Plainwell Pines Nursing and Rehabilitation Communi

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain a medication error rate less than 5% in 1 resident (Resident #29) of 5 residents reviewed for medication administration, resulting in the potential for medication adverse effects. The medication error rate was 6.25%.Findings include: Review of an admission Record revealed Resident #29 was originally admitted to the facility on [DATE].During an observation on 05/28/2026 at 7:39 AM in Resident #29's room, Agency-Licensed Practical Nurse (A-LPN) II handed Resident #29 her inhaler Breyna and the resident took 2 puffs. A-LPN II did not encourage Resident #29 to swish and spit with water following the inhaler.In an interview on 5/28/26 at 7:50 AM, A-LPN II reported that Breyna inhaler was not a steroid and did not require a swish and spit after administration. This surveyor requested that A-LPN II double checked that information. A-LPN II reviewed the label of Breyna and reported that yes, it says to swish and spit after administration to avoid…

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 effectively implement Enhanced Barrier Precautions (EBP) and maintain infection control standards during incontinence (involuntary leakage of urine and feces) care per Centers for Disease Control and Prevention (CDC) guidance, in 2 residents (Resident #39 & #4) from a total sample of 20 residents, resulting in the potential for cross-contamination and the development and spread of infection to a vulnerable population.Findings include:Resident #39Review of an admission Record revealed Resident #39 was originally admitted to the facility on [DATE].During an observation on 05/27/2026 at 6:40 AM in Resident #39's room, the resident was observed lying in bed and a bag with urine was observed hanging on the bed frame. There was no signage indicating that Resident #39 had EBP in place.During an observation on 05/27/2026 at 8:17 AM in Resident #39's room, Certified Nursing Assistant (CNA) R entered the room to assist the resident with care. CNA R…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes #2677662 and #2648515.Based on observation, interview, and record review, the facility failed to maintain an effective training program for all facility and agency staff, consistent with their role in the facility to ensure the safety of residents in 1 resident (Resident #101) of 2 residents reviewed for elopement, and 2 residents (Resident #102 and #107) of 4 residents reviewed for the administration of controlled substance, resulting in agency staff not responding properly to door alarms and licensed nursing staff not maintaining an accurate account of controlled substances. Findings include: Resident #101Review of a Face Sheet revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 8/29/25 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #101…

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 #2648515Based on observation, interview and record review, the facility failed to ensure that medication records were in order and that an account of all controlled drugs was maintained and accurately reconciled for 2 residents (Resident #102 and #107) of 4 residents reviewed for the administration of controlled medications, resulting in the potential for ineffective management of pain and the potential for diversion of controlled drugs. Findings include:Resident #102 Review of a Face Sheet revealed Resident #102 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: chronic pain.Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 10/6/25 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. During an observation and interview on 12/16/25 at 3:13 PM in Resident #102's room, the resident reported that she…

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 access to a call light in 4 of 10 sampled residents (Resident #104, R#102, R#105, and R#106) reviewed for call light placement, resulting in the inability to call for assistance and the potential for unmet care needs.Findings include: Resident #104Review of an admission Record revealed Resident #104 was a female with pertinent diagnoses which included Alzheimer's disease, diabetes, fracture of lower end of left femur, fractur of lower end of right femur, overactive bladder, and dementia. Review of current Care Plan for Resident #104, revised on 1/24/25, revealed the focus, .At risk for falls and subsequent injury related to fx (fracture) of fall w/ bilat femur fx prior to admission, incontinence, DM II (diabetes), vascular dementia, Alzheimer's, dependence in ADLs and transfers. with the intervention .Recline Broda chair when resident is unattended.Call light to be in reach.Instruct and remind to use call light to ask for assistance.…

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

Based on observation, interview, and record review, the facility failed to protect resident privacy during personal care for 1 (Resident #109) of 10 residents reviewed for privacy/dignity, resulting in the potential for feelings of embarrassment. Findings include: Review of an admission Record revealed Resident #109 was a male with pertinent diagnoses which included cellulitis of right lower limb, edema, changes in skin texture to BLE (bilateral lower extremities), cellulitis of left lower limb, and erythematous condition (red or abnormally reddened that appears red due to inflammation, infection, and other irritation). Review of current Care Plan for Resident #109, revised on 3/21/25, revealed the focus, .Resident has a bilateral lower extremity chronic venous ulcers with potential for infection and discomfort to the area . with the intervention .Administer analgesic as ordered prior to wound care, dressing changs or debridement, avoid friction and shearing during transfers or repositioning, conduct a systemic skin inspection weekly and PRN ( as needed). CNA to observe skin…

