The Manor of Novi

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable, and homelike environment for two (R79 and R98) of four residents reviewed for the environment, resulting in R79 having to clean their own bathroom at times and R98 expressing frustration with a non-working clock. Findings include: On 4/6/26 at 9:58 AM, R98 was observed lying in bed. At that time, an interview was conducted with the resident. R98 answered mostly with yes and no answers but appeared to understand the questions asked. The clock on the wall at the foot of R98s bed read 8:50 with the second hand staying in the same position. A second observation was made at 2:20 PM and the clock read the same time, 8:50. On 4/7/26 at 1:06 PM, an observation of R98's clock was made and it remained at 8:50. An interview was conducted with R98. When queried about whether she was able to read the clock, R98 nodded her head and said Yes. When queried about whether it was important for her to know the actual time, R98…

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 release a seatbelt restraint during supervised activities and supervised dining and document the removal of the restraint every two hours per the physician's order for one resident, (R60) of two residents reviewed for restraints. Findings include: On 4/6/26 at 10:25 AM, R60 was observed in their room in their wheelchair with a seatbelt across their waist. At that time, R60 was asked if they could unbuckle the belt and they did not answer the question or attempt to release the belt, rather they pleasantly chatted about an unrelated topic. On 4/7/26 at 2:58 PM, R60 was observed in the activity room seated in their wheelchair with their seatbelt fastened across their waist. Staff were observed to be present in the room during the scheduled music activity. On 4/8/26 at 12:50 PM, R60 was observed in the dining room in their wheelchair eating their lunch meal. It was noted their seatbelt was fastened across their waist. Several staff were…

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 2789175.Based on record review and interview, the facility failed to complete a thorough investigation of alleged mistreatment for one of one resident (R106) reviewed for injury of unknown origin. Findings include:Findings include:Clinical record review revealed R106 was originally admitted to the facility on [DATE] with most recent re-admission on [DATE] and had medical history of diabetes managed with insulin, End Stage Renal Disease (ESRD) and required hemodialysis. R106 was physically compromised and required a Hoyer Lift (mechanical device to transfer an induvial with limited mobility). R106 Minimum Data Set (MDS) assessed on 1/15/2026 documented a Brief Interview Mental Status (BIMS) 13/15 indicating no cognitive impairment.On 4/6/26 at 1:25 PM, a telephone interview with the spouse (complainant) alleged on Super Bowl Sunday 2/8/26, The spouse said a nurse over the weekend called them reporting the injury and that I&A (Investigation and Accident) form had to be completed.…

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 assist one (R98) of three residents reviewed for activities of daily with oral hygiene and feeding assistance. Findings include:On 4/6/26 at 9:58 AM, R98 was observed lying in bed receiving nutrition through a feeding tube. A cup of orange juice was observed on the resident's over-bed table with a straw. When R98 opened their mouth, a copious amount of thick, stringy, white substance was observed extending from the top of R98's mouth to the bottom. When queried, R98 reported staff did not often assist with brushing their teeth. When queried about their preference, R98 reported they would like their mouth cleaned and teeth brushed. A review of R98's clinical record revealed the following active physician's orders: Regular diet Pureed texture, Thin consistency, 1:1 (one to one) assistance at all meals for Pleasure feeding with a start date of 3/11/26. On 4/7/26 at 8:48 AM, Certified Nursing Assistant (CNA) 'V' delivered a breakfast tray 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.

Based on observation, interview and record review, the facility failed to adhere to professional standards of practice to assess and monitor the continued need for a PICC (Peripheral Inserted Central Catheter) for antibiotic administration for one (R4) of one reviewed for Intravenous (IV) therapy. Findings include:Clinical record review revealed R4 was admitted to facility on 3/12/26 for osteomyelitis (infection in the bone) of the left foot requiring amputation of the toes and required administration of intravenous (IV) antibiotics via PICC (Peripheral Inserted Central Catheter) line, had Acute Kidney Injury (AKI) due to kidney failure and required hemodialysis. R4 was alert, orientated, and capable of making their needs known.On 4/6/26 around 10:30 AM, during initial introductions, R4 voiced concern of the PICC line observed in their right upper arm. R4 said the PICC was placed for antibiotics, not used in a while. When asked if the line was flushed (to maintain patency), R4 said the last time someone tried, it would not flush. R4 said it is uncomfortable and starting to annoy…

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 that two Certified Nursing Assistants (CNA NN and SS) out of five CNAs reviewed for competency evaluations received new hire evaluations, continuous yearly evaluations and 1:1 training regarding falls and transfers. This deficient practice had the potential to affect all residents at the facility, including R5. Findings include: CNA NN On 4/6/26 at approximately 12:19 PM, R5 was observed lying in bed. Their left arm was in a sling. R5 reported that on 3/4/26, a CNA (herein after CNA NN) turned them on their side and placed a bedpan on the bed. CNA NN then left the room leaving them on their side, and they rolled off the bed. They were sent to the Hospital and diagnosed with a fracture to their left shoulder. A review of the facility Incident/Accident (IA) Report involving R5 revealed the following: .Alleged Incident.Date: 3/4/26.Resident (R5).Brief Description: Nurse was alerted to resident's room. (R5) was observed lying on the floor. She complained of left shoulder pain. Was transported 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.

