Life Care Center of Plainwell

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure updated and accurate advanced directive information was in place for 1 of 18 residents (Resident #7) reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), 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:Resident #7Review of an admission Record revealed Resident # 7 was originally admitted to the facility on [DATE] with a pertinent diagnosis that included: hypertensive heart disease with heart failure (damage to the heart caused by chronic high blood pressure that results in the heart not pumping blood properly).Review of a Minimum Data Set (MDS) assessment for Resident #7 with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact.Review of a Care Plan for…

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

Based on observation, interview, and record review the facility failed to ensure timely provision of podiatry services for 1 (Resident #15) of 1 resident reviewed for foot care resulting in a delay in foot care and potential worsening of conditions of the feet.Findings include:Review of Resident #15's diagnoses list included type 2 diabetes mellitus (condition of having elevated blood sugar levels) and other chronic pain. Review of Resident #15's diabetes care plan, revised 8/22/2025, stated, Diabetes Mellitus, is at risk of .infections. and noted an admission date of 5/12/2025. Review of Resident #15's brief interview for mental status, dated 11/8/25, was scored 14 which reflected she was cognitively intact.During an interview on 12/15/2025 at 10:04 AM, Resident #15 reported she had a concern that she had requested to see the podiatrist since she was admitted but hadn't seen the podiatrist yet or been assessed by the podiatrist. Resident #15 reported she had toe fungus, was diabetic, and needed the podiatrist to do nail care.On 12/16/2025 at 10:49 AM all podiatry documentation as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure urinary catheters were maintained appropriately for two residents (R8 and R76) of two residents reviewed for urinary catheter care resulting in over-filled indwelling catheter bag and sediment laden catheter tubing and connections, resulting in the potential for urinary tract infections. Findings include: R8According to the Minimum Data Set (MDS) dated [DATE], R8 was unable to complete his BIMS (Brief Interview Mental Status) indicating he was cognitively impaired. Section H-Bladder and Bowel revealed he had an indwelling catheter related to a diagnosis of obstructive and reflex uropathy. During an observation, interview, and record review on 12/15/2025 at 12:50 PM, Family Member (FM) RR stated R8 had a urinary foley catheter and used a leg bag to collect the urine. Observed a pouch underneath the resident's right lower pant leg. FM RR reported R8 had been anxious and agitated during the night and did not sleep. Staff had talked…

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 pre and post dialysis (procedure that removes excess water, solutes, and toxins from the blood in people whose kidneys cannot perform these functions) assessments were completed for 2 (Resident #3 and #101) of 2 resident reviewed for dialysis care, resulting in the potential of being unprepared for a potential decline in resident condition, due to the adverse effects from dialysis. Findings include: Resident # 3 Review of an admission Record revealed Resident #3 was originally admitted to the facility on [DATE] with pertinent diagnoses which included critical illness myopathy (severe muscle weakness and wasting in critically ill patients) and end stage renal disease. Review of a Minimum Data Set (MDS) assessment for Resident #15, with a reference date of 10/1/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #15 was cognitively intact. Review of Resident #3's Care Plan revealed, (Resident #3) is at…

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

Based on interview and record review, the facility failed to ensure the Medical Director fulfilled their responsibility of implementing Medication Regimen Review (MRR) policies/procedures to include coordination of care between the facility and the consulting pharmacist/pharmacy for 4 (Resident #88, 12, #15 and #80) of 5 residents reviewed for medications. This deficient practice has the potential to affect all residents that reside at the facility. Findings include:In an interview on 12/17/25 at 11:32 AM, Director of Nursing (DON) B reported the facility's Unit Managers were responsible for ensuring that Monthly Medication Reviews (MMR) were provided to the facility Medical Director, and that he had just recently learned that this might have been occurring. DON B was unable to report how many MMR's had been missed, or if the facility had completed any audits to ensure any missed MMR's were reviewed. In an interview on 12/17/25 at 1:45 PM, Nursing Home Administrator (NHA) A reported that the facility had jus recently identified that MD BBB had not been reviewing and responding to…

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

Based on interview and record review, the facility failed to: 1) effectively identify quality deficiencies, develop, and implement appropriate action to correct deficiencies; and 2) sustain a system to ensure corrective measures related to resident rights, dialysis, bowel/bladder incontinence/catheter care, and advance directives as evidenced by repeated deficiencies on the past three surveys. This deficient practice has the potential to affect all residents that reside in the facility. Findings include: In an interview in 12/17/2025 at 1:41 PM, Nursing Home Administrator (NHA) A reported the facility was currently working on PIPS (Process Improvement Projects) related to ensuring staff education was completed, and the QAPI team had just closed a PIP related to meal tickets not matching what was served in November 2025 after reaching 100% on audits. NHA A reported that the facility was obtaining feedback from the residents from resident council minutes and asking for resident feedback. NHA A reported the facility was not currently working on any performance improvement projects…

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 MI00153382 Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse for 1 (Resident #102) of 7 residents reviewed for abuse, resulting in Resident #101 punching Resident #102 in the face. Findings include: Resident #101 Review of an admission Record revealed Resident #101 was a male, with pertinent diagnoses which included: schizophrenia and autistic disorder. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 3/3/25 revealed a Staff Assessment for Mental Status assessment of Short- and Long-term Memory as Resident #101 having a Memory problem. Resident #102 Review of an admission Record revealed Resident #102 was a male, with pertinent diagnoses which included: major depressive disorder, single episode, moderate and generalized anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 3/20/25 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which…

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

This citation pertains to intake number MI00151225 Based on interview and record review, the facility failed to ensure nursing staff had appropriate skill sets and completed required annual trainings, resulting in the potential for the delivery of nursing and related services that did not support the attainment or maintenance of the Resident's highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an Education and Training Requirements policy with a reference date of 10/3/24 revealed Policy: The facility will maintain an effective in-service and orientation program for: a. all associates .Procedure .6. Training, in-service, and education should be based on the needs of the facility and the facility assessment. 7. Competencies and skill sets will for all new and existing staff, be consistent with their expected roles. 8. The facility will need to ensure staff are trained to be able to interact in a manner that enhances the resident's quality of life and quality of care .9. The following training requirements should be met .annually .c. iii.…

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 MI00151225 Based interview and record review, the facility failed to ensure individualized approaches were provided to 1 (Resident #103) of 3 residents reviewed for dementia care, resulting in Resident #103 experiencing avoidable stress responses to care interventions. Findings include: Review of The Unmet Needs Model, [NAME]-[NAME] and [NAME] (1995), revealed that those with Dementia develop problem behaviors from an imbalance in the interaction between life-long habits and personality, current physical and mental states and less than optimal environmental conditions. Review of an admission Record revealed Resident #103 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: metabolic encephalopathy (a change in how your brain works due to an underlying condition), dementia (a term used to describe a group of symptoms affecting memory, thinking, and social skills that interfere with daily life) and cognitive communication deficit…

