The Orchards at Redford

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes 2743619 and 2792857.Based on observation, interview and record review the facility failed to ensure call lights were fully functional for six residents (R901, R904, R905, R906, R907, R908) and two rooms of eight resident rooms reviewed for call light function. Findings include: R901On 03/04/26 at 8:59 AM and 9:46 AM, R901was observed to be lying in bed, with the head of the bed up around 20 - 30 degrees. The call light was under the covers at the right side of R901. At 10:28 AM, R901 continued in bed as before. R901's Responsible Party (RP) was at the bedside and expressed concerns for staff assistance with the resident's needs. On 03/05/26 at 8:01 AM, R901 was on their back in bed, the head of the bed up around 20 - 30 degrees. At 8:48 AM, staff were seated bedside. At 11:05 AM, R901 continued in bed positioned as before. The call pad style call light was hanging over the headboard of the bed. At 12:17 PM, R901 continued on their back as before. The call light was over 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 intakes 2743619 and 2792857.Based on observation, interview, and record review the facility failed to implement interventions for two residents (R901, R903) of three reviewed for falls. Findings include: R901On 03/04/26 at 8:59 AM and 9:46 AM, R901 was observed to be lying in bed, with the head of the bed up around 20 - 30 degrees and dressed in a hospital style gown. A pillow was under the bottom sheet at the right side. R901 was not supported by the pillow. A mat was on the left side of the bed and a urinary catheter bag hung on the left side of the bed frame toward the foot of the bed. The right side of the bed was against the wall. R901 was oriented with their right side to the wall. The call light was under the covers at the right side of R901. The resident answered questions in a hushed voice. It was not confirmed that R901 was assisted to eat their breakfast meal. R901 was skin and bones with minimal visible muscle tissue to the arms and collar bones and shoulder joints. At 10:28…

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

This citation pertains to Intake numbers 1293719 and 1293580.Based on observation, interview, and record review, the facility failed to answer a call light timely for one resident (R701) out of two reviewed for call lights. Findings include:On 7/9/2025 at 12:11 PM, R701 activated their call light. R701 stated they never answer the call light when it is activated and sometimes it will be on all night until the next day. R701 reported, the screen at the desk barely works. R701 reported the call light does not light up over the door, but rather shows up on a screen at the desk.A review of the medical record revealed that R701 admitted into the facility on 4/5/2024 with the following medical diagnoses, General Anxiety Disorder and Chronic Kidney Disease. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 14/15 indicating an intact cognition. R701 also required assistance with bed mobility and transfers. On 7/9/2025 at 12:18 and 12:26 PM, R701's call light was noted to still be activated. No one was observed to come and address…

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 dignified dining experience for six residents, of 13 residents reviewed for dining, resulting in the potential for embarrassment and disappointment with the dining experience. Findings include: On 4/1/25 from 12:16 PM until 12:55 PM, an observation of the lunch meal was conducted on the Transitional Care Unit. It was observed R#'s 59, 75, and 21 were seated together at a table. R59 and R75 were served their meals and began eating. R21 was not served their meal with R59 and 75. R59 and R75 finished their meals at 12:30 PM and their plates were collected and returned to the satellite kitchen. At approximately 12:35 PM, R21 was finally served their lunch meal. On 3/31/25 at approximately 12:15 p.m., Observations of the lunch meal were made and the following was observed: R44 was observed in the TCU (transitional care unit) dining room seated at a table. R44 was observed to have the front of their shirt completely covered in wetness with no clothing protector observed to be on them. The other residents…

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 two residents (R44 and R69) were provided the option of an alternate entree, beverages and preferred deserts during the scheduled meals. This deficient practice has the potential to affect all of the 78 residents who eat meals prepared and served by the kitchen. Findings include: On 3/31/25 at approximately 12:15 p.m., Observations of the lunch meal were made and the following was observed: R44 was observed in the TCU (transitional care unit) dining room seated at a table. R44 was observed to have the front of their shirt completely covered in wetness with no clothing protector observed to be on them. The other residents surrounding them were observed to be eating their lunch meal with R44 watching them eat. At approximately 12:19 p.m., R44's meal ticket was observed and revealed the following: feeding assist No straws. At that time, three other residents observed at R44's table eating the lunch meal. R44 was still observed to be watching the other residents eat without being assisted with their meal.…

