The Villa at Green Lake Estates

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain an effective grievance resolution process to ensure prompt resolution of resident concerns for one (R56) of one resident reviewed for grievances, and seven of eight residents who wished to remain anonymous who attend the resident council interview. Findings include: On 6/30/25 at 10:45 AM, R56 was observed seated in a wheelchair in her room. When queried about the care in the facility, R56 reported she has had clothes and other belongings stolen from her room. R56 reported she caught another resident going through her drawers, the resident took one of her shirts out of the drawer, threw it on the bed, and the next morning R56 noticed a blue and purple shirt were missing. R56 said she has talked to a staff member who no longer worked at the facility about her concerns. Additionally, R56 reported her cellular phone charging cord was taken from her room while she was at therapy. R56 said it was found with a staff member. R56 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 report injuries of unknown origin to the Administrator/Abuse Coordinator for one (R38) of four residents reviewed for abuse. Findings include: On 6/30/25 at approximately 9:40 AM, it was reported by another resident that R38 often wandered into her room, has gotten into her bed, and threw water on her one time. On 6/30/25 at approximately 10:00 AM, R38 was observed ambulating in the hallways of the second floor unit. R38 was observed standing very closely in other people's space. When spoken to, R38 talked non-sensically. On 7/1/25 at 10:45 AM, R38 was observed wandering the second floor unit, up and down each hallway. At approximately 10:51 AM, R38 entered another resident's room and approached their bed. The other resident yelled, No! Get out! Get out and go to your room! R38 was observed trying to get into the bed of the other resident who was not in the room at that time. At approximately 10:53 AM, a staff member redirected R38 into…

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 develop an integrated hospice care plan for one resident (R9) of one resident reviewed for hospice services resulting in the potential for unmet end of life care needs. Findings include: A review of R9's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: acute respiratory failure, high blood pressure, Alzheimer's disease and dementia. A review of a hospice contract indicated they admitted to hospice services on 2/10/25. A review of R9's hospice documentation revealed a care plan developed by the hospice company, however; a review of R9's facility care plans did not reveal a care plan for hospice services nor outline the coordination between the hospice company and the facility. On 7/2/25 at 11:40 AM, an interview was conducted with the facility's Director of Nursing (DON). They were asked if R9 should have a facility care plan that indicated R9 was on hospice and included interventions and coordination between…

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 dressing changes were completed as documented for one (R55) of two residents reviewed for Skin Conditions. Findings include: On 6/30/25 at 10:03 AM, R55 was observed lying in his bed. A gauze dressing dated 6/25 was observed on R55's left wrist. R55 was asked what the dressing was for. R55 explained he must have hit his wrist on something, and the nurse had wrapped it up. R55 was asked if he knew how often the dressing was changed. R55 explained it had been a couple of days since it had been changed. Review of the clinical record revealed R55 was admitted into the facility on 8/20/24 with diagnoses that included: diabetes, Parkinson's disease and heart disease. According to the Minimum Data Set (MDS) assessment dated [DATE], R55 was cognitively intact. Review of R55's progress notes revealed a Skin Observation note dated 6/15/25 at 6:50 PM that read, CNA (Certified Nursing Assistant) alerted writer that resident arm was bleeding.…

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: MI00151566 Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement effective interventions to prevent accidents and failed to assess and determine the root cause of a fall for three (R13, R38, and R72) of six residents reviewed for accidents and supervision, resulting in R13 eloping from the facility, R38 repeatedly entering other residents' rooms and the potential for avoidable accidents. Findings include: R13 On 6/30/25 at 10:13 AM, a resident was observed in R38's room and attempted to get into R38's roommate's bed. At that time, Licensed Practical Nurse (LPN) 'P' was asked if the resident in the room was R38's roommate. LPN 'P' reported the resident was R13 and they should not be in that room. At that time, LPN 'P' asked another staff member to get R13 out of the room. A review of R13's progress notes revealed the following: On 1/5/25, R13 was aggressive, combative, attempted to push other residents 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.