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 MI00149054. Based on interview and record review, the facility failed to thoroughly investigate and resolve grievances for 1 resident (Resident #3) of 3 residents reviewed for missing items, resulting in the resident missing property and the potential for further unresolved grievances to occur. Findings include: Resident #3(R3) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R3's original admission date to the facility was 3/22/2023 with diagnoses including dementia (impairment in brain function such as memory loss and judgement) and chronic kidney disease (long term condition that occurs when the kidneys are damaged and can't filter blood properly). Brief Interview for Mental Status (BIMS) reflected a score of 14 out of 15 which indicated R3 was cognitively intact (13 to 15 cognitively intact). During an interview on 1/27/2025 at 10:58 AM, R3 reported that he lost his wedding ring several months ago. He stated that he was married for 66 years and now it…

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, or serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents who consume food from the kitchen. Findings include: During a tour of the kitchen, at 8:35 AM on 10/9/24, it was observed that a full pan containing two beef roasts was found with a vented top in a shelf in the walk-in cooler. When asked when this item was cooled, Food Service Director (FSD) JJ stated it was cooked off yesterday and then cooled down. When asked if there was a cooling log for the item. FSD JJ stated that their cooling log is filled out with an erasable marker and it looks like it was erased when cleaning was being done. A temperature of the roast at this time was found to be 42.5F when checked with a rapid read thermometer. Additional food product temperatures were taken at this time and found to be between 37-38F in the walk-in cooler. The ambient air thermometer was found to be 38F. 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 Based on observation, interview, and record review, the facility failed to ensure an effective infection control program that included: 1. appropriate hand hygiene and glove use during resident care in 1 of 18 residents (R63), 2. cleaning and disinfecting of resident equipment for 3 of 18 residents (R36, Resident #67, and Resident #11), 3. implementation of Enhanced Barrier Precautions (EBP) per standards of practices for 1 of 18 residents (Resident #11) all reviewed for infection control, and 4. maintain an active and ongoing plan for reducing the risk of opportunistic pathogens of premise plumbing, resulting in the potential for cross-contamination, harborage of bacteria, and increased infections in a vulnerable population. Findings include: R63 According to the Minimum Data Set (MDS) dated [DATE], scored 13/15 (cognitively intact) on her BIMS (Brief Interview Mental Status) with diagnoses that included atrial fibrillation (abnormal heart rhythm) and Parkinson's disease Incontinence of bowel and bladder…

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

Based on interview and record review the facility failed to ensure accurate documentation of advance directives for 1 (Resident #5) of 18 residents reviewed for advance directive documentation. Findings include: Resident #5 Review of an admission Record revealed Resident #5 had pertinent diagnoses which included: multiple sclerosis (disabling disease of the brain and spinal cord (central nervous system)). Review of a Minimum Data Set (MDS) assessment for Resident #5, with a reference date of 8/26/2024 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #5 was cognitively intact. Review of Resident #5's medical record on 10/8/24 at 12:35 PM., revealed a document titled Advance Directives/Medical Treatment Decisions signed by Resident #5 and dated 3/20/2020 with the selection of .I do not choose to formulate or issues any advance directives at this time . noted. No other advance directive form was noted in Resident #5's medical record. Review of Order Summary for Resident #5 revealed .DNR (do not resuscitate) with comfort measures . active…

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#: MI00146614 Based on interviews, and record review, the facility failed to protect the residents right to be free from abuse for 2 (Resident's #61 and #80) of 8 residents reviewed for abuse, resulting in residents experiencing physical restraint, physical and/or verbal aggression, fear, and emotional distress. Findings include: Review of a facility policy, Area of Focus: Abuse and Neglect with a reference date of 11/27/23, revealed: Each resident has the right to be free from abuse .this includes but is not limited to .physical or chemical restraint . Residents must not be subjected to abuse by .other residents . Resident #80 Review of an admission Record revealed Resident #80, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: metabolic encephalopathy (serious condition that occurs when brain function is disrupted due to metabolic problems, irritability and agitation are symptoms of the condition), cognitive communication deficit (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a bed-hold to 2 of 3 residents (Resident #41, and #2) reviewed for hospitalization, resulting in the potential for the residents to not return to their same room upon readmission. Findings include: Review of a facility Bed-Hold Policy last reviewed 9/5/24 revealed, Policy The Bed-hold policy should be given upon admission, upon transfer of a resident to the hospital (if in an emergency within 24 hours), or the resident goes on therapeutic leave of absence. The facility will provide written information to the resident or resident representative the nursing facility policy on bed-hold periods and the residents return to the facility to ensure that residents are made aware of a facility's bed-hold and reserve bed payment policy before and upon transfer to a hospital or when taking a therapeutic leave of absence from the facility . Resident #41 Review of an admission Record revealed Resident #41 was a male, readmitted to the facility on [DATE] with…

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

Based on observation, interview and record review the facility failed to revise a person centered care plan for 1 (Resident #11) of 18 reviewed for person centered care plan revision resulting in an inaccurate reflection of the resident's current care needs. Findings include: Resident #11 Review of an admission Record revealed Resident #11 had pertinent diagnoses which included: Pressure ulcer of the sacral region (the base of the spine just above the buttock) stage 3 (full-thickness loss of skin). Review of a Minimum Data Set (MDS) assessment for Resident #11, with a reference date of 8/16/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #11 was cognitively intact. Review of Care Plan for Resident #11 revealed Focus .indwelling catheter: pressure wound coccyx, initiated on 9/4/2024 .intervention .has a 16 F (french) foley catheter with a 10 cc baloon, positon catheter bag and tubing below the level of the bladder . During an observation on 10/8/24 at 10:16 AM., Resident #11 was in bed in her room sleeping. No noted drainage bag for…

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

Based on interview and record review, the facility failed to consistently provide restorative exercises per therapy recommendations for 1 (Resident #76) of 1 resident reviewed for position/mobility, resulting in the potential for pain, stiffness, and avoidable decline. Findings include: Resident #76 Review of an admission Record revealed Resident #76 was a female, with pertinent diagnoses which included: hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (a stroke) affecting left non-dominant side. Review of a Minimum Data Set (MDS) assessment for Resident #76, with a reference date of 9/5/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #76 was cognitively intact. Further review of said MDS revealed Resident #76 had a Functional Limitation in Range of Motion of upper and lower extremity of one side. In an interview on 10/8/24 at 12:11 PM, Resident #76 reported she was paralyzed on her left side due to having had multiple strokes.…