Based on observation, interview and record review, the facility failed to implement and follow policies and procedures for Enhanced Barrier Precautions (EBP) for one (R4) of one reviewed for EBP. Findings include:Clinical record review revealed R4 was admitted to facility on 3/12/26 for osteomyelitis (infection in the bone) of the left foot requiring amputation of the toes and required administration of intravenous (IV) antibiotics via PICC (Peripheral Inserted Central Catheter) line, had Acute Kidney Injury (AKI) due to kidney failure and required hemodialysis. R4 was alert, orientated, and capable of making their needs known.On 4/8/26 at 11:30 AM, A pressure ulcer dressing observation with Licensed Practical Nurse (LPN) Q was conducted for R4. Prior to entering R4's room, it was observed there was no EBP signage or Personal Protective Equipment (PPE). LPN Q was observed donning only gloves to cleanse and provide treatment to an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage with the ulcer cannot be confirmed) coccyx pressure ulcer that 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 Complaint #2729896Based on interview and record review, the facility failed to report an injury of unknown origin to the State Agency (SA) for one (R701) out of one resident reviewed for neglect/injury of unknown origin. Findings include:A complaint was filed with the SA that alleged R701 sustained bruising to their right shoulder and a fracture to their hip during their five-day Hospice respite stay at the facility.A review of R701's clinical record revealed the resident was admitted to the facility for respite services on 12/28/25 with diagnosis that included: unspecified dementia, chronic respiratory failure and history of falling.Continued review of R701's record noted, in part, the following:12/28/25 (2:12 PM): Resident arrived to facility.pain 0/10.Medication verified with hospice.Skin note: R (right) top of ankle discoloration and slight redness to front peri area.12/29/25: Administration Note: .Resident able to go to the restroom with one person assist.12/29/25: History and Physical: .she was admitted to the. facility for hospice respite care.found…

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 respect a resident's right to choices for one resident (R601) of three residents reviewed for resident rights resulting in verbalized complaints, frustration, and dissatisfaction with an assigned caregiver. Findings include:A complaint received by the State Agency alleged a caregiver who was not supposed to be assigned to the resident's care was assigned to their care. On 7/15/25 at 11:30 AM, an interview was conducted with R601. They said they had a conflict with a Certified Nurse Aide (CNA) sometime in May. They said they were a new CNA, had a bad attitude, and they were rude. R601 was not able to identify the CNA in question by name but said they reported them to Unit Manager 'A'. They continued to say Unit Manager 'A' told them the CNA would no longer be assigned to their care. They went on to say the CNA they reported was again assigned to their care on the night shift of June 9th and so they made their complaint to the State Agency on June 10th.On 7/15/25 at 11:50 AM, an interview was conducted with Unit Manager 'A'.…

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

Based on interview and record review the facility failed to implement their grievance process for one resident (R601) of three residents reviewed for grievances, resulting in an undesired caregiver being assigned to the resident's care after they requested they no longer be assigned to their care. Findings include: On 7/15/25 at 11:30 AM, an interview was conducted with R601. They said they had a conflict with a Certified Nurse Aide (CNA) sometime in May. They said they were a new CNA, had a bad attitude, and they were rude. R601 was not able to identify the CNA in question by name but said they reported them to Unit Manager 'A' after the incident. They continued to say Unit Manager 'A' told them the CNA would no longer be assigned to their care. They went on to say the CNA they reported was again assigned to their care on the night shift of June 9th. They were asked if they were assisted to fill out a grievance form and said they were not. On 7/15/25 at 11:50 AM, an interview was conducted with Unit Manager 'A'. They were asked if R601 had reported a CNA's behavior and requested…

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.

