The Villa at the Bay

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide scheduled showers for two sampled Residents (#18, #73) and three Confidential Residents (CR#6, #9, and #14) of 18 Residents reviewed for Activities of Daily Living (ADLs). Findings include:During the resident council meeting conducted on 5/1/25 at 11:00 AM, three Residents who wished to remain confidential stated that they do not receive showers on a consistent basis and expressed subsequent feelings of frustration.Confidential Resident (CR)-14 reported getting less than one shower per week and sometimes going up to two weeks without a shower. CR-14 indicated each resident was scheduled to receive two showers per week. CR-6 stated they received, Maybe one shower per week. CR-9 explained, If they're [facility] short of help, they always come in and say we can't do showers today. Resident #18 (R18)During an interview on 5/20/25 at 11:38 AM, R18 was observed in their room lying in bed. R18's hair was uncombed and appeared greasy. R18…

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 complete assessments to ensure safe self-administration of medication for three Residents (R60, R61, and R230) of 18 residents reviewed for right to self-administer medications. Findings include: Resident #60 (R60) The medical record for R60 revealed an admission date to the facility on 6/11/24 with a primary diagnosis of respiratory failure. R60 had a Brief Interview Mental Status (BIMS) assessment score of 9 out of 15 indicating moderately impaired cognition. On 5/21/25 at 9:10 AM, an observation was made of R60 asleep and resting in their bed. R60 had a medication cup on their bedside table with six oral pills and a clear plastic cup with a light brown substance which measured approximately 6 ounces. On 5/21/25 at 9:18 AM, an interview was conducted with Licensed Practical Nurse (LPN) O after they entered R60's room. LPN O was asked how long the medications had been sitting on R60's bedside table and if R60 had a physician order to self-administer medications. LPN O replied, The medications have been there…

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 follow their grievance procedure and make prompt efforts to resolve grievances regarding complaints of missing items for three Residents (#5, #11 and #22) of three residents reviewed for inaction of grievances. Findings include: Resident #5 (R5) The medical record for R5 included a face sheet indicating an original admission date of 9/16/2008. The Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15 indicating intact cognition. On 5/22/25 at 10:14 AM, R5 complained she had many things that were missing. R5 said, I am missing two black tops, and I told staff but (heard) nothing. I guess the tops just disappeared. I am also missing an orange top. R5 stated she has tried to follow up and has asked staff about the items, but she has been told we don't know. R5 stated, Sometimes it gets upsetting. During an interview on 5/22/25 at 10:15 AM, Registered Nurse Consultant (RN) L…

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 revise and update care plans to reflect resident status for one Resident (#54) of 18 Residents reviewed for care plans. Findings include: Resident #54 (R54) R54 was admitted on [DATE] with diagnoses including stroke, quadriplegia, dysphagia (difficulty swallowing) following a stroke, protein-calorie malnutrition and anemia. The Minimum Data Set (MDS) assessment dated [DATE] indicated R54 had a feeding tube in place on admission and while a resident. The MDS assessment dated [DATE] indicated a feeding tube was not in place. A physician order dated 4/21/25 read, Contact Digestive Health to notify them of removal of PEG tube (percutaneous endoscopic gastrostomy tube inserted directly into the stomach providing an alternative for individuals who cannot swallow or received adequate nutrition orally.) and if any other follow up is needed, Patient/guardian decline replacement at this time. A physician order for Regular diet, Pureed texture, Honey-Thick…

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 restorative nursing services were provided to increase range of motion and/or to prevent further decrease in range of motion (ROM) for one Resident (#54) of one resident reviewed for limited range of motion. Findings include: Resident #54 (R54) R54 was admitted on [DATE] with diagnoses including stroke, quadriplegia, cerebral palsy, and traumatic brain injury. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15, signifying R54 was cognitively intact. On 5/20/25 at 11:51 AM, R54 was observed in his bed with severely contracted hands. R54 was able to open his fists slightly and said no staff helped him work on his hands and it, Probably would be a good idea. The physician order dated 2/9/25 included, Splint to L (left) hand off while awake and on at night every day and evening shift for hand splints. R54 stated he did not always like to wear 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 provide proper infection control measures pertaining to indwelling catheters (a tube inserted into the bladder to accommodate emptying of the bladder) for one Resident (#8) of two residents reviewed for indwelling catheters. This deficient practice resulted in the potential for infections and illness. Findings include: Resident #8 (R8) Review of R8's electronic medical record (EMR) revealed an admission date of 9/29/23 with diagnoses including neuromuscular dysfunction of bladder. R8's 4/5/25 Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 14/15 indicating no cognitive impairment. R8 was also marked on the MDS for the use of an indwelling catheter. On 5/21/25 at 2:07 p.m., R8 was observed being assisted by staff to go outside to the smoking shed which is across the facility parking lot. R8 was being pushed by an unidentified staff member in her wheelchair. R8's indwelling catheter urinary collection bag was observed underneath the wheelchair seat, not in a…