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

This citation pertains to intake: 2618457 and 2618789Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from staff to resident sexual abuse for 1 resident (Resident #108) reviewed for abuse, resulting in Resident #108 feeling concerned for physical safety enough to leave shortly after admission. Findings include: Review of Incident Summary submitted on 9/11/25, revealed, .Incident Summary: On 9/11/25, administrator received a call from staff of a sexual abuse allegation reported to them from resident (Resident #108), a newly admitted resident. Admin immediately went to the facility and made contact with the resident via phone, as resident has already left the building with her son prior to administrator's arrival. (Resident #108) reported that (LPN J), LPN, had performed a physical assessment of her, and during this assessment, when he got to my boobs, he pinched my nipples and rubbed them between his fingers. I don't think that is proper. He made me feel really uncomfortable. Resident states she is ok now and is…

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 1287744Based on interview and record review, the facility failed to prevent the misappropriation of narcotic pain medication in 1 of 10 residents (Resident #103) reviewed for misappropriation of property, resulting in the theft of narcotic medications and the potential for delayed pain treatment.Findings include: Resident #103: Review of an admission Record revealed Resident #103 was a male with pertinent diagnoses which included MS (multiple sclerosis), polyneuropathy (multiple sites of nerve damage), heart failure, end stage renal disease, and osteoarthritis (flexible tissue at the end of bones wears down). Review of current Care Plan for Resident #103, revised on 1/28/25, revealed the focus, .Resident has potential/actual pain r/t (related to) MS, hx (history) of falls, ESRD on dialysis, CHF (congestive heart failure), HTN (high blood pressure), Anemia, OA (Osteoarthritis). with the intervention .Administer pain medications as ordered.Review of Order dated 4/26/25 for Resident #103,…

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 update and revise the person-centered care plan in a timely manner with appropriate interventions for the prevention of undefined care concerns for 1 of 10 residents (Resident #102) reviewed for care plans, resulting in the potential for physical, mental, and psychosocial unmet care needs and harm. Findings include: Resident #102: Review of an admission Record revealed Resident #102 was a male with pertinent diagnoses which included displaced midcervical fracture of right femur (break in the middle part of the neck of the femur, bone fragments, and are no longer aligned), adult failure to thrive, intracapsular fracture of femur (break of femoral neck which is located within the hip joint's capsule), anxiety, dysphagia (difficulty swallowing foods and liquids), and stroke. Review of current Care Plan for Resident #102, revised on 12/2/24, revealed the focus, .At risk for falls and subsequent injury related to dementia with cognitive…

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 clean and sanitary shared medical equipment, wheelchair cleaning for 1 (Resident #106) of 10 residents, resulting in the potential for cross contamination, infections, and bacterial harborage. Findings include: Resident #106: During an observation on 09/15/25 at 2:33 PM, Resident #106 was observed seated in a scoot/broda chair next to the side of his bed. His chair was visibly dirty, the pad under his bottom had dried liquid material on it, tan, white, brown in color. The arm rest on the right side on the outside had smeared white material, dirt and debris built up on it. The floor in his room was dirty and had splatters on it with dark brown material in it. During an observation on 09/16/2025 at 8:16 AM, Resident #106 was observed lying in bed, his chair had dried food material on the arms rests, on the front down the front of it, and the sides of the seat. His room had chocolate chip cookie pieces on the floor and dirt/debris.…

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 employ a staff member with appropriate credentials to supervise and manage the dietary department, resulting in the potential for food service sanitation failures, food borne illness and for clinical areas of dietary needs of all residents being compromised and unmet. Findings include: During the initial kitchen tour on 5/5/2025 at 8:33 AM, Dietary Manager (DM) H stated that he had been at the facility for over a year now (date of hire 1/23/2024) and had his food manager certification. He said he was trying to complete the Certified Dietary Manager course but had been so busy with the facility. Review of DM H's certification revealed that he completed the Food Protection Manager certificate on 4/25/2025 which was a certificate that could be completed in a day instead of completing a full course of study in management which takes a year plus to complete. During another interview on 5/6/2025 at 9:17 AM, DM H stated that the Dietetic Technician, Registered (DTR) comes to the facility every week to do clinical work and the…