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 care for a resident with an indwelling foley catheter (tube inserted into the bladder to drain urine) in one resident (R63) of 1 residents reviewed for catheter care, resulting in the potential for urinary tract injury and/or infection. Findings include: According to the Minimum Data Set (MDS) dated [DATE], scored 13/15 (cognitively intact) on her BIMS (Brief Interview Mental Status) with diagnoses that included obstructive uropathy that required her to be dependent on staff for her ADLs (activities of daily living) and the use of an indwelling catheter. Review of R63's Order Summary dated 12/1/23, revealed, Change catheter bag as needed for infection, obstruction, or when the closed system is compromised. R63's Order Summary dated 7/22/24, revealed, Indwelling catheter to straight drainage. Size: 22 Fr (French referring to the size of the tubing) Bulb: 30 cc (amount of normal saline (NS) the balloon holds to keep it in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to identify Post Traumatic Stress Disorder (PTSD) triggers and develop and implement care plan interventions to mitigate emotional triggers in 1 (Resident #47) of 5 reviewed for trauma informed care resulting in the potential for re-traumatization due to staff not being informed or knowledgeable of the resident's past trauma and unmet care needs. Findings include: Review of Witness Statement dated 8/29/2024 revealed I (Name Omitted) witnessed Resident #79 verbal assault and threaten Resident #47. The Resident #79 stated she would slap the shit out of you if Resident #47 did not shut the f* up. The witness was noted to report Resident #79 repeated the threatening statement to Resident #47 more than once. Repeated attempts to contact witness were unsuccessful. Review of an admission Record revealed Resident #47 had pertinent diagnoses which included: Post traumatic stress disorder, dementia with psychotic disturbance, adjustment disorder with mixed…

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 #'s MI00145569 & MI00146066 Based on interviews and record review, the facility failed to protect the residents' right to be free from mental and verbal abuse by staff for 3 residents (Resident #102, 103, & 105) of 6 residents reviewed for abuse/neglect, resulting in verbal intimidation, and the potential for psychosocial harm. Findings include: This surveyor requested Concern and Grievance reports from the Nursing Home Administrator (NHA A) on 8/21/24, for Resident #102, #103, and #105. Resident #102 Review of an admission Record revealed Resident #102 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: stroke. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 7/12/24 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #102 was cognitively intact. Review of Resident #102's Care Plan revealed no information related to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #'s MI00145569 & MI00146066. Based on interview and record review, the facility failed to report allegations of abuse to the State Agency in a timely manner for 3 residents (Resident #102, #103, & #105) reviewed for abuse and neglect, resulting in the potential for continued violations involving mistreatment, neglect, or abuse going undetected, unreported, or without thorough investigation. Findings include: Resident #102 Review of an admission Record revealed Resident #102 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 7/12/24 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #102 was cognitively intact. Review of Resident #102's a Witness Interview/Statement Form, dated 8/4/24 revealed, .Incident date/time: 8/3/24 NOC (night time) .person conducting interview: (Registered Nurse (RN) D). The following is 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 #'s MI00145569 & MI00146066. Based on interview and record review, the facility failed to thoroughly investigate and protect residents after allegations of abuse were made for 3 residents (Resident #102, #103, and #105) of 6 residents reviewed for abuse, resulting in the alleged perpetrator not being immediately suspended, an incomplete investigation, and the potential for future mistreatment or abuse. Findings include: Resident #102 Review of an admission Record revealed Resident #102 was originally admitted to the facility on [DATE], Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 7/12/24 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #102 was cognitively intact. Review of Resident #102's a Witness Interview/Statement Form, dated 8/4/24 revealed, .Incident date/time: 8/3/24 NOC (night time) .person conducting interview: (Registered Nurse (RN) D). The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake # MI00146066. Based on interview, and record review, the facility failed to ensure care plan interventions were in place per standard of care, to prevent the development of pressure ulcers for 1 resident (Resident #102) of 3 residents reviewed for pressure ulcers, resulting in the development of a Stage 2 pressure ulcer on the right buttock and a deep tissue injury (DTI) on the coccyx. Findings include: Resident #102 Review of an admission Record revealed Resident #102 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: stroke. Resident #102 discharged on 8/4/24 to the hospital. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 7/12/24 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #102 was cognitively intact. Review of Resident #102's Care Plan revealed no information related to the residents level of assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00146066. Based on interview, and record review, the facility failed to maintain professional standards of care, and provide adequate incontinence care in 2 of 3 residents (Resident #102 and #106) reviewed for incontinence care, resulting in MASD (moisture associated skin disorder). Findings include: Resident #102 Review of an admission Record revealed Resident #102 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 7/12/24 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #102 was cognitively intact. Review of Resident #102's Care Plan revealed no information related to the residents level of assistance with toileting, urinary continence status, skin integrity interventions, and/or risk for pressure ulcers. Review of Resident #102's Braden Assessments (assessment to predict pressure sore risk) dated 7/10/24…

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 timely monitoring of weight for a newly admitted resident at risk for malnutrition in 1 resident (Resident #105) of 6 residents reviewed for nutrition, resulting in a delay in identifying significant weight loss, and the potential for alteration in nutrition and hydration status. Findings include: Review of a facility policy, Weight monitoring, long term care dated 8/19/24 revealed, .a resident's weight should be recorded at the time of admission, weekly for 4 weeks, and then monthly .a decrease in weight of 5% or more in a month or of more than 10% in 6 months should be reported to the practitioner for further evaluation . Resident #105 Review of an admission Record revealed Resident #105 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 6/13/24 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which…

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

Based on observation, interview, and record review the facility failed to implement a resident care plan in 1 (Resident #102) of 3 residents reviewed for care plan implementation, resulting in the potential for a decline in oral intake of food, a decline in oral intake of fluids, and improper body alignment and/or comfort. Findings include: Review of an admission Record revealed Resident #102 had pertinent diagnoses which included: Parkinson's disease (a progressive disease that affects the nervous system and the parts of the body controlled by nerves), dementia, muscle weakness and lack of coordination. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 3/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #102 was cognitively intact. Review of Physician Orders for Resident #102 revealed . adaptive device: pt (patient) to have lateral wedge cushion to R (right) side to decrease lateral leaning . started on 12/18/2023 . Review of Care plan for Resident #102 revealed . provide resident with…

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

Based on observation, interview, and record review the facility failed to ensure that a dependent resident had access to fluids for hydration in 1 (Resident #102) of 3 residents review for hydration status resulting in the potential for dehydration. Findings include: Resident #102 Review of an admission Record revealed Resident #102 had pertinent diagnoses which included: Parkinson's disease (a progressive disease that affects the nervous system and the parts of the body controlled by nerves), dementia, muscle weakness and lack of coordination. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 3/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #102 was cognitively intact. During an observation on 6/26/24 at 10:19 AM., Resident #102 was in bed and Resident #102's over the bed table with a styrofoam cup of water was out of reach towards the foot of her bed. Resident #102's lips appear to be dry and cracked. During an observation and interview on 6/26/24 at 12:22 PM., Resident #102 was in her Geri…