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

Based on observation, interview, and record review, the facility failed to ensure sanitary storage, labeling, and cleaning of respiratory equipment for three Residents (#23, #42, and #61) of 3 residents reviewed for respiratory services. Findings include: Resident #23 (R23)Review of R23's electronic medical record (EMR) revealed initial admission to the facility on 4/8/25 with diagnoses including chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia (low levels of oxygen in body tissues). Review of R23's admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 6, indicative of severe cognitive impairment. Review of R23's EMR revealed the following physician's order, initiated 5/8/25:Continuous O2 [oxygen] via (NC/MASK) [nasal cannula] at 2 L/m [2 Liters per minute].On 5/20/25 at 10:52 AM, an unoccupied wheelchair was observed at the foot of R23's bed with undated oxygen tubing connected to a portable oxygen tank. The tubing was observed laying in the wheelchair seat with no protective covering. R23…

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 properly perform hand washing and hand hygiene during wound dressing changes. Findings include: Resident # 42 (R42) On 5/20/25 at 2:25 PM, an observation was made of R42 lying in their bed. R42 summoned Certified Nurse Aide (CNA) H to take a used fast food chain coffee cup R42 was using as a urinal from them prior to dressing change. The used fast food chain coffee cup had visible coffee stains on the outer edges of the cup. CNA H took the used fast food chain coffee cup from R42 and placed it on their bedside table. During wound care dressing changes for R42 on 5/20/25 at 2:25 PM, the following observations were made: - At 2:34 PM, Licensed Practical Nurse (LPN) D removed gloves and changed gloves without hand sanitization. - At 2:40 PM, LPN D removed gloves and washed their hands for only eight seconds, did not turn water on prior to dispensing soap, and turned water off with their bare hands. - At 2:45 PM, LPN D removed gloves and changed gloves without hand sanitization, then applied Dakin's solution 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.

This citation pertains to intake numbers: MI00150212 and MI00150297. Based on interview and record review, the facility failed to notify the residents emergency contact and attending physician of a change in condition for one Resident (#3) of three residents reviewed for notifications. Findings include: Resident #3 (R3) Review of complaint intake number MI00150212 to the State Agency (SA), dated 2/11/25 revealed, R3 was transfer to a local hospital by emergency medical services (EMS) in critical condition after a four-day admission from the facility. Family was notified by hospital intensive care unit (ICU) doctor. Family/emergency contact was not notified by facility of the transfer to the local hospital. Review of complaint intake number MI00150297 to the SA, dated 2/13/25 revealed, on the early morning of 2/9/25, R3 was transferred to a local hospital by EMS. The facility never contacted family to let them know R3's condition was declining or that R3 was taken to the hospital. This resulted in R3 being all alone in the local hospital on 2/9/25. Review of R3's face sheet revealed…

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 numbers: MI00150212, MI00150215, and MI00150297. Based on interview and record review, the facility failed to ensure sufficient staff to provide for resident's care needs, for one Resident (#3) of three residents reviewed for staffing. Findings include: Resident #3 (R3) Review of complaint intake number MI00150212 to the State Agency (SA), dated 2/11/25 revealed, R3 was transferred to a local hospital by emergency medical services (EMS) in critical condition after a four-day admission from the facility due to his colostomy not being cared for and resulting in stool contaminating the surgical incision and drains. R3 now had positive blood cultures for VRE (vancomycin-resistant enterococcus) and was in septic shock. Review of complaint intake number MI00150215 to the SA, dated 2/11/25, revealed, on 2/5/25, R3 was discharged from the hospital in stable condition to the facility for rehabilitation. On 2/9/25, R3 was admitted to the local hospital in critical condition with low oxygen saturation and blood pressure. R3 had an abdominal binder over his…

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 numbers: MI00150212, MI00150215, and MI00150297. Based on interview and record review, the facility failed to ensure competent staff to provide for resident's care needs, for one Resident (#3) of three residents reviewed for staffing. Findings include: Resident #3 (R3) Review of complaint intake number MI00150212 to the State Agency (SA), dated 2/11/25 revealed, R3 was transferred to a local hospital by emergency medical services (EMS) in critical condition after a four-day admission from the facility due to his colostomy not being cared for and resulting in stool contaminating the surgical incision and drains. R3 now had positive blood cultures for VRE (vancomycin-resistant enterococcus) and was in septic shock. Review of complaint intake number MI00150215 to the SA, dated 2/11/25, revealed, on 2/5/25, R3 was discharged from the hospital in stable condition to the facility for rehabilitation. On 2/9/25, R3 was admitted to the local hospital in critical condition with low oxygen saturation and blood pressure. R3 had an abdominal binder over his…