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

Based on observation, interview, and record review, the facility failed to ensure proper label and dating of foods and discarding of foods in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include: During the initial tour of the kitchen on 5/5/2025 at 8:33 AM, the following was observed: The reach in refrigerator had a pitcher of iced tea, half full with a use by date of 5/4/2025. The walk-in refrigerator had 3 trays of individual juices in 12 oz plastic glasses with no label and date. During a full kitchen tour on 5/6/2025 at 9:17 AM, the following was observed in the dry storage room: An open crystal light lemonade packet in a plastic bag with an open date of 3/13/2025 and use by date of 4/12/2025 An open fruit punch packet in a plastic bag with an open date of 3/13/2025 and use by date of 4/12/2025 An open big bag of sugar flakes cereal with no label and date. On 5/6/2025 at 9:45 AM, the following was observed in the walk-in refrigerator: A small open container of ham base with an open date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake number MI00151548 Based on observation, interview, and record review the facility failed to: 1.) maintain a clean and homelike environment for 5 residents (R82, R15, R182, R134, and R135), and 2.) maintain comfortable noise level for 2 residents (R134 and R135) of 12 residents reviewed for homelike environment, resulting in potential for dissatisfaction with living conditions for the 5 residents and residents who are able to ambulate in the facility. Findings include: Facility tour on 5/05/25 at 10:52 AM, revealed the handrail outside of room [ROOM NUMBER] had a hole, approximately 2 inches in width, with exposed sharp-jagged pieces of plastic. During a tour of the facility on 5/6/25 at 8:15 AM, observation, interview, and record review were conducted with Maintenance F. Observed a handrail outside of room [ROOM NUMBER] that had a hole, approximately 2 inches in width, with exposed sharp-jagged pieces of plastic. Maintenance F stated, I did not know that was there. That needs to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an effective infection control program that included: 1. cleaning of resident equipment for 1 of 16 residents (R82), 2. appropriate hand hygiene and glove use (PPE-Personal Protection Equipment) during resident care in 2 of 16 residents (R82 and R29), 3. implementation of Enhanced Barrier Precautions (EBP) per standards of practices for 2 of 16 residents (R29), reviewed for infection control, resulting in the potential for cross-contamination, harborage of bacteria, and increased infections in a vulnerable population. Findings include: Upon entering facility, 5/5/25, Nursing Home Administrator (NHA) A announced all staff in resident areas were to wear masks due to a staff testing positive for Covid-19. Tour of facility on 5/5/25 at 9:14 AM, revealed outside of room [ROOM NUMBER] a high-backed wheelchair splattered with a dried white substance on seat cushion, foot cushion, and frame of chair. The nuts on the frame had a buildup 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 MI00151548 Based on observation and interview, the facility failed to maintain dignity for 2 of 4 residents (R29 and R21) reviewed for dignity, resulting in the potential for feelings of embarrassment based on the reasonable person concept. Findings include: R29 According to the MDS dated [DATE], R29 scored 4/15 on his BIMS (Brief Interview Mental Status) indicating he was severely cognitively impaired. He required the use of a wheelchair for mobility and had diagnoses that included pressure wounds. Review of R29's Care Plan as of 5/8/25, there was no resident-specific treatment plan for the resident to receive his medications in a common area. During an observation on 05/06/25 at 11:30 AM, R29 was sitting by the nursing station with other residents and staff at the nursing station. Without removing R29 from the congested area, and providing him privacy, Therapist W pulled up the resident's pant legs and exposed both legs from the knees to his ankles. Therapist W explained out…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were assessed to determine if self-administration of medication was clinically appropriate in 2 of 2 residents (Resident #9, Resident #17) reviewed for self-administration of medications, resulting in unsupervised administration of medications and the potential for mismanagement of medication and adverse side effects. Findings include: Resident #9 (R9) Review of the Facesheet and Minimum Data Set (MDS) dated [DATE] revealed R9 admitted to the facility on [DATE] with pertinent diagnoses including dementia (decline in mental abilities severe enough to interfere with daily life) and depression. Brief Interview for Mental Status (BIMS) reflected a score of 7 out of 15 which indicated R9 was severely cognitively impaired (00 to 07 is severe cognitive impairment). During an observation and interview on 5/5/2025 at 9:31 AM, R9 had a prescription nasal spray on her bedside table {ipratropium bromide solution .03% (percent) 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 Based on observation, interview, and record review the facility failed to complete advance directives completely and accurately for 1 (Resident #134) of 12 residents reviewed for advance directives, resulting in the potential for resident preferences for medical care to not be followed by the facility staff. Findings include: Review of an admission Record revealed Resident #134 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: chronic systolic heart failure (condition in which the heart cannot pump blood effectively), aortic stenosis (narrowing of the aortic valve), tricuspid valve insufficiency (heart valve disease causing insufficiency of blood circulation within the heart), atherosclerotic heart disease (buildup of plaque in artery walls). Review of a Care Plan for Resident # 134 with a reference date of [DATE], revealed no focus/goal/interventions related to the resident's wishes for Cardiopulmonary Resuscitation (CPR). Review of an Advance Directives facility policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to notify the resident representative of a resident exiting the facility in 1 of 2 residents (R15) reviewed for notification of changes, resulting in the responsible party not being made aware that R15 walked out a door observed but unattended and subsequent placement of a wander guard. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R15 scored 4/15 on her BIMS (Brief Interview Mental Status) indicating she was severely cognitively impaired. Diagnoses included schizoaffective disorder and dementia. Section GG-Functional Abilities and Goal indicated supervision or touching assistance was required when walking at least 150 feet in a corridor or similar space. Review of R15's Incident/Accident Report dated 4/23/25, indicated the resident was wandering/exit seeking and opened an exit door and went outside the facility. A wander guard was applied, and care plan was updated. The family member/resident representative was not notified…

