The Villa at Silverbell Estates

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #2737537. Based on interview and record review, the facility failed to honor an advanced directive for one resident (R902) of one resident reviewed for code status/advanced directives, resulting in five rounds of CRP/chest compressions (Cardiopulmonary Resuscitation) being performed against their wishes and subsequent emergency transfer to an acute care hospital. Findings include:On [DATE] a concern submitted to the State Agency (SA) was reviewed which alleged the facility did not honor a residents' advanced directive/code status.On [DATE] at 10:59 a.m., during an interview with the Director of Nursing (DON), the DON was queried if the facility had completed any recent CPR/Code events on any younger male residents in the facility, and they reported that R902 had a Code Blue ran on them in late January/early February.On [DATE] at approximately 11:05 a.m., The DON was queried regarding R902's CPR event on [DATE] and they reported they had identified some issues with the process 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 Complaint #2582127.Based on observation, interview, and record review, the facility failed to report an injury of unknown origin to the Administrator/Abuse Coordinator within the required timeframe for one (R801) of two residents reviewed for abuse. Findings include: A review of a complaint submitted to the State Agency revealed an allegation that on 7/25/25 at 8:00 PM, R801 was observed to not be herself, she wasn't speaking and seemed to have a change in condition. It was alleged R801 had bruising around the resident's collar bone area. A full body assessment was completed, the Administrator was contacted, and R801 was sent to the hospital for further assessment. It was alleged R801 was dropped from the (mechanical) lift by (Certified Nursing Assistant - CNA 'B' earlier in the day.On 9/2/25 at 8:07 AM, an interview was conducted with the complainant. When queried about what happened with R801, the complainant reported they believed R801 was injuring while being given a shower by CNA…

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 Complaint #2582127.Based on observation, interview, and record review, the facility failed to adequately assess the resident's skin and conduct a thorough assessment for a potential change in condition for one (R801) of two residents reviewed for abuse. Findings include: A review of a complaint submitted to the State Agency revealed allegations that on 7/25/25, when rounding on the residents, R801 appeared to not be herself, she wasn't speaking and seemed to have a change in condition. It was alleged R801 had bruising around the collar bone area and was sent to the hospital. On 9/2/25 at 10:18 AM, R801 was observed lying in bed. When asked if she injured herself recently, she said she did. When asked how it happened, she said she fell. When asked for more details she said I don't remember. When asked what kind of injury she had she said I don't remember but said it was her shoulder. R801 appeared contracted in the lower extremities as her legs were bent up toward her body. A review of…

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

Based on interview and record review, the facility failed to provide adequate staffing to meet the care needs of the residents, with the potential to affect all residents (including R10 and R85). Findings include: Review of the data staffing report submitted to the State Agency for the Second Quarter of 2025 (January 1, 2025, through March 31, 2025) revealed the facility triggered for low weekend staffing and had a one-star rating for staffing (below average staffing), yielding staffing concerns for the facility. On 6/16/25 at 9:05 AM, R85 was observed sitting in a wheelchair. When asked about care at the facility, R85 explained it depended on how many staff were working on the weekends, especially when there was not enough staff. R85 explained what would normally take a half hour would take two hours or more. R85 was asked what specifically would take that long. R85 explained since they required two staff plus a mechanical lift, getting into or out of bed was difficult when there was not enough staff. On 6/17/25 at 11:00 AM a Resident Council meeting was conducted with seven…

