Rivergate Terrace

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement interventions used to prevent the development or worsening of pressure injuries for two of five (R206 and R155) residents reviewed for pressure ulcers. Findings include: On 2/24/25 at 9:39 AM, 11:01 AM, 1:40 PM, 2:50 PM, and at 3:16 PM, R206 was observed lying on their back in bed on an alternating mattress with posey boots (soft foam booties to protect heels) in place. An elongated triangle- shaped positioning wedge was observed on the resident's right side of the bed, not in use for positioning. The resident was lying on their back without use of a positioning wedge during all five observations (5.5 hours). On 2/24/25 at approximately 3:17 PM Certified Nursing Assistant (CNA) Y came into the room and was queried about R206's repositioning schedule. CNA Y said the resident had been repositioned a couple of times throughout the day shift. CNA Y said, I checked on the residents every couple hours, throughout the day. CNA Y could…

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 oxygen cylinder was stored properly in a resident's room (R85) resulting in the potential for fire hazards. This deficient practice had the potential to affect the two residents (R85 and R145) that resided in that room facility. Findings include: On 2/25/25 at 9:59 AM three oxygen tanks were observed in R85's room. R85 was not present in the room and R145 was laying in bed. One of the oxygen tanks was observed to be leaning against the resident's dresser and not inside a metal carrier. R145 was asked about the oxygen tank and said, It's not for me. It's for my roommate. I don't pay no attention to it. At this time Respiratory Therapist (RT) N entered R85's room and was interviewed about oxygen tank storage. RT N said, We do not store oxygen tanks like this! These tanks are flammable and must be stored in a metal carrier. This is a safety and fire hazard. RT N left the room to acquire a metal carrier to safely transport the oxygen tank to the oxygen tank storage area. On 2/26/25 at approximately 9:30…

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 and appropriate care for indwelling urinary catheters (foley) for one (R211) of three residents reviewed for catheter care resulting in R211's indwelling catheter not being changed or securely anchored as prescribed and a urology consult not being scheduled in accordance with physician's orders. Findings include: During an observation on 2/24/25 at 10:48 AM, R211 was lying in bed on their left side. The resident was wearing a brief with the foley catheter's tubing pulled out through the top of the brief and over their right leg. There was no anchoring device in place to secure the catheter. R211 said they have had several urinary tract infections that are not resolving. R211 was upset and said, I called my family. They are coming up here and taking me to see my doctor. They give me pills here that aren't helping me and make my stomach sick. On 2/24/25 at 12:49 PM, Nurse Practitioner (NP) H and Registered Nurse E were 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 administer oxygen as prescribed to one (R206) of six residents reviewed for oxygen therapy resulting in R206 sustaining a low pulse oximetry reading of 82% (device that measures the amount of oxygen in the blood, normal range is 90-100%). Findings include: On 2/24/25 at 9:39 AM, 11:01 AM, 1:40 PM, 2:50 PM, and 3:16 PM, R206 was observed lying in bed without oxygen in place via a nasal cannula (flexible tube that delivers oxygen through the nose) in place. The undated oxygen tubing and nasal cannula was observed on the floor underneath the resident's bed on all five observations (5.5 hours). The oxygen concentrator was at the resident's bedside, turned on, and set at 3 liters per minute with an undated empty humidification bottle. R206 was unable to be interviewed due to severe cognition impairment and non-verbal status. R206 was resting comfortably with normal respirations and did not appear to be in any distress on all five observations.…

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 includes two DPS. Deficient Practice Statement #1: Based on observation, interview, and record review the facility failed to don appropriate personal protective equipment (PPE) for one resident (R206) of one resident reviewed for enhanced-barrier precautions resulting in the potential for the transmission of infectious organisms. Findings include: On 2/25/25 at 1:20 PM, Certified Nurse Aide (CNA) L was observed to enter R206's room with License Practical Nurse (LPN) J. Observations were made of staff gathering wet towels and performing hygiene on R206 without any PPE. CNA L exited the room with the soiled items. On 2/25/25 at 1:30 PM, LPN J was observed administering medications to R206 through their peg tube without the indicated PPE. LPN J was queried about the enhanced barrier sign posted on R206's door. LPN J said CNA L should have worn a gown when providing hygiene care. LPN J added they should have also worn a gown when administering medications through R206's peg tube. On 2/25/25 at 1:40 PM,…