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 psychotropic medications were not used without medical indication for use for 3 (Resident #134, Resident #182, and Resident #29) of 5 residents reviewed for chemical restraints. Findings include: Review of a Psychotropic Medication Use facility policy with a reference date of 1/2025 revealed Policy: Residents are not given psychotropic medication unless the medication is necessary to treat a specific condition, diagnosed and documented in the clinical record .Pre-admission screening may be used to determine indications for use of psychotropic medications ordered upon admission to the facility. Resident #134 Review of an admission Record revealed Resident #134was originally admitted to the facility on [DATE] with pertinent diagnoses which included: depression (persistent sad mood), metabolic encephalopathy (brain disorder caused by disruptions in the body's metabolic processes, leading to brain dysfunction). Review of a Care Plan…

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 written bed hold notice and transfer/discharge notice for 1 of 1 resident (Resident #5) reviewed for hospitalizations, resulting in the potential of residents and/or resident representatives being uninformed of the reason for transfer and not being able to hold a bed in the facility. Findings include: Resident #5 (R5) Review of the Facesheet and Minimum Data Set (MDS) dated [DATE] revealed R5 admitted to the facility on [DATE] with pertinent diagnoses including hypoglycemia (low blood sugars), lupus (illness that occurs when the immune system attacks healthy tissues and organs) and epilepsy (disorder in which nerve cell activity in the brain is disturbed causing seizures). Brief Interview for Mental Status (BIMS) reflected a score of 13 out of 15 which indicated R5 was cognitively intact (13 to 15 cognitively intact). R5 had a legal financial guardian. During an interview on 5/5/2025 at 10:13 AM, R5 stated that she had been in and out of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide meaningful activities to promote psychosocial well-being for 1 (Resident #27) of 12 residents reviewed for activities. This deficient practice resulted in social isolation, feelings of loneliness, frustration and boredom. Findings include: Review of an admission Record revealed Resident #27 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: depression (persistent sad mood). Review of a Minimum Data Set (MDS) assessment for Resident #27 with a reference date of 3/18/25, revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #27 was moderately cognitively impaired. Section D of the MDS revealed Resident #27 reported he rarely felt lonely or isolated from those around him. Section E of the MDS revealed Resident #27 displayed no behaviors during the 14-day assessment period. Section F revealed the resident reported it was somewhat important to him to be around…

