The Springs at Rochester Hills Rehab and Nursing C

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake 2662526.Based on observation, interview and record review, the facility failed to provide an environment that promoted and enhanced residents' dignity for three (R12, R49 and R23) of three residents reviewed for dignity. Findings include: On 12/2/25 at 10:55 AM, R12 was observed sleeping in a geriatric (geri) chair holding a baby doll. On 12/2/25 at 12:56 AM, Unit Manager [UM] C was observed to enter R12's room, go behind the geri chair R12 was reclining in and turn the chair around and pull R12 in the chair backwards out of the room. UM C then proceeded to pull R12 backwards down the hall to the dining room and continue to pull R12 backwards to a table on the far side of the room to a table. On 12/2/25 at 1:00 PM, UM C was interviewed and asked if she usually pulled residents backwards in geri chairs. UM C explained she always pulled the chairs as it was easier to pull the chair than to push. Review of the clinical record revealed R12 was admitted into the facility on 3/3/25 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 accurate advance directive information was in place for one (R33) of four residents reviewed for advance directives. Findings include: Review of the clinical record revealed R33 was admitted into the facility on [DATE] with diagnoses that included: major depressive disorder, vision loss and chronic kidney disease. According to the Minimum Data Set (MDS) assessment dated [DATE], R33 scored had severely impaired cognition. Review of the facility's electronic medical record [emar] revealed at the top of the screen next to Advance Directive R33 was listed as Full Code.Review of a document titled, Advance Directive for R33 revealed an 'X' was marked in the box labeled Do Not Resuscitate (DNR) MUST HAVE ORDER ON FILE OR INITIATE DNR PAPERWORK, it was signed by R33, dated 12/27/24, signed by two witnesses on 12/27/24, and signed by a physician on 12/27/25. Then next page of the document was titled, DO-NOT-RESUSCITATE ORDER signed by the physician 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 Incident #2569672 and Complaint #2677444.Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for one (R5) of six residents reviewed for abuse and neglect, resulting in the resident being confined to bed and their room, not receiving any oral hygiene, and not being changed out of a hospital gown. Findings include:On 12/2/25 at 9:44 AM, R5 was observed asleep in bed. Signage was hung throughout the room and noted the following, Bra on always, Hospital gown on always, No wheelchair or gerichair, No oral care. The signage was signed by R5's responsible party. R5 was observed lying on her back in bed, wearing a hospital gown.On 12/2/25 at 2:35 PM, R5 was observed lying on her back in bed. R5 was awake and did not respond via eye contact or verbally when addressed. R5 was observed in a hospital gown.On 12/3/25 at 8:45 AM, R5 was observed lying on her back in bed wearing a hospital gown.On 12/3/25 at 10:44 AM, R5 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 This citation pertains to Incident #2569672 and Complaint #2677444. Based on observation, interview, and record review, the facility failed to report incidents of neglect to the Abuse Coordinator and the State Agency for one (R5) of six resident reviewed for abuse and neglect. Findings include:On 12/2/25 at 9:44 AM, R5 was observed asleep in bed. Signage was hung throughout the room and noted the following, Bra on always, Hospital gown on always, No wheelchair or gerichair, No oral care. The signage was signed by R5's responsible party. R5 was observed lying on her back in bed, wearing a hospital gown.On 12/2/25 at 2:35 PM, R5 was observed lying on her back in bed. R5 was awake and did not respond via eye contact or verbally when addressed. R5 was observed in a hospital gown.On 12/3/25 at 8:45 AM, R5 was observed lying on her back in bed wearing a hospital gown.On 12/3/25 at 10:44 AM, R5 was weighed using a mechanical lift by Certified Nursing Assistant (CNA) 'K' and CNA 'M'. Second floor Unit Manager, Licensed…

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 PASSAR (Preadmission Screening/Annual Resident Review) documentation and OBRA Level II exemption criteria were completed appropriately for two residents (R3 and R20) of three residents reviewed for PASSAR/OBRA (Omnibus Budget Reconciliation Act) assessments. Findings include:R3A review of R3's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Bipolar disease, paranoid schizophrenia, PTSD (post-traumatic stress disorder) and chronic pain. Continued review of R3's clinical record noted a document dated November 6, 2024 that read, .completed an OBRA Level II Evaluation on the above named individual (R3).Determination.Specialized Mental Health Services.Individual's physical, mental and psychosocial needs can be met in a nursing facility.If the above named individual remains in the nursing facility a Level II Evaluation is needed by November 5, 2025. *It should be noted that the Level…