Water Pitcher: On 1/30/25 9:20 AM observation of the C-hall medication cart had a clear plastic pitcher filled with water and ice stored on top of the cart. There was a sticker that had a handwritten date of 1/28. On 1/30/25 at 9:26 AM, Nurse 'E' was observed to return to the medication cart and confirmed they were assigned to the entire unit. When asked about the process for changing the water, ice, and plastic pitchers stored on the medication cart, Nurse 'E' reported they forgot to change the pitcher. When asked how often that gets changed, Nurse 'E' reported they would get a fresh pitcher every two to three days and further stated We don't have a standard of when we change our pitchers. Nurse 'E' was then observed to remove the existing sticker dated 1/28 and placed a new sticker dated 1/30. On 1/30/25 at 9:55 AM, an interview was conducted with Unit Manager (UM 'F') who reported had been in their role since Friday 1/24/25. When asked about the changing of the water pitchers on the medication carts, UM 'F' reported those should be changed out at the end of each night shift 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 observation, interview, and record review the facility failed to protect personal health information for nine residents (R#'s 89, 45, 266, 71, 73, 26, 38 and 42) of nine residents reviewed for personal privacy. Findings include: On 1/28/25 at 9:18 AM and 1/29/25 at 4:15 PM, an observation of the nursing station on the A unit revealed a bulletin board visible from anyone passing by that listed R89, R45, R266, R71, R73, R26, R38, and R42's names and the times they were to attend dialysis treatments. On 1/30/24 at 10:45 AM, an interview was conducted with the Director of Nursing regarding resident's private health information observed on the A unit and they indicated the Unit Manager posted the schedules but it should not be visible to anyone passing by and could have had a privacy cover placed over it. According to the facility's policy titled HIPAA (Health Insurance Portability and Accountability Act) Policy Regarding Use and Disclosure of PHI (Protected Health Information) for Treatment dated 9/30/2021: .Privacy and confidentiality. The resident has a right to 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 observation, interview, and record review, the facility failed to ensure appropriate use of restraints, documented medical symptoms for the use of restraints, and consent for use for two residents (R#'s 59 and 67), of two residents reviewed for restraints. Findings include: R59 On 1/29/25 at 10:05 AM, R59 was observed in their room seated in a Merry [NAME] (a wheeled walker with a seat surrounded by a frame containing a hinged gate and belt to secure the user in the device that is not considered a restraint if the resident can exit the walker). At that time, R59 was asked of they could unbuckle the belt, lift the gate, and exit the framed walker. R59 responded Yes. They were asked to demonstrate their ability to exit the walker and repeated Yes. They were asked again to demonstrate their ability to get out of the walker and again repeated Yes, showing no indication they understood the request or their ability to physically complete the request. A review of R59's clinical record revealed they admitted 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 develop a comprehensive care plan to address a resident's use of a midline intravenous (IV) line, use of antibiotics, and multiple infections for one (R111) of two residents reviewed for infection care planning. Findings include: On 1/30/25 at 8:34 AM, R111 was observed laying in bed asleep, with a blue wedge pillow under their right torso, and their left arm was observed swollen and propped on a pillow. There was a urinary catheter drainage bag secured to the side of the bed and an IV (Intravenous) pole with an empty bag of antibiotic medication placed next to their bed. Review of the clinical record revealed R111 was admitted into the facility on [DATE] with diagnoses that included: acute gastritis with bleeding, pneumonia, urinary tract infection, and cellulitis. According to the Minimum Data Set (MDS) assessment dated [DATE], R111 had intact cognition and had an indwelling urinary catheter. Review of R111's physician orders included…

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 care was provided per professional nursing standards for one resident, (R75) of five residents reviewed during the medication administration observation. Findings include: On 1/29/25 at 9:23 AM, Nurse 'J' was observed preparing medications for administration to R75 at the medication cart in the hallway. The medications prepared were placed in a medication cup and it was not observed Tylenol had been removed from the cart and placed into the cup. Upon completing the preparation, Nurse 'J' entered R75's room and handed them the medication cup. R75 looked at the pills in the cup and asked Nurse 'J' if one of the large pills in the cup was Tylenol. Nurse 'J' told them no and said, the little pill is the Tylenol. R75 then proceeded to take the medications. On 1/29/25 at 9:39 AM, an interview was conducted with Nurse 'J'. They were asked why they told R75 one of the pills in the medication cup was Tylenol when no Tylenol had been prepared and taken into the room. In a defensive tone, Nurse 'J' said, I don't…

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 routine showers/baths and hygiene care were provided for two (R91 and R52) of five residents reviewed for activities of daily living (ADL's). Findings include: R91 On 1/28/25 at 11:55 AM, R91 was observed seated in a wheelchair just outside of their room. When asked about their care and whether they received baths or showers per their schedule, R91 reported they were supposed to get a shower last Friday, but they never did and they further reported it had been a while since they had one. When asked if staff informed them of the reason they might not be able to get a shower on their scheduled days, R91 reported they say they'll be too busy. Review of R91's shower/bath schedule in the task section of the Electronic Medical Record (EMR) documented and the resident was scheduled to have a shower/bath on Tuesdays and Fridays on the PM (evening) shift. Review of the clinical record revealed R91 was admitted into the facility on [DATE]…