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 adequately assess, monitor, and treat a change of skin condition in 1 of 1 resident (R21) reviewed for quality of care, resulting in a delay in assessment, treatment, pain, and the potential for worsening of condition and infection. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R21 scored 99/15 on her BIMS (Brief Interview Mental Status) indicating the resident was severely cognitively impaired, was dependent on cares and mobility with diagnoses including Alzheimer's disease and dementia. Observed on 5/5/25 at 8:55 AM, R21 with a gauze dressing covering the top of her right hand with three spots of red drainage showing through. The dressing was not dated. Review of R21's Order Summary indicated an order to treat a wound on resident's right hand was not made until after survey began (5/5/25). Review of R21's Care Plan did not have a resident-specific treatment plan for the injury to top of right hand. Observed on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician's orders to complete a wound dressing in 1 of 1 resident (R29) reviewed for pressure ulcer care, resulting in a missed opportunity to provide care needed to heal a pressure wound and prevent infection. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R29 scored 4/15 on his BIMS (Brief Interview Mental Status) indicating he was severely cognitively impaired. Section M-Skin Conditions revealed R29 was not at risk for a pressure ulcer and had an unhealed pressure wound. Diagnoses included dementia and anxiety. Review of R29's Wound Management Report created 4/14/25, reported the resident had a right trochanter wound measuring 5.5 cm x 3.5 cm. Mild amount of serosanguinous (bloody fluid) drainage noted. 100 percent of wound covered by slough tissue (by-product of inflammation and can be a barrier to healing). Review of R29's Medication/Treatment Administration Report (MAR/TAR) dated 5/1/25-5/31/25…

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 interventions to ensure a safe environment in 1 of 1 resident (R15) and, 2. ensure the safety of residents during wheelchair transport in 2 of 3 residents (R134 and R182) reviewed for safety, resulting in the potential for R15 to elope from the facility and increase potential for injury for R134 and R182. Findings include: R15 According to the Minimum Data Set (MDS) dated [DATE], R15 scored 3/15 indicating she was cognitively impaired. Diagnoses included dementia, manic depression (bipolar disease), and schizophrenia. Her mobility status was evaluated to require supervision or touching assistance for sitting standing, toilet transfer, and walking for at least 150 feet. Review of R15's Progress Note dated 9/18/24 at 4:22 PM indicated around 2:30 PM, R15 was pulling on the slider door in the dining room. Approximately 2 hours later, R15 was taken outside and stood with her for a few minutes which seemed to take care of 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 Based on observation, interview, and record review, the facility failed to provide adequate urinary catheter care and assessment for the need of an indwelling catheter (catheter inserted in through the urethra and into the bladder) for 1 of 1 resident (R29) reviewed for catheter care, resulting in the potential for the dislodgement, injury, pain, development of urinary infection and decline in overall health status. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R29 scored 4/15 on his BIMS (Brief Interview Mental Status) indicating he was severely cognitively impaired. Diagnoses included urinary retention. Review of R29's Order Summary dated 4/22/25, revealed: -Ensure urinary catheter fixation device is in place to prevent trauma and irritation Q shift - Catheter Care every shift Type: Indwelling Size: 16 French Balloon: 10 cc Review of R29's Medication/Treatment Administration Record dated 5/1/25-5/31/25 indicated the licensed nurses for all shifts verified a catheter fixation device…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide ongoing communication and collaboration with the contracted dialysis facility regarding dialysis care for 1of 1 resident (Resident #135) reviewed for dialysis, resulting in the potential for unmet medical needs. Findings include: Review of a Dialysis Policy and Procedure facility policy with a reference date of 1/2025, revealed Policy: It is the policy of (name of organization omitted) to meet the needs of those residents undergoing dialysis treatment. Procedure .There must be communication between the facility and the dialysis center weekly .The (nutrition specialist) should review the residents pre and post weights and labs from the dialysis center and notify the dietitian if the resident is at nutritional risk or if the resident and labs vary significantly. Review of an admission Record revealed Resident #135 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: end stage renal disease 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 interview and record review, the facility failed to ensure COVID-19 immunizations were offered to 1 (Resident #21) of 5 residents reviewed for COVID-19 immunizations, resulting in an increased risk for infection, and the potential spread of COVID-19 infection to other residents, staff, and visitors. Findings include: Upon entering facility, 5/5/25, Nursing Home Administrator (NHA) A announced all staff in resident areas were to wear masks due to a staff testing positive for Covid-19. Review of an admission Record revealed Resident #21 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alzheimer's disease (disease resulting in a progress decline in cognitive abilities). The admission Record also revealed Resident #21 had a durable power of attorney (DPOA) for medical decision making. Review of a Minimum Data Set (MDS) assessment for Resident #21 with a reference date of 1/20/25, revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated…

