Ingham County Medical Care Facility

Based on observation, interview, and record review, the facility failed to provide bath/showers for one Residents (#13) of three Residents reviewed.Findings Included: Resident #13 (R13): Review of the medical record demonstrated that R13 was admitted to the facility 09/26/2023 with diagnoses that included cerebral infarction, schizoaffective disorder depressive, dementia, chronic obstructive pulmonary disease (COPD), atrial flutter, sleep disorder, hypertension, hyperlipidemia (high fat content in blood), and anxiety. Review of R13's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/02/2025, revealed R13 had a Brief Interview for Mental Status (BIMS) of 09 (severe cognitive impairment) out of 15. During observation and interview on 12/09/2025 at 01:39 p.m. R13 was observed sitting up wheelchair. R13 explained that she had not been receiving showers as frequently she wanted. She explained that she wanted to shower twice per week.Review of R13's MDS, with an ARD of 12/02/2025, section GG- Functional Abilities revealed that she was dependent for showers. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During interviews, observations and record review the facility failed to provide meaningful activities to one of one resident (R86) resulting in boredom, isolation and disengagement. Findings Include Resident #86 (R86)Review of the medical record reflected that R86 was admitted to the facility on [DATE]. Diagnoses of traumatic subdural hemorrhage without loss of consciousness, fracture of left great toe, emphysema, atrial fibrillation, heart failure, dyspnea with repeated falls. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/07/2025 revealed R86 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15.Under section GG0115, Functional Limitation in Range of Motion reveals R86 had impairment on both sides, used a walker and wheelchair for ambulation and required substantial/maximal assistance for all care. During an observation and interview on 12/09/2025 at 1:44 PM, R86 did not have any activities, magazines, books, or coloring materials for her to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure resident safety during staff assisted mechanical lift transfer for 1 of 3 sampled residents (Resident #3) reviewed for accidents, resulting in Resident #3 right lower leg laceration that required hospital transfer and sutures. Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R3 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included chronic osteomyelitis, heart failure, morbidly obese, diabetes, venous insufficiency, and depression. The MDS reflected R3 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required staff assist with dressing, hygiene, bathing and transfers.During an observation and interview on 12/09/2025 at 4:05 PM, R3 was sitting in wheelchair in resident room and appeared calm, pleasant and able to answer questions without difficulty. R3 reported an incident on 12/5/25, when staff…

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 and document interventions designed to prevent further weight loss, including consistent monitoring and documentation of dietary intake, nutritional supplements, and snacks in two (Resident #10, Resident #116) out of 4 reviewed for nutrition. Findings include: Resident #10 (R10) Review of the medical record revealed R10 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, anxiety disorder, and insomnia. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/25 revealed R10 scored 00 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), ate a mechanically altered diet, and required setup or clean-up assistance with eating. On 12/15/25 at 9:58 AM. R10 was observed ambulating independently exiting the lounge and walking down the hallway. On 12/15/25 at 10:22 AM, R10 continued wandering the hallway while 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 observation, interview, and record review the facility failed to ensure that bed rails were assessed and measured to prevent possible entrapment for one Resident (#7) of one resident reviewed for Residents using bed rails. Findings Included:Resident #7 (R7)Review of the medical record demonstrate that R7 was admitted to the facility 12/12/2024 with diagnoses that included cerebral infarction (stroke), dementia, chronic obstructive pulmonary disease (COPD), dysphagia (difficulty swallowing), type 2 diabetes, hypothyroidism (low thyroid hormone), anemia (low red blood cells), depression, psychosis (mental state where you lose touch with reality), hyperlipidemia (high fat content in blood), hypertension, anxiety, and insomnia. Review of R7's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/2025, revealed R7 had a Brief Interview for Mental Status (BIMS) of 07 (severe cognitive impairment) out of 15. During observation and attempted interview on 12/11/2025 at 09:31 a.m. R7 was observed lying down in her bed. A half-length side rail was observed on the…