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

Based on interview and record review, the facility failed to administer physician ordered antibiotic medication for one Resident (#3) of three residents reviewed for medication administration. Findings include: Resident #3 (R3) Review of R3's hospital discharge paperwork, dated 2/3/25, read in part .Cefazolin 6 g (grams) per 24 hours continuous infusion (or 2 g IV [intravenous] q [every] 8 hours . Review of R3's progress note, dated 2/5/25 at 9:35 PM, read in part Resident admitted from (local hospital) . Unable to use any or all devices. Needs assistance with devices .Medication review: A medication reconciliation/review occurred. Findings and actions: Clarified with (local hospital). Review of R3's progress note, dated 2/5/25 at 10:26 PM, read in part Received report .Cefazolin last given at 5:00 PM . Review of R3's new admission phone report form, dated 2/5/25, read in part .Arrived by: EMS (emergency medical services) 1800 ish (approximately 6:00 PM) . Antibiotics: cefazolin - PICC (peripheral inserted central catheter) Q (every) 8 hours last dose 17:00 (5:00 PM) . Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 77 residents. Findings include: On 7/15/24 at approximately 10:15 AM, three pans of leftover food were observed in the upright refrigerator in the kitchen and included (as labeled) a pan of Chicken pot pie, Chicken parmesan, cheese soup. An interview with Kitchen Manager (KM) A was conducted. KM A was requested to produce documentation for the proper cooling for the leftover food. KM A stated that they did not complete cooling logs for leftover food. Immediately following the interview with KM A, an interview was conducted with the Regional Dietary Manager (RDM) F who stated leftovers were not supposed to be saved, pursuant to company policy. On 7/16/24 at approximately 7:15 AM, a flat pan, on a wheeled cart was observed in the walk-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 interview and record review, the facility failed to report Payroll Based Journal (PBJ) information to CMS (Centers for Medicare and Medicaid). This deficient practice resulted in inaccurate reporting of staffing levels with the potential to affect all 77 residents. Findings include: Review of the CMS PBJ Staffing Data Report FY (fiscal year) Quarter 2 2024 (January 1- March 31) revealed the metric Excessively Low Weekend Staffing Triggered with daily infractions from 1/1/24 to 3/31/24. An interview was conducted with the Nursing Home Administrator (NHA) on 7/17/24 at 1:05 p.m. The NHA stated corporate is responsible for submitting the data to the CMS PBJ report. The NHA confirmed they used agency staffing to meet the needs of the residents. A review of the Facility assessment dated , undated, revealed, .Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies: Staff type: Identify the type of staff .that are needed to provide support and care for residents. Potential data sources include staffing…

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 and interview, the facility failed to maintain a safe, functional, and sanitary environment, potentially exposing all 77 residents to unsafe and unsanitary conditions. Findings include: On 7/15/24 at approximately 12:30 PM, resident rooms [ROOM NUMBERS] were observed to have exposed pipes running along the floor at the east wall juncture. The pipes included 1 white plastic; 1/2 copper wrapped in black foam insulation, ¾ electrical conduit and 1/4 copper. On 7/15/24 at approximately 1:30 PM, an interview was conducted with Maintenance Supervisor (MS) G, who identified the pipes as originating from the wall mounted air conditioning units located in the corridor outside each of the respective rooms. When asked why the piping had never been boxed in and sealed, MS G stated he did not know and agreed that they should be boxed in and sealed. On 7/16/24 between 2:00 PM and 3:30 PM, resident rooms on the South (300) and North (100) units were observed without functioning night lights. The south unit…

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 determine and honor food preferences for five residents (R6, R5, R17, R20, R27) and additional residents in a confidential group meeting. This deficient practice resulted in resident complaints of their food choices being ignored, extended wait times for alternate food choices, decreased meal enjoyment, and the potential for weight loss and nutritional decline. Findings include: On 7/15/24 at 11:31 AM, R17 was in his room and stated the food could be better. He said the only things he really could not eat were broccoli and cauliflower. He said somehow, he gets these vegetables all the time and he had a medical condition in which prevented him from eating them. On 7/16/24 at 1:06 PM, R17 was in the north dining room and was finally served lunch. The other two residents at his table had finished their meal. R17 said he lived at the end of the hall, so he had to wait for the third food cart and his tablemate's trays were on the first cart. R17 received mixed vegetables with broccoli and cauliflower included. His…