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 MI00147768. Based on observation, interview, and record review the facility failed to provide adequate supervision for one resident (R912) of three residents reviewed for elopement, resulting in a cognitively impaired resident walking through the front door and into the parking lot unsupervised with the potential for injury. Findings include; According to a Facility Reported Incident (FRI) on 10/20/24 at 1:34 PM, R912 walked out the front door of the facility behind a visitor. R912 was returned to the facility on 1:39 PM by another visitor that was entering the facility without injury. The Investigation report indicated that the receptionist was not adequately supervising the front door when they pressed the release button to open the front door for the visitor to leave and did not notice the resident (R912) following closely behind. On 10/29/24 at 8:15 AM upon entry into the main entrance of the facility, the first set of doors opened automatically into a foyer area where a receptionist was seated behind a desk. The second set of doors that led…

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 MI00146019. Based on observation, interview and record review the facility failed to ensure adequate assistance during a mechanical lift (Hoyer) transfer for one resident (R601) out of three residents reviewed for injuries of unknow origin, resulting in a fracture of the right lower leg and hospitalization. Findings include: Review of an admission Record revealed, R601 admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included dementia, Alzheimer's disease late onset, age-related osteoporosis (thinning of bone), and fracture of upper and lower end of right fibula (8/8/24). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R601 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 7 out of 15. In an observation and interview on 8/9/24 at 9:26 a.m., R601 laid in bed, had a soft cast on the right lower leg and wore heel boots. Certified Nursing Assistant (CNA) A reported R601 does not get out of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI144703 Based on observation, interview, and record review the facility failed to provide adequate supervision for one resident (R701) or two residents reviewed for elopements, resulting in a cognitively impaired resident with risk for elopementr exiting the facility unsupervised and the potential for injury. Findings include: Review of the facility investigation and other pertinent documentation regarding a facility reported incident (FRI) that occurred on 5/15/24, revealed that it was reported R701 exited the facility to the outside through the main entrance following an activities aide at approximately 2:56 p.m. Resident #701 was brought back into the facility at approximately 2:58 p.m. by the Director of Rehab with no injury. Review of the clinical record documented R701 was admitted into the facility on 5/9/24 with diagnoses that included dementia, history of falling, anxiety, and psychotic disorder with hallucinations. According to the admission Minimum Data Set assessment…

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 MI00142807. Based on interview and record review, the facility failed to adequately provide infection control surveillance for all residents resulting in missed opportunities to decrease the potential risk of the spread of infections. Findings Include: Record review of the facility's Infection Control Book revealed no completed documentation of infection surveillance for January 2024 and February 2024. There was no evidence that data was compiled and monitored in a timely manner during those months to provide an overview of the facility's infection control practices. During an interview on 3/14/22 at 12:22 PM with Assistant Director of Nursing (ADON), it was reported that the facility did not have anyone consistently monitoring infection control program in January of 2024 until the end of February 2024. It was reported that the facility could not provide documentation or evidence that a complete line listing (names of residents with probable or diagnosed infections); or mapping (a color-coded map of facility to show possible clusters of infections of…

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

Based on observation, interview, and record review the facility failed to maintain an effective pest control program to ensure that the facility is free of pests, resulting in an increased potential for contamination of food, both food and non-food contact surfaces, and foodborne illness potentially affecting staff, visitors and all 219 residents. Findings include: On 3/13/24 at 10:42 AM, thirty live ants were observed in the kitchen's dry storage room. Upon observation the surveyor inquired with Dietary Director, staff A, on the current state of the insects in this area to which they responded, I'll have someone clean this up. At this time the surveyor observed staff A asking Dietary Aide, staff D, to clean the area. On 3/13/24 at 10:45 AM, the surveyor requested the facility's pest control policy to review to which staff A responded, I am not the best one to talk to about that, but maintenance has a book. On 3/13/24 at 10:49 AM, the surveyor inquired with Maintenance Director, staff C on if they were aware of the pest conditions in the dry storage room to which they stated, No. We…

