facility failed to maintain a safe and comfortable temperature in resident rooms in 2 of 17 residents (Resident #111, #114) reviewed for homelike environment, resulting in the potential for hyperthermia and dehydration. Findings include: Review of Portable A/C Unit Placement received on 6/26/24, revealed, .6/12/13- portable that we have in house placed in room [ROOM NUMBER] .6/13/24-four units purchased and placed in rooms 18, 29, 34, and 36 .6/18 24 - Unit purchased and placed in room [ROOM NUMBER] .6/20/24- units purchased and placed in Rooms 10, 16, 20, 28, and 42 . During an observation on 6/20/24 at 10:58 AM, Resident #111's room was located at the end of the hallway and it was noted for the temperature to increase as you approached the end of the hallway were the room was located. The sun was shining through the exit doors. The room was very stuffy and hot even with fans running in the room. No AC unit 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.

This citation pertains to intake: MI00143691 Based on observation, interview, and record review the facility failed to ensure proper infection control protocols and practices including enhanced barrier precautions (EBP) for 2 residents (#110, #114) of 5 residents, resulting in the increased potential for the spread of infection, bacterial harborage, cross contamination, and disease transmission for residents residing in the facility. Findings include: Review of Centers for Disease Control and Prevention (CDC) dated March 20,2024, revealed, .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities .EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .EBP are indicated for residents with any of the following: o Infection or colonization…

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 intakes: MI00145073, MI00144852, MI00145032. Based on observation, interview, and record review, the facility failed to provide an environment that promoted and enhanced resident dignity in 2 (Resident #111 and #101) of 17 residents reviewed for dignity, resulting in the potential of feelings of humiliation and embarrassment. Findings include: Resident #111: Review of an admission Record revealed Resident #111 was a female with pertinent diagnoses which included muscle weakness, muscle wasting, need for assistance with personal care, abnormal weight loss, and severe protein calorie malnutrition. Review of current Care Plan for Resident #111, revised on 12/29/2022 revealed the focus, .(Resident #111) is at risk for nutritional problem or potential nutritional problem r/t (related to) dx (diagnosis) of Malnutrition, hx of weight loss and Anorexia. I have a terminal illness. Anticipate decline in nutritional status with continued decline in overall health status . with the intervention .Offer hydration qshift (every shift) and with cares. Assist (Resident…

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 implement resident comprehensive care plans for 1 resident of 17 (Resident #113) reviewed for care planning resulting in a lack of service for residents to maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #113: Review of an admission Record revealed Resident #113 was a female with pertinent diagnoses which included cerebral palsy (caused by damage to or abnormalities in the brain that permanently affect body movement, muscle and coordination), epilepsy (disorder nerve cell activity in the brain is disturbed causing seizures), intellectual disabilities, and Rett's syndrome (rare genetic brain disorder and development disorder with loss of motor skills, language, causes seizures, unusual hand movements, and slowed growth). Review of current Care Plan for Resident #113, revised on 10/30/23, revealed the focus, .(Resident #113) has an ADL self-care performance deficit r/t cerebral palsy, epilepsy, generalized anxiety disorder, depression, Rett'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 ensure a resident was provided daily personal hygiene care in 3 (Resident #110, #111, #113) of 17 residents reviewed for activities of daily living resulting in unmet personal hygiene needs. Findings include: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 50742-50744). Elsevier Health Sciences. Kindle Edition.Personal hygiene affects patient's comfort, safety, and well-being. Hygiene care included cleaning and grooming activities that maintain personal body cleanliness and appearance. Personal hygiene activities which as taking a bath or shower and brushing and flossing the teeth also promote comfort and relaxation foster a positive self-image, promote healthy skin, and help prevent infection and disease . Resident # 110: Review of current Care Plan for Resident #110, revised on 5/2/24, revealed the focus, .(Resident #110) has an ADL self-care…

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 sufficient hydration in 1 (Resident #111) of 17 residents reviewed for hydration resulting in the potential for dehydration, unmet resident needs, and unnecessary negative physical, mental and psychosocial outcomes. Findings include: Resident #111: Review of an admission Record revealed Resident #111 was a female with pertinent diagnoses which included muscle weakness, muscle wasting, need for assistance with personal care, abnormal weight loss, and severe protein calorie malnutrition. Review of current Care Plan for Resident #111, revised on 12/29/2022 revealed the focus, .(Resident #111) is at risk for nutritional problem or potential nutritional problem r/t (related to) dx (diagnosis) of Malnutrition, hx of weight loss and Anorexia. I have a terminal illness. Anticipate decline in nutritional status with continued decline in overall health status . with the intervention .Offer hydration qshift (every shift) and with cares. Assist (Resident #111) as needed with hydration and keep hydration within…