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 prevent an injury due to smoking for one resident (R21) of two residents reviewed for smoking. This deficient practice resulted in R21 receiving two burns due to unsafe smoking habits. Findings include: Review of R21's Electronic Medical Record (EMR) revealed admission to the facility on 2/26/19 with diagnoses including contracture of hand and muscle weakness. Review of R21's Brief Interview for Mental Status (BIMS) score revealed a score of 10, indicative of mild cognitive impairment. On 7/15/24 at approximately 12:01 p.m., R21 was observed sitting in the main dining room waiting for lunch. A small burn was observed on both the index finger and middle finger of R21's right hand which were noted yellow in color. Review of R21's Smoking Risk Evaluation, dated 6/10/24, revealed the following, Does Resident Smoke? Yes .Is Resident interested in smoking cessation? Yes .Smoking materials: Cigarettes .Risk Category: Check all that apply (score is 1 point for any checked box on questions 1-7) checked: Resident has…

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 monitoring of weight and following of physician orders in providing proper diets to prevent weight loss for two Residents (#66 and #67) of two residents reviewed for significant weight loss, resulting in potential for delayed treatment, continued weight loss and decline in function. Findings include: Resident #66 (R66) R66 was admitted on [DATE] with diagnoses including heart failure, malnutrition, thyroid disorder, and depression. Review of the MDS (Minimum Data Set) assessment for R66, dated 6/16/2024 revealed set up assistance was required for eating and had a baseline weight of 153 pounds (lbs.). Review of the Electronic Medical Record (EMR) for R66 on 7/16/2024 at 9:32 a.m., revealed the following recorded weights: 6/10/2024 at 11:01 p.m.: 153.0 lbs. 6/25/2024 at 2:08 p.m.: 118.6 lbs. (*Note- Weight was struck through with message entered by RN K on 6/26/2024 at 6:56 a.m. Incorrect Documentation. No follow-up weight was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide fluids in the prescribed texture/consistency for two residents (Resident #14 and #37) of two residents reviewed for therapeutic diet orders. This deficient practice resulted in the delivery of fluid of inappropriate consistency resulting in the potential for decreased fluid intake, aspiration (accidental inhalation of food/fluid into the lungs), and associated respiratory complications. Findings include: Resident #14 (R14): Review of R14's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including dementia, dysphagia (difficulty swallowing), and chronic obstructive pulmonary disease (COPD). Review of R14's most recent Minimum Data Set (MDS) assessment, dated 4/27/24, revealed a Brief Interview for Mental Status (BIMS) score of 6, indicative of severe cognitive impairment. On 7/17/24 at 8:39 AM, R14 was observed laying in bed with a white foam cup dated 7/17/24 filled with water…

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 correctly identify, label and use personal protective equipment (PPE) for Enhanced Barrier Precaution (EBP) rooms per standards of practice for infection control measures according to the Centers for Disease Control and Prevention's (CDC) guidelines. This deficient practice resulted in the potential transmission of infectious agents to all 77 vulnerable residents in the facility. Findings include: Resident 18 (R18): Review of R18 Electronic Medical Record (EMR) revealed admission to the facility on 5/10/24 with diagnosis of a pressure-induced deep tissue damage of the right heel and sacral region diagnosed on [DATE] and a pressure-induced deep tissue damage of unspecified site on 6/14/24. Review of the facility's Facility Matrix CMS Form-802 revealed R18 was marked as S (suspected deep tissue injury) in category 5 for Pressure Ulcer(s). On 7/15/24 at 2:18 p.m., during an observation and interview with R18, it was observed that there 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 #MI00143565 Based on interview and record review, the facility failed to ensure resolution of resident grievances for Four Residents (R4, R5, R6, and R7) of six residents reviewed for grievance resolution. Findings include: The Resident Council Meeting minutes for February 2024 documented residents' concerns including but not limited to: (a) slow call light response, (b) staff not checking on residents during the night for incontinence care/brief checks, (c) lack of staff in the dining room during meal times, (d) staff being loud at the nurses' station in the mornings, and (e) receiving fresh water only once per day. The Resident Council Meeting minutes documented these issues as ongoing concerns that had been discussed in previous Meetings. The documentation indicated the Resident Council members reported these issues were not better. The section of the February meeting minutes titled Concerns continued from last month documented staff were educated to communicate at an appropriate volume while on the units. The meeting minutes indicated Staff were…