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 wound care treatments were provided per physician's orders for one resident (R46) of one resident reviewed for non-pressure ulcer wound care, resulting in verbalized complaints and the potential for the worsening of wounds. Findings include: On 1/30/25 at 9:24 AM, R46 was observed lying in their bed. They had soft heel boots on both of their feet and bulky bandages were wrapped around their feet and ankles. The tape securing the bandaging was observed to be dated 1/28/25. At that time R46 was asked if staff provided them wound care per physician's orders and said they did not. They indicated the dressings on their feet were to be changed daily, however; it was not being done daily. A review of R46's clinical record was conducted and revealed they admitted to the facility on [DATE] with diagnoses that included: chronic kidney disease, deep vein thrombosis (blood clots), diabetes, and high blood pressure. A review of a wound 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement interventions and provide care to prevent accidents for two residents, (R#'s 67 and 74) of three residents reviewed for accidents, resulting in a fall and the potential for injuries. Findings include: On 1/28/25 at 11:30 AM, R67 was observed in their room. They were seated in their wheelchair equipped with a seatbelt fastened around their waist. The wheelchair was not equipped with anti-tipping devices. An interview was attempted with R67, however; they did not respond. On 1/28/25 at approximately 4:00 PM, R67 was observed sleeping in their bed. Their wheelchair was placed in the hallway and the cushion was not observed with Dycem (a non-slip material used to stabilize surfaces) in place. A review of R67's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included; falls, femur fracture, cataracts, anxiety, and dementia. Their most recent Minimum Data Set (MDS) assessment dated [DATE] indicated…

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

Based on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5% when two medication errors were made for two residents (R#'s 57 and 75) of five residents reviewed during the medication pass observation, resulting in a medication error rate of 7.69%. Findings include: On 1/28/25 at 9:12 AM, Nurse 'K' was observed preparing medications for administration to R57. Nurse 'K' prepared multiple medications including a 600 mg (milligram) calcium supplement. Nurse 'K' entered the room, administered the medications to R57, exited the room and signed the medications out as given on the medication administration record. On 1/30/25 at 11:22 AM, a review of R57's medication orders was conducted and revealed R57 did not have an order for a 600 mg calcium supplement, rather they had an active order for Calcium Carbonate-Vitamin D 500 mg-200 mg combination supplement. On 1/29/25 at 9:23 AM, Nurse 'I' was observed preparing medications for administration to R75. The medications prepared included Dorzolamide eye-drop 2% (glaucoma treatment) with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to obtain physician ordered x-rays for one resident, (R69) of one resident reviewed for radiology/diagnostic services. Findings include: Review of R69's physician orders included an order dated 12/28/24 for an x-ray of the right shoulder and hips related to pain. Review of the record did not reveal documentation that the x-rays had been obtained. Further review of the record revealed that R69 was admitted to the facility on [DATE] with diagnoses that included: type 2 diabetes, insomnia, and end-stage renal disease. On 1/29/25 at 8:44 AM, an interview was conducted with the Director of Nursing (DON). When asked about the timeframe for a diagnostic order (x-ray) to be completed, the DON reported if it was a STAT order, usually within 4 to 6 hours but if it was a general order the nurse practitioner would put it in for three days so it would not get missed. The DON was then asked if they could locate the results of R69's x-ray ordered on 12/28/24 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.