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 assistive devices as ordered in 1 (Resident #102) of 3 residents reviewed for assistive devices, resulting in the potential for a decline in oral intake of food and fluids. Findings include: Review of an admission Record revealed Resident #102 had pertinent diagnoses which included: Parkinson's disease (a progressive disease that affects the nervous system and the parts of the body controlled by nerves), dementia, muscle weakness and lack of coordination. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 3/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #102 was cognitively intact. Review of Physician Orders for Resident #102 revealed Regular diet .all drinks in sip cups (cup with a lid and sip spout) plate guard . adaptive device: pt (patient) to have lateral wedge cushion to R (right) side to decrease lateral leaning . started on 12/18/2023 . Review of Care plan for Resident #102 revealed .Focus . at risk for…

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

Based on observation, interview, and record review the facility failed to ensure that infection control enhanced barrier precautions were implemented in 1 (Resident #102) of 3 residents reviewed for infection control resulting in the potential for the spread of infection, cross contamination, and disease transmission. Findings include: Review of an admission Record revealed Resident #102 had pertinent diagnoses which included: Parkinson's disease (a progressive disease that affects the nervous system and the parts of the body controlled by nerves), dementia, muscle weakness and lack of coordination. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 3/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #102 was cognitively intact. During an observation on 6/26/24 at 9:06 AM., signage indicating the use of enhanced barrier precautions by staff when providing care to Resident #102 was noted posted on her room door. A clear and black plastic bin with three drawers stocked with yellow gowns and boxes of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI0143736. Based on observation, interviews, and record review, the facility failed to protect the resident's right to be free from verbal abuse by another resident in 1 of 3 sampled residents (Resident #103) reviewed for abuse, resulting in Resident #104 cussing and threatening physical violence to Resident #103. Findings include: Resident #103 Review of an admission Record revealed Resident #103 was a male, with pertinent diagnoses which included: muscle weakness, anxiety disorder, and essential (primary) hypertension (high blood pressure). Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 3/21/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #103 was cognitively intact. Resident #104 Review of an admission Record revealed Resident #104 was a male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: mild neurocognitive…

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 MI0143736. Based on observation, interviews, and record review, the facility failed to update and revise the person-centered comprehensive care plan in a timely manner for 1 resident (Resident #104) of 5 residents reviewed for care plan revisions, resulting in the potential for physical, mental, and psychosocial unmet care needs. Findings include: Resident #104 Review of an admission Record revealed Resident #104 was a male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: mild neurocognitive disorder due to known physiological condition with behavioral disturbance. Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 1/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated Resident #104 was moderately cognitively impaired. Review of a Health Status note dated 3/10/24 at 9:46 PM revealed, Note Text: Pt (patient) had increased confusion…

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. Clean food and non-food contact surfaces to sight and touch; 2. Ensure the installation of an air gap; 3. Properly datemark and discard food product; and 4. Ensure all hand sinks have hot water. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 88 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the facility, at 9:48 AM on 12/4/23, observation of the two door Traulson freezer found accumulation of spotted black debris on the top portion of the door gasket seals. During the initial tour of the facility, at 9:50 AM on 12/4/23, it was observed that the two door true cooler was found with an accumulation of spotted black debris on the top portion of the door gasket seals. During the initial tour of the facility, at 9:52 AM on 12/4/23, it was observed that non-food contact areas of the drink station were found with an accumulation of splash debris on the underside spouts of the coffee…

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, interviews, and record review, the facility failed to develop and implement person centered comprehensive care plans for 5 (Resident #79, #27, #51, #45 and #8) of 5 residents reviewed for care plans, resulting in the potential for residents not being able to achieve their highest practicable level of physical and psychosocial wellbeing. Findings include: Resident #79 Review of an admission Record revealed Resident #79, was originally admitted to the facility on [DATE] with pertinent diagnoses which included unspecified dementia with other behavioral disturbance. Review of Resident #79's Care Plan did not reveal a focus area related to Resident #79's dementia diagnosis. During an interview on 12/06/23 at 3:08 PM, Unit Manager E reported that Resident #79 did not have a care plan related to his dementia diagnosis. Unit Manager E was not able to report any interventions that the facility had in place to help guide care related to Resident #79's dementia diagnosis. Unit Manager E reported that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #21 Review of an admission Record revealed Resident #21 had pertinent diagnoses which included: major depressive disorder (persistent feelings of sadness), muscle weakness, and dementia (neurocognitive disorder that affects the memory and thinking). During an observation on 12/4/23 at 10:32 AM., Resident #21 was in bed, awake, and counting out loud. No other noise noted in her room. During an observation on 12/4/23 at 1:28 PM., Resident #21 was sitting in her wheelchair in her room in silence. During an observation on 12/5/23 at 10:00 AM., Resident #21 was lying in bed, sleeping. No other noise noted in room. Review of Activity Log (2023) for Resident #21 revealed .recorded entry for one-to-one activities included on 8/13 asked MDS questions . 11/23 attempted to talk to her about what she's thankful for .12/4 checked in and talked to her . Review of Group Activity Log for Resident #21 revealed .group activity attendance on 4 days in the month of September 2023, 6 days in the month of October 2023, 3…

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: 1.)monitor and complete documentation of weights for 1 residents (Resident #8), 2. obtain orders and complete wound dressing changes for 3 residents (Resident #53, Resident #442, and Resident #57) and, 3.) complete neurological checks following a fall for 1 resident (Resident 79) of 6 residents reviewed for quality of care, resulting in potential for negative resident outcomes. Findings include: Resident #8 Review of an admission Record dated 5/1/23 revealed Resident #8 was admitted to the facility with the following pertinent diagnoses: acute on chronic combined systolic and diastolic congestive heart failure (weakened and stiff heart muscle condition causing the heart to not contract normally, resulting in fluid collecting in the body), adult failure to thrive (state of decline that is multifactorial and may be caused by chronic concurrent conditions), venous insufficiency (improper functioning of the vein valves in the leg, causing…