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 post-dinner snacks were available and offered for 18 residents residing in the Green Houses of a total of a total census of 78. Findings include: On 4/01/25 at approximately 12:31 p.m., during observations of the lunch meal in the Redford House Certified Nursing Assistant I (CNA I) was queried regarding post-dinner snacks for the residents in the [NAME] Houses. CNA I reported they did not have any snacks because the kitchen never sends them over to the houses. CNA I indicated that the kitchen is run by different staff and they do not give any snacks to the residents. On 4/01/25 at approximately 12:51 p.m., [NAME] House Manager F (GHM F) was queired regarding snacks for after the dinner meal and they reported the [NAME] Houses are not provided snacks from the Kitchen because the kitchen staff do not have a contract with the [NAME] Houses. GHM F was queried if they could remember the last time the [NAME] houses were provided evening snacks, and they indicated they have not had any snacks in a long time…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice had the potential to result in food borne illness among all residents of the [NAME] House that consume food from the kitchen. Findings include: On 04/01/25 at 12:45 PM, the [NAME] House dish machine was checked with [NAME] House Manager F. The dish machine was a low temperature, chemical sanitizing dish machine. When asked how staff checks the dish machine for sanitization, [NAME] House Manager F pointed to a dish machine log, and some Smart Power test strips (test strips used to test the levels of DDBSA and lactic acid sanitizer). Observation of the chemicals for the dish machine showed 1 bottle of liquid detergent, and 2 bottles of liquid rinse aide, hooked up to the automatic chemical dispenser for the dish machine. There was no sanitizer attached to the dish machine, to ensure that dishes were being sanitized. When asked how 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 Deficient Practice #1 Based on observation, interview and record review, the facility failed to ensure enhanced barrier precautions (EBP) were in place and implemented by staff for one resident, (R66) of one resident reviewed for EBP, resulting in the potential for the development of infection. Findings include: On 3/31/25 at 10:45 AM, R66 was observed in their bed. R66 was not responsive to attempts at verbal communication. At that time, R66 was observed to have a urinary catheter, a feeding tube, a tracheostomy, and was receiving oxygen through a tracheostomy mask. An observation of the door to R66's room from the hallway did not reveal any signage to indicate R66 was on enhanced barrier precautions. On 3/31/25 at 1:55 PM, Nurse 'C' and Certified Nurse Aide (CNA) 'B' were observed entering R66's room; they did not don an isolation gown or gloves prior to entering the room. At approximately 1:59 PM, entry was made into the room. Nurse 'C' was observed in the room and CNA 'B' had used the adjoining bathroom 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 observation, interview and record review, the facility failed to ensure an environment with a functioning resident call system for four residents (R10, R16, R17 and R41) of seven residents reviewed for environmental concerns, of a total census of 78. Findings include: On 3/31/25 at approximately 9:11 a.m., R10 was observed in their room, up in their bed. R10's bathroom was observed to have an alert pull-cord tied to a non functioning piece of plastic on the alert box next to their toilet, rendering the cord to be unable to be used to call for assistance if needed. On 3/31/25 at approximately 10:55 a.m., R17 was observed in their room, up in their wheelchair. R17's bathroom was observed to have the Shower pull-cord that was connected to the alert system tied to a solid plastic piece on the box in a non-functional position, rendering the cord to be unable to be used to call for assistance if needed. On 3/31/25 at approximately 11:18 a.m., R41 was observed in their room, laying in their bed. R41's bathroom was observed to have a shower with the shower pull-cord detached 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure urinary catheter care, assessment and monitoring was provided for one resident, (R66) of three residents reviewed for catheter care, resulting in the development of a urinary tract infection. Findings include: On 3/31/25 at 2:13 PM, R66 was observed in their bed. R66 was awake and alert, however; they did not respond to attempts at verbal conversation. It was observed R66 had an indwelling urinary catheter. The tubing connected to the collection bag revealed dark, cloudy urine with sediment built up in the tubing. A review of R66's clinical record revealed they admitted to the facility on [DATE] and most recently re-admitted on [DATE]. R66's diagnoses included: respiratory failure, epilepsy, protein calorie malnutrition, neuromuscular dysfunction of the bladder and urinary tract infection. A review of R66's physician's orders, medication administration records, treatment administration records, and certified nurse aide tasks was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure nutritious meals, and provide ongoing assessment and monitoring for weight loss for one resident, (R44) of four residents reviewed for nutrition resulting in weight loss. Findings include: On 3/31/25 at 12:27 PM, an observation of the lunch meal on the Transitional Care Unit was conducted. R44 was observed seated at the table with their pureed lunch meal in front of them. Their meal consisted only of a pureed sweet potato and an unidentifiable light greenish/tan pureed food. R44 was observed to be given one-to-one assistance from Certified Nurse Aide (CNA 'B') with the meal. CNA 'B' was asked what the unknown pureed item was and said they did not know. They further indicated R44 was a vegetarian and did not receive pork that was on the menu for that day. Staff in the satellite kitchen on the unit were asked what R44 was served and said they were served a pureed sweet potato and pureed cabbage with green beans. On 4/1/25 at 8:15 AM,…