Based on observation, interview and record review, the facility failed to ensure a doorway frame was maintained in a safe manner for two (R36 and R54) of two residents reviewed for safe environment, resulting in the potential for injury (laceration). Findings include: On 1/28/25 at 11:35 AM, 1/29/25 at 2:15 PM, and 1/30/25 9:30 AM, observations of the C-Hall revealed the room occupied by R36 and R54 was observed to have a doorway frame that had a sharp metal strip around the bottom portion that was pulled away and exposed sharp metal edges (at about the ankle height of anyone that entered the room). On 1/30/25 at 9:55 AM, an interview was conducted with Unit Manager (UM 'F') who reported they were in their role since Friday 1/24/25. When asked about the process if staff identified concerns with the environment such as broken door frames, UM 'F' reported they used the TELS (an electronic reporting system). UM 'F' was asked about the state of R36 and R54's doorframe and confirmed the sharp metal and stated they would have to be covered right away. They denied being aware of this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake# MI00147133 Based on observation, interview and record review the facility failed to ensure the residents right to receive unopened and private mail delivery for one (R701) out of four residents reviewed for resident rights. Findings include: A complaint was filled with the State Agency (SA) that alleged the facility opened R701's postal package containing items from a pharmacy a week prior to them receiving the package. In addition, they alleged that some of the items, including mouth wash and bed pads, were missing from the package. On 11/12/24 at approximately 11:28 AM, R701 was observed lying in bed in their room. The resident was alert and able to answer questions asked. R701 was asked if they had had any concerns regarding mail acceptance. The resident noted that they receive items via the mail monthly that contain items like mouth wash and disposable pads. R701 noted that in early September 2024, a package was delivered to the facility with their name on it. The box was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation is pertains to intake MI00147430. Based on observations, interview, and record review the facility failed to notify appropriate discipline wound physician/practitioner and implement and update interventions for one (R704) resident of one resident reviewed for pressure injuries. Findings Include: On 11/12/24 at 9:30 AM, the Complainant was interviewed via phone called and stated that residents are not being turned every two hours as they should, because they are short staffed and are contracting bad wounds because of the lack support on the midnight shift. The Complainant was then asked could they provide a specific resident who had been affected by the lack of staffing and stated R704 is someone who had been affected. A review of the medical record revealed that R704 was admitted to the facility on [DATE] with the diagnosis of type two diabetes, sleep apnea, and muscle wasting and dystrophy. R704's most recent Brief interview for mental status score was a 3, indicating impaired cognition. 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 Intakes #MI00146313 and MI00146302 Based on observation, interview and record review the facility failed to protect the resident's right to be free from physical abuse by another resident resulting in R501 hitting R502 in the head out of four residents reviewed for abuse. Findings include: A facility reported incident (FRI) was submitted to the State Agency (SA) that documented on 6/30/24, R502 entered R501's room and when R502 would not leave, R501 hit R502 on the head/face causing redness. A review of the facility's Incident report documented, in part, the following: .Summary of incident: On 6/30/24, (R502) entered (R501)'s room. (R501) asked (R502) to leave (R501) hit him on his head .(R501): He came into the room. I didn't want him to take anything and asked him to leave. He wouldn't leave so I hit him on the side of the head. He was standing at the end of the bed. He hollered out, and the nurse came down .Nurse K interview statement: (R502) went into (R501)'s room. I heard shouting…

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. Deficient Practice #1-This citation pertains to Intake MI00146302 Based on observation, interview and record review, the facility failed to protect a likely accidental opioid ingestion for one (R503) of three residents reviewed for narcotic medications. Findings include: A complaint was filed with the State Agency (SA) that alleged in part that R503 does not take any narcotic medications, but on 6/23/26, R503 was found unresponsive and EMS (emergency medical services) administered Narcan (opioid reversal agent) and then R503 became responsive. Review of a National Institute on Health (NIH) article titled, Naloxone (Narcan) DrugFacts dated January 2022 read in part, .Naloxone is a medicine that rapidly reverses an opioid overdose. It is an opioid antagonist. This means that it attaches to opioid receptors and reverses and blocks the effects of other opioids . But, naloxone has no effect on someone who does not have opioid in their system . On 8/27/24 at 9:01 AM, R503'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 This citation pertains to Intake MI00146302 Based on observation, interview and record review, the facility failed to ensure a urine drug test was collected per physician orders for one (R503) of three residents reviewed for narcotic medications. Findings include: A complaint was filed with the State Agency (SA) that alleged in part that R503 does not take any narcotic medications, but on 6/23/26, R503 was found unresponsive and EMS (emergency medical services) administered Narcan (opioid reversal agent) and then R503 became responsive. Review of a National Institute on Health (NIH) article titled, Naloxone (Narcan) DrugFacts dated January 2022 read in part, .Naloxone is a medicine that rapidly reverses an opioid overdose. It is an opioid antagonist. This means that it attaches to opioid receptors and reverses and blocks the effects of other opioids . But, naloxone has no effect on someone who does not have opioid in their system . On 8/27/24 at 9:01 AM, R503's Guardian was interviewed by phone and asked what…

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 monitor the dish machine for adequate sanitization, and failed to maintain the ice machines in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 12/19/23 between 8:40 AM-9:30 AM, during an initial tour of the kitchen with Dietary Manager (DM), the following items were observed: The ice machine in the main kitchen was observed with an accumulation of dust on the side ventilation slats. The ice machine located in the [NAME] garden dining room was observed with a black mold-like substance on the drip tray. When queried regarding who was responsible for cleaning the ice machines, DM stated the kitchen staff cleans the outside of the ice machine in the kitchen, and housekeeping cleans the outside of the ice machine in the dining room. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, .(C) Nonfood-contact surfaces of equipment shall be kept free of…