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

This citation pertains to Intakes #MI00143557, #MI00143565, #MI00143601 Based on observation, interview, and record review, the facility failed to provide sufficient numbers of Certified Nursing Assistants (CNAs) to provide necessary care and services for four Residents (R4, R5, R6, and R7) of six residents reviewed for sufficient staffing. This deficient practice had the potential for unmet care needs and the provision of inadequate care for all 69 residents in the facility. Findings include: Confidential Resident #4 (R4) was interviewed on 5/8/24 at 8:00 a.m. R4 said there were not enough CNAs to help the residents in the facility, and residents had to wait a long time for call lights to be answered or their needs to be met. R4 was alert and oriented, scoring 15 of 15 on a Brief Interview for Mental Status (BIMS) examination on 3/16/24, indicating R4 was cognitively intact. Confidential Resident #5 (R5) was interviewed on 5/28/24 at 8:08 a.m. R5 said she had limited physical mobility and required staff assistance with turning in bed, dressing, toileting, transferring, and personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intakes #MI00144121 and MI00144264 Based on interview and record review, the facility failed to develop a care plan and implement interventions to reduce hazards and risks to prevent falls for one Resident (R1) of two residents reviewed for falls. Findings include: Resident #1 (R1) was admitted to the facility on [DATE]. An admission Fall Risk Assessment (FRA) evaluation was completed on 4/19/24 and identified R1 at high risk for falls. The FRA indicated R1 had a history of falls. Factors contributing to the fall-risk included weakness, poor mobility, confusion, and psychotropic medication use. Nurses' progress notes for R1 documented two unwitnessed falls, both occurring on 4/21/24. No other falls were documented in the nurses' progress notes. The incident reports for R1 were requested. Two incident reports were provided by the facility. One incident report documented one fall occurrence on 4/19/24. The second incident report documented one fall occurrence on 4/21/24. R1's care plans…

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 respectful and dignified treatment for one Resident (R3) of three residents reviewed for resident rights. This deficient practice resulted in feelings of being disrespected and staff being rude. Findings include: This deficiency pertains to Complaint Intake MI00141559. Review of the Complaint Intake revealed the following Complainant H allegation, in part: . I directly observed a staff person being verbally aggressive with a resident. The tone of the verbal exchange was severe enough that I felt the need to enter the hallway and began to enter the room where the verbal argument was going on. The resident, [R3], was observed in her bed with a staff person, later identified as [Registered Nurse (RN) B] standing in the room doorway yelling at [R3] . The staff person was heard yelling at the resident about how she 'has 20 other residents and that she doesn't just work for her' . the tone was aggressive enough that it drew me out 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 observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to ensure potentially hazardous foods (tortellini) were stored at proper temperature while waiting to be served. 2. Failing to demonstrate the proper cooling of potentially hazardous foods which were destined to be served at a later date. 3. Failing to ensure staff washed their hands after touching their head and hair 4. Failing to ensure staff were wearing proper hair restraint devices when present in food service and clean dish washing areas. These deficient practices have the potential to result in food borne illness among any and all 76 residents of the facility. Findings include: 1. On 9/18/23 at approximately 11:57 AM, observations were made during the noon meal service. A stainless steel pan of tortellini was observed in the steam table, waiting to be served. The temperature of the tortellini was measured using a metal stem probe thermometer and found to be 122°F. 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 they were using the updated Michigan DNR Act verbiage, accurate advanced directive information and missing signatures was in place for five residents (#13, 30, 50, 56 and 65) of five residents reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), from a total sample of 18 residents, resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers. Findings include: Residents 30, 50, 56, 65 and 13 (R13, R30, R50, R56 and R65) Record review revealed that R30's electronic medical record order stated R30 was a Do Not Resuscitate (DNR), code status form that R30 signed was a full code dated 07/25/23. During an interview on 09/19/23 at 08:14 AM, Social Worker (SW) D stated that she had been employed at the facility for four weeks, still had a lot to learn, and although had the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise resident care plans in 6 of 18 reviewed for care plans (Resident #19, #22, #27, #32, #38, & #46), resulting in the potential for unmet needs and services. Findings include: Resident #27 (R27) R27 was observed sitting in a wheelchair in the dining room on 9/19/23 at 4:45 PM. R27's Minimum Data Set (MDS) assessment with an assessment reference date of 6/08/23 revealed she was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 14 (13-15 Cognitively Intact). R27 had the diagnoses of diabetes mellitus, hypertension, anxiety, schizophrenia, and depression. Mental Health evaluation dated 2/21/23 indicated R27 reported improved sleep since an increase in Trazodone (antidepressant with side effect of drowsiness). Note to Attending Physician Prescriber dated 4/22/23 revealed R27 Trazodone had been discontinued. Mental Health…