This citation pertains to intake #MI00150133 Based on interview and record review the facility failed to ensure a stop date for antibiotic treatment for one resident (R#306) of three residents reviewed for antibiotic stewardship resulting in the resident receiving numerous additional doses of antibiotic medication. Findings include: On 3/26/25 at 12:30 PM, a review of R306's physician's orders and Medication Administration Record (MAR) for February 2025 and March 2025 was conducted and revealed Nurse Practitioner (NP) 'H' prescribed Ivermectin (antibiotic) on 2/10/25 for the treatment of possible scabies. The order indicated the medication was to be administered on day 1 (2/10/25), day 2 (2/11/25), day 8 (2/17/25), day 9 (2/18/25) and day 15 (2/24/25). It was noted the order did not include a stop date and the medication was continued to be given once daily (with the exception of a few refusals from R306) after day 15 until it was discontinued on 3/26/25. On 3/27/25 at 12:48 PM, a telephone interview was conducted with NP 'H' regarding R306's order for the Ivermectin antibiotic.…

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 #MI00150928 Based on interview and record review, the facility failed to ensure freedom from misappropriation for one resident, (R302) of two residents reviewed for misappropriation, resulting in a staff member stealing R302's money. Findings include: On 3/27/25 at 9:50 AM, a review of a facility reported incident folder for R302 was completed. The folder contained investigation documentation that included a summary that read, .On 2/27/25 (R302) was brought to the Administrator's office by (Nurse 'D') .(R302) was crying when she entered the office .(Nurse 'D') reported (R302) was upset because she suspected her money had been taken .(R302) confirmed she was upset because she suspected money had been taken from her. (R302) reported she had spoken to her bank after having received and reviewed her bank statement. (R302) said she noticed transactions that she did not make because they happened outside the facility. (R302) had not left the facility, other than for hospital visits, since her admission in early May of 2024. (R302) stated, 'Certified Nurse…

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 #MI00150133. Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices related to transmission based precautions (TBP) for two residents (R#'s 300 and 307) of six residents reviewed for infection control. Findings include: R300 On 3/26/25 at 10:05 AM, R300 was observed seated in their wheelchair near the nursing station on the second floor. An interview was attempted, however; R300 did not offer any verbal response at the attempt. An observation of R300's room revealed no signage to indicate they were on any type of TBP or an isolation caddy hanging on the door containing personal protective equipment (PPE). Additional observations of the room on 3/26/25 at 1:38 PM and 3/27/25 at 10:00 AM continued to reveal no signage for TBP or isolation caddy on the door. On 3/26/25 at 12:00 PM a review of R300's physician's orders was conducted and revealed an active order dated 2/18/25 that read, Contact Isolation for Scabies. R307 On 3/26/25 at 9:55 AM, an observation of R307's room revealed an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake #MI00149522. Based on observation, interview, and record review, the facility failed to prevent a fall with injury for one Resident (R701) of three residents reviewed for falls and accidents, resulting in actual harm, when R701 required stitches to their shoulder after falling out of bed. Findings include: On 2/04/25 at 12:25 p.m., R701 was observed in their bed positioned on their back, wearing a hospital gown. R701's left arm was observed flexed at the elbow, with a clenched fist. On 2/04/25 at 12:27 p.m., R701 reported they sustained a fall recently when they rolled off their bed onto the floor. R701 stated, My aide was changing me and (they) stepped out and left me unattended. I rolled out of bed. (They) work the night shift, and it happened on the night shift. I fell over there . R701 pointed to the right side of their hospital bed, to the floor. R701 continued, I didn't have pain, just a cut, and pointed to their left arm, at the shoulder. R701 reported they required 11…