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

Based on observation, interview, and record review the facility failed to ensure monitoring and inspection of resident bed frames and mattress for one resident (#7) of one resident reviewed for bed safety. Findings Included: Resident #7 (R7):Review of the medical record demonstrate that R7 was admitted to the facility 12/12/2024 with diagnoses that included cerebral infarction (stroke), dementia, chronic obstructive pulmonary disease (COPD), dysphagia (difficulty swallowing), type 2 diabetes, hypothyroidism (low thyroid hormone), anemia (low red blood cells), depression, psychosis (mental state where you lose touch with reality), hyperlipidemia (high fat content in blood), hypertension, anxiety, and insomnia. Review of R7's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/2025, revealed R7 had a Brief Interview for Mental Status (BIMS) of 07 (severe cognitive impairment) out of 15. During observation and attempted interview on 12/11/2025 at 09:31 a.m. R7 was observed lying down in her bed. A half-length side rail was observed on the right side of the bed 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 This citation pertains to intake 2575199.Based on observation, interview and record review, the facility failed to protect R1's right to be free from sexual abuse by R2 and R4.Findings Include: R1:Review of the medical record reflected R1 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/19/25, reflected R1 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was independent for transfers and walking at least 150 feet.R2:Review of the medical record reflected R2 admitted to the facility on [DATE], with diagnoses that included dementia. The admission MDS, with an ARD of 6/2/25, reflected R2 scored eight out of 15 (moderate cognitive impairment) on the BIMS and was independent for transfers and walking at least 150 feet.R4:Review of the medical record reflected R4 admitted to the facility on [DATE], with diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety. Findings include: An observation of the main kitchen reach in cooler on 10/08/24 at 08:36 AM with Dining Services Manager (DSM) P revealed the following: - a container of chicken with a use by date of 10/4/24 - two containers of pureed vegetables with a use by date of 10/4/24 - a container of blue cheese dressing with a use by date of 10/7/24 - a container of pureed pasta with a use by date of 10/3/24 - an unlabeled/undated container of food. DSM P removed the expired/undated food items from the cooler and reported they believed the unlabeled container was pumpkin pie filling. On 10/08/24 at 08:50 AM, upon entrance into the rehab kitchen, a cloth hamper was observed overflowing with soiled rags and aprons. There were numerous fruit flies flying above the hamper. DSM P agreed there were fruit flies and reported the hamper should have been emptied the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure witnesses observed the signing of a Do-Not-Resuscitate (DNR) document by one (Resident #78) of one reviewed. Findings include: Review of the medical record reflected Resident #78 (R78) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included encephalopathy and left side hemiplegia and hemiparesis following cerebral infarction (stroke). R78's DNR form reflected the resident signed the form on 3/1/24, the Physician signed the form on 3/5/24, and two witnesses signed the form on 3/6/24. The Attestation of Witnesses section of the DNR document reflected, The individual who has executed this order appears to be of sound mind, and under no duress, fraud, or undue influence . In an interview on 10/09/24 at 12:40 PM, Social Services Supervisor (SS) K reported two witnesses had to sign the DNR document, indicating the person signing on behalf of the resident was of sound mind at the time of signing. SS K reported they would…

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 appropriate preventive measures and take corrective action for allegations of abuse for 3 of 3 residents (R#'s 9, 113 and 33) reviewed for abuse. Findings include: Resident #33 Review of the clinical record including the Minimum Data Set, dated [DATE] reflected Resident # 33 (R33) was admitted to the facility on [DATE] with fractured fibula. R33 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 10/08/24 01:56 PM during a bedside interview with R33 it was reported that things at the facility were going well with the exclusion of being molested by another resident (Resident #113) during bingo last week. Resident #33 stated while assisting R113 with the bingo cards, R113 allegedly touched R33's upper thigh, left breast and calf . R33 stated the incident was reported and investigated by management. When queried what was done to ensure the incident didn't happen again, R33 reported R113 now…

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 MI00146701 Based on observation, interview, and record review, the facility failed to meet transfer/discharge documentation requirements for 2 of 2 reviewed (R#19 & R#39) from a total of 24 sampled residents, resulting in the potential for these residents and/or their representatives not obtaining their due rights. Findings include: Resident 39 (R39) Review of the medical record reflected R39 was an initial admission to the facility on [DATE] with a readmission on [DATE]. Diagnoses of Respiratory Failure, Pneumonia, Kidney Failure, Heart Failure, Diabetes Mellitus, Heart Failure, Chronic Obstructive, Pulmonary Disease and schizophrenia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/21/2024, revealed R39 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R39 requires maximum assistance to dependent with personal care. Record review revealed R39…