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 6 (Resident #79, #27, #60, #76, #83, and #54 ) of 8 residents reviewed for behavioral health received behavioral health care services resulting in Resident #79 being hospitalized due to physical aggression and a potential for the other residents to experience a decline in their psychosocial well-being. Findings include: Resident #79 Review of an admission Record revealed Resident #79, was originally admitted to the facility on [DATE] with pertinent diagnoses which included unspecified dementia with other behavioral disturbance, anxiety, depression and adjustment disorder with mixed disturbance of emotions and conduct. Review of Resident #79's Care Plan revealed, Focus: (Resident #79) is/has potential to be verbally aggressive with staff during care/activities r/t (related to) dx (diagnosis) of traumatic brain injury that affects his mental and emotional state. He has been noted to make sexual, racial and demining remarks to staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide medically related social services to 2 resident (Resident #79, Resident #83) of 18 sampled residents resulting in residents not receiving requested psychological support services and the potential for a decline in psychological well-being. Findings include: Resident #76 Review of an Admissions Record for Resident #76 dated [DATE] revealed the resident was admitted to the facility with the following pertinent diagnoses: bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder, dissociative disorder (mental disorder characterized by the existence of two or more different personality states), schizoaffective disorder(mental health condition including schizophrenia and mood disorder symptoms), Post Traumatic Stress Disorder (PTSD), and suicidal ideations (thoughts about self-harm). Review of a Minimum Data Set (MDS) assessment for Resident #76 dated [DATE] revealed a Brief…

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: 1.) implement an effective infection control program 2.) don the appropriate Personal Protective Equipment (PPE) when entering resident rooms which required PPE 3.) provide water needed for hand washing and daily hygiene care in 1 of 2 residents (Resident #57), 4. ) follow the infection control protocols when performing resident care in 1 of 2 residents (Resident #78) and, 5.) properly handle storage of open and exposed linens in spa rooms, cleaning products/linens/ and personal hygiene products and 6.) properly clean linen bins in the laundry room per facility infection control protocols, resulting in the potential for further development and transmission of communicable diseases and infections. Findings include: During an interview on 12/5/23 at 2:30 PM with Director of Nursing (DON) B and Infection Preventionist (IP) E, IP E reported that he had been in the position since April 2023, but he was not able to report how often he spent…

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 1.) Implement and operationalize an antibiotic stewardship program and 2.) failed to ensure appropriate use of an antibiotic for 2 (Resident # 441 and #45) of 5 residents reviewed for antibiotic use, resulting in the potential for inappropriate antibiotic utilization and antibiotic resistance. Findings include: During an interview on 12/5/23 at 2:30 PM with DON B and IP E reported that the facility followed McGeer 's criteria (screening tool to meet criteria for definitive infections) for ordering antibiotics. DON B reported that the facility only prescribed antibiotics after a culture had been completed or if the resident was meeting SIRS criteria (a screening tool used to identify septic patients). IP E was not able to report how he was monitoring antibiotic use in the facility. IP E and DON B were not able to provide any documentation for how the facility was monitoring antibiotic use among residents in the facility. On 12/07/2023 at 7:54 AM, this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that staff treated residents with dignity and respect in 1(Resident #23) of 7 residents reviewed for dignity, resulting in feelings of frustration and the potential for depression, loss of self-worth and an overall deterioration of psychological well-being. Findings include: Resident #23 Review of an admission Record revealed Resident #23, was originally admitted to the facility on [DATE] with pertinent diagnoses which included depression. Review of a Minimum Data Set (MDS) assessment for Resident #23 with a reference date of 10/3/23, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #23 was cognitively intact. During an interview on 12/06/23 at 10:08 AM, Resident #23 reported that he had a bad interaction with a nurse the day before. Resident #23 reported that Registered Nurse (RN) ZZZ entered his room with his medication in a pill cup that she had her fingers in. Resident #23 reported that he asked RN…

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 call lights were in reach for 2 (Resident #53, and #78) of 3 residents reviewed for accommodation of needs resulting in resident's inability to call for staff assistance with the potential for unmet care needs. Findings include: Resident #53 Review of an admission Record revealed Resident #53, was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and difficulty in walking. Review of a Minimum Data Set (MDS) assessment for Resident #53, with a reference date of 11/1/23 revealed a Brief Interview for Mental Status (BIMS) score of 10/15 which indicated Resident #53 was moderately cognitively impaired. Review of Resident #53's Care Plan revealed, (Resident #53) is at risk for falls d/t (due to) muscle weakness, difficulty walking, impaired balance, unsteady gait, incontinence, impaired cognition with poor safety awareness, pain, medications and h/o (history of) falls. Date Initiated:…

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 accommodate a resident's right to make choices that were consistent with their assessment and plan of care for 1 of 2 sampled residents (Resident #5) reviewed for resident choices, resulting in the resident not meeting their highest practicable level of well-being. Findings include: Review of an admission Record revealed Resident #5 was a female with pertinent diagnoses which included multiple sclerosis, paraplegia, stage 4 pressure ulcer of right buttock, tobacco use, anxiety and depression. Review of a Minimum Data Set (MDS) assessment for Resident #5, with a reference date of 9/20/23, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident #5 was cognitively intact Review of current Care Plan for Resident #5, revised on 03/08/22, revealed the focus, .(Resident #5) has a history of being a smoker, she is aware of the risk vs benefits of being a smoker and has been educated on health concerns associated with smoking . with the intervention .Educate her and her…

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 MI00140935. Based on interview, and record review, the facility failed to notify the responsible party of a change in resident condition in 1 of 19 residents (R45) reviewed for notification of changes, resulting in the resident representative not being made aware immediately of an accident resulting in the lack of ability to participate in timely medical decision-making. Findings include: Review of the policy/procedure Changes in Resident's Condition or Status, dated 8/9/23, revealed .This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status .A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is .An accident involving the resident which results in injury and has the potential for requiring physician intervention . According to the Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that physician orders for immediate care were in place for 1( Resident #442) of 1 resident reviewed for new admission orders, resulting in missed assessments and monitoring for potential side effects related to use of psychotropic and pain medications. Findings include: Resident #442 Review of an admission Record revealed Resident #442, was originally admitted to the facility on [DATE] with pertinent diagnoses which included type 2 diabetes mellitus and chronic kidney disease. Review of Resident #442's Medication and Treatment Administration Orders revealed, Order: Ativan Oral Tablet 1 MG (Lorazepam) (anti-anxiety medication) Give 1 tablet by mouth every 4 hours as needed for anxiety Order Date: 12/01/2023. Order: Haloperidol Lactate Oral Concentrate 2 MG/ML (Haloperidol Lactate)(antipsychotic medication) Give 0.25 ml by mouth every 6 hours as needed for anxiety. Order Date 12/01/2023. Order: SEROquel Oral Tablet 50 MG (Quetiapine Fumarate)…