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 # MI00147358 Based on interview and record review, the facility failed to provide written transfer notification to the resident's representative including reason, effective dates, and the location to which the resident was being transferred and Ombudsman notification for one Resident (R901) of two residents reviewed for transfers/discharge out of the facility. Findings include: R901's clinical record was reviewed and revealed R901 was admitted to the facility on [DATE] after a hospital stay. R901's admitting diagnoses included aphasia, dementia, anxiety disorder, nutritional deficiency, and chronic obstructive pulmonary disease (COPD). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed that R901's primary language was not English and they had severe cognitive impairment. R901 had limited ability to communicate due to their diagnosis of aphasia, cognitive impairment and language barrier. R901's spouse was appointed as their Durable Power of Attorney (DPOA) 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 interview and record review, the facility failed to ensure controlled substance medications were documented per facility policy and professional standards on the Medication Monitoring/Control Record and Medication Administration Record for two residents (R#'s 704 and 705) of three residents reviewed for professional standards, resulting in the potential for loss of accountability for controlled substances. Findings include: R704 A review of R704's physician orders, medication administration record (MAR), and Medication Monitoring/Control Record (Control Record) was conducted and revealed the following: An order for alprazolam (controlled substance anti-anxiety medication) on 6/21/24 0.5 mg (milligram) 1 tablet by mouth as needed with instructions that read, PLEASE ALLOW 1 TABLET TO BE GIVEN ONCE EVERY CALENDAR DAY. A review of the MAR was conducted and revealed on 6/24/24 the medication was documented as given at 2:55 AM and again at 10:06 AM. A review of the Control Record revealed one documented as…

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

Based on observation, interview, and record review the facility failed to ensure appropriate storage of medication and treatment supplies in two of five medication carts. This deficient practice had the potential to affect multiple residents residing in the facility. Findings include: On 7/2/24 at approximately 10:10 AM, the medication cart located on the third floor was observed. Registered Nurse (RN) B who was standing near the cart, reported that they had concerns about medication administration and medication storage. RN B pulled out three (brand named) insulin pens that did not have any dates to indicate when they were removed from the refrigerator and placed in the medication cart. RN B reported they should have been dated and was unsure as how to proceed. On 7/2/24 at 12:30 PM, a review of the first floor medication cart was conducted with Nurse 'A'. Review of the cart revealed two insulin pens in the top drawer both sealed with unbroken tamper resistant red tape. It was observed both pens had a sticker that indicated they should be kept in the refrigerator until ready 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 This citation pertains to intake MI00144470 Based on interview and record review, the facility failed to provide reasonable accommodation of resident needs by not promptly responding to the call lights for three residents (R800, R801, R802) of three residents interviewed resulting in the residents contacting the facilities receptionist to assist in contacting nursing staff. A complaint was received by the State Agency on 5/11/24 alleging a resident was observed requesting assistance from nursing staff for the duration of their visit (approximated time of 45 minutes to one hour) resulting in the visitor involving assistance from the facility receptionist. A clinical record review revealed R800 was admitted to the facility on [DATE] with a diagnosis of Multiple Sclerosis (MS) (an autoimmune disease that attacks the nerves in the body) resulting in a self-care performance deficit requiring extensive total staff assistance with ADL's (Activities of Daily Living). A Brief Interview of Mental Status (BIMS) score…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that resident rights to private and confidential mail delivery was maintained for all residents that reside within the facility. Findings include: According to the facility policy titled, Resident Rights dated Revised February 2021: .Federal and state laws guarantee certain basis rights to all residents of this facility. These rights include the resident's right to .exercise his or her rights as a resident of the facility and as a resident or citizen of the United States .access to a telephone, mail and email .communicate in person and by mail, email and telephone with privacy . According to MCL-Section 445.33, Sec. 3 2019, Act 48, Eff. [DATE]: .Taking, holding, concealing, or destroying mail addressed to another person; prohibited conduct; violation as a crime; penalties; applicable whether alive or deceased . On [DATE] at 10:30 AM, a resident council interview was conducted with 11 residents who wished to remain anonymous. When asked about…

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 residents and visitors had access to previous survey results, resulting in residents and visitors being uninformed of deficiencies identified in the facility. This had the potential to affect all residents who resided in the facility. Findings include: According to the facility policy titled, Resident Rights dated Revised February 2021: .Federal and state laws guarantee certain basis rights to all residents of this facility. These rights include the resident's right to .examine survey results . On 5/7/24 at 10:30 AM, a resident council interview was conducted with 11 residents who wished to remain anonymous. When asked about whether they knew where they could access and review the facility's survey binder which included past reports of non-compliance and findings from the State Agency, none could identify where or that anyone had discussed this with them previously. On 5/7/24 at 11:10 AM, Receptionist 'U' was asked where the facility's survey binders were kept and they denied being aware of what 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.