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 #MI00142839 Based on interview and record review, the facility failed to maintain ensure accurate medical records for 1 resident (Resident #101) of 9 sampled residents reviewed for accurate medical records, resulting in inaccurate documentation of allergies. Findings include: Resident #101 Review of an admission Record revealed Resident #101 had pertinent diagnoses which included: dependence on renal dialysis (treatment to remove waste and excess water from the body when the kidneys are no longer able to do it), muscle weakness, and urinary tract infection. Review of Allergies for Resident #101 revealed No Known Allergies. Review of Census for Resident #101 revealed 12/29/23 In house, 1/2/24 in house, 1/20/24 in house, and 2/16/24 stop billing. Indicating Resident #101 resided in the facility from [DATE] until discharge on [DATE]. Review of Transfer Care Record from (Name Omitted) acute care hospital, printed on 12/29/24 at 5:24 PM., revealed .Allergies Not on File. Review of…

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

This citation pertains to intake #MI00142839 Based on observation, interview, and record review, the facility failed to develop, implement, and update person centered care plans in 3 (Resident #101, Resident #104, and Resident #109) of 4 residents reviewed for care planning, resulting in the potential for unmet care needs and a potential for injury to resident. Findings include: Resident #101 Review of an admission Record revealed Resident #101 had pertinent diagnoses which included: dependence on renal dialysis (treatment to remove waste and excess water from the body when the kidneys are no longer able to do it), muscle weakness, and urinary tract infection. Review of Care Plan for Resident #101 revealed no care plan related to allergies and Resident #101 was listed as having no known allergies. Review of Transfer Care Record from (Name Omitted) acute care hospital, printed on 12/29/24 at 5:24 PM., revealed .Allergies Not on File. Review of Discharge Service Communication dated 2/23/24 at 13:49 PM., revealed .Allergies . allergen-penicillin reaction-anaphylaxis, allergen-morphine…

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 #MI00142839 Based on observation, interview, and record review, the facility failed to ensure safe transfers of residents with gait belt use during transfer and two staff members during mechanical lift transfer in two (Resident #102 and Resident #109) of four residents reviewed for transfers, resulting in the potential for injury during transfer. Findings include: Resident #102 Review of an admission Record revealed Resident #102 had pertinent diagnoses which included: Alzheimer's disease with late onset, lack of coordination, and unsteadiness of feet. During an observation and interview on 3/5/24 at 10:13 AM., Certified Nurse Assistant (CNA) G placed her hands/arms into Resident #102's armpits, with the palm of her hand against Resident #102's back near his shoulder blades and lifted Resident #102 from a seated position in his wheelchair (parked parallel to his bed) and transferred Resident #102 onto his bed. CNA G did not use a gait belt during the transfer. CNA G reported that she can find transfer status information for a resident in their care…

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 #MI00142839. Based on interview and record review the facility failed to ensure that (1) pre and post dialysis treatment assessment and monitoring communication between themselves (the facility) and the dialysis provider (Name Omitted) was maintained and (2) a physician order was in place for dialysis treatments in 2 (Resident #101 and Resident #104) of 2 residents reviewed for dialysis services, resulting in the potential for unrecognized adverse reactions or resident decline related to dialysis treatments and the disruption in the continuity of care. Findings include: Resident #101 Review of an admission Record revealed Resident #101 had pertinent diagnoses which included: dependence on renal dialysis (treatment to remove waste and excess water from the body when the kidneys are no longer able to do it), muscle weakness, and urinary tract infection. Resident #104 Review of an admission Record revealed Resident #104 had pertinent diagnoses which included: End stage renal disease (decreased function of the kidneys), sepsis (full system infection),…

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

Based on observation and interview, the facility failed to provide an environment that promoted a dignified dining experience for 5 residents (R#104, #108, #109, #110, #111, #112) of 13 residents reviewed for dignity, resulting in feelings of disappointment with the dining experiences. Findings include: Resident #104: Review of an admission Record revealed Resident #104 was a female with pertinent diagnoses which included dementia, anxiety, adult failure to thrive, need for assistance with personal care, diabetes, and sacral pressure ulcer stage 3. Resident #108: Review of an admission Record revealed Resident #108 was a female with pertinent diagnoses which included cerebral palsy (caused by damage to or abnormalities in the brain that permanently affect body movement, muscle and coordination), epilepsy (disorder nerve cell activity in the brain is disturbed causing seizures), intellectual disabilities, and rett's syndrome (rare genetic brain disorder and development disorder with loss of motor skills, language, causes seizures, unusual hand movements, and slowed growth). Resident…