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

Based on observations and interviews, the facility failed to ensure the environment was maintained in a safe, sanitary and functional manner to protect residents, staff and visitors. Findings include: As evidenced by allowing an unbalanced ventilation system in the laundry area. This unbalanced ventilation system resulted in a large negative pressure within the room/area, which could potentially result in the back drafting of poisonous gases, emitted by the natural gas fired dryers, into the work space, and could result in the lack of laundry functions for all 76 residents and any staff working. Findings include: On 9/19/23 at approximately 9:40 AM, observations were conducted of the laundry area with laundry supervisor (LS) AA. When attempting to enter the the laundry area through the door from the corridor, it was observed that the door was extremely difficult to pull open. Once entered into the area, the door was quickly pulled closed due to a large negative (vacuum) pressure. An interview with LS AA at this time revealed the facility had modified the make up air conditioning…

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 treat residents with dignity and respect and failed to provide an environment that promoted and enhanced resident quality of life and individuality for four residents (Resident council group) of five residents reviewed for dignity, from a total sample of 18 residents, resulting in the potential for feelings of inferiority, depression, and loss of self-worth. Findings include: During a Resident Council meeting on 09/19/23 at 2:04 PM, five residents attended that meeting and would like to remain anonymous. Writer asked if residents were aware of the resident rights. Five of five residents stated no. Two of five residents stated the activity director had mentioned some but they did not know what that entailed. Writer asked resident council group if they felt their grievances were investigated, resolved and they were notified of the finding in a timely fashion. Four out of five stated no. Resident council group shared that they share their concerns verbally and in writing but never hear back. No communication…

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 act promptly on grievances reported in resident council meetings and provide responses to grievances in five of five residents, as reported during a confidential resident council interview, in a total sample of 18 residents and a total census of 84 residents, resulting in unresolved resident concerns and decreased quality of life. Findings include: During a Resident Council meeting on 09/19/23 at 2:04 PM, five residents attended that meeting and would like to remain anonymous. Writer asked if residents were aware of the resident rights. Five of five residents stated no. Two of five residents stated the activity director had mentioned some but they did not know what that entailed. Writer asked resident council group if the felt their grievances were investigated, resolved and they were notified of the finding in a timely fashion. Four out of five stated no. Resident council group shared that they share their concerns verbally and in writing but never…

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 #MI00138037 Based on observation, interview, and record review, the facility failed to report allegations of abuse for four (Resident #18 and 65) of 4 reviewed, resulting in allegations of abuse that were not reported and the potential for further allegations of abuse to go unreported. Findings include: Resident #65 According to the clinical record, including the Minimum Data Set (MDS) with an assessment reference date of 08/04/23, Resident # 65 (R65) was admitted to the facility on [DATE], with diagnoses that included developmental disorder of scholastic skills, major depression, anxiety and bi-polar disorder. R65 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of the complaint intake #MI00138037, alleged that in April of 2023, agency License Practical Nurse (LPN) F was frustrated with R65's behaviors and tied R65 to her wheelchair and that former agency Certified Nursing Assistant (CNA) A untied R65, another unidentified…

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 #MI00138037 Based on observation, interview and record review, the facility failed to ensure the protection of residents and thoroughly investigate allegations of abuse for two (Resident #18 and 65) of 4 reviewed for abuse, resulting in the potential for further abuse to occur and allegations of abuse not being thoroughly investigated. Findings include: Resident #65 According to the clinical record, including the Minimum Data Set (MDS) with an assessment reference date of 08/04/23, Resident # 65 (R65) was admitted to the facility on [DATE], with diagnoses that included developmental disorder of scholastic skills, major depression, anxiety and bi-polar disorder. R65 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of the complaint intake #MI00138037, alleged that in April of 2023, agency License Practical Nurse (LPN) F was frustrated with R65's behaviors and tied R65 to her wheelchair and that former agency Certified 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 Based on interview and record review, the facility failed to notify the resident and/or resident's representative of the facility policy for bed hold for one (Resident #50) of one reviewed for hospitalization resulting in the potential of residents and/or representatives to be uninformed of the bed hold policy. According to the clinical record Resident # 50 (R50), was admitted to the facility with diagnosis that included RHEUMATOID ARTHRITIS, shoulder replacement and major depression. R50 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) further record review reflected R50 was transferred to the hospital on [DATE] and 7/25/23. On 09/19/23 at 09:52 AM, during a bed side interview with Resident # 50 , he stated he had been to hospital twice this year and was not given information about returning to the facility or what the process was to hold his bed. On 09/19/23 at 08:08 AM, during an interview with Registered Nurse (RN)B she reported having had multiple roles over the last…