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 MI00146701 Based on interview and record review the facility failed to provide a written copy to two of two residents (R #19 and R#39) reviewed for bed hold notification in a language that was understandable, resulting in potential for lack of understanding and knowledge for and what the bed hold policy entailed. Findings include: Resident 39 (R39) Review of the medical record reflected R39 was an initial admission to the facility on [DATE] with a readmission on [DATE]. Diagnoses of Respiratory Failure, Pneumonia, Kidney Failure, Heart Failure, Diabetes Mellitus, Heart Failure, Chronic Obstructive, Pulmonary Disease and schizophrenia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/21/2024, revealed R39 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R39 requires maximum assistance to dependent with personal care. Record review revealed R39…

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 MI00146701. Based on interview and record review, the facility failed to permit timely readmission from the hospital for one (Resident #19) of two reviewed. Findings include: Review of the medical record reflected Resident #19 (R19) was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included metabolic encephalopathy, diabetes and heart failure. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/9/24, reflected R19 scored eight out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R19's medical record reflected they transferred to the hospital on 8/21/24 due to being unresponsive. A Hospital Progress Note for 8/26/24 reflected R19 was stable to discharge, pending placement. A Hospital Progress Note for 8/28/24 reflected R19 was medically stable for discharge. A Case Manager was assisting with placement, as prior placement was declined due to payment…

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 Level II determination was completed for two residents (Resident #83 and Resident #104) of two reviewed. Findings include: Resident #83 (R83) Review of the medical record revealed R83 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included schizoaffective disorder, vascular dementia with anxiety, dementia with psychotic disturbance, and anxiety disorder. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/4/24 revealed R83 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Physician's Orders revealed R83 had been prescribed Zyprexa (an antipsychotic medication) and Remeron (antidepressant medication) since admission to the facility. Review of the Change in Condition Preadmission Screening (PAS)/Annual Resident Review (ARR) Level I Screening completed on 3/14/24 revealed R83 was marked yes for questions 1-4 in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement care planned interventions to promote the healing of wounds for one (Resident #78) of 24 reviewed. Findings include: Review of the medical record reflected Resident #78 (R78) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included encephalopathy and left side hemiplegia and hemiparesis following cerebral infarction (stroke). The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/20/24, reflected R78 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R78 was coded for one stage four pressure ulcer and one unstageable pressure, both present on admission/entry or reentry. R78's Care Plan reflected they were dependent on two staff for repositioning and turning in bed. An intervention for 3/5/24 reflected R78 had an alternating pressure mattress. On 10/08/24 at 9:03 AM, R78 was observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a meaningful, diverse and engaging activity program for one resident (#58) of two reviewed for activities. Findings include: Review of the clinical record reflected Resident # 58 (R58) was admitted to the facility on [DATE] with diagnosis that included dementia and depression. Review of the Minimum Data Set (MDS) with an assessment reference date of 7/18/2024 and it was revealed R58 had long and short term memory impairment and severely impaired decision making skills. On 10/08/24 at 10:30, PM R58 was observed in his room sitting in his wheel chair up against the wall, a television (TV) was above him and not on. R58 sat in the room which was dark, TV not on, music not on. R58 observed in the same position after lunch again no TV, sitting in his room in wheelchair. On 10/09/24 at 01:22 PM, R 58 was observed being brought back from the dining room after lunch, staff observed leaving R58 in room sitting against wall under the TV, 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 Based on observation, interview and record review, the facility failed to ensure drug regimens were reviewed at least once a month by a licensed pharmacist and provider, in one of five residents reviewed for medication management and monitoring (Resident #3), resulting in the potential for increased adverse consequences related to medication therapy. Findings include: Resident #3 (R3) Review of the medical record reflected R3 was an initial admission to the facility on [DATE]. Diagnoses of Anxiety, Schizophrenia, Diabetes Mellitus, Coronary Artery Disease and other orthopedic conditions. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/12/2024, revealed R3 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R3 was independent or required minimal assistance with personal care. Record review revealed on the 04/17/24 Monthly Medication Review (MMR) pharmacy made…