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. Consistently complete neuro checks following unwitnessed falls for one resident (#77); 2. Ensure medications were ordered in a timely manner for two residents (#209, #379); and 3. Ensure skin assessments were consistently completed for one resident (#71). These deficient practices resulted in residents feeling anxious, delay in identification and treatment of a skin care concern, and the potential for delay in addressing other resident care needs. Findings include: Resident #77 - Review of the admission Record for Resident #77 (R77) documented an admission date of 9/19/23 with diagnoses that included chronic obstructive pulmonary disease, acute and chronic respiratory failure, and major depressive disorder. A Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition. A review of R77s care plans documented in part the following: Focus: Resident is at risk for falls due to muscle weakness and multiple medical…

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 219 residents to include (R222) and it's staff resulting in an increased potential for harm. Findings include: On 3/12/24 between 1:22 PM, and 1:58 PM, during an environmental tour of the facility the following observations were made: Personal items such as a jacket, an opened beverage, an opened can of shaving cream, and a bottle of window cleaner were observed stored inside and on top of a fully loaded clean linen cart. An accumulation of dust and debris was observed on top of and behind the washing machines in the laundry room, and on the blades and the protective grill of the wall mounted fan in the soiled linen room. Lift batteries and charging stations were observed being stored in all five soiled utility rooms. Soiled conditions were observed in the blue and green hall's nourishment room's refrigerator and freezer. On 3/12/24, at 1:41 PM, upon interview with Laundry…

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 allow unlimited visitation for one resident (R382) out of thirty-eight residents reviewed for resident's rights. Findings include: During an observation and interview on 3/12/24 at 10:54 AM, R382's room was observed to be in a private room. Resident appeared thin, frail, and weak in appearance. Family Member (FM) M was at bedside. R382 was asked how the treatment was at the facility, R382 said, I guess its ok. FM M then reported that there had been an issue with visitation. FMM further reported that R382 was admitted to the facility and was receiving hospice services. R382 wanted family to stay at night, but the facility told family members they must leave after 11:00 PM, they even called the police. Resident was asked, do you want family to stay with you at nighttime, R382 said, Yes. Record review of R382's electronic medical record (EMR) revealed admission into the facility on 3/1/24 with a pertinent diagnosis of malignant neoplasm (cancer) of prostate. According to the Health Status Note dated 3/1/24 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 interview and record review, the facility failed to ensure Advance Directives (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were in place timely for two (R47 and R149) of 19 residents reviewed for Advance Directives, resulting in the potential for unmet medical needs in the event of an emergency. Findings include: R47 On 3/13 at 4:21 PM, documentation of Advance Directives for R47 was reviewed. The Advance Directive review revealed the form was incomplete. Review of the clinical record of R47 admitted [DATE] revealed an MDS (Minimum Data Set) indicating a BIMS (Brief Interview for Mental Status) score of 4 which indicates severe impairment in cognitive function. On 3/14/24 at 8:45 AM, Social Worker E and Social Worker F were interviewed and provided 3 forms for review and explained the sequence of events: On 5/5/22 R47 Advance Directive…

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 resolve a grievance in a timely manner for one (R173) of one resident reviewed for grievances, resulting in unresolved resolutions of grievances and frustration. Findings Include: On 3/13/24 at 2:21 P.M., R173 reported every weekend the facility ran out of bariatric briefs. The resident stated every week end her assigned aide would inform her of the shortage and to obtain additional bariatric briefs the aide would have to get someone to go to the shed which was outside of the facility. R173 reported the concern to Social Worker (SW) E R173 stated nothing had changed since reporting the concern about the bariatric briefs. R173 reported not having any bariatric briefs the previous weekend and that the staff member (not sure of name) promised to obtain a package but never came back with the bariatric briefs. Review of the R173's Face Sheet documented R173 was readmitted to the facility on [DATE], with diagnoses of acute and chronic…