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 is linked to intake # MI00145717 Based on interview and record review the facility failed to provide an environment free from abuse in 3 residents (Resident #100, Resident #101, and Resident #102) of 5 residents reviewed for abuse, resulting residents experiencing fear, avoidable pain, bruising, and a potential for more serious injury. Findings include: Resident #100 Review of an admission Record revealed Resident #100, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified dementia, cellulitis of right lower limb, major depressive disorders, generalized anxiety disorder, chronic pain syndrome and bursitis of the right knee (painful swelling of the fluid-filled pads that act as a cushion at the joints). Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 6/03/24 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #100 was moderately cognitively impaired. Review of a Care…

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

Based on observations, interviews, and record reviews, the facility failed to: (1) effectively clean and maintain food service equipment and (2) date mark all potentially hazardous ready-to-eat food products effecting 33 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness. Findings include: On 06/25/24 at 08:08 A.M., An initial tour of the food service was conducted with Dietary Manager G and Dietary [NAME] BB. The following items were noted: 1 of 2 hand sink faucet assemblies were observed loose-to-mount. Dietary [NAME] BB indicated she would contact maintenance for necessary repairs as soon as possible. The pre-wash sink overhead spray arm handheld valve assembly was observed invading the flood plane level of the sink basin. Dietary Manager G indicated he would have maintenance correct the issue as soon as possible. The 2017 FDA Model Food Code section 5-205.15 states: A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. The Juice Machine (backsplash, undersplash, and…

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

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 33 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 06/25/24 at 12:46 P.M., A common area environmental tour was conducted with Director of Environmental Services E. The following items were noted: East Hall Housekeeping Closet: The overhead light assembly was observed non-functional. Director of Environmental Services E indicated he would replace the faulty bulb as soon as possible. Nursing Station Restroom: An active water leak was observed, adjacent to the overhead light assembly. The damaged ceiling surface measured approximately 12-inches in diameter. West Hall Clean Linen Room: Two acoustical ceiling tiles were observed stained from previous moisture exposure. South Hall Nursing Station: One of two chairs were observed (etched, scored, worn). The bi-lateral arm rests were also observed worn and torn, exposing the inner Styrofoam padding and metal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an environment that promoted and enhanced resident dignity in one resident (R7) of 12 residents reviewed for dignity, resulting in the potential of feelings of humiliation and embarrassment. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R7 scored 99 on her BIMS (Brief Interview Mental Status) indicating the resident was unable to complete the interview due to her cognitive state. R7 had impairment in both of her legs requiring substantial maximal assistance for toileting. Diagnoses included fracture, anxiety, depression, and a psychotic disorder other than schizophrenia. During an observation and interview on 6/25/24 at 8:50 AM R7 was receiving incontinence care in her bed by two Certified Nursing Assistants (CNA). During care one CNA left the room to summons a nurse. The remaining CNA stood at R7's bedside while the resident was left in a supine position naked from waist down. After approximately 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.