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 tube feeding formula was delivered at the physician ordered rate for one resident, (R73) of two residents reviewed for tube feeding. Findings include: On 3/31/25 at 11:00 AM, R73 was observed in their room in bed, asleep. R73 was receiving tube feeding formula via pump. The pump was observed to be programmed to deliver the formula at a rate of of 70 mL (milliliters) per hour. On 4/1/25 at 8:19 AM and 11:00 AM, additional observations were made of R73 receiving tube feeding via pump. The pump was observed to be programmed to deliver the formula at 70 mL per hour. The bottle of formula being delivered was observed to have a delivery rate of 75 mL per hour written on it. A review of R73's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: acute respiratory failure, stroke, aspiration pneumonia, presence of a tracheostomy and a feeding tube. A review of R73's physician's orders was conducted…

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 incapacitated resident (R17) was provided a legally authorized representative to make informed healthcare decisions of one residents reviewed for medically related Social Services. Findings include: On 3/31/25 at approximately 10:55 a.m., R17 was observed in room up in wheelchair. R17 was observed to have difficulty communicating and was unable to answer questions. On 4/1//25 the medical record for R17 was reviewed and revealed the following: R17 was initially admitted to the facility on [DATE] and had diagnoses including Cerebral Palsy and Polyneuropathy. A review of R17's MDS (minimum data set) with an ARD (assessment reference date) of 3/18/25 revealed R17 needed assistance from facility staff with their activities of daily living. R17's BIMS score (brief interview for mental status) was 10 indicating moderately impaired cognition. A review of R17's comprehensive careplan revealed the following: Focus-Cognition: I have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to attempt non-pharmacological interventions prior to PRN (as needed) anti-anxiety medication administration for one resident (R32) of six residents reviewed for unnecessary medication. Findings include On 3/31/25 at 9:00 AM, R32 was obsereved sitting in a chair in the dining room at a table with head down in breakfast plate. Resident appeared to be sleep and not easily aroused. On 3/31/25 at 1:00 PM, R32 was observed at table in the dining room with head on table and eyes closed. R32 was not easily aroused when name was called. On 04/01/25 at 2:06 PM, R32 was observed in dining room with head down on the table and eyes closed. On 4/1/25 the medical record for R32 was reviewed and revealed the following: R32 was admitted to the facility on [DATE] with a readmit date of 2/10/25 with multiple diagnoses including Dementia, Delusional Disorder, Depression, and Anxiety. A review of the minimum data set assessment (MDS) dated [DATE] revealed a brief interview of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the primary kitchen, the [NAME] house, and [NAME] house resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 75 residents who receive meal services (2 nothing by mouth residents, or NPO) out of the facility's total census of 77 residents. Findings include: 1. On 2/13/24 between 9:45 AM, and 10:52 AM, the following non-food contact surfaces in the kitchen were observed soiled and with visible debris on their surfaces: On the flooring underneath the fryer, the top and sides of the fryer, and sides of the oven next to the fryer. On the ovens stainless steel backsplash. On the flooring throughout the transitional care unit's serving kitchen. Upon observation the surveyor inquired with Dietary Director, Staff N, on if they thought these areas were being cleaned timely and sufficiently to which they replied, not to my liking. On 2/13/24 at 10:53 AM, 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 and interview the facility failed to provide a safe, functional, and sanitary environment for the facilities census of 77 residents and its staff resulting in an increased potential for harm. Findings include: On 2/13/24 at 10:36 AM, cracked window glass was observed in the transitional care units dining room. At this time the surveyor inquired with Dietary Director, Staff N, on the current state of the window to which they stated, I was unaware of it. I will let the maintenance staff and our Director of Nursing know about it right away. On 2/13/24 at 12:07 PM, the surveyor observed the broken glass on this window covered with cardboard and taped over on its edges. On 2/13/24 at 11:40 AM, in the [NAME] house, paper towels were observed not available for use at the dining rooms designated hand washing sink. On 2/13/24 at 11:42 AM, a visibly wet stack of paper towels was observed placed on a countertop next to the wall mounted paper towel dispenser adjacent to the kitchen's designated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one resident (R17) of three residents reviewed for dignity, were treated in a dignified manner during dining. Findings include: On 2/14/24 at 8:42 AM, R17 was observed in the dining area sitting in a reclined geri chair. Observed on the table in front of R17 was a covered plate. R17 was asked about their meal and was unable to be interviewed due to having a impaired cognition. On 2/14/24 at 12:16 PM, R17 was observed reclined in their geri chair with a Certified Nursing Assistant (CNA C), feeding R17 fruit from a small bowl. CNA C was standing on the side of R17, feeding and leaning over towards R17. A review of R17's medical record noted, R17 was admitted to the facility on [DATE] with diagnosis of Alzheimer's Disease. A review of R17's Minimum Data Set (MDS) assessment dated [DATE] revealed, R17 with a severely impaired cognition and total dependent of staff for eating assistance and other Activities of Daily Living (ADLs). 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 observation, interview and record review, the facility failed to ensure a clean environment for one resident (R46) of one resident reviewed for homelike environment. Findings include: On 2/13/24 at 9:46 AM, R46 was observed lying in bed, a tube feeding pole was observed as visibly soiled, with dried tube feed formula observed dried and caked to the floor. The surrounding areas of R46's bed was observed to also have a dried yellow unknown substance underneath the bed, in addition to trash. Attempts to interview R46 were unsuccessful, as they were confused. On 2/13/24 at 1:58 PM, R46's room remained in the same condition as observed that morning. A review of R46's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Paraplegia, Peripheral Vascular Disease, and Depression. Further review revealed that the resident was severely cognitively impaired, and was totally dependent on staff for Activities of Daily Living. On 2/14/24 at 9:37am, 11:50am, 12:29pm,…