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 failed to maintain accurate medical records for 1 of (Resident #100) of 12 residents reviewed for comprehensive and accurate medical records, resulting in an inaccurate reflection of the resident's medical treatments administered resulting in the potential for providers to not have an accurate picture of resident status and condition. Findings include: Resident #100 Review of an admission Record revealed Resident #100, was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 11/27/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #100 was cognitively intact. Review of Resident #100's Orders revealed, Cleanse right buttock with NS (normal saline) pat dry apply xeroform (dressing cover for wounds) to open / excoriated area cover with bordered gauze. Change daily and as…

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: MI00142287 Based on interview and record review, the facility failed to facilitate a resident initiated discharge per resident choice, in 1 of 1 residents (Resident #102) reviewed for resident initiated discharge, resulting in the resident's delay in discharge and the accumulation of a bill for services which were no longer required. Findings include: Resident #102: Review of an admission Record revealed Resident #102 was a male with pertinent diagnoses which included diabetes, diabetic neuropathy (nerve damage which can occur with diabetes), fracture of right tibia (larger lower leg weight bearing bone between knee and foot), wound right great toe, falls, heart disease, muscle weakness, retention of urine (difficulty urinating), acquired absence of left leg below knee, peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs), and malignant neoplasm of prostate (cancer in the prostate). Review of Care Management Assessment completed by referring…

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: MI00142287. Based on interview and record review, the facility failed to complete accurate assessments for 1 of 13 residents (Resident #102) reviewed for assessments, resulting in an inaccurate reflection of the resident's status and the potential for impaired medical and functional problems due to unidentified needs. Findings include: .Gerontological nursing provides care that addresses mutually established goals for an older adult, his or her family, and health care team members. A comprehensive assessment, including strengths, limitations, and resources, provides a baseline of the older adult's health and functional status. Nursing diagnoses and interventions are selected to either maintain or enhance physical abilities and activity .and to create environments for psychosocial and spiritual well-being . [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing, Tenth Edition - E-Book (Kindle Location 11794 of 76897). Elsevier Health…

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: MI00142287 Based on interview and record review, the facility failed to completely assess and establish a baseline care plan for 1 resident (Resident #102) of 13 residents reviewed for baseline care plans, that included measurable goals, and interventions to address priority risk factors and individual needs resulting in the potential for ineffective care and continuity of care to be provided to the resident. Findings include: Resident #102: Review of an admission Record revealed Resident #102 was a male admitted on [DATE] with pertinent diagnoses which included diabetes, diabetic neuropathy (nerve damage which can occur with diabetes), fracture of right tibia (larger lower leg weight bearing bone between knee and foot), wound right great toe, falls, heart disease, muscle weakness, retention of urine (difficulty urinating), acquired absence of left leg below knee, peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs), and malignant neoplasm 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.