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

Based on observation and interview, the facility failed to dispose of expired medications in one of four medication carts and one of three medication storage rooms reviewed, resulting in the potential for decreased efficacy of medications and adverse side effects in a current facility census of 132 residents. Findings include: During an observation on 10/09/24 at 08:50AM of Blue Cart a bottle of Thiamin Vitamin B-1 100mg with an expiration date of 03/24. During an observation on 10/09/24 at 09:00AM in the Blue Medication Room, observed a bottle of Move+Vision+Bones+Supplement expired on 04/24. During an observation on 10/09/24 at 09:10AM of the [NAME] Ridge Medication Room, two bottles of Calcium Carbonate 500mg with an expiration date of 04/24. During an interview on 10/11/24 at 09:20 AM, DON B stated nurses checked them on the night shift. DON B also stated the central supply person was supposed to have helped monitor the medication carts and the medication rooms, but she did not the carts and rooms.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer an influenza immunization per consent for one (Resident #46) of five reviewed. Findings include: Review of the medical record revealed Resident #46 (R46) was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included dementia and heart failure. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/9/24 revealed R46 had moderately impaired cognitive skills for daily decision making. The medical record revealed R46 had a legal guardian. Review of the Infection Note dated 10/13/24 revealed messages were left with R46's guardian to get consent for the influenza vaccine and that a letter was sent on 8/26/24 with no reply. R46 was then hospitalized from [DATE] to 10/24/24. The hospital documents revealed no immunizations were given during hospitalization. Review of the Influenza Vaccine Informed Consent/Declination revealed on 10/25/23, R46's guardian gave verbal consent for R46 to receive the influenza…

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 MI00142898. Based on observation, interview, and record review, the facility failed date mark all potentially hazardous ready-to-eat food products in two resident refrigerators of three reviewed. Findings include: An observation of the rehab unit resident refrigerator on 7/9/24 at 3:56 PM revealed signage that read STOP ANY PATIENT WHO WISHES TO HAVE FOOD IN THIS REFRIGERATOR MUST HAVE THEIR NAME, ROOM NUMBER, AND DATE THAT IS PLACED IN HERE ON THE CONTAINER PLEASE MAKE SURE IT IS MARKED. Another sign included the Dining Services Department Food Storage Chart which indicated maximum storage timelines. Inside the refrigerator, the following was observed: a bowl of an unknown food that was undated 3 containers of Chobani blueberry Greek yogurt that expired 7/8/24 a squirt bottle of what appeared to be salad dressing that was not labeled or dated a bowl of peas that was undated a cup of milk that was undated a container of a roasted turkey BLT from the facility's bistro with a date of 6/30/24 a container of salad that was undated a container of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains To Intake #MI00145470 Based on interview and record review, the facility failed to 1. ensure one resident (resident #7) of three residents reviewed were free of significant medication errors. 2. notify the physician of missed doses of physician ordered medication, resulting in the potential for increased seizure risk. Findings include: Review of the clinical record including the Minimum Data Set (MDS) dated [DATE] revealed Resident 7 (R7) was admitted to the facility with diagnosis that included seizure disorder, muscular dystrophy. Resident 7 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS). Review of R7's June and July 2024's monthly physician orders reflected acetazolamide 250 milligrams (mg) was ordered 3 times a day for seizure disorder. Review of R7's medication administration record for June and July 2024 reflected the acetazolamide afternoon and evening dose was not administered to R7 on June 30, 2024 and the morning dose of acetazolamide was not administered on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to MI00139667 Based on observation, interview, and record review, the facility failed to immediately report abuse allegations for 1 Resident (Resident #6) of 3 reviewed for abuse resulting in allegations of abuse that were not reported to the Nursing Home Administrator (NHA) and the State Agency timely and the potential for further allegations of abuse to go unreported and not thoroughly investigated. Findings include: Resident #6 Review of the medical record revealed Resident #3 (R3) was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, neuromuscular dysfunction of bladder, and complex regional pain syndrome. The Minimum Data Set (MDS) dated [DATE] revealed R6 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 12/11/23 2:32 PM, R6 was observed in her room nicely groomed and seated in her chair. R6 was easily conversant. R6…

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 MI00140195 and MI00140198 Based on observation, interview, and record review, the facility failed to ensure the protection of residents from abuse for two (Resident #7 and #8) of 7 reviewed, resulting in the potential for further abuse to occur. Findings Include: Resident #7 (R7) Review of the medical record revealed that R7 was admitted to facility [DATE] with diagnoses including unspecified dementia, heart failure, and insomnia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] reflected that R7 was sometimes understood and sometimes able to understand others with a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 3 (Severe Cognitive Impairment). Section G of the same MDS revealed that R7 required one-person extensive assist for bed mobility, transfers, and toilet use. On [DATE] at 2:43 PM, R7 was observed self-propelling wheelchair off Red River Road Hall toward South Unit Dining Room. R7 stated she was doing…