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 accurately complete the Minimum Data Set (MDS) assessment for one (Resident #19) of 18 reviewed, resulting in an inaccurate MDS assessment and the potential for unmet care needs. Findings include: Review of the medical record revealed that Resident # 19 (R19) readmitted to facility 11/28/22 with diagnoses including chronic obstructive pulmonary disease and solitary pulmonary nodule. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/28/23 revealed that R19 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 8 (moderately impaired cognition). Section G of the same MDS revealed that R19 required one-person extensive assist with bed mobility, transfers, and toilet use, and supervision with eating. Section O of the same MDS indicated that R19 had not utilized oxygen within the 14-day assessment period (7/15/23 - 7/28/23). In an observation and interview on 9/18/23 at 8:17 AM, R19 was observed sitting in wheelchair in South Dining Room consuming…

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 Pertain To Intake #MI00139343 Based on interview and record review, the facility failed to develop and implement an effective patient centered discharge planning process for one resident (#48) of one reviewed for discharge planning, resulting in frustration, anger and an against medical advice discharge. Findings include: According to the clinical record, including the Minimum Data Set (MDS) dated [DATE], Resident # 48 (R48) was admitted to the facility for short term rehabilitation and had a diagnosis of left femur fracture and diabetes. R48 scored 8 out of 15 (moderately impaired cognition) on the Brief Interview Mental Status (BIMS) for Section Q of the MDS reflected R48 and her and Guardian or legally authorized representative participated in assessment, section Q0400 reflected active discharge planning already occurring for the resident to return to the community. Review of the care management note dated 7/21/23 reflected R48's discharge plan was to return home and that she had a part time…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide assistance with activities of daily living (ADLs) for two (Resident #12, #38) of four reviewed, resulting in unmet care needs and the potential for a decline in emotional and physical health. Resident #12 Review of the medical record revealed that Resident #12 (R12) was readmitted to facility 5/16/22 with diagnoses including unspecified dementia, morbid obesity, and type 2 diabetes mellitus. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/7/23 revealed that R12 was understood by others and able to understand others with a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 3 (severe cognitive impairment). Section G of the same MDS revealed that R12 required two-person extensive assist with bed mobility, two-person dependent assist with transfer, one-person dependent assist with toilet use, and that bathing had not occurred during the entire 7-day assessment period. In 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 prevent and accurately assess pressure ulcers for one resident (R32) of 3 residents reviewed resulting in delayed treatment of the wound. Findings include: Resident #32 (R32) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R32 admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, and nutritional deficiency. Brief Interview for Mental Status (BIMS) was not completed since R32 did not participate in the BIMS assessment and since resident was rarely/never understood. Review of the latest Braden Scale for Predicting Pressure Ulcer Risk dated 08/16/2023 revealed a score of 12 which indicated R32 was at high risk for pressure ulcers. Review of Progress Note titled Pressure Ulcer/Injury on 09/13/2023 at 02:24 AM revealed, Resident has NEW skin issue(s) observed. 1. Left buttock - 3 open areas. No S/S of infection. Skin turgor with good elasticity. Skin color is normal for ethnic group. Skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adaptive smoking equipment for 1 of 1 resident reviewed for smoking (Resident #27), resulting in a burn. Findings include: Resident #27 (R27) R27 was observed sitting in a wheelchair in the dining room on 9/19/23 at 4:45 PM. R27's Minimum Data Set (MDS) assessment with an assessment reference date of 6/08/23 revealed she was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 14 (13-15 Cognitively Intact). R27 had the diagnoses of diabetes, hypertension, anxiety, schizophrenia, and depression. Incident Report dated 11/23/23 at 3:45 AM revealed R27 had a blistered area following a burn on her third finger on her right hand. The same incident report indicated no staff were interviewed. R27's smoking care plan dated 6/09/23 revealed her goal was to not suffer injury from unsafe smoking practices. R27 was to be encouraged…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a toileting program in one of one residents was reviewed for bowel and bladder incontinence (Resident #27), resulting in continued incontinence, decreased quality of life, and risk of skin breakdown. Findings include: Resident #27 (R27) R27 was observed sitting in a wheelchair in the dining room on 9/19/23 at 4:45 PM. Mental Health note dated 2/21/23 indicated at time of the evaluation, R27 was wet from incontinence. The same note indicated if bowel continence was improved, R27 would be a candidate for a lesser restrictive setting. The same note revealed R27's family could no longer bring her to their home for visits due to incontinence. The same note suggested R27 wear a watch with a timer set for every two hours to help R27 remember to use the restroom. R27's Minimum Data Set (MDS) assessment with an assessment reference date of 6/08/23 revealed she was admitted to the facility on [DATE], had a Brief Interview for Mental…