This citation pertains to intake #MI00143647. Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen and ensure food items were labeled, dated and discarded when expired. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 5/6/24 from 9:08 AM - 10:00 AM, during an initial tour of the kitchen with Certified Food Manager (CFM 'N'), the following items were observed: There were personal items (bags and sweatshirts/jackets stored on top of the containers for bulk oatmeal. CFM 'N' reported those should not be stored on top of the food storage bins. According to the 2017 FDA Food Code section 3-307.11 Miscellaneous Sources of Contamination, FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. The bin which contained white located near the desk of CFM 'N' was observed with the scoop stored inside the bin, with the handle resting in the rice. CFM 'N' confirmed the scoop should not have…

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

Based on interview and record review, the facility failed to ensure that grievances were promptly documented, investigated, tracked and resolved for residents that participate in the resident council. Findings include: On 5/7/24 at 9:30 AM, an interview was conducted with the Activity Director. When asked to review the resident council minutes, they reported there had been an accident and coffee had been spilled on some of the documents. When asked about whether there was any documentation of follow-up to the concerns/grievances identified in the past resident council meetings as that documentation was not included in the information provide for review, the Activity Director reported since last annual survey, they were putting concerns on grievance forms. When asked where those forms were kept and to provide for review, the Activity Director reported they would follow-up. There was no additional documentation or follow-up regarding the grievances provided by the end of the survey. Review of previous resident council minutes identified the following concerns: On 2/28/24: Nursing…

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 R56 On 5/6/24 at 9:57 AM, R56 was observed sitting up in a wheelchair. R56 reported only receiving 2 showers since their admission (on 4/11/2024) and expressed displeasure related to missing scheduled showers. Review of the clinical record revealed R56 was admitted to the facility on [DATE] with diagnoses that included: muscle weakness and polyarthritis. According to the Minimum Data Set (MDS) assessment dated [DATE], R56 scored 15/15 (which indicated intact cognition). On 5/8/24 at 12:31 PM, DON was queried regarding their current process for documenting resident showers. The DON reported that resident showers should be documented in the electronic health record but they are also documented on paper (shower sheets). A review of the R56's shower task report and of the paper shower sheets provided by the DON revealed resident received one shower on 4/27/24 and refused one shower on 4/24/24. No additional showers were documented and no rationale was provided for the missed showers. A review of the facilities…

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 an environment was free from accident hazards regarding storage of sharps (blood sugar testing lancets) in one of four medication carts reviewed for medication storage. This has the potential to affect multiple residents on the first floor. Findings include: On 5/7/24 at 8:15 AM, observation of the first floor medication cart revealed concerns with storage of sharps. There was a small, white plastic container with a handle (no covering/lid) that contained several items including approximately 40 individual blood sugar testing lancets. There was no nurse in view of the cart, or surrounding area. On 5/7/24 at 8:18 AM, Nurse 'W' who was currently assigned to this medication cart and Nurse 'C' (Agency Nurse arriving to start shift and take over the medication cart) approached the cart and were asked about the storage of the lancets. Nurse 'W' reported they should be in the cart and was unable to explain why they were stored in the storage container on the top of the cart. On 5/7/24 at 8:19 AM, the Director…

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 have a system in place prior to installing assist bars/rails to ensure appropriate consent, assessment, and physician orders were completed with ongoing monitoring and assessment for eight (R32, R42, R9, R14, R21, R25, R26, R57, and R74) resulting in the potential for inappropriate use and or injury from the device. This deficient practice has the potential to affect all 76 residents of the facility. Findings include: R32 R32 was a long-term resident of the facility. R32 was admitted to the facility on [DATE]. R32's admitting diagnoses included Gout, insomnia, restlessness, and viral hepatitis. Based on the Minimum Data Set Assessment (MDS) dated [DATE], R32 had Brief Interview of Mental Status (BIMS) score of 8/15, indicative of moderate cognitive impairment. R32 had assist rails/bars on their bed. Review of R32's Electronic Medical Record (EMR) did not reveal any initial/follow-up assessment(s) and clinical rationale for use of assist…