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 provide Activities of Daily Living (ADL) assistance to 2 sampled resident (Resident #5 and Resident #14), resulting in assistance with ADL and/or bowel/bladder not provided, the potential for skin breakdown, resident's needs to go unmet, discomfort and frustration to a reasonable person. Findings Include: Resident #5 (R5) Review of the medical record revealed R5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included major depressive disorder, unspecified benign prostatic hyperplasia with lower urinary tract symptoms, cognitive communication deficit and anoxic brain damage. The Minimum Data Set (MDS) dated [DATE] revealed R5 scored 9 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS). Review of the Care Plan revealed that R5 required (assistance) by (2) staff for toileting. On 12/14/23 at 1:16 PM, R5 was observed in his room. R6 was sitting in a specialized high back wheelchair…

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 cleanliness of kitchen equipment, food storage temperatures were documented, and food products were dated, resulting in the potential for food borne illness to occur in a current facility census of 171 residents. Findings Included: In an observation on 8/28/2023 at 9:14 AM, during the initial kitchen tour, revealed the juice machine had thick sticky debris on the pour spouts of the apple and cranberry juice, and the front of the juice machine observed to have sticky thick debris on it. During observation of the walk in cooler an opened bag of shredded cheese, which was not tied close, was observed to not have any date on the package of when the cheese package was opened, nor did it have a use by date on the bag. A container of stir fry sauce was observed to have an opened date of 7/10/2023 and an expiration date of 8/9/2023, a container of teriyaki sauce had an opened date of 7/3/2023 and an expiration date of 8/2/2023, and a container of barbeque sauce had a use by date of 8/16/2023. Observation inside…

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 During an observation on 8/29/2023 at 8:20 AM, the call light for room [ROOM NUMBER], that was visible outside of the room door, was on. At 8:25 AM, five staff members were observed to walk past room and did not stop to address the resident's need. On 8/29/2023 at 8:44 AM, the call light was on for room [ROOM NUMBER] two staff members walked past and did not address the call light or resident needs, and at 8:48 AM, two other staff members walked by and did not address the call light or the resident's needs. At 8:49 AM, four other staff members were observed to walk by room [ROOM NUMBER] and did not stop and address the call light or the resident's needs. In an observation on 8/30/2023 at 9:44 AM, room [ROOM NUMBER]'s call light was on. Two staff members walked by room [ROOM NUMBER] and did not address the call light or the resident's needs. A nurse was observed standing at the medication cart in the hall, but did not address the call light or resident's needs. In an observation on 8/30/2023 at 9:55 AM, a call…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to assess, update, and ensure advance directive information was in place for 1 resident (Resident 109) of two residents reviewed, resulting in the potential for resident's preferences for medical care to not be followed by the facility staff. Findings Include: Resident #109 (R109) A review of the medical record revealed R109 admitted to the facility on [DATE] with diagnoses that included urinary tract infection, type 2 diabetes, aphasia, and adult failure to thrive. R109 had a brief interview for mental status (BIMS), a short performance based cognitive screen for nursing home residents, score of 10 (8-12 moderately impaired) which was completed on 8/26/2023. On 08/28/23 at 03:06 PM a record review was conducted, and code status wasn't found under physician orders, underneath R109 name, in the progress notes, under miscellaneous or the care plan. During an interview on 08/29/23 at 07:40 AM, Nursing Department Unit Secretary (NDUS) P stated that everything…

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 was free from physical restraints in one of one resident reviewed for physical restraints (Resident #59), resulting in the likelihood of injuries, depression, and unmet needs. Findings include: Resident #59 (R59) Review of the medical record revealed R59 was admitted to the facility on [DATE] with diagnoses that included hypertension, type two diabetes, major depressive disorder, unspecified dementia, and vascular dementia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/18/23 revealed R59 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). The same MDS reflected that R59 required extensive assistance of one person for dressing and total dependence for transferring and toileting. In an observation on 08/28/23 at 1:57 PM, R59 was observed in a wheelchair, holding onto the wheelchair armrest, and repeatedly shaking the armrest of the wheelchair. When interviewed,…