Based on observations, interviews and record review, the facility failed to develop and implement person centered care plan for 1 of 12 residents (Resident #26) reviewed for care planning, resulting in unmet care needs. Findings include: Resident #26 Review of an admission Record revealed Resident #26, was originally admitted to the facility with pertinent diagnoses which included: history of falling, unspecified dementia, and type 1 diabetes mellitus (lifelong condition in which the pancreas does not make sufficient insulin to maintain stable blood sugar levels) with diabetic retinopathy (damage to the blood vessels in the eyes causing poor vision). Review of a Minimum Data Set (MDS) assessment for Resident #26, with a reference date of 5/20/24 revealed a Brief Interview for Mental Status (BIMS) score of 4/15 which indicated Resident #26 was severely cognitively impaired. Section GG of the MDS revealed Resident #26 required maximal assistance (helper does more than 50% of the effort) to transfer from his bed to his wheelchair and an attempt to assess the residents ability to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide sufficient staffing to meet residents needs in three residents (Resident #7, Resident #20, Resident #26) of 12 residents reviewed for staffing resulting in falls with injuries and unmet resident care needs. Findings include: During an interview on 6/26/2024 at 8:05 AM, Certified Nursing Assistant (CNA) O' stated that staffing isn't adequate during the day to get things done and is worse on the weekends. CNA O' said that 2 CNAs during a shift isn't enough to get her tasks done. She stated that she tries her best and sometimes doesn't have time to get showers done. CNA O said sometimes management helps but not often. During an interview on 6/26/2024 at 8:20 AM, CNA Q stated that there were only 2 CNAs scheduled that day and they should have 3 on first shift. CNA Q stated she doesn't have time to get tasks done on her shift and sometimes showers aren't given because of this. During an interview on 6/26/24 at 9:49 AM, Registered Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow up on pharmacist recommendations and ensure the physician documented review of pharmacy recommendations for one resident (Resident #6) of five residents reviewed for unnecessary medication use potentially resulting in incomplete monitoring of the use of medications for residents. Findings Include: Resident #6 (R6) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R6's admission date to the facility was on 10/17/2022 and she had diagnoses of hallucinations, cognitive communication deficit, depression, and anxiety. Brief Interview for Mental Status (BIMS) score was a 12 which indicated her cognition was moderately impaired (8-12 moderately impaired). During an interview on 6/25/2024 at 10:05 AM, resident was pleasant and confused. She was unable to answer some questions. Review of the Pharmacy Consultation Report recommendations dated 1/14/2024 revealed (R6) receives azathioprine and does not have a recent CBC (Complete…

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 residents of the facility were free from unnecessary psychotropic medication by completing gradual dose reductions for two residents (Resident #6, Resident #22) of five residents reviewed for unnecessary medication use resulting in incomplete monitoring of medications. Findings include: Resident #6 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R6's admission date to the facility was on 10/17/2022 and had diagnoses of hallucinations, cognitive communication deficit, depression, and anxiety. Brief Interview for Mental Status (BIMS) score was a 12 which indicated her cognition was moderately impaired (8-12 moderately impaired). During an interview on 6/25/2024 at 10:05 AM, resident was pleasant and confused. She was unable to answer some questions. Review of the June Medication Administration Record (MAR) revealed that one of the medications R6 received was citalopram (celexa) for depression, 20 mg (milligrams) 1 tab…

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 a double-lock system for a controlled substance in the facility's medication refrigerator resulting in the potential for diversion and/or misappropriation of medication. Findings include: Observed on 6/27/24 at 8:00 AM the medication room refrigerator unlocked through window of medication room. Observed on 6/27/24 at 8:05 AM MDS RN (Minimum Data Set Registered Nurse) C using RN H keys to enter medication room with supplies. RN did not watch MDS RN while in room. Medication room refrigerator unlocked. During an observation and interview on 6/27/24 at 8:20 AM, RN H entered medication room and observed medication refrigerator was unlocked. Inside of the refrigerator were vials and pens of insulin, vaccines, and a container that held doses of Lorazepam ((Ativan) a controlled substance (benzodiazepines) (sedative)). The RN stated, Myself, the DON (Director of Nursing), and ADON (Assistant Director of Nursing) have the keys to the medication refrigerator. I believe the person that stocks this supply room,…

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 proper use of personal protective equipmen, during cares for 2 (Resident #26 and Resident #82), hand hygiene, labeling/dating IV tubing, and clean medication administration for 1 resident (Resident #82) of 12 residents reviewed for infection control, resulting in a potential for the transmission/transfer of pathogenic organisms and cross contamination between residents and staff. Findings include: Resident #26 During an observation on 6/26/24 at 1:21pm, Registered Nurse (RN) H completed a blood glucose test for Resident #26 as he sat in a common area outside the nurse's station, with 2 other residents nearby. RN H did not wear gloves during the testing as she used the lancet (a sharp medical instrument) to pierce the skin on Resident #26's finger and placed a drop of his blood on a test strip. RN H then handled the test strip with ungloved hands as she placed it in the glucometer. RN H disposed of the soiled test strip and the lancet, and assisted Resident #26 back to his room without completing hand…

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 interview and record review, the facility failed to ensure individualized approaches were provided to 1 (Resident #101) of 3 residents reviewed for dementia care, resulting in Resident #101 experiencing avoidable stress responses to care interventions. Finding 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 #101, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: vascular dementia without behavioral disturbance, aphasia (deficit with verbally expressing self) delusional disorder, psychotic disorder, and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 3/16/24 revealed a Brief Interview for Mental Status (BIMS) score…

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