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 #MI00141921. Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff was provided for the residents that resided on the first floor (including R72 and multiple residents from the confidential resident council meeting), resulting in delayed medication administration and increased potential for unmet care needs. Findings include: Review of allegations reported to the State Agency included complaints of not having adequate nursing staff to provide timely care and assistance. Review of the resident council minutes included the following concerns: On 2/28/24, .there are still issues with the call lights not being answered in a timely manner when agency is in the building . On 3/27/24, .States that there isn't enough of nursing in the building . On 5/7/24 at 10:30 AM, during the confidential resident council meeting, residents were asked if they felt there was adequate nursing staff to meet their needs. Nine of the 11 residents 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 ensure appropriate infection control practices with regards to Enhanced Barrier Precautions (EBP), and linen storage for eight of eight residents (R34,R21,R62,R57,R33,R74,R55 and R29) reveiwed for EBP. Findings include: A review of the facility's Enhanced Barrier Precautions policy revealed in part Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply .Gloves and gown are applied prior to performing the high contact resident care activity .EBPs are indicated (when contact precautions do not other apply) for residents with wounds and/or indwelling devices regardless of MDRO colonization .Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE…

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 MI00143647 Based on observation, interview and record review, the facility failed to treat a resident with dignity and respect for one (R73) of five resident reviewed for dignity. Findings include: On 5/6/24 at 10:42 AM, R73 was observed sitting in a wheelchair in their room. An aircast brace was observed on R73's left leg from the knee to the foot. R73 was asked about the care in the facility. R73 explained she had a lot of issues with a particular nurse, Licensed Practical Nurse (LPN) F, like LPN F would say they are drug seeking in front of other residents and staff when they ask for their pain medication and they felt it had affected how other staff treated them at the facility. Review of the clinical record revealed R73 was admitted into the facility on 3/1/24 and readmitted [DATE] with diagnoses that included: traumatic subdural hemorrhage (brain bleed) with loss of consciousness, displaced trimalleolar fracture (three breaks in the ankle) and adult physical abuse,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one resident (R12) was assessed for safe self-administration of medication of one resident reviewed for self-administration, with potential for inappropriate administration of medication. Findings include: R12 R12 was a long-term resident of the facility originally admitted to the facility on [DATE]. R12 was recently admitted to hospital and readmitted back to the facility on 5/6/24. R12's admitting diagnoses included Pneumonia, lung cancer and depression. R12 had multiple hospitalizations due to their diagnoses and comorbidities. Based on the Minimum Data Set (MDS) assessment dated [DATE], R12 had a Brief Interview for Mental Status (BIMS) assessment score of 15/15, indicative of intact cognition. An initial observation was completed on 5/6/24, at approximately 3:30 PM. R12 was observed sitting in their bed. An interview was conducted during this observation. R12 reported that they just got back from the hospital. R12 was receiving…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident, with a confirmed history of physical abuse, was not threatened to change rooms for staff convenience for one (R73) of one resident reviewed for room change. Findings include: On 5/6/24 at 10:42 AM, R73 was observed sitting in a wheelchair in their room. An aircast brace was observed on R73's left leg from the knee to the foot. R73 was asked about the care in the facility. R73 explained she had a lot of issues with a particular nurse, Licensed Practical Nurse (LPN) F and had asked not to have LPN F as their nurse, but had been told they would have to change rooms to not have LPN F as their nurse. R73 explained they loved their room, that it felt like it was their safe place and they did not want to change rooms, but also did not want LPN F as their nurse. When asked who had told them they had to change rooms to have a different nurse, R73 explained it had been the Administrator. Review of the clinical record revealed R73…