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 that Minimum Data Set (MDS) assessments were accurate in 1 resident (Resident #54) of 18 sampled residents reviewed for Minimum Data Set (MDS) quarterly assessment, resulting in the potential for inaccuracy of treatments, interventions, and cares. Findings include: Review of an admission Record revealed Resident #54 had pertinent diagnoses which included other frontotemporal neurocognitive disorder (disorder affecting the frontal and temporal lobe of the brain), adjustment disorder with mixed disturbance of emotions (feeling sad and anxious both), unspecified dementia (disease that affects memory and thinking), and anxiety. Review of Health Status Note for Resident #54 dated 9/18/23 revealed .grunting loudly. Redirection ineffective .Face red and diaphoretic. Unable to comfort. Review of Behavior Note for Resident #54 dated 9/24/23 revealed .non-stop yelling out loudly . Review of Minimum Data Set for Resident #54 dated 9/29/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to confirm the Pre-admission Screening and Resident Review (PASARR) Level II determination request was sent to the Community Mental Health Services Program (CMHSP) for a Level II OBRA review and/or evaluation for 2 residents (Resident #60 and #45) of 3 residents reviewed, resulting in the potential for the residents to not receive or have delayed mental health services. Findings include: Review of OBRA - Specialized Nursing Homes dated 2023, revealed, .This review process begins with the completion of a screening form (Level I DCH-3877) usually by a nursing facility, hospital, or community agency/provider. If the responses to the questions on the form indicate the presence of a mental illness and/or an intellectual/developmental disability (or a related condition), the person is referred to the local community mental health services program (your local OBRA Coordinator) to assess if a comprehensive evaluation (Level II) is needed. This…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents received annual Level 1 and follow up Level II PASARR (pre-admission screening/annual resident review) to ensure appropriate mental health services were provided in 1 resident (Resident #71) reviewed for PASARR, resulting in the potential for Resident #71 not being placed in an appropriate setting or receive treatment specific for his mental health needs. Findings include: Resident #71 Review of an admission Record revealed Resident #71 was admitted on [DATE] and had pertinent diagnoses which included schizophrenia, anxiety disorder, and Parkinson's disease (a progressive disorder that affects the nervous system). Review of Resident #71 electronic record on 12/5/23 at 9:10 AM., revealed no PASARR Level I available. During an interview on 12/6/23 at 10:03 AM., Director of Nursing (DON) B reported that PASSAR should be located under the documents tab in a resident's record. DON B unable to locate PASSAR Level I in Resident #71's record.…

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 interviews and record review, the facility failed to ensure a baseline care plan was in place for 1 (Resident #442) of 19 sampled residents, resulting in the potential for ineffective care to be provided to the resident. Findings include: Resident #442 Review of an admission Record revealed Resident #442, was originally admitted to the facility on [DATE] with pertinent diagnoses which included type 2 diabetes mellitus and chronic kidney disease. Review of Resident #442's Care Plan on 12/4/23 revealed, Focus areas: At risk for elopement. Date Initiated: 12/01/2023. Interventions: Add resident to the Elopement Book. Date Initiated: 12/01/2023. Encourage to participate in activities to divert from exit seeking behavior. Date Initiated: 12/01/2023. Frequent monitoring (specify frequency) Date Initiated: 12/01/2023. The resident has (Specify: impaired cognitive ability /impaired thought processes r/t) (sic) Date Initiated: 12/01/2023. Interventions: Allow extra time for resident to respond to questions and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI0040935 Based on observation, interview, and record review, the facility failed to follow professional standards of practice by 1.) not following McGeer's criteria for ordering an antibiotic for 1 resident (R45), 2.) documenting completion of wound dressing changes when they were not done for 2 residents (R53 and R57), 3.) not ensuring neurological checks were completed after unwitnessed falls for 1 resident (R79) of 19 residents reviewed for professional standards, resulting in the increase chance of R45 developing medicine-resistant bacteria, potential of R53 and R57 developing infection and R57, R53, and R79 developing worsening conditions and unmet care needs. Findings include: R45 According to the Minimum Data Set (MDS) dated [DATE], R45 scored 4/15 (severely cognitively impaired) on her BIMS (Brief Interview Mental Status), required the use of a wheelchair to self-ambulate around the facility with diseases that included Alzheimer's, dementia, and schizophrenia. 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 interview and record review, the facility failed to ensure a resident was consistently provided with showers/bathing for 1 of 4 residents (Resident #78) reviewed for activities of daily living, resulting in unmet personal hygiene needs with the potential for isolation, psychosocial harm, skin breakdown, harboring infection, and decreased self-esteem. Findings include: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 50742-50744). Elsevier Health Sciences. Kindle Edition.Personal hygiene affects patient's comfort, safety, and well-being. Hygiene care included cleaning and grooming activities that maintain personal body cleanliness and appearance. Personal hygiene activities which as taking a bath or shower and brushing and flossing the teeth also promote comfort and relaxation foster a positive self-image, promote healthy skin, and help prevent infection and disease . Resident #78: Review of an admission Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement interventions to prevent falls after a fall in 1 (Resident #442 ) of 7 residents reviewed for accidents, resulting in a potential for additional skin tears and falls. Findings include: Resident #442 Review of an admission Record revealed Resident #442, was originally admitted to the facility on [DATE] with pertinent diagnoses which included type 2 diabetes mellitus and chronic kidney disease. In an observation on 12/04/23 at 10:39 AM, Resident #442 was sitting in his bed repeatedly calling out Mom. Resident #442's call light was twisted on the right side of his bed and out of his reach. Resident #442 had two skin tears on his left arm, a bandage on his right arm, and bruising noted around his right eye. Resident #442 continued to call out Mom but staff did not come in to assist him. Review of Resident #442's Incident Reports revealed, Incident Description: At 14:45 (2:45 PM) this nurse noted resident on his hands and knees 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 appropriate indwelling catheter care, monitoring the patency of the tubing, and collection bag for 1 (Resident #78) of 3 residents reviewed for indwelling catheter care, resulting in the potential of a urinary tract infection. Findings include: Review of an admission Record revealed Resident #78 was a female with pertinent diagnoses which included pressure ulcer of sacral region, stage 4, pressure ulcer of right ankle, stage 3, pressure ulcer of left heal, unstageable, stiffness of right hand, contracture right foot, contracture left foot, multiple sclerosis, urosepsis, gangrene, chronic pain, and cognitive communication deficit. Review of Care Plan for Resident #78, revised on 03/23/2023, revealed the focus, .The resident has indwelling foley catheter r/t (related to) stage 4 decubitus ulcer to the coccyx . with the intervention .Catheter care every shift. Date Initiated: 03/10/2023 .Check tubing for kinks at each encounter .Observe for and document for pain/discomfort due to catheter .Observe for and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure consistent availability of hydration and/or nutrition based on resident needs in 3 of 3 residents (Resident #27, #51, and #78) reviewed for nutrition/hydration, resulting in the potential for dehydration. Findings include: Resident #27 Review of an admission Record revealed Resident #27 was a female with pertinent diagnoses which included dementia, macular degeneration (loss in the center of the field of vision), heart failure, stroke, anxiety, osteoporosis (bones become weak and brittle), and cyst in right knee. Review of current Care Plan for Resident #27, revised on 6/27/23, revealed the focus, .Resident #27 is at risk for falls r/t (related to) deconditioning, h/o CVA, muscle weakness, limited vision, demetia with impaired cognition poor safety awareness & delusions/hallucinations at times due to dementia with the intervention .Blue mat to the floor surface next to the bed when in bed to decrease the risk of injury. Blu mat to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure adequate care for residents who received enteral nutrition (tube feeding) in 1 (Resident #443) of 2 sampled residents reviewed for tube feeding, resulting in the potential for aspiration pneumonia. Findings include: Resident #443 Review of an admission Record revealed Resident #443, was originally admitted to the facility on [DATE] with pertinent diagnoses which included dysarthria (difficult or unclear articulation of speech) and following cerebral infarction (stroke). Review of Resident #442's Orders revealed, Enteral Feed Order: every shift Head of bed elevated at least 30 degrees. Order date: 11/13/2023. Review of Resident #443's Care Plan revealed, (Resident #443) requires tube feeding r/t (related to) Dysphagia (trouble swallowing), Swallowing problem. Date Initiated: 11/16/2023. Goal: (Resident #443) will be free of aspiration through the review date .(Resident #443) will remain free of side effects or complications related to tube…