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 On 6/16/25 at approximately 9:07 AM, a refrigerator located in the large resident dining room was observed. A piece of paper was taped on the door that read: Resident Fridge Only ensure food is labeled and dated. Upon opening the refrigerator, the following medications were observed in the bottom drawer: Semglee (insulin), Lantus (insulin x2), TPN (Total Parenteral Nutrition x2 bags), Thiamine (Vitamin B1 x2), Infuvite (multivitamin x2) and SMOFLipid (lipid injectable used in parenteral nutrition x2). On 6/16/25 at approximately 10:34 AM, an observation and interview were conducted with the Director of Nursing (DON). The DON was queried as to why resident's medications were stored in the Resident Fridge (Only). The DON reported that the fridge located in the storage room was not working and a new fridge was ordered. The DON was not able to provide the date the fridge stopped working and an actual order form. On 6/17/25 at approximately 10:34 AM and again on 6/18/25 prior to exit at approximately 2:00 PM, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical and verbal abuse by a resident for two (R53 and R78) of four residents reviewed for abuse, resulting in R53 and R78 verbally abusing and intimidating each other on multiple occasions leading to R53 punching R78 in the stomach and on a different occasion, R78 hitting R53 in the face. Findings include: R53 On 6/16/25 at approximately 8:54 AM, R53 was observed sitting in a wheelchair in their room. The resident was only wearing a brief and indicated that he usually does not care to wear other clothes. R53 was queried about care in the facility and reported that a few days prior another resident hit him, pointing to the area on his right side. The resident noted that it caused pain. R53 was not able to provide the name of the resident but did provide a description. R53 reported the resident who hit him is always in the hallway yelling. A review of R53's clinical record revealed the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report allegations/incidents of resident-to-resident physical and verbal abuse to the State Agency (SA) for two residents (R53 and R78) out of four residents reviewed for abuse. Findings include: R53 On 6/16/25 at approximately 8:54 AM, R53 was observed sitting in a wheelchair in their room. The resident was only wearing a brief and indicated that he usually does not care to wear other clothes. R53 was queried about care in the facility and reported that a few days prior another resident hit him, pointing to the area on his right side. The resident noted that it caused pain. R53 was not able to provide the name of the resident but did provide a description. R53 reported the resident who hit him is always in the hallway yelling. A review of R53's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: cerebral infarction (stroke), Type II diabetes and memory deficit. A review of the resident'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 interview and record review the facility failed to thoroughly investigate allegations of abuse and actual abuse for two (R53 and R78) and potential unidentified residents out of four residents reviewed for abuse. Findings include: R53 On 6/16/25 at approximately 8:54 AM, R53 was observed sitting in a wheelchair in their room. The resident was only wearing a brief and indicated that he usually does not care to wear other clothes. R53 was queried about care in the facility and reported that a few days prior another resident hit him, pointing to the area on his right side. The resident noted that it caused pain. R53 was not able to provide the name of the resident but did provide a description. R53 reported the resident who hit him is always in the hallway yelling. A review of R53's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: cerebral infarction (stroke), Type II diabetes and memory deficit. A review of the resident's Minimum Data Set…

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 routine nail care for one (R34) out of two residents reviewed for Activities of Daily Living (ADL). Finding include: On 6/16/25 at approximately 8:54 AM, R34 was observed lying in bed. They had long fingernails extending approximately one quarter inch past the nail bed with brown debris under multiple nails. R34 was asked about the nails and noted they needed to be cut. On 6/17/25 at approximately 8:55 AM, the resident's nails remained long with dark debris underneath most of their nails. On 6/18/25 at approximately 8:38 AM, R34's nails again appeared long with debris. R34 was asked if they would allow staff to cut their nails and they indicated that they would. On 6/18/25 at approximately 8:40 AM, Certified Nursing Assistant (CNA) Y was observed in the hall. CAN Y was asked as to the facility policy regarding cutting resident's nails, they indicated that nails are usually care for on resident's shower days. When…

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 R78 On 6/16/25 at 9:25 AM, R78 was observed standing in their room. R78 was asked if he had any concerns at the facility. R78 explained he would walk around the whole facility for exercise . had clocked it so he knew how many miles he walked a day . there was another resident, he only knew their first name, that would always flip his middle finger at him every time he walked past . one day he was walking and this resident had his wheelchair in the doorway of his room . he ignored him when he went past . the next time around this resident was all the way in the hall . he thought he wanted to talk to him so he stopped and asked what he wanted . the resident flipped him the middle finger, so he grabbed his finger . the resident hit him in the stomach, so he pushed his index fingers in his eyes . the nurses came and were yelling at us . he put his hands up and stepped away from the resident. Review of the clinical record revealed R78 was admitted into the facility on 2/8/25 with diagnoses that included: epilepsy,…

