Northville Manor

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate coordination of emergency or routine care and unmet care needs, affecting all 27 residents who resided in the facility. Findings include: On 5/30/2024 at 2:22 PM review of the staffing timecards with Scheduler B for the following dates revealed there was no consecutive 8 hour scheduled RN coverage: April 1st, 2nd, and 15th. (2024) May 12th, 14th and 26th. (2024) On 5/30/2024 at 2:25 P.M. the Director of Nursing (DON) was interviewed and said that he recently accepted the position as the DON and that there was another RN that worked midnights and weekends but went on an extended vacation. When asked how the facility ensured there was daily 8-hour RN coverage the DON replied, We just hired another RN to help cover when I am not working. The DON agreed there needs to be daily 8 consecutive hours of RN coverage and acknowledged there was a problem with staffing. Review of the Facility…

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 observations, interviews, and record reviews, the facility failed to: (1) effectively clean and maintain food service equipment, and (2) effectively date mark all potentially hazardous ready-to-eat food products effecting 27 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, resident foodborne illness. Findings include: On 05/29/24 at 09:10 A.M., An initial tour of the food service was conducted with Dietary Manager E. The following items were noted: One-half gallon of Prairie Farms whole milk was observed with a manufacturer's use-by-date that read May 26. The half-gallon of whole milk was also observed within the Traulsen 2-door reach-in cooler without an open or out date. Dietary Manager E stated: We date mark the product when opened for a total of 7 days, if the manufacturer's use-by-date allows. The 2017 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated,…

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 effectively maintain continuity of internal programs throughout leadership changes, such as: reporting of abuse, Minimum Data Set (MDS) assessments, Quality Assurance and Improvement (QAPI/QAA) meetings, in-service, competencies/employee training, staffing, infection control, and vaccine policy affecting all 27 residents. Findings include: On 5/30/24 at 9:06 AM during interview with the Minimum Data Set (MDS) Coordinator L review of resident MDS assessments revealed a delay in the processing of the assessments. The MDS Coordinator L explained the facility had been without an MDS Coordinator for about a 3 month period. The current MDS Coordinator L hire date was 3/25/24. We are pretty far behind she said. MDS records over 120 days late were for the following residents: R15, R 2, R22, R21, R 12 and R20. On 5/31/24 at 3:29 PM the NHA was interviewed and acknowledged the lapse and explained the MDS assessments need to be completed and submitted on time in order to be in line with state regulations and policies and…

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

Based on interview and record review, the facility failed to consistently implement a comprehensive infection control program that conducted proper facility surveillance to readily identify trends of infections, resulting in missed opportunities for corrective actions and the potential for spread of infectious organisms throughout the facility affecting the entire census of 27 residents. Findings include: On 5/31/24 at 9:49 AM, the facility's Infection Control Program was reviewed with the Director of Nursing (DON) who was the Infection Preventionist, and the following was noted: 1. The DON received certification as an Infection Preventionist on 5/20/24. The facility's previous Infection Preventionist's employment ended November 2023. 2. When asked for documentation regarding infection identification, tracking, monitoring, analysis of surveillance data, responding follow-up activity, and antibiotic stewardship, the DON said this had not been completed since November 2023. 3. The facility's Influenza Vaccination policy was last updated 11/1/22. 4. The staff call-in log that 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.

On May 29, 2024 at 9:38 AM, the floor underneath Resident #128's (R128) tube feeding pole and at the head of R128's bed was soiled with debris, including torn paper, personal protective equipment (PPE) ties, fingernail clippings, a plethora of small unidentifiable particles, and clumps of hair. On May 30, 2024 at 8:07 AM, the floor underneath R128's tube feeding pole and at the head of R128's bed remained soiled with debris, including torn paper, personal protective equipment (PPE) ties, fingernail clippings, a plethora of small unidentifiable particles, and clumps of hair. On May 30, 2024 at 10:44 AM, Housekeeper C said she was responsible for processing the laundry, cleaning the common areas, and sweeping and mopping all of the residents' rooms but had not been able to do it all. Housekeeper C stated, I try to do it, because the residents should have a clean room. Housekeeper C stated that today she had cleaned the high numbered rooms. This included R128's room. On May 31, 2024 at 8:53 AM, the floor underneath R128's tube feeding pole and at the head of R128's bed remained soiled…