Based on observation, interview, and record review, the facility failed to implement resident comprehensive care plans for 1 resident (Resident #108) of 9 residents reviewed for care planning, resulting in a lack of service for residents to maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #108: Review of an admission Record revealed Resident #108 was a female with pertinent diagnoses which included cerebral palsy (caused by damage to or abnormalities in the brain that permanently affect body movement, muscle and coordination), epilepsy (disorder nerve cell activity in the brain is disturbed causing seizures), intellectual disabilities, and rett's syndrome (rare genetic brain disorder and development disorder with loss of motor skills, language, causes seizures, unusual hand movements, and slowed growth). Review of current Care Plan for Resident #108, revised on 10/27/23, revealed the focus, .(Resident #108) has an ADL self-care performance deficit r/t (related to) cerebral palsy, epilepsy, generalized anxiety disorder,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00142287. Based on observation, interview, and record review, the failed to follow professional standards of nursing practice in 1 (Resident #102) of 13 residents reviewed for standards of practice when the facility 1). failed to ensure orders were in place for catheter care and monitoring 2.) failed to ensure Resident #102's wound was assessed and treated and 3.) failed to ensure Resident #102 received follow up care with an orthopedic surgeon as recommended resulting in the potential for worsening of health conditions. Findings include: Resident #102: Review of an admission Record revealed Resident #102 was a male with pertinent diagnoses which included diabetes, diabetic neuropathy (nerve damage which can occur with diabetes), fracture of right tibia (larger lower leg weight bearing bone between knee and foot), wound right great toe, falls, heart disease, muscle weakness, retention of urine (difficulty urinating), acquired absence of left leg below knee, peripheral 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 This citation pertains to intake: MI00142287 Based on observation, interview and record review, the facility failed to ensure assistance with Activities for Daily Living (ADL) care was provided for 2 (Resident #102 and #108) of 9 residents reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for residents who are dependent on staff for assistance. Findings include: Resident #102: Review of an admission Record revealed Resident #102 was a male with pertinent diagnoses which included diabetes, diabetic neuropathy (nerve damage which can occur with diabetes), fracture of right tibia (larger lower leg weight bearing bone between knee and foot), wound right great toe, falls, heart disease, muscle weakness, retention of urine (difficulty urinating), acquired absence of left leg below knee, peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs), and malignant neoplasm of prostate (cancer in the prostate). Review of current Care Plan for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00142075 and MI00142287. Based on interview and record review, the failed to ensure quality of care for 2 (Resident #101 and #102) of 13 residents reviewed for quality of care when the facility failed to 1.) ensure assessment and treatment were completed for reported pain and elevated blood glucose levels for Resident #101 and 2.) ensure diabetic monitoring was in place for Resident #102 resulting in the lack of assessment, monitoring, and documentation and the potential for the worsening of a medical condition and the delay in treatment. Findings include: Resident #101 Review of an admission Record revealed Resident #101, was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and type 2 diabetes. During an interview on 2/15/24 at 11:34 AM, Family Member (FM) P reported that Resident #101 began reporting left foot pain on 12/24/23. FM P reported that Resident #101 had reported her foot pain to staff, but they were 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00138391 and MI00142287. Based on observation, interview, and record review, the facility failed to accurately assess, monitor, treat, and implement interventions for a residents with pressure ulcers for 2 (Resident #100 and Resident #102) of 6 residents reviewed for pressure ulcers resulting in the potential for worsening condition of a pressure ulcer. Findings include: Resident #100 Review of an admission Record revealed Resident #100, was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 11/27/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #100 was cognitively intact. Review of Resident #100's Orders revealed, Cleanse right buttock with NS (normal saline) pat dry apply xeroform (dressing cover for wounds) to open / excoriated area cover with bordered gauze. Change daily and as needed,…

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 MI00142075. Based on interview and record review, the facility failed to complete a medical evaluation of resident's condition, review the appropriateness of the resident's medical treatment, and implement orders for 1 (Resident #101) of 8 residents reviewed for physician orders and treatment resulting in Resident #101 experiencing unresolved pain and untreated high blood glucose levels. Findings include: Resident #101 Review of an admission Record revealed Resident #101, was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and type 2 diabetes. During an interview on 2/15/24 at 11:34 AM, Family Member (FM) P reported that Resident #101 began reporting left foot pain on 12/24/23. FM P reported that Resident #101 had reported her foot pain to staff, but they were not addressing the concern. FM P reported that Resident #101's foot began to swell, was painful to touch, and she was unable to walk. FM P reported that on 12/28/23 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 ensure timely physician visits for 1 resident (Resident #102) out of 9 residents reviewed, resulting in the potential for unmet medical needs. Findings include: Resident #102: Review of an admission Record revealed Resident #102 was a male with pertinent diagnoses which included diabetes, diabetic neuropathy (nerve damage which can occur with diabetes), fracture of right tibia (larger lower leg weight bearing bone between knee and foot), wound right great toe, falls, heart disease, muscle weakness, retention of urine (difficulty urinating), acquired absence of left leg below knee, peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs), and malignant neoplasm of prostate (cancer in the prostate). Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 11/20/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident #102 was cognitively intact.…