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 an antibiotic stewardship program and to ensure accurate monitoring and documentation of appropriate antibiotic use, with potential to affect all residents in the facility, and resulting in the potential for misuse of antibiotics and development of antibiotic resistance. Findings include: Review of the facility's Infection Prevention and Control binder revealed that the line listing grid did not include information on whether criteria for antibiotic use was met. No documentation provided for each month included in the binder which covered January 2023 through November 2023. On 12/20/23 at 11:00 AM, the Director of Nursing (DON) was queried regarding documentation of use of McGeer's criteria and whether or not they could show where that was documented in the facility's binder or in the electronic health record (EHR). On 12/21/23 at 10:50 AM, an interview with the Director of Nursing (DON) was conducted. The DON reported that the Infection Prevention program consisted of an Infection Preventionist (Nurse A), 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.

Based on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment timely for four (R8, R29, R49, R69 ) of 10 reviewed for timely assessments. Findings include: Review of the triggered resident assessment task identified there were 10 resident MDS assessments noted as having an MDS record over 120 days, which meant they were either not completed and/or submitted as required. Review of the incomplete comprehensive MDS assessments included: R8 The annual MDS with an Assessment Reference Date (ARD) of 11/13/23 had a current status that read In Progress. Sections A, F, GG, H, I, J, L, M, N, O, P, and V were highlighted in red and/or yellow and showed as In Progress (incomplete). The previously completed/submitted MDS assessment had an ARD of 8/15/23. R29 The annual MDS with an ARD of 11/13/23 had a current status that read, In Progress. Sections A, B, C, D, E, F, GG, H, I, J, L, M, N, O, P, Q ,and V were highlighted in red and/or yellow and showed as In Progress. The previously completed/submitted MDS assessment had an ARD of 8/15/23.…

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

Based on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment timely for six (R17, R40, R47, R57, R67, and R93) of 10 reviewed for timely assessments. Findings include: Review of the triggered resident assessment task identified there were 10 resident MDS assessments noted as having an MDS record over 120 days, which meant they were either not completed and/or submitted as required. Review of the incomplete quarterly MDS assessments included: R17 The quarterly MDS with an ARD (assessment reference date) of 11/10/23 had a current status as Export Ready. The history section read, Batch Status .Assessment was never added to a batch . The previously completed MDS assessment had an ARD of 8/10/23. R40 The quarterly MDS with an ARD of 11/11/23 had a current status as In Progress. Sections A, GG, H, I, J, L, M, N, O, and P were highlighted in red and showed as In Progress. The previously completed MDS assessment had an ARD of 8/11/23. R47 The quarterly MDS with an ARD of 11/12/23 had a current status as In Progress. Sections A, GG, H,…

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 Minimum Data Set (MDS) assessments were transmitted to CMS (Center for Medicare and Medicaid) timely for ten (R8, R17, R29, R40, R47, R49, R57, R67, R69, and R93) of ten residents reviewed during the Resident Assessment review. Findings include: Review of the triggered resident assessment task identified there were 10 resident MDS assessments noted as having an MDS record over 120 days, which meant they were either not completed and/or submitted as required. Review of these MDS assessments included: R8 The annual MDS with an Assessment Reference Date (ARD) of 11/13/23 had a current status that read In Progress. Sections A, F, GG, H, I, J, L, M, N, O, P, and V were highlighted in red and/or yellow and showed as In Progress (incomplete). The previously completed/submitted MDS assessment had an ARD of 8/15/23. R17 The quarterly MDS with an ARD of 11/10/23 had a current status as Export Ready. The history section read, Batch Status .Assessment was never added to a batch . The previously completed MDS assessment had an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to store and handle medications in accordance with acceptable pharmaceutical standards of practice: 1.) for four of four(4 of 4) medication rooms 2.) ensure medication refrigerator temperatures outside of acceptable parameters were addressed; 3.) ensure Hall A medication cart was secured and locked when unattended; 4.) ensure medications were not expired in D unit medication (med) storage room; and 5.) the freezers in the med room were maintained regularly without ice build-up, resulting in the potential for contamination of medications, incorrect administration of medications, a lack of therapeutic benefits necessary to promote healing for residents, increased potential for adverse effects, and resident, staff or visitor access to unsecured medication cart. Findings Include: On [DATE] at 11:54 PM, during an observation tour of the med storage room in C Unit, it was observed that the Refrigerator #1 storing medications had a temperature…