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 Minimum Data Set (MDS) assessments were signed and submitted to CMS (Centers for Medicare and Medicaid Services) in a timely manner for six residents (R2, R12, R15, R20, R21, and R22), resulting in a delay in monitoring of the quality of care provided to the facility's residents and potential for delay in the identification of resident's health concerns. Findings include: On 5/30/24 at 9:06 AM, Licensed Practical Nurse (LPN)/MDS Coordinator L, was queried about MDS submissions to CMS. LPN L said her hire date was 3/25/24 and that the facility was without a MDS coordinator for about three months. LPN L stated, We are pretty far behind. A review of MDS submissions was conducted with LPN L to determine compliance with CMS guidelines. According to LPN L, the following MDS assessments have not been submitted and are considered late: 1. Resident #2's quarterly MDS assessment dated [DATE] was due for submission on 5/6/24 but had not been submitted. 2.…

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 certified nurse aides (CNAs) fulfilled the requirement to complete 12 hours of in-service education annually for four of five certified nurse aides (B, H, I, J) resulting in the potential for unmet resident care needs. Findings include: On 5/30/2024 at 2:30 PM, the following five certified nurse aide annual 12-hour nurse aide training/ in-services were reviewed: -CNA B was hired on 6/26/21. There were no 12-hour training/ in-services provided by the facility. -CNA H was hired on 10/25/22. There were no 12-hour training/ in-services provided by the facility. -CNA I was hired on 12/1/23. There were no 12-hour training/ in-services provided by the facility. -CNA J was hired on 9/7/23. There were no 12-hour training/ in-services provided by the facility. There was no evidence provided by the facility that annual 12-hour trainings/ in-services were completed for the certified nurse aides reviewed. On 5/30/24 at 3:45 PM the Director of Nursing (DON)/Staff Development Coordinator was interviewed and stated I do not have a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, interview, and record review, the facility failed to store biologicals and medications at the recommended temperature parameters for 12 residents (R2, R8, R9, R10, R11, R12, R13, R14, R16, R19, R23, and R24) and to consistently document the refrigerator temperatures for 27 residents reviewed for storage of drugs and biologicals. Findings include: On 5/31/24 at 8:56 AM, an observation was made of the medication refrigerator temperature. The temperature read 32 degrees Fahrenheit. On 5/31/24 at 8:59 AM, an observation was made of the refrigerator temperature monitoring logs from January 2024 thru May 2024. Documentation of refrigerator temperatures were omitted on the temperature monitoring logs on the following dates: January 2024: 1/1 thru 1/11, 1/13, 1/14, 1/17, and 1/22. February 2024: 2/1, 2/20, 2/22, 2/23, and 2/27. May 2024: 5/14, and 5/23 thru 5/31. The following dates revealed when the refrigerator temperatures were less than 36 degrees Fahrenheit: January 2024: 1/12, 1/15, 1/16, 1/18,…

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.

Based on interview and record review, the facility failed to ensure consents for immunizations were obtained for three residents (R6, R8, and R10) and failed to ensure influenza and pneumococcal vaccines were offered for one resident (R18) out of five residents reviewed for immunizations, resulting in the potential for diminished ability to make informed decisions regarding plan of care and the spread of influenza and pneumonia among the 27 residents in the facility. Findings include: On 5/31/24 at 9:49 AM, the facility's Infection Control Program and resident clinical records were reviewed with the Director of Nursing (DON) who was the Infection Preventionist, and the following was noted: Resident #6 (R6) has resided in the facility since 5/12/22 and was over the age of 65. R6 received the influenza vaccine on 9/13/23. There was no documentation of a consent to administer the influenza vaccine. Resident #8 (R8) has resided in the facility since 10/6/17 and was over the age of 65. R8 received the influenza vaccine on 9/13/23. There was no documentation of a consent to administer 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 pertains to intake MI00143600. Based on interview and record review the facility failed to supervise residents to prevent a physical altercation for two residents (R16 and R26) of three residents reviewed for abuse, resulting in one resident receiving physical injuries. Findings include: According to the facility's Facility Reported Incident (FRI) summary report, on 3/16/24 at 7:40 PM Licensed Practical Nurse (LPN) A heard commotion coming from the dining room. Once entering the dining room, LPN A observed R26 grab R16 by the shirt. R26 scratched R16 on the chest and hit R16 in the face leaving multiple abrasions on R16's chest and the left side of the face. LPN A approached R16 and R26 and stopped the altercation. On 5/31/24 at 10:29 AM LPN A was interviewed regarding the incident that occurred on 3/16/24. LPN A said that the incident occurred at the middle of shift change. LPN A said that R16 is a frequent wanderer. LPN A said at approximately 7:40 PM she went into the dining room because she…