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

Based on observation, interview, and record review the facility failed to: 1. Properly store raw animal product in order to reduce the risk of contamination; 2. Provide accurate test strips; 3. Ensure proper working order of the hot water sanitizing dish machine; 4. Ensure cleanliness of ice scoop holder; 5. Properly air-dry pots and pans; and 6. Ensure general cleanliness of kitchen exhaust ventilation. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 53 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the kitchen, starting at 11:35 AM on 7/17/23, observation of the two door True cooler found raw chicken thawing on the second to bottom shelf over pork loin and bacon. An interview with [NAME] U, found that staff should store raw animal products according to the poster on the front of the door. A review of the poster found that chicken and poultry products should be stored on the bottom shelf, under ingredients that require lower cooking temperatures and food 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 follow standards of infection control practices related to 1. hand hygiene while providing assistance with meals. 2. hand hygiene during medication admininstration. 3. Donning personal protective equipment before entering a resident's room who was on transmission based precautions. and 4. Ensuring resident shared equipment was sanitized after use, for 8 (Resident #23, #50, #51, #57, #3, #20, #412, and #313) out of 15 residents reviewed for infection control, resulting in the potential for the transmission/transfer of pathogenic organisms and cross contamination between residents. Findings include: During an observation on 07/17/23 at 12:16 PM, Maintenance Director R was observed going room to room checking the water temperatures in the bathroom sinks. MD R was observed not performing hand hygiene prior to entering a room and not performing hand hygiene when he exited a room prior to going in another room. MD R used his shirt to wipe off…

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 pertians to intake: MI00132310. Based on observation, interview and record review the facility failed to 1. ensure a clean, comfortable and homelike environment 2. ensure proper storage of items underneath sinks/waste water lines, and contain open and dripping ventilation/pipes in laundry and dry storage were sealed and not leaking resulting in the potential for cross contamination, bacterial harborage and feelings of dissatisfaction for residents residing in the facility. Findings include: In an observation on 7/19/23 at 9:57 AM., room [ROOM NUMBER] window to the outside on the right-hand side had a large linear crack in the glass which ran across the entire window. The entire window was heavily soiled on the inside with a film, noted on the outside a film of dried water spots covering the entire surface of the window. In an observation on 7/19/23 at 10:00 AM., room [ROOM NUMBER] window inside and out was heavily soiled with a thick film on the inside, and heavy accumulation of water spots on the…

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

Based on observation, interview, and record review, the facility failed to provide an environment that promoted and enhanced resident dignity in 1 (Resident #6) of 3 residents reviewed for dignity, resulting in the likelihood of feelings of humiliation, embarrassment, and a negative psychosocial outcome for the resident impacting their quality of life. Findings include: Resident #6: Review of an admission Record revealed Resident #6 was a female with pertinent diagnoses which included Alzheimer's disease, dysphagia (damage to the brain responsible for production and comprehension of speech), anemia (blood doesn't have enough red blood cells), muscle weakness, and diabetes. Review of a Minimum Data Set (MDS) assessment for Resident #6, with a reference date of 6/12/23 revealed, .Section G: Eating: Extensive Assistance, One person Assist . Review of current Care Plan for Resident #6, revised on 12/28/22, revealed the focus, .(Resident #6) has an ADL self-care performance deficit r/t (related to) Alzheimer's, Dementia, Impaired balance, Limited mobility . with the intervention…

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 residents with their preferred practice to maintain hygiene for 1 of 3 residents (Resident #25) reviewed for self-determination, resulting in feelings of frustration, feeling dirty and the potential for the residents to not meet their highest practicable well-being. Findings include: Resident #25 Review of an admission Record revealed Resident #25, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: heart failure. Review of a Minimum Data Set (MDS) assessment for Resident #25, with a reference date of 5/17/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #25 was cognitively intact. Further review of Resident #25's MDS assessment revealed: G-Functional Status-How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair) . Code for most dependent in self-performance and support. Personal…

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 a Minimum Data Set (MDS) discharge assessment was transmitted to the Centers for Medicare and Medicaid Services (CMS) for 1 (Resident #54) of 15 sampled residents, resulting in the potential for inaccurate tracking of the resident's assessment and discharge status. Findings include: Review of an admission Record revealed Resident #54 was admitted to the facility on [DATE]. Review of a Progress Note dated 3/7/23 at 4:52 PM for Resident #54 revealed, Note Text: Pleasantly confused. Appetite good. Discharge today, daughter transporting. Daughter read and signed discharge papers. Medications called and faxed to (pharmacy name omitted) . Review of Resident #54's electronic medical record MDS Screen revealed a Discharge Return Not Anticipated . MDS with a reference date of 3/7/23 and a status of Completed (the status was not Accepted to indicate it had been transmitted successfully and accepted by CMS). In an interview on 7/19/23 at 9:04 AM, Minimum…