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, (based on the reasonable person standard), the facility failed to ensure two residents (R49 and R59) of five residents reviewed for dignity, were treated in a dignified manner during dining. Findings include: On 12/21/23 at approximately 8:25 a.m., during a dining observation of the assisted dining room, six residents were observed eating the breakfast meal with cafeteria style trays underneath their plates. R49 and R59 were observed to each be seated at separate tables with with clothing protectors on and watching the other residents in the room eat their breakfast meals. On 12/21/23 at approximately 8:37 a.m., Certified Nursing Assistant H (CNA H) was queried why R49 and R59 had not been served the breakfast meal and were still waiting to eat. CNA H reported out loud in the dining room that R49 and R59 were feeders and that they both had to wait because there were not enough staff to help them eat and they needed assistance. Further observation of the residents in the dining room, revealed six residents that were served their…

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 Resident's personal preference for care was honored for one (R26) of one resident reviewed for self-determination/choices. Findings include: On 12/19/23 at 12:19 PM, an interview was completed with R26. When asked about whether they had any concerns about the care they received, R26 reported they did have a concern with an aide that worked with them last night on the midnight shift. R26 reported they had complained to administration about this aide a couple of times before and had requested to not have them assigned to care for them. R26 further reported this initial incident with this aide was about two or two and half months ago and had concerns with how the aide talked to them and felt it was rough at times and that they slept most of the night while working and their perception was when they came in to answer their call light, it's like they don't want to work. When asked what administration told them to address their concern at that time,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement effective pressure ulcer interventions for one Resident (R34) of three residents reviewed for pressure ulcers, resulting in the worsening of a facility-acquired pressure ulcer, infection, and hospitalization. Findings include: A review of the clinical record revealed R34 was most recently admitted to the facility on [DATE] after hospitalization related to sepsis (serious condition when the body responds improperly to an infection) as a result from a stage four (full thickness skin and tissue loss) medial sacral (lower back, end of spine) pressure ulcer with osteomyelitis (infection in the bone). Further review of the record revealed that R34 had the following diagnoses: seizures, multiple strokes, left sided paralysis, dysphagia (difficulty swallowing), aphasia (impaired understanding of language as well as reading and writing), gastrostomy tube, and dementia Further review revealed that R34 was bedbound, nonverbal, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure adequate monitoring of weights for one resident (R1) of four residents reviewed for nutrition/weight loss, resulting in the potential for continued unidentified weight loss and implementation of timely dietary interventions. Findings include: On 12/19/23 at approximately 9:50 a.m., R1 was observed in their room, laying in their bed. R1 was observed to be thin/frail. On 12/20/23 the medical record for R1 was reviewed and revealed the following: R1 was initially admitted to the facility on [DATE] and had diagnoses including dementia, protein-calorie malnutrition and dysphagia. A review of R1's careplan revealed the following: Focus-Potential for alteration in nutrition r/t (related to): [R91] was admitted to facility on a level 1 puree diet with large portions and 1:1 assist needed. [R91] has a dx (diagnosis) of Dementia, hyperlipidemia, encephalopathy, dysphagia, depressive d/o (disorder) and convulsions. PO (by mouth) intake good per…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain and routinely change the dressing for a Peripherally Inserted Central Catheter (PICC-a long, thin tube inserted through a vein in the arm) for one resident (R106) of one resident reviewed for vascular access. Findings include: On 12/29/23 at approximately 9:26 AM, R106 was observed lying in bed. The resident had a PICC in the right arm connected to a bag for TPN (Total Parenteral Nutrition-a high risk pharmaceutical nutritional preparation containing high concentration of vitamins, electrolytes, carbohydrates etc). The transparent dressing over the insertion site was dated 12/11/23. R106, who was alert and able to answer questions asked, was asked about care provided for their PICC line and other concerns. R106 reported that they have had significant digestive issues since they were a child including several surgeries. They had utilized a feeding tube, but it caused several problems They currently were receiving TPN via the PICC…

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 REFER TO INTAKE # MI00141500 Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% when two (2) medication errors were observed from a total of 26 opportunities, affecting two (Resident #65 and Resident #562) of eight residents observed for medication administration, resulting in an error rate of 7.69%. Findings include: On 12/19/23 at 4:37 PM, Nurse X was observed for Resident #65's (R65) medication administration. The medications scheduled to be given at 5:00 PM were administered, and a blood sugar check (accucheck) was performed by Nurse X. The result of the accucheck was 153, and the nurse explained to R65 that since the result of the accucheck was 153, R65 would be receiving two (2) units of insulin. Nurse X then prepared the insulin pen and set it to 2 units ready to inject. Nurse X then asked which site R65 would prefer. The arm or tummy? R65 started removing the sleeve of their sweater. R65 then expressed confusion about the insulin they…