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

This citation pertains to intake MI00143600. Based on interview and record review the facility failed to report an incident of abuse to the State Agency in a timely manner for two residents (R16 and R26) of three residents reviewed for abuse. Findings include: According to the facility's Facility Reported Incident (FRI) summary report, on 3/16/24 at 7:40 PM Licensed Practical Nurse (LPN) A heard commotion coming from the dining room. Once entering the dining room, LPN A observed R26 grab R16 by the shirt. R26 scratched and hit R16 in the face leaving multiple abrasions on R16's chest and the left side of the face. LPN A approached R16 and R26 and stopped the altercation. The Director of Nursing (DON), emergency contacts, and physician were notified of the incident. R16 and R26 were separated, R16 and R26 were assessed for injuries, and the local police were contacted at 8:00 PM. A review of the FRI revealed the incident occurred on 3/16/24 at 7:40 PM and was discovered on 3/16/24 at 7:40 PM. As documented in the FRI, the Nursing Home Administrator (NHA) did not submit the incident…

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 weight monitoring occurred for one resident (R128) deemed to be at nutrition risk out of three residents reviewed for nutrition status, resulting in the potential delay in identification of undesirable change in weight status and compromise in nutrition status. Findings include: During an observation on 5/29/24 at 9:38 AM, Resident #128 (R128) was observed asleep with the head of the bed raised at approximately 45 degrees. A tube feeding formula was infusing at 55 ml/hr (milliliter/hour). R128 was thin in appearance. A review of the Face Sheet for R128 documented an admission date of 5/7/24. R128's diagnoses included Cerebral Palsy, Dysphagia, and Moderate Protein-Calorie Malnutrition. Record review of R128's care plans documented in part the following: Communication care plan of 5/9/24: I have difficulty making myself understood. I am non-verbal. Nutritional Status care plan of 5/8/24: Resident requires feeding tube related to history of protein calorie malnutrition, history of inadequate oral…

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 resident food preferences were honored for one resident (R129) out of three residents reviewed for food preferences, resulting in resident meal dissatisfaction. Findings include: The posted menu for lunch on 5/29/24 in the facility included sausage & peppers on bun, roasted red potatoes, sauteed onions, wheat roll, cinnamon applesauce, coffee or tea, and milk. The posted menu for dinner on 5/29/24 included stuffed green peppers, buttered corn, sauteed summer squash, wheat bread, strawberries with whipped topping, coffee or tea, and milk. On 5/29/24 at 12:49 PM, Resident #129 (R129) was observed in her room with her lunch meal tray in front of her. R129 was alert, able to speak and express herself clearly. R129 said she likes vegetables and ate the peppers and onions off the sausage. R129 said she asked staff for carrots and green beans to eat. R129 said no meal alternative was offered to her. On 5/29/24 at 1:49 PM, R129 said she did not receive her requested green beans or carrots. On 5/30/24 at 8:35…

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 did not meet the requirement for an Infection Preventionist member of Quality Assurance and Performance Improvement (QAPI), Quality Assessment and Assurance (QAA) committee for three quarters, resulting in the potential for impaired resolution of infection control and prevention issues or decreased quality of care with the potential to affect all 27 residents residing in the facility. Findings include: On 5/31/24 at 10:45 AM during Quality Assurance and Performance Improvement (QAPI) survey meeting and review, the past Quality Assessment and Assurance (QAA/QAPI) quarterly meeting notes were reviewed with the Nursing Home Administrator (NHA). For three quarters (September 2023, January 2024, and May 2024) the member sign-in sheet did not show a signature for an Infection Preventionist (IP). The NHA explained that the previous NHA O at that time also was serving as Director of Nursing (DON) and was an Infection Preventionist as well. During further interview the NHA said that the current DON currently holds an IP certification. On…