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 accurately complete a Minimum Data Set (MDS) assessment for 1 of 3 residents (Resident #60) reviewed for closed records, resulting in an inaccurate reflection of the resident's disposition upon discharge from the facility. Findings include: Review of an admission Record revealed Resident #60 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #60, with a reference date of 5/31/23, indicated that Resident #60 discharged on 5/31/23 to an Acute Hospital. Review of Resident #60's Discharge Note dated 5/26/2023 at 10:48 AM revealed, Note Text: Resident and his family plans to have him dc to (Assisted Living Facility name omitted) on 5/31/2023 with homecare and a wheelchair. Family agrees to pay privately for a few days and will pay balance at discharge. Review of Resident #60's Nurses Note dated 5/31/2023 at 2:55 PM revealed, Nursing Note Text: Alert and oriented. Unusually anxious about discharge…

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 professional standards of practice for administering a subcutaneous injection of insulin in 1 of 1 resident (Resident #412) reviewed for standards of practice, resulting in the potential for inaccurate dose administration. Finding include: Resident # 412 Review of an admission Record revealed Resident #412, a male with pertinent diagnoses which included: Type 2 diabetes mellitus with unspecified complications, protein-calorie malnutrition, and heart disease. Review of a Minimum Data Set (MDS) assessment for Resident #412, with a reference date of 7/18/23 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #412 was cognitively intact. During an observation on 7/18/23 at 12:00 PM., Registered Nurse (RN) N cleansed Resident #412's right deltoid (top part of the arm at the shoulder) area with an alcohol swab, pressed needle attached to insulin pen with pressure into the deltoid area to inject…

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: MI00132310 Based on interview and record review, the facility failed to ensure a resident was consistently provided with showers/bathing for 1 of 4 residents (Resident #18) reviewed for activities of daily living, resulting in unmet personal hygiene needs with the potential for isolation, psychosocial harm, skin breakdown, harboring infection, and decreased self-esteem. Findings include: Resident #18: Review of an admission Record revealed Resident #18 was a male with pertinent diagnoses which included traumatic brain injury (TBI), heart failure, muscle weakness, abnormalities of gait and mobility, abnormal posture, anxiety, morbid obesity, mild cognitive impairment, and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #18, with a reference date of 5/29/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident #18 was cognitively intact. Review of current Care Plan for Resident #18,…

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 a timely, comprehensive nutritional assessment and follow-up was completed for 1 (Resident #20) of 1 newly admitted resident reviewed nutritional status, resulting in a newly admited resident with indicators of significant nutritional risk not being comprehensively assessed, and the potential for unidentified nutritional status decline. Findings include: Resident #20 Review of an admission Record revealed Resident #20, a female, originally admitted to the facility on [DATE] with pertinent diagnoses which included: Abscess of the buttock, pressure injury of the coccyx (lowest part of the back above the tailbone), dependence of renal dialysis (a blood purifying treatment), kidney failure, and type 2 diabetes (a condition where the body is not able to properly use sugar from the blood). Review of a Minimum Data Set (MDS) assessment for Resident #20, with a reference date of 6/28/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents diagnosed with Post Traumatic Stress Disorder (PTSD) received trauma informed care for 2 (Resident #7 and Resident #26) of 15 sampled residents resulting in the potential for exposure to trauma triggers and re-traumatization. Findings include: Review of an admission Record revealed Resident #7 was originally admitted to the facility on [DATE] with pertinent diagnoses which included PTSD. Review of a Minimum Data Set (MDS) assessment for Resident #7, with a reference date of 5/23/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident # 7 was cognitively intact. Review of Resident #7's Care Plan did not reveal any care planned focus areas related to Resident #7's PTSD diagnosis. Review of Resident #7's Behavioral health progress notes from a local behavioral health provider indicated that Resident #7 was being treated for behavioral health services, but Resident #7's PTSD diagnosis 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to track and offer the pneumococcal vaccine for 1 (Resident #40) of 5 residents reviewed for immunizations, resulting in a delay in Resident #40 being given the opportunity to receive or decline the pneumococcal vaccination. Findings include: Review of an admission Record revealed Resident #40 originally admitted to the facility on [DATE]. Review of the Immunization screen in Resident #40's electronic medical record revealed no evidence that a pneumococcal vaccination had been offered to or declined by Resident #40, or their representative, and no evidence of tracking of historical data of previous pneumococcal immunization for Resident #40. On 7/18/23 at 11:35 AM, State Agency (SA) requested evidence of administration or declination of pneumococcal vaccination for Resident #40 from facility administration. In an interview on 7/19/23 at 11:04, Director of Nursing, Infection Control and Preventionist (DONICP) B reported pneumococcal vaccination status of a…

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