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 MI00142660. Based on interview and record review, the facility failed to report an unwitnessed fall which resulted in serious injury to the State Agency for one resident (#579) out of six residents reviewed for falls, resulting in the potential for future incidents of residents sustaining serious injury to go unreported. Findings include: It was reported to the State Agency (SA) that a resident fell out of bed, sustained a head injury, and not long after passed away. On 3/12/24 at 9:07 AM, the family member/guardian for Resident #579 (R579) said R579 passed away on 2/22/24 from a brain bleed that resulted from a fall at the facility. A copy of R579's death certificate was provided. On 3/12/24 at 9:21 AM, a document titled, Certification of Vital Record and Certificate of Death, dated 1/30/24 was reviewed and revealed in part the following: -Decedent's Name: (R579) -date of death : 1/22/24 -Enter the chain of events - diseases, injuries, or complications - that directly caused 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 follow a post dental care physician's order for one (#178) out of one resident reviewed for physician's orders, resulting in the resident verbalizing oral discomfort and the potential for the resident oral cavity to become infected. Findings include: On 3/14/2024 at 3:11 p.m. R178 was observed waiting in the hallway outside the conference room with a complaint of not getting proper dental follow up after dental treatment. On Monday (3/11/2024), R178 went out on a dentist appointment and had teeth pulled. R178 stated, I was supposed to be getting antibiotics or something afterward and I am not getting it. My mouth was sore after getting the teeth pulled and the Dentist order was to keep my mouth from infection. According to the electronic medical record, R178 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses Diabetes Mellitus-Type two, and heart disease. R178's quarterly Minimum Data Set (MDS) with 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 provide proper foot care for one resident (R93) out of two residents reviewed for skin conditions who were dependent upon staff for performance of activities of daily living (ADL), resulting in unmet care needs regarding skin care. Findings include: On 3/12/24 at 11:02 AM, during the initial tour of the facility, Resident #93 (R93) was observed asleep in bed. R93's feet were visible and appeared very dry and with peeling skin. On 3/13/24 at 8:30 AM, R93 was observed asleep in bed. R93's feet were visible and appeared to be dry and scaly. A review of R93's clinical record documented an admission date of 11/3/22 with diagnoses that included acute respiratory failure, venous insufficiency, chronic obstructive pulmonary disease (COPD), and obesity. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment and partial to moderate assistance for personal hygiene. A physician order dated 9/20/23 documented to topically…

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 offer, educate and administer vaccines in a timely manner for two residents (R20 and R379) out of three residents reviewed for influenza and pneumococcal vaccines. Findings Include: R20 Review of R20's Immunization Report and electronic medical records (EMR) revealed resident had not been offered, administered, or educated on influenza or pneumococcal vaccination in a timely manner in 2023 and 2024 until 3/14/24. Review of progress notes dated 3/14/24 at 1:07 PM documented, Note Text: Wrier contacted RP (representative) (resident's daughter) r/t (related to) not receiving vaccine consent via mail. RP confirmed vaccine consents with writer. Record review of R20's electronic medical record revealed admission into the facility on 3/22/19 with pertinent diagnosis of Alzheimer's disease. According to the Minimum Data Set (MDS) dated [DATE], R20 had intact cognition and required assistance with Activities of Daily Living (ADLS). R379 Review of R379's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to offer, educate and administer a COVID-19 vaccine in a timely manner for one resident (R379) out of three residents reviewed for COVID-19 vaccines. Findings Include: Review of R379's Immunization Report and electronic medical records (EMR) revealed resident had not been offered, administered, or educated on Covid-19 vaccinations in a timely manner in 2023 and 2024 until 3/14/24. Review of Progress Notes dated 3/14/24 at 12:57PM documented, Note Text: Writer went to residents' room this am to educate resident on vaccines and get consent, resident refused vaccines and education information. Resident refused to sign declinations and ask writer to leave the room. Record review of R379's electronic medical records (EMR) revealed resident was admitted into the facility on [DATE] with a pertinent diagnosis of paraplegia (paralysis). According to the Minimum Data Set (MDS) dated [DATE], R379 had intact cognition and required assistance with Activities of Daily…

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 MI00141958 and MI00142078. Based on interview and record review the facility failed to prevent sexual abuse, for one resident (R902) out of three residents reviewed for abuse, resulting in an employee responding with inappropriate text messages to R902. Findings include: Record review revealed on 1/3/24 that facility reported there was a staff to resident sexual abuse incident. Record review of 902's electronic medical records (EMR) revealed admission into facility on 8/27/22 and had a diagnosis of post-traumatic stress disorder (PTSD). According to the Minimum Data Set (MDS) dated [DATE], R902 had intact cognition and was required limited assistance with Activities of Daily Living (ADLS). During an interview on 1/17/24 with R902, it was reported that CNA (Certified Nursing Assistant) C had texted the resident several times. Record review of text messages provided by the facility revealed messages were between CNA C and R902. Further review on snapshot #2 revealed CNA C full name…