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 post dialysis (procedure that removes excess water, solutes, and toxins from the blood in people whose kidneys cannot perform these functions) assessment and monitoring were completed for 1 (Resident #441) of 1 resident reviewed for dialysis care, resulting in the potential of being unprepared for a decline in resident condition, due to adverse effects of dialysis. Findings include: Resident #441 Review of an admission Record revealed Resident #441, was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and end stage renal (kidney) disease. During an interview on 12/04/23 at 10:16 AM, Resident #441 reported that he went to dialysis three days a week, and he was unaware if nursing staff would come in and assess him when he returned from dialysis. During an interview on 12/06/23 at 10:57 AM, LPN M reported that nurses were responsible for completing an assessment when a resident returned from…

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 identify PTSD (Post Traumatic Stress Disorder) triggers and implement interventions to mitigate triggers for 1 of 8 residents (Resident # 76) reviewed for trauma informed care, resulting in the potential risk of re-traumatization and unmet care needs. Findings include: Review of an Admissions Record for Resident #76 dated 2/8/23 revealed the resident was admitted to the facility with the following pertinent diagnoses: bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder, dissociative disorder (mental disorder characterized by the existence of two or more different personality states), schizoaffective disorder(mental health condition including schizophrenia and mood disorder symptoms), Post Traumatic Stress Disorder (PTSD), and suicidal ideations (thoughts about self-harm). Review of a Minimum Data Set (MDS) assessment for Resident #76 dated 10/17/23 revealed a Brief Inventory for Mental Status (BIMS) assessment score of 15/15, which indicated 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 dementia care treatment that included individualized care interventions that were monitored in 1 of 2 residents (Resident #54) reviewed for dementia care, resulting in facility staff not knowing if interventions were effective and/or appropriate and the potential for residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an admission Record revealed Resident #54 had pertinent diagnoses which included other frontotemporal neurocognitive disorder (disorder affecting the frontal and temporal lobe of the brain), adjustment disorder with mixed disturbance of emotions (feeling sad and anxious both), unspecified dementia (disease that affects memory and thinking), and anxiety. Review of Behavior Notes for Resident #54 dated 7/26/23 revealed .yelled out continuously during am care . Review of Health Status Notes for Resident #54 dated 8/9/23 revealed .behaviors today of screaming/yelling out during care/feeding . Review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident remained free from unnecessary mediations in 1 (Resident #45) of 19 residents reviewed for antibiotic use, resulting in the potential of developing a medicine-resistant bacteria. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R45 scored 4/15 (severely cognitively impaired) on her BIMS (Brief Interview Mental Status), required the use of a wheelchair to self-ambulate around the facility with diseases that included Alzheimer's, dementia, and schizophrenia. Review of R45's Incident Report (IR) #1810 dated 10/22/2023 18:50 (6:50 PM), reported the resident's wheelchair's left wheel got caught in the leg of a mechanical lift. A skin tear (layers of skin separate or peel back) was noted to her LFA (left forearm). Review of R45's Physician Note dated 10/23/2023 revealed, .Reason for Evaluation: I am asked by the nursing staff to evaluate patient's left forearm after a fall . Assessment: Dirty wound. Plan .Start…

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 residents were screened for eligibility to receive pneumococcal and influenza vaccinations and receive vaccination if eligible for 3 (Resident #19, #53 and #59) of 5 residents reviewed for vaccinations, resulting in the potential of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia and/or influenza. Findings include: Resident #19 Review of an admission Record revealed Resident #19, was originally admitted to the facility on [DATE] with pertinent diagnoses which included moderate protein calorie malnutrition and muscle weakness. Review of Resident #19's Immunization Record on 12/11/23 revealed that Resident #19 was noted to have received Pneumovax dose 1 on 8/13/2009 as a historical vaccine, and Pneumovax dose #2 on 10/26/16 as a historical vaccine. During an interview on 12/5/23 at 2:30 PM with Director of Nursing (DON) B and Infection Preventionist (IP) E, DON B reported that Resident #19 had already received…

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 COVID-19 immunization were offered to 2 (Resident #53 and #59) out of 5 residents, reviewed for COVID-19 immunizations, resulting in the increased likelihood of severe infection and complications/death related to COVID-19. Findings include: Resident #53 Review of an admission Record revealed Resident #53, was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and difficulty in walking. Review of Resident #53's Immunization Record on 12/11/23 revealed that Resident #53 had last received SARS-COV-2 (Covid-19) Pfizer bivalent booster vaccine on 10/5/22. During an interview on 12/5/23 at 2:30 PM with Infection Preventionist (IP) E reported that Resident #53's guardian had given consent for Resident #53 to receive a Covid-19 vaccine on 10/18/23, and he did not know why the vaccine had not been administered. IP E reported that it had just been missed. Resident #59 Review of an admission Record…

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

Based on interview and record review, the facility failed to ensure Certified Nurse Aides (CNA's) completed the required 12 hours of training to ensure continued competence in 1 of 5 CNA's reviewed for competency, resulting in the potential for a decrease in resident safety. Findings include: Review of Facility Assessment dated October 2023, revealed . all education is prepared by (facility name) for quality consistency and adherence to standards of practice across all sites .Training includes: communication, resident rights, abuse/neglect/exploitation, infection control, culture change, required standard training, resident change in conditions, cultural competency . Review of employee file for CNA V revealed a hire date of 6/22/22. Review of Training Course Assignment for CNA V revealed all annually required in-services were assigned and all but one was listed as incomplete or not attempted. During an interview on 12/11/23 at 12:18 PM., HR Director (HRD) YY reported that CNAs are required to complete in-services annually. HRD YY reported that in-services are assigned by both the HR…