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 and implement comprehensive care plans for 3 (Resident #21, #34, and #309) of 32 residents reviewed resulting in the potential for unmet care needs. Findings include: Resident #34 Review of the medical record revealed that Resident #34 (R34) was readmitted to facility 4/5/22 with diagnoses including left hand contracture, right hand contracture, rheumatoid arthritis, and chronic ischemic heart disease. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/6/2023 revealed that R34 was rarely/never understood with a staff assessment for mental status reflecting short and long-term memory problems with severely impaired cognitive skills for daily decision making. Section G of the same MDS revealed that R34 required one-person total assist with bed mobility, dressing, and eating; two-person total assist with transfers and toilet use; and had an upper extremity functional limitation in range of motion on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to revise Care Plans for one (Resident #130) of 32 reviewed for Care Plans, resulting in the potential for unmet care needs. Findings include: Resident #130 (R130): Review of the medical record reflected R130 was admitted to the facility on [DATE], with diagnoses that included unspecified dementia, idiopathic normal pressure hydrocephalus (excessive accumulation of fluid within the brain), major depressive disorder and insomnia. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/15/23, reflected R130 scored twelve out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R130 extensive assistance of one person for most activities of daily living. On 08/29/23 at 1:26 PM, R130 was observed propelling herself in the hallway in the direction of her room. R130 reported that there had been sexual problems at the facility. R130 reported…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents received assistance with care according to their personal preferences and care plans for 1 residents(R21) of 3 residents reviewed for hygiene and grooming , resulting in missed grooming, skin breakdown and the increased likelihood for inadequate hygiene and feelings of embarrassment. Findings include: Resident #21 (R21) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R21 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included anemia, hypertension (high blood pressure), heart failure, heart disease, renal disease, peripheral vascular disease, facility acquired pressure ulcer stage 4, anxiety, and depression. The MDS reflected R21 had a BIM (assessment tool) which indicated her ability to make daily decisions was severely impaired, and she required two person physical assist with bed mobility, transfers, dressing, toileting, hygiene, bathing and one person…

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 During observation, interview, and record review the facility failed to provide failed to provide meaningful, individualized activities for one resident (#59) of two residents reviewed for activities resulting in the potential for depression, boredom, and feelings of lack of self-worth. Findings Include: Resident #59 (R59) Review of the medical record revealed R59 was admitted to the facility on [DATE] with diagnoses that included hypertension, type two diabetes, major depressive disorder, unspecified dementia, and vascular dementia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/18/23 revealed R59 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). The same MDS reflected that R59 required extensive assistance of one person for dressing and total dependence for transferring and toileting. In an observation on 08/28/23 at 1:57 PM, R59 was observed in a wheelchair, holding onto the wheelchair armrest, and repeatedly shaking the armrest of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate safety measures to ensure resident safety for one resident (R309) of four residents reviewed for accidents and hazards, resulting in R309's repeat falls post surgical repair with re-fracture and increased likelihood for additional accidents and/or injuries. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R309 was a [AGE] year-old female admitted to the facility on [DATE] post left hip fracture repair related to fall at home, with diagnoses that included hypertension (high blood pressure), dementia, heart disease, orthostatic hypotension, urinary tract infection and depression. The MDS reflected R309 had a BIM (Brief Interview for Mental status) score of 3 which indicated her ability to make daily decisions was severely impaired, and she required one-person physical assist bed mobility, transfers, walk in room and corridor, locomotion on unit, toileting, dressing, eating,…

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 MI00138710. Based on observation, interview, and record review, the facility failed to provide treatment and services to restore as much normal bowel and bladder function as possible in one of two residents reviewed for bowel and bladder incontinence (Resident 149#), resulting in continued or worsened incontinence. Findings include: Resident #149 (R149) On 8/28/23 at 10:44 AM, R149 was observed sitting in her room in a wheelchair. R149's family member was interviewed at the same date and time and stated R149 was admitted to the facility for short-term rehabilitation following a stroke, and the plan was for her to return home with services. R149's family member voiced a concern that the facility had refused to work on bowel and bladder training for R149's incontinence. R149's Minimum Data Set (MDS) dated [DATE], revealed she was admitted to the facility on [DATE], introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home…