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 Physician ordered laboratory (lab) diagnostic was completed and failed to notify the physician/provider timely on abnormal lab results for one resident (R80) of one resident reviewed for diagnostics, resulting in the potential for decline in health conditions. Findings include: Record review revealed that R80 was a long-term resident of the facility, originally admitted to the facility on [DATE]. R80 had a recent hospitalization and they were readmitted back to the facility on 3/18/25. R80's admitting diagnoses included pneumonia, congestive heart failure, chronic kidney disease, major depressive disorder, and gout. Based on Minimum Data Set (MDS) assessment dated [DATE], R80 had a Brief Interview for Mental Status (BIMS) score 9/15, indicative of moderate cognitive impairment. R80 had a guardian (daughter) who was making decisions on their behalf. Review of R80's physician orders revealed an order dated 6/9/25 for the following diagnostics:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a urinary catheter drainage bag (s) (leg bag and bedside/night bags) in a sanitary manner for one of one sampled resident (R44) reviewed for infection control with urinary catheter with potential for contamination and spread of disease to a vulnerable population. Findings Include: Record review revealed R44 was long term resident admitted to the facility on [DATE]. R44's admitting diagnoses included myelopathy, bipolar disorder, and neuro muscular dysfunction of the bladder. Based on the Minimum Data Set (MDS) assessment dated [DATE], R44 had a Brief Interview for Mental Status (BIMS) score of 14/15 indicating an intact cognition. R44 had a urinary catheter due to their medical condition. R44 needed some level of staff assistance to complete their lower body dressing and toileting hygiene tasks. An initial observation was completed on 6/16/25 at approximately 9:30 AM. R44's room door had a signage for Enhanced Barrier Precautions…

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 #MI00147108 Based on observation, interview and record review, the facility failed to ensure scheduled pain medication was available per physician orders and maintain accurate documentation of controlled substances for one (R601) of three residents reviewed for medications. Findings include: A complaint was filed with the State Agency (SA) that alleged in part, .(R601) has chronic pain . (R601) feels as though (they) must beg to get (their) medication . On 10/8/24 at 10:23 AM, R601 was observed lying in bed. R601 was asked about their pain medications. R601 explained the facility runs out of their Morphine and they have to go a couple days without it. Review of the clinical record revealed R601 was admitted into the facility on 3/14/24 and readmitted [DATE] with diagnoses that included: primary generalized osteoarthritis, rheumatoid arthritis and chronic pain syndrome. According to the Minimum Data Set (MDS) assessment dated [DATE], R601 had moderately impaired cognition. Review…

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 #: MI00145908 Based on observation and interview, the facility failed to store tracheostomy supplies in a clean and sanitary condition for one (R903) of one Resident reviewed for infection control resulting in the potential to cause an infection(s) for a compromised resident with multiple comorbidities. Findings include: A record review revealed R903 was a long-term resident of the facility. R903's diagnoses included intracranial hemorrhage (brain bleed), seizures, and respiratory distress. R903 was breathing through tracheostomy (a surgical opening created into the trachea (windpipe) from outside the neck to assist with breathing). R903 was receiving their nutrition and hydration through Percutaneous Endoscopic Gastrostomy (PEG - A percutaneous endoscopic gastrostomy tube is a feeding tube surgically placed through abdomen into the stomach) tube. R903 needed staff assistance for most of their Activities of daily Living (ADLs) such as mobility, toileting, dressing etc. R903 had family member appointed as their guardian. On 8/13/24 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.