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 #MI00141921. Based on interview, and record review, the facility failed to ensure medications were administered and/or the physician was notified of the late administration according to professional standards of practice for one (R72) of one resident reviewed for medication administration. Findings include: Review of complaints filed with the State Agency included allegations that medications were not being administered per physician orders. On 5/7/24 at 10:30 AM, during the confidential resident council meeting, several residents voiced concerns that they frequently received their medications late on the first floor. On 5/7/24 at 11:00 AM, R72 reported concerns with not getting their scheduled medications and asked, Is it my job to ask for my scheduled medications? I was supposed to take them at 9:00 AM but I still haven't received any for today. According to the profile information, R72 was their own responsible party. According to the Minimum Data Set (MDS) assessment dated…

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 consistently implement interventions to prevent the development of a new pressure ulcer and/or worsening of one facility acquired pressure ulcer for one resident (R42) and failed to ensure skin assessments were completed for one (R9) of three residents reviewed for pressure ulcer prevention and management. Findings include: R42 R42 was long-term resident of the facility, originally admitted to the facility on [DATE]. R42 was recently readmitted after an extended hospital stay due to pneumonia from 2/4/24 and 4/8/24. R42's admitting diagnoses included chronic obstructive pulmonary disease (COPD), heart failure, respiratory failure, and kidney failure. Based on the Minimum Data Set (MDS) assessment dated [DATE], R42 needed substantial staff assistance to roll/reposition in bed and they were dependent on staff assistance with a Hoyer (total body lift) to get in and out of their bed. R42 had a Brief Interview of Mental Status (BIMS) score 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 MI00144347 Based on observation, interview and record review, the facility failed to ensure complete and accurate documentation of intermittent (straight) catherization for one (R74) of two residents reviewed for catheters. Findings include: On 5/6/24 at 11:39 AM, R74 was observed sitting in a wheelchair in their room. R74 was asked about care at the facility. R74 explained early that morning, they were having difficulty urinating, they were locked-up and it was very uncomfortable, so they asked if the nurse could straight catheterize (cath) them, the midnight nurse told them they would have to wait for the day nurse to do it as it was almost shift change . and when the day nurse finally did, it took more than one urinal to hold it all. It should be noted that the urinal in R74's room held 1000 milliliters (ml) or 1 liter (L). Review of the clinical record revealed R74 was admitted into the facility on 4/5/24 with diagnoses that included: quadriplegia incomplete (weakness but not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident prescribed psychotropic medication (Antipsychotic/AP) had adequate indication for use, appropriate consent to receive the medication, clinical rationale to support continued use in absence of mood/behavior symptoms, as well as identify and monitor resident specific behaviors and approaches for one (R179) of five residents reviewed for unnecessary medication, resulting in unnecessary use of psychotropic medication and the inability to monitor the effectiveness of the prescribed treatment due to lack of supporting documentation. Findings include: On 5/6/24 at 10:19 AM, R179 was observe laying in their bed. The resident reported they were in the facility for some therapy after recently falling and fracturing several ribs prior to admission. Review of the clinical record revealed R179 was initially admitted into the facility on 4/19/24 with diagnoses that included: spinal stenosis, multiple fractures of ribs, vascular…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00141154. Based on interviews and record reviews the facility failed to ensure facility staff consistently ensured residents were treated in a dignified manner for one (R403) of two residents reviewed for abuse/negligence, resulting in the resident to have felt disrespected. Findings include: Review of a complaint submitted to the State Agency (SA) documented in part . (R403 name) indicated she needed to make an incident report with an officer in reference to some improper care she had received from a CNA (Certified Nursing Assistant) . (R403 name) who stated on this same date, 11-16-23 at 0630 hrs., she was asleep in her room (room number) when she was awakened by a staff member, later ID'd as (CNA J name), cleaning her genitals with a washcloth. Her pajama pants and incontinence pad were lowered onto her thighs. (R403 name) asked (CNA J name) what she was doing, and she did not respond. (CNA J) continued to wash her genitals. (R403 name) feels this activity was indicative 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: MI00141154. Based on interview and record review the facility failed to report an allegation of neglect to the State Agency (SA) for one (R402) of one resident reviewed for Cardio Pulmonary Resuscitation (CPR). Findings include: Review of the medical record revealed R402 was admitted to the facility on [DATE] with diagnoses that included: dementia, chronic systolic and diastolic congestive heart failure, systemic lupus, and end stage renal disease. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 8 (which indicated moderately impaired cognition) and required staff assistance for all Activities of Daily Living (ADLs). Review of a facility Verification Of Investigation form documented in part . DATE OF FINDING: [DATE] . ALLEGATION: On [DATE] at approximately 4:55 PM a code blue was initiated for (R402 name). Facility nurses continued CPR until (Fire Department Name) arrived at 5:11 PM and continued advanced life…