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 perform nutritional assessments and implement nutrition interventions for two (Resident #109 and Resident #146) of six reviewed, resulting in the potential for continued weight loss and a decline in nutritional status. Findings include: Resident #146 (R146) Review of the medical record revealed R146 admitted to the facility on [DATE] with diagnoses that included dementia, cervical disc disorder, and insomnia. According to the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/3/23 revealed R146 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), required extensive assistance of one person for eating, weighed 125 pounds (#), sustained a significant weight loss of 5% or more in the last month or 10% or more in the last six months and was not on a prescribed weight loss regimen. Review of Mini Nutritional assessment dated [DATE] 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 ensure three out of six Certified Nurse Aids (CNA) have completed a yearly competency/skills check list resulting in the potential for compromised resident care and unmet needs. Findings Included: In an interview on 8/30/2023 at 10:13 AM, CNA W stated that she had been telling Director of Nursing (DON) B, and even wrote a letter that she needed to get her skills competency checklist completed. CNA W stated she also told Unit Manager X, and she had been telling them for three months that her skills check list was due at the end of the month. In an interview on 8/30/2023 at 2:18 PM, [NAME] President of Human Resources (VP/HR) D stated that the CNA skills competency checklist was to be completed yearly. VP/HR D said it must be done in person. VP/HR D stated that CNA W was registered, but must have missed the group in person training, and said that the group in-person skills/competency checklist were held maybe in May and December. VP/HR D said management sets up the group training. VP/HR D said CNA W's skills competency…

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 monitor the use of an antipsychotic for one (Resident #144) and attempt non-pharmacological interventions prior to the use of a PRN (as needed) antianxiety medication for one (Resident #68) of five reviewed, resulting in the potential for adverse reactions and unnecessary medications. Findings include: Resident #68 (R68) Review of the medical record revealed R68 admitted to the facility on [DATE] with diagnoses that included vascular dementia with behavioral disturbance, mixed receptive expressive language disorder, major depressive disorder, and anxiety. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/1/23 revealed R68 had moderate cognitive impairment, too antipsychotic, antianxiety, and antidepressant medications. Review of the Physician's Progress Note dated 11/1/22 revealed Restart Ativan 0.5 mg (milligrams) every 6 hours PRN indefinitely. Do not want to schedule Ativan as she does not require this every day.…

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 the medication error rate was less than 5% when three medication errors were observed from a total of 34 opportunities for three residents (Resident #4, Resident #70, and Resident #103) of six residents reviewed for medication administration, resulting in a medication error rate of 8.82% and the potential for adverse reactions/side effects. Findings include: Resident #103 (R103) Review of the medical record revealed R103 admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease. On 8/30/23 at 8:00 AM, Licensed Practical Nurse (LPN) Q was observed preparing and administering medications to R103. LPN Q administered Senna 8.6 milligrams (mg), a laxative medication. Review of the Physician's Order dated 8/15/22 revealed an order for Senna S 8.6-50 mg (sennosides-docusate sodium), a laxative and stool softener medication. On 8/30/23 at 8:11 AM, LPN Q agreed R103 was ordered to receive Senna S and Senna was administered.…

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 administer insulin according to physician orders in one of five residents reviewed for medication administration (Resident #59), resulting in an increased risk of hypoglycemia or hyperglycemia. Findings include: Resident #59 (R59) R59's Minimum Data Set (MDS) assessment with an assessment reference date of 7/18/23 introduced a Brief Interview for Mental Status (BIMS), a brief performance-based cognitive screener for nursing home residents, score of 10 (08-12 Moderate Impairment). The same MDS revealed R59 had the diagnoses of diabetes mellitus, non-traumatic brain dysfunction, anemia, dementia, and lung disease. In review of R59's physician order dated 4/21/23, NovoLog Solution (Insulin Aspart) 100 Units/Milliliter (ml), was to be administered per sliding scale: if 150 - 200 = 3 units. 201 - 250 = 4 units. 251 - 300 = 5 units. 301 - 350 = 7 units. 351 - 400 = 8 units. 401+ = 9 units, subcutaneously before meals and at bedtime for type 2 Diabetes Mellitus with Hyperglycemia (high blood sugar). In review of R59's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure drugs and biological's stored in a medication cart were securely locked while the cart was unattended, resulting in the potential for residents to access medications. Findings Included: In an observation on the 200 hall on 8/29/2023 at 11:16 AM, Licensed Practical Nurse (LPN) S was observed in the hall administering medications to a resident. The medication cart was was observed to be located by room [ROOM NUMBER], and LPN S was located by rooms 209-213. The medication cart was observed to be left unlocked while LPN S was down the hall administering medications to a resident. The time the cart was unattended was approximately 4 minutes. In an interview on 8/29/2023 at 2:19 PM, LPN S stated that the facility's policy was to lock the medication carts when the cart in not be attended to and before walking away from the cart. LPN S said did realize that she had left the cart unlocked until she returned to the cart. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00138710. Based on observation, interview, and record review, the facility failed to provide food and drink per assessment and individualized care plan, in 2 of 19 reviewed for dining (Resident #51 & #149), resulting in the potential for choking, decreased food acceptance, protein deficiency, and burns (Resident #51). Findings include: Resident #51 (R51) On 8/28/23 at 12:30 PM, R51 was observed sitting in a wheelchair in the dining room at a table alone with no other residents. R51's lunch meal ticket was on the table next to her lunch and instructed to cut meats into bite sized pieces; and to serve hot liquids with a lid. R51 at the same date and time indicated she was finished, her plate was observed with a serving of chicken breast untouched, and not cut into bite-sized pieces. R51 had a coffee in a cup without a lid. There we no extra napkins on the table and her meal was not served a bowl. On 8/29/23 at 12:49 PM, R51 had just finished her lunch. R51's plate was observed…