This citation pertains to intake #MI00145455. Based on observation, interview and record review, the facility failed to ensure that a portable oxygen tank was properly secured while left unattended resulting in the potential for the tank to be knocked over, causing a potential rocketing of the cylinder and injury to all residents in the immediate area, of a total census of 86. Findings include: On 7/23/24 a concern submitted to the State Agency was reviewed and indicated that the facility was unsafe for residents. On 7/23/24 at approximately 8:59 a.m., A free-standing portable oxygen tank half full of oxygen was observed leaning up on it's side against a wall and was unsecured/unattended by any staff in the front Nursing Station that was located next to the dining room and a resident area hallway. At that time, multiple residents were observed in the dining room and hallway. On 7/23/24 At approximately 9:01 a.m., Nurse A was shown the unsecured oxygen tank leaning against the wall and was queried if that was a safe way to store oxygen tanks. Nurse A reported that it 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 observation, interview, and record review, the facility failed to ensure food was prepared served, and stored in a sanitary manner for one resident (R32) of one resident reviewed for food storage. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 5/6/24 between 8:45 AM-9:30 AM, during an initial tour of the kitchen, the following items were observed: Dietary Staff L was observed with a long beard, but was not wearing beard restraint. Dietary Manager K confirmed Staff L should have on a beard restraint. According to the FDA Food Code section 2-402.11 Effectiveness, (A) Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. There were 3 ceiling vent covers observed with dust and peeling paint 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure treatment in a dignified manner for seven residents (R#s 5, 42, 66, 13, 7, 55, and 289) of seven residents reviewed for dignity. Findings include: A review of a facility provided policy titled, Resident Rights, dated 11/2017 was reviewed and read, .The right to be treated with respect and dignity . On 5/6/24 at 10:00 AM, an interview was being conducted with R5 in their room with the door closed. During the interview, Certified Nurse Aide (CNA) 'B' entered the room without knocking or asking permission to enter. At approximately 10:05 AM, observations from the hallway revealed CNA 'B' entering R42 and R66's room retrieving breakfast trays. CNA 'B' was not observed to knock on the door and ask permission for entry. Upon exiting the room CNA 'B' was then observed to enter several other rooms on the hallway collecting breakfast trays without knocking or asking permission for entry to the rooms. On 5/6/24 at 10:10 AM, an interview was…

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

This citation pertains to intake#MI00144094. Based on interview and record review, the facility failed to ensure sufficient nursing staff were provided to meet resident needs for three residents (R58) and two other residents (who preferred to remain anonymous), potentially affecting all 87 residents residing in the facility. Findings include: On 5/6/24 a review of the payroll based journal report (PBJ-A total of Nursing hours worked reported by the facility to the Center for Medicare and Medicaid Services) was conducted and revealed the facility had excessively low weekend staffing hours during FY (fiscal year) Quarter one (October through December 2023). On 5/7/24 at 10:30 a.m., during the anonymous group meeting, two residents indicated the facility was short staffed, they had to wait a long time for call light responses on the weekend shifts, and the (meal) tray pass was slow due to not enough Nursing aides to help pass the trays timely. One resident indicated that there were times when only one Nursing aide is passing trays at a time which resulted in cold food being served. 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 ensure three insulin pens were stored in the appropriate place and two of four medication carts observed unlocked. Findings include: On 5/6/24 at approximately 4:17 p.m., a nursing treatment/medication cart located on the Oakland hallway containing various wound care treatments/creams was observed unlocked and unattended by any nursing staff. On 5/7/24 at 8:39 AM after Nurse O finished with a medication pass, an inspection of the cart on Oakland was made, there were three unopened insulin pens in the top drawer. Nurse O was asked where should unopened insulin be located and stated that it should be in the refrigerator. On 5/7/24 at approximately 10 AM, a medication cart located on the [NAME] unit was observed unlocked and unattended. On 5/7/24 at approximately 1PM, a medication cart located on the Oakland unit was observed unlocked and unattended. On 5/8/24 at 11:00 AM the Director of Nursing (DON) was interviewed and asked should…