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 MI00141409. Based on observation, interview and record review the facility failed to apply splints (device to maintain position) to a contracture (tightenning of muscles and tendons), for one resident (R901) out of three residents reviewed for Activities of Daily Living (ADLS), resulting in splints not being applied daily and the potential for worsening of resident contractures. Findings include: During an interview on 1/17/24 at 11:14 AM, R901 when queried about ADL care at facility, it was reported that they (facility) do not apply splints to left hand. R901 then reported that it was a fear that hand may get worse. It was then observed that R901's left hand- ring and pinky finger were contracted and was not able to move at will. Record review of R901's electronic medical record (EMR) revealed admittance into the facility on 6/9/23 with a pertinent diagnosis of contracture of left hand added on 8/15/23. According to Minimum Data Set, dated [DATE], R901 had intact cognition and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes MI00136174 and MI00139020. Based on observation, interview, and record review, the facility failed to ensure meals were delivered in a timely manner and in accordance with the scheduled mealtimes for the residents observed during dining observations, resulting in resident dissatisfaction and the potential for diminished nutrient intake. It was reported to the State Agency that residents' meals were not served in a timely manner. On 10/18/23 at 1:02 PM, Certified Nurse Aide (CNA) J said they had one meal cart delivered to the Orange Court and they are waiting on one more. On 10/18/23 at 1:12 PM, the second meal cart for Orange Court was delivered. CNA L stated, The trays just got here. We're waiting on coffee cups. CNA M stated, Where's the coffee at? They didn't bring it. (The kitchen staff) usually don't bring the coffee down until the second cart. But this time, the cups did not come with the second cart. Cups were delivered to Orange Court at 1:32 PM. CNA M stated, It's after…

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 MI00136174 and MI00139020. Based on observation, interview, and record review, the facility failed to assist in ADL care for two (R603 and R616) of six residents reviewed who were dependent upon staff for performance of activities of daily living (ADL), resulting in unmet care needs regarding skin care, showers, and resident dissatisfaction. Findings include: It was reported to the State Agency that residents were not being provided appropriate foot care and residents were not receiving requested showers. Resident #603 - On 10/18/23 at 12:04 PM, an interview with Licensed Practical Nurse (LPN) F and observation of Resident #603's (R603) feet was conducted. LPN F said that to her knowledge R603 does not have problems with her feet. LPN F described R603's feet as follows: -Left foot: skin was real dry. There was discoloration between her toes, peeling and flaky skin between the big toe and second toe. -Right foot: more dryness on the right foot. LPN F stated, She needs lotion 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 This citation pertains to intake MI00139265. Based on interview and record review, the facility failed to ensure that wound care treatments for pressure ulcers (damage to skin and underlying tissue from prolonged pressure to skin) were consistently provided for two resident (R618 and R642) of three residents reviewed for wound care, resulting in the potential for worsening of pressure ulcers. Findings include: Resident #618 Review of an admission Record revealed, R618 originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included Stage 4 Pressure Ulcer of the Sacral and Sacrococcygeal region. Review of a Minimum Data Set (MDS) assessment, with a reference date of 9/20/23 revealed R618 had severe cognitive impairment. R618 required total dependence of two staff with bed mobility. Review of a care plan revealed R618 had focus, At risk for break in skin integrity. Interventions included treatments as ordered. Review of Physician orders revealed, R618 had orders 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 This citation pertains to intake MI00139265. Based on observation, interview, and record review the facility failed to follow the standards of infection control during wound care (hand hygiene and gloves), for one resident (R618) out of three residents reviewed for wound care, resulting in the potential for increased cross-contamination of diseases which place a vulnerable population at high risk for infections. Findings include: Review of an admission Record revealed, Resident #618 (R618) originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included Stage 4 Pressure Ulcer of the Sacral and Sacrococcygeal region . Review of a Minimum Data Set (MDS) assessment, with a reference date of 9/20/23 revealed R618 had severe cognitive impairment. R618 required total dependence of two with bed mobility. Review of Physician orders revealed, R618 had orders to treat the sacrum, coccyx, right gluteal fold, left gluteal fold, lower midline of back, right lower back, left heel,…

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.