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

This citation pertains to MI00140570. Based on observation, interview, and record review, the facility failed to consistently follow facility-wide planned menu and secure Registered Dietitian approval for menu change, resulting in a missed opportunity to ensure the nutritional adequacy of the substitution and serve expected meals to all residents consuming food from the kitchen. Findings include: A concern was reported to the State Agency regarding meals served to residents eating in their room. On 12/18/23 beginning at 9:00 AM breakfast observations were made for residents eating in their room. The breakfast items served included a combination of pancakes, cold cereal, orange juice, milk, and coffee. On 12/18/23 at 10:05 AM, facility [NAME] B was queried about the breakfast served to the residents eating in their room. A review of the printed breakfast menu indicated Scrambled Egg Casserole was to be served for breakfast. [NAME] B said she did not cook the casserole because the residents will not eat it. [NAME] B said the residents eating in the dining room were served eggs 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 This citation pertains to MI00140570. Based on observation, interview, and record review, the facility failed to provide a homelike environment for one resident (R103) reviewed for homelike environment resulting in an unsanitary environment with a buildup of dried feces on two urinals sitting on the resident's overbed table and the resident's dissatisfaction with their living condition. Findings include: It was reported to the State Agency that the resident did not receive timely incontinence care. On 12/18/23 at 9:08 AM, Resident #103 (R103) was observed awake and lying in bed. R103 said he notifies staff after he has a bowel movement, but his soiled briefs are not changed in a timely manner, and as a result when R103 uses his urinal, it gets stained with feces. Two urinals were observed sitting on the resident's overbed table. Smears, stains, and specks of a dark brown substance was observed along the rim and down the outside of both urinals. R103 said the urinals have been stained for three days. A 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.

Based on interview and record review, the facility failed to perform and document neurological checks after a fall for one resident (R101) of three residents reviewed for injuries of unknown origin, resulting in the potential for head injuries to go unassessed and treated in a timely manner. Findings include: A review of R101's EMR (Electronic Medical Record) revealed R101 was admitted to the facility 10/6/17. R101 had medical diagnoses that included Dementia, muscle weakness, and repeated falls. A review of the MDS (Minimum Data Set) dated 11/17/23 revealed R101 had a BIMS (Brief Interview of Mental Status) score of 0/15 (severely cognitively intact). A review of R101's care plan dated 4/17/23 revealed, Problem: (R101) is at risk for falls r/t history of falls. Impaired mobility, decreased safety awareness, resident will attempt to ambulate without assistance and attempt to get out of bed unassisted Osteoarthritis. 2/21/2023 no injury. 6/18/2023 no injury. 7/10/2023 major injury . Intervention: Call light within reach while in room .Chair and bed alarm . Keep resident in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00139248. Based on interview and record review the facility failed to prevent misappropriation (theft of resident property) of resident narcotic medications, effecting seven residents (R2, R3, R4, R5, R6, R7, and R8) out of seven residents reviewed for diversion of medications, resulting in resident narcotic medications being stolen out of an unsupervised and unlocked nursing medication cart. Findings include: During an interview on 9/27/23 at 9:30 AM with Complainant E via phone, it was reported that the facility did not report an incident of resident's missing narcotic medications. Record review found no facility reported incidents of missing narcotics reported through the appropriated reporting system. During and interview on 9/27/23 at 10:00 AM with Registered Nurse (RN) A, it was reported that on 8/23/23 when occupying the role as acting Director of Nursing, RN C called and reported narcotics were missing from the medication cart. When asked what had happened to 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 pertains to intake MI00139428. Based on interview and record review the facility failed to report an incident of misappropriation (theft of resident property) of resident narcotics to the state agency, effecting seven residents (R2, R3, R4, R5, R6, R7, and R8) out of seven residents reviewed for the diversion of medications, resulting in the potential for continued unreported incidents of misappropriation to the State Agency. Findings include: During an interview on 9/27/23 at 9:30 AM with Complainant E via phone, it was reported that the facility did not report an incident of resident's missing narcotic medications. R2 Record review revealed R2 was admitted into the facility on 8/14/23 with a pertinent diagnosis of type 2 diabetes. Review of Controlled Drug Record dated 8/19/23 revealed resident had 18 remaining doses of Oxycodone (narcotic for pain) 5mg (milligrams) Give one tablet by mouth every six hours- misappropriated. R3 Record review revealed R3 was admitted into the facility on 2/2/22 and…