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

On 5/6/24 at 12:20 PM, residents were observed in the dining room, being served soup from a soup kettle. The internal temperature of the soup inside the kettle was measured to be 117 degrees Fahrenheit. On 5/6/24 at 12:25 PM, when queried, Dietary Manager K looked at the kettle and stated the temperature dial needed to be adjusted to a higher temperature. According to the 2017 FDA Food Code section 3-501.16 Potentially Hazardous Food (Time/Temperature Control for Safety Food), Hot and Cold Holding. 1. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C ) of this section, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be maintained: 1. (1) At 57 ºC (135ºF) or above . Based on observation, interview, and record review, the facility failed to ensure palatable meals for six residents (R#'s 66, 70, 9, 65, 35, and 10) of twelve residents reviewed for food palatability, and failed to serve food at a palatable temperature, resulting 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.

Based on observation, interview, and record review, the facility failed to ensure food preferences for seven residents (R#'s 66, 35, 70, 41, 68, and 65) of 12 residents reviewed for food preferences, resulting in verbalized complaints and dissatisfaction with meals. Findings include: On 5/6/24 at 9:51 AM, R66 was asked about the food in the facility. They said they were never served coffee. Their breakfast tray was observed and did not contain coffee. A review of R66's meal ticket revealed a liked food/drink item was coffee. On 5/6/24 at 10:45 AM, R65 was interviewed about the food and said it was, awful. They said they frequently requested items from the always available menu but they were rarely provided what they asked for. On 5/6/24 at 1:08 PM, R66 was asked about their lunch meal and said It tastes like chicken. It was noted the ticket did not contain the menu items served to R66. R66 said the ticket never listed their food items and they were never provided with a menu. R66 said they would like a hamburger every once and awhile. They further verbalized their frustration 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 appropriately implement enhanced barrier precautions (EBP, infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) and wear the required personal protective equipment (PPE) for resident's on EBP for four residents, (R#'s 64, 45, 49, and 33) of seven residents reviewed for transmission based precautions, resulting in the potential for the transmission of multidrug-resistant organisms. Findings include: On 5/6/24 at 10:18 AM, R64 and R45 were observed in their beds. They were each observed with a urinary catheter. There was no signage on the door that indicated the residents were treated with enhanced barrier precautions (EBP), as defined by the Center For Disease Control, .Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use…

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 coordinate a transfer to the hospital per the resident's choice for one resident, (R35) of two residents reviewed for choices, resulting in R35 feeling the facility did not take their health condition seriously. Findings include: On 5/6/24 at 11:05 AM, an interview was conducted with R35. R35 said an incident occurred in March (2024) where they were not feeling well and requested to go to the emergency room. R35 said they were pretty sure they had pneumonia and needed antibiotics. They further indicated staff told them they didn't need to go out and a transfer was not coordinated per their request. R35 reported they called 911 themselves and went to the emergency room where they were diagnosed with pneumonia and received intravenous (IV) antibiotics. R35's clinical record was reviewed and revealed they originally admitted to the facility 11/23/22, and most recently re-admitted on [DATE] with diagnoses that included: multiple sclerosis, paraplegia,…

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 correct and completed involuntary discharge transfer documents for one resident of one resident reviewed for discharge. Findings include: On 5/6/24 at 10:48AM, R58 was observed in their room watching television. R58 was interviewed about the care received while in the facility. R58 stated that the facility was involuntarily discharging them due to a small bottle of unopened whiskey they found in the resident's nightstand. R58 was then asked how many times were they warned or educated on the matter of having alcohol in the facility. R58 stated this was the second time they were caught with an unopened bottle. R58 stated that they were allowed to go on leave of absences(LOA). R58 stated that the facility told them that they had a month to find new living arrangements. A record review revealed that R58 was admitted to the facility on [DATE] with the diagnosis of chronic obstructive pulmonary disease, chronic respiratory failure and acquired absence…