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: MI00136948. Based on interview and record review, the facility failed to thoroughly investigate an injury of unknown origin for one sampled resident (R34) of one resident reviewed for injury of unknown origin. Findings include: On 2/13/24 at 12:08 PM, R34 was observed sitting in their geri chair in the common area alert and confused. On 2/14/24 at 10:00 AM, an interview was completed with Confidential Witness M regarding R34's fractured femur, and they explained that the resident sustained a fractured femur April 2023, and explained that the facility didn't appear to have completed a thorough investigation regarding what occurred. A review of R34's medical record revealed that they were admitted into the facility on 9/20/20 with diagnoses that included Dementia, Chronic Obstructive Pulmonary Disease, and Anxiety. Further review revealed that the resident was severely cognitively impaired and required extensive assistance for Activities of Daily Living. Further review of the medical record revealed the following progress notes: 4/26/2023 22:33…

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 develop and implement care plan interventions to meet the needs for two residents (R46 and R74) of 19 residents reviewed for care planning. Findings include: On 2/13/24 at 9:46 AM, R46 was observed lying in bed without heel protectors on, or floor mats in place. Attempts to interview R46 were unsuccessful, and they were confused. On 2/13/24 at 1:58 PM, R46's room was observed without heel protector boots or floor mats observed in place. A review of R46's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Paraplegia, Peripheral Vascular Disease, and Depression. Further review revealed that the resident was severely cognitively impaired, and was totally dependent on staff for Activities of Daily Living. Further review of R46's medical record revealed the following order: Order Summary: 6/1/23 Heel protector boots at all times. A review of R46's skin management care plan revealed 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 has two deficient practices. Deficient Practice #1. This citation pertains to MI00142209. Resident R57 Based on observation, interview and record review, the facility failed to ensure a dependent resident (R57) of three whose skin management was reviewed, was repositioned timely resulting resident distress and the potential for further skin tissue breakdown. Findings include: On 02/13/24 at 10:26 AM, 11:29 AM, 1:03 PM and R57 was observed to be in bed on their back in bed. A pillow was not observed to be at the side of the torso to turn R57 left or right. At 1:03 PM, a therapy staff exited the room, the head of the bed was up around 60 degrees. At 4:26 PM, a nurse was in the room to set up R57's tube feeding. R57 was observed to be on their back in bed uncovered without any pillows/device at the sides of the torso to turn the resident of their back. On 02/14/24 at 8:16 AM, R57 was observed to be on their back in bed. R57 moved their head around slowly but did not respond to queries. On 02/14/24 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide ancillary services related to a hearing impairment for one resident (R74) of one reviewed for hearing services. Findings include: On 2/13/24 at 1:31 PM, R74 was observed in their room lying down. Attempts to interview the resident were difficult due to their difficulty hearing the surveyor. R74 was asked if they had seen an audiologist since admission, and explained that they had not. A review of R74's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Dysphagia following Cerebral Infarction, Acute Respiratory Failure, and Unspecified Hearing Loss, Left Ear. Additional review of the medical record revealed that the resident was cognitively intact, and according to their quarterly Minimum Data Set assessment dated [DATE] revealed that the resident's hearing was highly impaired. Further review of R74's medical record did not reveal a care plan for the resident's hearing loss. 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 provide a safe number of staff during a 2 person mechanical transfer with a Hoyer lift, as well as timely report and assess for potential injury for one resident (R30) of seven reviewed for accidents, resulting in pain in legs and feet. Findings include: On 2/13/24 at 12:11 PM, R30 indicated that their feet hurt after an incident with a hoyer lift. R30 continued and stated, they have not seen the doctor concerning the pain and would like an X-ray. On 2/14/24 at 9:56 AM, R30 was asked, when the incident happened. R30 stated, Three days ago. R30 reported Certified Nurse Assistant (CNA) E was alone during the transfer with a Hoyer lift. R30 said, their feet got stuck during the transfer and it felt like the CNA was trying to break their feet off. R30 was asked if they reported the pain or the incident to a nurse and stated, The night nurse. On 2/15/24 at 7:58 AM, R30 was observed in bed and was asked how they were feeling and stated, My…