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

This citation pertains to Intake MI00139311. Based on observation, interview, and record review, the facility failed to ensure qualified kitchen staff were available to manage and operate the kitchen properly, potentially affecting all residents eating meals from the kitchen, increasing the potential for cross-contamination and resident foodborne illness. Findings include: It was reported to the State Agency that there was no cook available for the facility. On 9/13/2023 at 10:15 AM, [NAME] Manager E was observed alone in the kitchen. [NAME] E said she works double shifts every day and primarily works alone in the kitchen. Certified Nurse Aides (CNAs) will help occasionally. [NAME] E stated, When I'm not here, CNAs do the cooking. [NAME] E said she was gone from the facility during most of August 2023. A review of a facility document titled, Food Temperature Log, was used to determine additional staff responsible for food preparation and service. The review determined that from 8/8/2023 through 8/31/2023 CNA F worked as the facility cook. On 9/13/2023 at 11:30 AM, CNA F stated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00139200 and MI00139311. Based on interview and record review the facility failed to administer medications in a timely manner for one (R104of three residents reviewed for late medication administration, resulting in the potential for unmet care needs. Findings include: On 9/13/23 at 4:00 PM, R104's medication administration record for the month of August was obtained by the Administrator/ DON. Review of the document revealed the following: -Avapro 150 mg tablet due once a day .Scheduled for 9:00 AM .Date charted: 8/17/23 at 12:06 PM .Late administration: Charted late. - Avapro 150 mg tablet due once a day .Scheduled for 9:00 AM .Date charted: 8/18/23 at 01:04 PM .Late administration: Charted late. - Gabapentin 100mg tablet due three times a day .Scheduled for 9:00 AM .Date charted: 8/17/23 at 12:06 PM .Late administration: Charted late. - Gabapentin 100mg tablet due three times a day .Scheduled for 9:00 AM .Date charted: 8/18/23 at 01:04 PM .Late administration: Charted late.…

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 practices. This citations pertain to MI00139022. Deficient practice #1. Based on interview and record review, the facility failed to initiate blood sugar monitoring in a timely manner and consistently monitor blood sugars for one resident (R102) out of three residents diagnosed with diabetes reviewed for blood sugar monitoring, resulting in the potential for hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar) to go undetected. Findings include: It was reported to the State Agency that staff were not checking a resident's blood sugars and administering insulin appropriately causing the resident's blood sugars to be out of control. On 9/13/2023 at 10:22 AM, Resident #102 (R102) said he went to the hospital in August because his blood sugar was high. During an interview and record review on 9/13/2023 at 3:20 PM, Licensed Practical Nurse (LPN) I revealed that no blood sugar numbers were available for R102 for the day. When queried about R102's blood sugar monitoring,…

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 MI00138959. Based on interview and record review the facility failed to secure narcotic medication and failed to document the incident of missing narcotics, resulting in drug diversion and the potential for further incidents of missing narcotics. Findings include: On 9/13/23 at 4:23 PM, A statement for Nurse L was obtained from the Administrator/ DON (Director of Nursing) regarding the incident that took place 8/23/23. The statement was documented as follows: Approximately 9 PM to 10 PM, writer (staff nurse) was busy passing meds when he discovered that Narcotics of controlled drugs were missing at the last or bottom drawer of med cart. Which writer chose to keep temporarily, as there was no room to accommodate in the controlled drug box. All of the controlled partial blister pack, a total of 16 at the beginning of the writer's shift were counted with the outgoing .the count resulted with 16 partial blister packs and 38 full blister packs .As the writer was busy doing meds 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.