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 X-rays were ordered in a timely manner after a fall for one resident (R32) of one resident reviewed for diagnostic testing. Findings include: On 5/6/24 at 1:16 PM, R32 was observed in their room in their wheelchair. They were asked about their stay in the facility and said they had a fall last night. They said they hurt their left arm and their left leg. An observation of their right arm revealed it was slightly reddened in comparison to their left. On 5/6/24 at 1:44 PM, a review of a progress notes entered into the record by Nurse 'H' revealed the following: 5/6/24 6:35 AM, .Upon Morning medication pass resident is found behind door on floor next to W/C (wheelchair) on L (left) side of body in fetal position. Resident is alert and inquiring who moved her Blankets and pillow .Resident c/o (complains of) pain in LUE (Left Upper Extremity) w/ (with) 10/10 pain & LLE (Left Lower Extremity) w/ 9/10 pain . 5/6/2024 at 7:23 AM, .On call per (Doctor's Name) Group paged r/t (related to) office closed .…

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 vision care was provided for one resident (R21) of one resident reviewed for vision/hearing. Findings include: On 5/06/24 at approximately 11:08 a.m., R21 was observed up in their wheelchair in the dining room. R21 was queried if they had any concerns regarding their care and they reported they had difficulty with their vision and the facility was not helping them with it. On 5/7/24 at approximately 3:19 p.m., R21 was observed in their room, sitting up in their bed. R21 was asked if they were able to see other objects and they indicated they can only see straight but nothing on the sides (peripheral vision), they again reported they felt the facility has not helped them with their vision. On 5/6/24 the medical record for R21 was reviewed and revealed the following: R21 was initially admitted to the facility on [DATE] and had diagnoses including Dementia and Legal blindness. A review of R21's MDS (Minimum Data Set) with an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure Physician's orders were followed for oxygen therapy administration for two residents (R58 and R63) of two residents reviewed for respiratory care. Findings include: On 5/6/24 at approximately 1:01 p.m., R63 was observed in their room, laying in their bed. R63 was observe to have oxygen delivered via nasal cannula at 1.5 liters per minute (LPM). R63 was queried if they knew how many liters per minute of oxygen they should be on and they reported it should be at three liters. On 5/6/24 at approximately 3:58 p.m., R63 was observed in their room, laying in their bed with oxygen still being delivered via nasal cannula at 1.5 LPM. On 5/6/24 the medical record for R63 was reviewed and revealed the following: R63 was initially admitted to the facility on [DATE] and had diagnoses including Chronic obstructive pulmonary disease (COPD) and pulmonary collapse. A review of R63's MDS (Minimum Data Set) with an ARD (assessment reference date) 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 pain management services for two of two residents (Resident 84 and 290 ) reviewed for pain, resulting in unrelieved pain. Findings include: R209 On 5/6/24 at 9:18AM, R290 was observed laying on their back watching television. R290 was asked how their care was at the facility. R290 stated it was okay and explained that have only been here for a couple of days because they broke their arm. R290 further explained that they were in a lot of pain and the facility took their walker and now had to hold the side of the wall to walk down the hallway. R290 was asked what they received for pain stated, Nothing, in the hospital I was getting morphine and oxycodone, then I got here and I don't even get an aspirin. A record review revealed that R290 was admitted to the facility on [DATE] with the diagnosis of displaced fracture of surgical neck of left humerus, chronic obstructive pulmonary disease, and muscle weakness. A further 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.