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 review and document lab values for monitored medications (Digoxin and Keppra) and follow medication administration recommendations (for cholestyramine and Digoxin) for one of one residents (R46) reviewed for therapeutic medications. Findings include: A review of the facility medical record for R46 revealed R46 was admitted into the facility on [DATE] with a re-admission on [DATE]. Diagnoses included Atrial Fibrillation (irregular heart rate) and Epilepsy. A review of the orders documented: an order dated 01/04/24 Digoxin oral tablet 125 mcg (micrograms) give one tablet one time a day . an order dated 04/12/23 Cholestyramine light packet 4 G (grams). Give one packet one time a day . and Levetiracetum (Keppra) oral solution 100 mg/ml (milligrams/milliliters). Give 20 ml every 12 hours . Review of the care plans revealed a care plan which addressed the monitoring of the Digoxin was not found. A review of the I have altered cardiovascular status . 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00139144. Based on observation, interview, and record review, the facility failed to honor food allergies during a dining observation for one (R15) resident of 19 reviewed for dining. Findings include: On 2/13/24 at 12:34 PM, R15 was observed with their head down on the dining table. Observed in front of R15 was a cup of pink juice and a cup with a piece of uneaten frosted cake that had red fruit pieces baked into the cake. Certified Nursing Assistant (CNA C) was observed to come to the table and to pick up the cake and juice and stated, Wait, is this strawberries? CNA C was observed to take away the cake and juice. CNA C was asked if R15 was able to have strawberries and stated, No. [R15] is allergic to a lot of things. CNA C was asked if R15 was allergic to strawberries and stated, Yes. CNA C was asked if the items were strawberries and stated, I am not sure. During an observation in the kitchen the frosted cake was confirmed that it was strawberry cake. On 2/15/24 at 8:17…

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 MI00138500 Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 9/5/23 between 10:30 AM-11:00 AM, during a tour of the kitchen with Dietary Manger (DM) A, the following items were observed: There was a personal cell phone charging next to the food processor on the food preparation counter. On the door leading into the kitchen, there was a sign posted that stated, No cell phones past this point. According to the 2017 FDA food code, Section 7-209.11 Storage, Except as specified under §§ 7-207.12 and 7-208.11, Employees shall store their personal care items in facilities as specified under 6-305.11(B), and Section 6-403.11 Designated Areas, .(B) Lockers or other suitable facilities shall be located in a designated room or area where contamination of food, equipment, utensils, linens, and single-service and single use articles can not occur. The black rolling cart…

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 MI00138500 Based on observation and interview, the facility failed to provide comfortable, warm water temperatures in rooms 5,7, 13, 21, and Shower RM [ROOM NUMBER], and failed to provide a functional sink and home-like environment in room [ROOM NUMBER]. Findings include: On 9/5/23 at 11:00 AM, hot water temperatures were measured with Maintenance Supervisor B with the following results: room [ROOM NUMBER]: 95 degrees Fahrenheit room [ROOM NUMBER]: 85 degrees Fahrenheit room [ROOM NUMBER]: 85 degrees Fahrenheit room [ROOM NUMBER]: 93 degrees Fahrenheit Shower room [ROOM NUMBER]: 93 degrees Fahrenheit. On 9/5/23 at 11:15 AM, the facility boilers and hot water tanks were observed. Maintenance Supervisor B stated the boiler was functioning because the red light was illuminated, but was unsure of the water temperature in the hot water tanks, and stated the building did not have a mixing valve. On 9/5/23 at 1:30 PM, the running water at the bathroom sink in room [ROOM NUMBER] was…

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