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 nutritional supplements and alternate foods per resident preferences in one of four reviewed for weight loss (Resident #46), resulting in a severe weight loss in one month and the potential for continued weight loss. Findings include: Resident #46 (R46) R46 was observed on 9/18/23 at 12:00 PM sitting on the side of bed in front of her over-the-bed table, her lunch tray was just delivered. There was no mighty shake observed on the tray. The meal consisted of potatoes and greens. Chicken was the main protein source served on this day. R46's meal did not include chicken or an alternate protein source to replace chicken. Certified Nurse Assistants (CNA's) V and U were interviewed on 9/18/23 at approximately 12:05 PM stated R46 did not receive chicken with her lunch because she would not eat meat, and the resident's daughter had informed them that she was a vegetarian. R46's Annual Minimum Data Set (MDS) indicated she was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent when three medication errors were observed from a total of twenty-nine opportunities for three residents (Resident #69, #14 and #61) of four reviewed for medication administration, resulting in a medication error rate of 10.34% and the potential for reduced efficacy of medications and increased risk of adverse reactions/side effects. Findings include: Resident #69 Review of the medical record revealed that Resident #69 (R69) was admitted to facility on 8/2/2023 with diagnoses including unspecified glaucoma and bipolar disorder. Review of R69's active orders included Diclofenac Sodium Ophthalmic Solution (a solution used to treat pain or swelling of the eye) 0.1% (percent) with instruction to instill 1 drop in both eyes four times a day for eye drop steroid. On 9/19/23 at 7:21 AM, Registered Nurse (RN) K was observed to prepare R69's oral medications and eye drops for administration,…

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 follow up with dental care for two residents (Resident #18 and #27) of 3 residents reviewed resulting in potential for tooth issues and unmet dental needs. Finding Include: Resident #18 (R18) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R18 admitted to the facility on [DATE] with diagnoses of dementia, anemia, severe protein-calorie malnutrition. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R18 was cognitively intact. During an interview on 09/18/23 at 08:13 AM, R18 was sitting on his bed, was alert and well groomed. R18 said that he has a loose tooth and it scares him. R18 showed surveyor the loose tooth and pushed it out with his tongue. R18 said he had a dental appointment with the county, and they checked him out and sent him back to the facility with paperwork. He stated that, this was a year ago and there was no follow-up from the facility.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide palatable food tray products effecting Resident #30 and all residents who consume room food trays, resulting in decreased food acceptance and nutritional decline in a current facility census of residents. Based on observation, interview, record review, 4 of 5 from the confidential group meeting, and 2 (15, 24) of 18 total sampled residents, the facility failed to provide palatable food products effecting 54 residents, resulting in decreased food acceptance and reduced caloric intake. Review of the medical record revealed Resident #30 (R30) was admitted to the facility on [DATE] with diagnoses that included lung and liver cancer, Chronic Obstructive Pulmonary Disease and Sepsis. According to Resident #30 (R30)'s Minimum Data Set (MDS) dated [DATE], revealed R30 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R30 requires minimal assistance…

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 honor residents' food preferences and serve warm food on the menu for one resident (R30) one reviewed, resulting in resident not receiving food of their choice and experiencing dissatisfaction during dining. Findings Include: Review of the medical record revealed Resident #30 (R30) was admitted to the facility on [DATE] with diagnoses that included lung and liver cancer, Chronic Obstructive Pulmonary Disease and Sepsis. According to Resident #30 (R30)'s Minimum Data Set (MDS) dated [DATE], revealed R30 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R30 requires minimal assistance with activities of daily living and ambulation. During an interview and observation on 09/18/23 at 08:21 AM, R30 stated the food is so bad he can't eat it. R30 also stated the food is always cold and he cannot eat it. R30 stated he drinks protein supplements and that'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.

Based on observation, interview, and record review, the facility failed to 1) use gloves during eye drop administration for one resident (#69) and 2) routinely change and store oxygen tubing off floor for one resident (#19) from a total sample of 18 residents, resulting in the potential for cross-contamination, spread of infection, and facility acquired infections. Findings include: Resident #69 Review of the medical record revealed that Resident #69 (R69) was admitted to facility on 8/2/2023 with diagnoses including unspecified glaucoma and bipolar disorder. Review of R69's active orders included Diclofenac Sodium Ophthalmic Solution (a solution used to treat pain or swelling of the eye) 0.1% (percent) with instruction to instill 1 drop in both eyes four times a day for eye drop steroid. On 9/19/23 at 7:21 AM, Registered Nurse (RN) K was observed to prepare R69's oral medications and eye drops for administration, enter R69's room, and place medication cup on over the bed table while continuing to hold eye drop container in hand. R69 was observed to be sitting at edge of bed on left…

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.