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 meet resident individualized food preferences in one (Resident #208) of 19 residents reviewed, resulting in the potential for weight loss, decreased meal enjoyment and/or frustration. Findings Include: Resident #208 (R208) According to the facility's admission record, R208 admitted to the facility on [DATE] with diagnoses that included cirrhosis of the liver disease/excess abdominal fluid, chronic obstructive pulmonary disease (COPD, lung disease), type 2 diabetes, and hyperlipidemia (high cholesterol). A review of the MDS (Minimum Data Set) dated 08/28/2023 reflected R208 had a brief interview for mental status (BIMS), a short performance based cognitive screen for nursing home residents, score of 14 (13-15, cognitively intact). During an interview on 08/29/23 at 10:00 AM, R208 indicated she didn't get to choose what she wanted to eat. She said they bring out food without choices. R208 stated that there weren't any alternates to choose…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adaptive equipment for one (Resident #146) of 19 reviewed, resulting in the potential for decreased independence with drinking. Findings include: Review of the medical record revealed R146 admitted to the facility on [DATE] with diagnoses that included dementia, cervical disc disorder, and insomnia. According to the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/3/23 revealed R146 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and required extensive assistance of one person for eating. On 8/28/23 at 11:43 AM, R146 was observed arriving to the dining room after staff assisted her to the bathroom. R146 was served two cups of juice in regular cups. R146 spilled half of a cup of juice on the table while trying to drink. On 8/29/23 at 8:13 AM, R146 was observed in the dining room prior to meal service. R146 was served…

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

Based on observation and interview, the facility failed to ensure appropriate hand hygiene and infection control practices during lunch time meal pass, resulting in missed opportunities for hand hygiene, improper hand hygiene techniques, and the potential for the spread of infection. Findings Include: In an observation on 08/28/23 at 12:11 PM, an observation was made of a staff member grabbing a plate containing a resident's lunch and delivering the plate to the resident. The staff member returned to the kitchen and grabbed another resident's plate containing their lunch and proceeded to deliver to a different resident without performing hand hygiene in between residents. The same staff member returned to the kitchen, grabbed another plate containing food and passed to a third resident without performing hand hygiene The same staff member assisted a resident with repositioning in a wheelchair, and proceeded to continue to the kitchen area. The same staff member obtained another plate containing food and passed it to a fourth resident. The staff member opened silverware and began…

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 administer a pneumococcal immunization timely to one (Resident #146) of five reviewed for immunizations, resulting in the potential to contract a pneumococcal infection, and/or experience serious illness or complications. Findings include: Review of the medical record revealed R146 admitted to the facility on [DATE] with diagnoses that included dementia, cervical disc disorder, and insomnia. According to the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/3/23 revealed R146 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) Review of R146's immunization history revealed no documentation for a pneumococcal immunization history. Review of the Pneumococcal Vaccine Informed Consent/Declination revealed on 7/10/23, consent was given for R146 to receive a pneumococcal immunization. The medical record revealed R146 had not yet received 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.