Based on observation, interview, and record review the facility failed to maintain a medication error rate of less than five percent when three medication errors were observed and one medication not signed out from a total of 25 opportunities observed during medication administration, resulting in a medication error rate of 12%. Findings include: On 5/7/23 at 08:39 AM Nurse O was observed during a medication administration pass for R42. Nurse O properly pulled and administered medication to resident and when exited the room, nurse O signed out the medications. Nurse O was asked if R42 received everything that they were supposed to for this medication pass. Nurse O stated, Yes. A record review of the physician orders and Medication Administration Record (MAR) revealed that upon reconciliation Nurse O had not administered Fenofibrate 54mg, Loratadine and Sertraline 25mg, and did not sign out the as needed Tylenol that was administered. On 5/7/24 at 11:40 AM Nurse O was interviewed and asked why didn't they administer all due medications. Nurse O replied, I did administer 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 pertinent resident information was documented in the medical record for one resident (R24) of one resident reviewed for Social Services/Guardianship resulting in the potential for clinical misrepresentation of the resident and errors in providing a continuum of care. Findings include: On 5/6/24 at approximately 9:50 a.m., R24 was observed to be confused and unable to answer any questions. On 5/6/24 the medical record for R24 was reviewed and revealed the following: R24 was initially admitted to the facility on [DATE] and had diagnoses that included: Adult failure to thrive, Dementia and Cerebral Infarction (stroke). A review of R24's MDS (minimum data set) with an ARD (assessment reference date) of 3/25/24 revealed R24 had a BIMS score (brief interview of mental status) of one indicating severely impaired cognition. Further review of the medical record revealed R24 did not have a legal representative to assist with informed decision making. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number(s): MI00138031, MI00138863, MI00140340, and MI00141846. Based on observation, interview, and record review, the facility failed to document administration of schedule II (2) controlled substances (drugs that have high potential for abuse and/or addiction) according to professional standards of practice for nine (R502, R504, R509, R511, R512, R513, R514, R515, and R516) of 12 residents reviewed for medications. Findings include: On 4/3/24 at 1:03 PM, an observation of the Oak Unit medication cart was conducted with Licensed Practical Nurse (LPN) 'B' and the following observations were made: R509 LPN 'B' was asked to present R509's Morphine Sulfate Solution (a controlled liquid medication used to treat pain). The amount of medication in the bottle was compared with the amount documented on R509's Medication Monitoring/Control Record (a form used to document medication removed from the supply in order to keep an accurate record of the medication). The amount of medication 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 Deficient Practice #1 This citation pertains to Intake Number(s): MI00138031, MI00138863, MI00140340, and MI00141846. Based on observation, interview, and record review, the facility failed to ensure schedule II (2) controlled substances (drugs that have high potential for abuse and/or addiction) were accurately reconciled, administered, and documented; and discrepancies in counts were addressed for eight (R502, R509, R511, R512, R513, R514, R515, and R516) of 12 residents reviewed for medications. Findings include: A review of a complaint submitted to the State Survey Agency revealed an allegation that staff were not administering medications (controlled substances) according to physician's orders and proper procedures. On 4/3/24 at 1:03 PM, an observation of the Oak Unit medication cart was conducted with Licensed Practical Nurse (LPN) 'B' and the following observations were made: R509 LPN 'B' was asked to present R509's Morphine Sulfate Solution (a controlled liquid medication used to treat pain). The amount…

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 promptly report abnormal x-ray results to the physician/physician extender for one (R501) of four residents reviewed for change in condition. Findings include: A complaint was filed with the State Agency (SA) that alleged on 10/13/23 the complainant observed R501's arm was swollen, and they were having difficulty breathing. The complainant further noted that the facility was not paying attention to the residents change in condition, so they requested that R501 be sent to the Hospital. A review of R501's clinical record revealed the resident was initially admitted to the facility on [DATE] and their last admission date was 2/13/24 with diagnoses that included, in part: diabetes, chronic kidney disease, obesity and heart failure. A review of the Minimum Data Set (MDS) dated [DATE] noted the resident's Brief Interview for Mental Status (BIMS) score was 15/15 (intact cognition) and noted the resident needed one-to-two-person assistance for most Activities…

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.