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 timely accurate advanced directive/code status was in place for two residents (R226 and R68) out of three residents reviewed for Advanced Directives. Findings include: Resident #226 On 5/9/23 the medical record for R226 was reviewed and revealed the following: R226 was initially admitted to the facility on [DATE] and had diagnoses including Congestive heart failure, Chronic obstructive pulmonary disease and Malignant Neoplasm of colon. A review of R226' MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/30/23 revealed R226 needed extensive assistance with most of their activities of daily living. R226's BIMS score (brief interview of mental status) was 14 indicating intact cognition. A review of R226's EMR (electronic medical record) front profile page revealed R226 had a code status of full code A Physician's order dated 3/25/23 revealed the following: Full code A facility document titled code status elective form…

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 professional Nursing standards were appropriately practiced for three residents ( R14, R24 and R58) of three residents reviewed for standards of practice. Findings include: Resident #14 On 5/9/23 at approximately 10:00 a.m., R14 was observed in their room, sitting up in their bed. R14 was queried if they had any concerns regarding their care and they reported that sometimes the facility runs out of their medication. On 5/9/23 the medical record was reviewed. R14 was initially admitted to the facility on [DATE] and had diagnoses including Chronic obstructive pulmonary disease and Muscle Weakness. A review of R14's MDS (minimum data set) with an ARD (assessment reference date) of 3/24/23 revealed R14 had a BIMS score (brief interview of mental status) of 15 indicating intact cognition. A review of R14's May 2023 medication administration record (MAR) revealed R14 was not administered four medications of 5/6/23. The Nursing administration codes for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure accurate skin assessments, and treatments for pressure ulcers were ordered and completed per physician's orders for two residents (R#'s 71 and 226) of four residents reviewed for pressure ulcers. Findings include: A review of a facility provided policy dated 11/28/17 was conducted and read, .To ensure residents that are admitted to the facility are evaluated to determine appropriate measures to be taken by the interdisciplinary care team to determine appropriate measures and individualized interventions to prevent, reduce and treat skin breakdown. It is the practice of this facility to properly identify and evaluate residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care . R71 On 5/9/23 at 8:51 AM, R71 was observed in their bed. R71 was observed with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident was transferred into a transportation vehicle in a safe manner for one resident (R74) out of three residents reviewed for accidents, resulting in R74 hitting their head on the top latch of the transportation/van vehicle causing excessive bleeding, a trip to the emergency department, and a diagnosis of minor closed head injury. Finding include: A review of R 74's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: displaced fracture of left ulna, heart disease, end stage renal failure, dementia, psychotic disturbance and muscle weakness. A review of the resident's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 6/15 indicating the resident was significantly cognitively impaired. Continued review of R74's clinical record documented, in part, the following: Health Status Note (2/17/23) 12:48 PM (authored by Nurse E): At approximately…

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 legally authorized representative signed a binding arbitration agreement (a legal contract that dictates an out-of-court alternate form of dispute resolution) for one resident (R8) of three residents reviewed for binding arbitration agreements. Findings include: On 5/10/23 the medical record for R8 was reviewed and revealed the following: R8 was initially admitted on [DATE] and had diagnoses including Dementia and CVA (stroke). A review of R8's MDS (minimum data set) with an ARD (assessment reference date) of 11/29/22 revealed R8 needed extensive assistance from facility staff with their activities of daily living. R8's BIMS score (brief interview of mental status) was three indicating severely impaired cognition. A review of R8's binding arbitration agreement revealed it was signed by R8's daughter on 11/22/2019. Further review of the agreement revealed the following documentation: .Do you have any other questions about the agreement? [Yes]…

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.