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, interviews, and record review, the facility failed to provide an environment that promoted and enhanced resident dignity and respect in 5 (Resident #108, #118, #119, #121, and #123) of 9 residents reviewed for dignity/respect, resulting in long call light wait times, staff behaviors that did not promote dignity and respect to or in the presence of residents, and feelings of frustration, embarrassment, and loss of self-worth for the residents thus impacting their quality of life. Findings include: Resident #108 Review of an admission Record revealed Resident #108 was a male, with pertinent diagnoses which included: other lack of coordination, morbid (severe) obesity, difficulty walking, anxiety disorder, and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #108, with a reference date of 7/10/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #108 was cognitively intact. Further review of said MDS revealed Resident #108 required extensive, one-person physical…

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 #MI00136333 and #MI00136123. Based on interview and record review the facility failed to prevent misappropriation of medications and personal funds in 6 residents (Resident #108, #109, #110, #111, #122, and #106) of 6 sampled residents reviewed for misappropriation of personal items, resulting in the potential for ineffective pain management and a loss of financial security. Findings include: Resident #108 Review of an admission Record revealed Resident #108 had pertinent diagnoses which included Surgical aftercare following surgery on the genitourinary system and encounter for attention to other artificial opening of the urinary tract. Review of a Minimum Data Set (MDS) assessment for Resident #108, with a reference date of 7/10/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #108 was cognitively intact. Resident #109 Review of an admission Record revealed Resident #109 had pertinent diagnoses which included diabetes and chronic kidney disease. Review of a Minimum Data Set (MDS) assessment for 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 This citation pertains to Intake # MI00139066, # MI00139073, # MI00136333, & # MI00139098. Based on observation, interview, and record review, the facility failed report timely and accurately to the State Agency required reportable incidents in 8 (Resident #114, #108, #109, #110, #111, #122, #115, & #116) of 10 residents reviewed for reporting, including inappropriate use of a restraint (Resident #114), misappropriation of resident medications (Resident #108, #109, #110, #111, & #122), an improper transfer with major injury/delayed wound care (Resident #115), and a significant medication error resulting in hospitalization (Resident #116), resulting in the potential for additional reportable incidents to go unreported, investigations continuing to be inaccurately reported to the State Agency, and/or cause a delay in the investigative process. Findings include: Resident #114 Review of an admission Record revealed Resident #114 had pertinent diagnoses which included repeated falls, dementia, Alzheimer's disease,…

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 # MI00139073. Based on interview, and record review, the facility failed to notify the responsible party of a change in resident condition in 1 of 4 residents (Resident #115) reviewed for notification of changes, resulting in the primary physician and representative not being made aware immediately of an accident resulting in a significant wound, and the lack of ability to participate in timely medical decision-making. Findings include: Review of the policy/procedure Changes in Resident's Condition or Status, dated 8/9/23, revealed .This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status .A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is .An accident involving the resident which results in injury and has the potential for requiring physician…

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 #: MI00136331. Based on interview and record review, the facility failed to protect the resident's right to be free from staff to resident verbal abuse in 1 (Resident #107) of 5 residents reviewed for abuse, resulting in the potential for emotional distress. Findings include: Review of an Incident Summary report received by SA (State Agency) on 2/1/23 at 8:18 PM revealed, Incident Summary An allegation was reported where a nurse overheard a CNA (also referred to as CENA) say you better not touch me which made her run around the corner of her desk at the nurses station where she saw the CNA move toward a resident saying don't touch me - you won't mess with me or I will kick your (profanity omitted) (profanity omitted). The nurse immediately intervened and had the employee go down the hall and told him his behavior was unacceptable . Resident #107 Review of an admission Record revealed Resident #107 was a male, with pertinent diagnoses which included: unspecified dementia moderate with agitation, adjustment disorder with mixed disturbance of emotions…

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 #: MI00136331. Based on interview and record review, the facility failed to implement the abuse policy regarding timely notification of a staff to resident abuse to the abuse coordinator in 1 (Resident #107) of 5 residents reviewed for abuse, resulting in delayed reporting of the incident to the State Agency, delayed initiation of an investigation of the allegation, and allowed the alleged perpetrator to continue to work with Resident #107 and other vulnerable residents. Findings include: Resident #107 Review of an admission Record revealed Resident #107 was a male, with pertinent diagnoses which included: unspecified dementia moderate with agitation, adjustment disorder with mixed disturbance of emotions and conduct, psychotic disorder with hallucinations due to known physiological condition, depression, and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #107, with a reference date of 11/22/22 (most recent prior to incident) revealed a Brief Interview for Mental Status (BIMS) score of 03, out of a total possible score…

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

This citation pertains to Intake # MI00138569. Based on interview, and record review, the facility failed to adhere to professional standards related to accurate transcription of physician orders in 1 (Resident #113) of 23 residents reviewed for professional standards, resulting in missed medication(s) dose(s). Findings include: Review of an admission Record revealed Resident #113 had pertinent diagnoses which included Paraplegia (paralysis of the lower half of the body) and chronic pain. Review of a Minimum Data Set (MDS) assessment for Resident #113, with a reference date of 8/18/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #113 was cognitively intact. During an interview on 9/11/23 at 3:09 PM, Resident #113 reported that on the evening of 7/28/23 he did not receive his evening dose of Methadone. Resident #113 reported that in the evening on 7/28/23 he told the agency nurse that was assigned to him that he should receive 4 Methadone tablets with his evening medications. Resident #113 reported the agency nurse told him the doctor…

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 # MI00138569. Based on interview, and record review, the facility failed to ensure that resident's medical records were accurate in 1 resident (Resident #113) of 23 residents reviewed for accuracy of medical records, resulting in Resident #113 not consistently receiving his medications with the potential for a diminished medical outcome. Findings include: Review of an admission Record revealed Resident #113 had pertinent diagnoses which included Paraplegia (paralysis of the lower half of the body) and chronic pain. Review of a Minimum Data Set (MDS) assessment for Resident #113, with a reference date of 8/18/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #113 was cognitively intact. Review of Physician Orders for Resident #113 revealed an order for Methadone HCL 10 mg (milligram) tablets, give four (4) tablets by mouth three times a day for pain from an auto accident. This order ended on 7/7/23. Review of Medication Administration record for Resident #113 revealed an order for Methadone HCL 10 mg give 4…

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.