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 Number(s): MI00135477. Based on observation, interview, and record review, the facility failed to operationalize their abuse policy to protect residents during an investigation of abuse for one (R804) of four residents reviewed for abuse and residents assigned to the alleged perpetrator. Findings include: Review of a complaint submitted to the State Agency in March 2023 revealed an allegation that Certified Nursing Assistant (CNA) 'R' had a verbal altercation with resident (R804), she came at her, other staff told (CNA 'R') to get out but she didn't get out and when she did leave she came back in and stood next to the resident yelling at her. On 10/4/23 at 9:37 AM, R804 was observed lying in bed. When queried about any concerns with staff, R804 reported they were mistreated by CNA 'R' a few months ago. When queried about what happened, R804 explained they (the resident) made a sarcastic comment to CNA 'R' when they collected their meal tray because they remove them quickly which…

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 Number(s): MI00135477. Based on observation, interview, and record review, the facility failed to report an allegation of verbal abuse and misappropriation of property to the State Agency for one (R804) of four residents reviewed for abuse. Findings include: Review of a complaint submitted to the State Agency in March 2023 revealed an allegation that Certified Nursing Assistant (CNA) 'R' had a verbal altercation with resident (R804), she came at her, other staff told (CNA 'R') to get out but she didn't get out and when she did leave she came back in and stood next to the resident yelling at her. On 10/4/23 at 9:37 AM, R804 was observed lying in bed. When queried about any concerns with staff, R804 reported they were mistreated by CNA 'R' a few months ago. When queried about what happened, R804 explained they (the resident) made a sarcastic comment to CNA 'R' when they collected their meal tray because they remove them quickly which ended in a verbal argument. R804 reported they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two deficient practice statements (DPS). DPS #1 This citation pertains to intake number(s): MI00136651. Based on observation, interview, and record review, the facility failed to ensure there were physicians orders for a intrathecal baclofen pump (a device that delivers baclofen, a medication used to treat muscle spasms, directly into the spinal canal. It is surgically placed under the skin of the abdominal region of the body. Attached to the pump is a tiny catheter that extends into the spinal canal) that included instructions for maintenance and monitoring of the pump site for one (R803) of two residents reviewed for skin management. Findings include: Review of a complaint submitted to the State Agency revealed an allegation that on 5/17/23 when R803 was seen by an outside doctor, it was noted that R803 had a baclofen pump with a band-aid over the pump site. The complainant alleged the band-aid was not dated and appeared to be old and dirty and that the residents care is being neglected 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number(s): MI00137760. Based on observation, interview, and record review, the facility failed to transfer two (R802 and R801) of three residents reviewed for accidents, in a safe manner, resulting in R802 falling in the shower. Findings include: R802 Review of a complaint submitted to the State Agency revealed an allegation that R802 fell on the floor during a transfer into the wheelchair during a shower on 6/8/23. On 10/4/23 at 9:05 AM, R802 was observed seated on the edge of their bed, eating breakfast. R802 repeatedly leaned over and pointed to a bag of sodas located on the floor. When queried about any falls R802 had in the shower, R802 talked non-sensically and stated, Lies! R802 was unable to answer questions directly and clearly. Review of R802's clinical record revealed R802 was admitted into the facility on 9/20/21 and readmitted on [DATE] with diagnoses that included: osteoarthritis of left hip, dementia, history of a right foot fracture, type 2 diabetes mellitus, 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 number(s): MI00134971. Based on observation, interview, and record review, the facility failed to ensure there was a physician's order for oxygen, ensure application of a continuous positive airway pressure (CPAP) machine according to physician's orders, and ensure a physician ordered sleep study was completed for one (R805) of one resident reviewed for respiratory care. Findings include: Oxygen Review of a complaint submitted to the State Agency revealed an allegation that the facility was not putting him on his CPAP machine that he required for sleep apnea. On 10/4/23 at 12:00 PM, R805 was observed sleeping in bed. R805 was receiving oxygen via nasal cannula. The oxygen concentrator was set for three liters per minute (3 LPM/ leader per minute) of oxygen. On 10/5/23 at 12:15 PM, R805 was observed lying in bed awake. R805 did not verbally respond when spoken to, but made some eye contact. R805's oxygen concentrator was running and set to 3 LPM. The nasal cannula was observed out of R805's nostrils and was to the right side of the nose. At that time,…

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.