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 professional standards for Nursing were practiced including performing accurate assessments and maintaining an accurate treatment record for two residents (R5 and R64) of two residents reviewed for Professional Standards. Findings include: On 12/2/25 at 9:44 AM, R5 was observed lying in bed sleeping. A tube feeding pole was observed tucked behind the privacy curtain, but no tube feeding formula was hung or infusing. On 12/2/25 at approximately 12:20 PM, an observation of R5 was made. When spoken to R5 did not respond or make eye contact. No tube feeding was hung in the room at that time. A review of R5's Physician's Orders revealed an active order for .Jevity 1.5 via pump per PEG (Percutaneous Endoscopic Gastrostomy - a tube surgically inserted into the stomach to deliver nutrition) at 65 ml/hr (milliliters per hour) x 18 hours (up at 6pm) or until total volume of 1170 mL is reached daily . On 12/3/25 at 8:13 AM, R5 was observed in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide nail care and eating assistance for three dependent residents (R3, R23 and R26) of three residents reviewed for activities of daily living (ADL's). Findings include: On 12/2/25 starting at approximately 12:35 p.m., the following observations were made during the lunch meal in the second-floor dining room: At approximately 12:42 p.m., R26 was observed in dining room attempting to each the lunch meal by themself without any assistance. R26 was observed to be having a hard time getting any food off of their plate. At that time, a review of R26's Meal ticket (an informational paper that states the residents assistive deices, diet order and assistance level) was conducted which indicated R26 required assistance from staff with meals. At approximately 12:51 p.m., R23 was observed in the dining room, attempting to eat the lunch meal. R23 was observed sitting in their chair. R23 was observed to be silently staring, and their food was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure timely identification of pressure ulcers for one (R12) of three residents reviewed for pressure ulcers resulting in R12's right heel pressure ulcer and right gluteal fold pressure ulcer being first identified as an Unstageable (obscured full-thickness skin and tissue loss) pressure ulcer. Findings include:This citation pertains to Intake 2598727On 12/2/25 at 10:55 AM, R12 was observed sleeping in a geriatric (geri) chair holding a baby doll.On 12/2/25 at 11:40 AM, R12's Power of Attorney (POA) was interviewed by phone and asked about the care at the facility. R12's POA explained back in the first part of April 2025, she had noticed R12's socks were dirty and seemed wet on the bottom so she took them off and found an open wound on R12's right heel. then a little while later R12 got a pressure ulcer on the left heel. then in September 2025, R12 got a pressure ulcer on her bottom. was told it was from the brief rubbing on R12's skin.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two deficient practices. Deficient Practice #1 Based on observation, interview and record review the facility failed to ensure effective interventions were implemented to prevent multiple/re-occurring falls for one resident (R49) of nine residents reviewed for Accidents/Hazards. Findings include: Resident #49 On 12/2/25 at approximately 10:51 a.m., R49 was observed in the second-floor dining room, up in their wheelchair. R49 was observed to have a large green/yellow bruise on their upper left extremity. R49 was queried how they got the bruise and they reported they could not remember. On 12/2/25 the medical record for R49 was reviewed and revealed the following: R49 was originally admitted to the facility on [DATE] and had diagnoses including Parkinsons and Lack of coordination. A review of R49's MDS (minimum data set) with an ARD (assessment reference date) of 11/2/25 revealed R49 needed assistance from staff with their activities of daily living. A review of R49's 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 pertains to Intake #2597945Based on interview and record review the facility failed to ensure timely catheter care was provided and guardian recommendations were timely addressed for one R (48) of one resident reviewed for catheter care/urinary tract infection (UTI). Findings include:A complaint was filed with the State Agency (SA) that alleged they had made several attempts to contact the facility to request that R48 be sent to the hospital as they were showing signs of a UTI. A phone interview was conducted with the complainant/guardian on 12/4/25 at approximately 10:52 AM. The complainant reported that on numerous occasions they tried to contact the facility to let them know that R48 was showing signs of a UTI. They reported that the facility would not answer the call timely and when they finally did answer they received information that the resident did not need to be sent out. Finally, their request was addressed and when they got to the hospital, R48 was diagnosed with a UTI, dehydration and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Physician ordered weight monitoring was obtained and completed for two residents (R64 and R70) of two residents reviewed for weight loss. Findings include: Resident #70 On 12/2/25 at approximately 10:38 a.m., R70 was Observed in their room, laying in their bed. R70's Breakfast tray was observed to be untouched. R70 was queried if they had lost any weight or had any issues with the facility food and they reported they did not know. On 12/2/25 the medical record was reviewed and revealed the following: R70 was initially admitted to the facility on [DATE] and had diagnoses including Dysphagia and Muscle weakness. A review of R70's MDS (minimum data set) with an ARD (assessment reference date) of 11/11/25 revealed R70 needed assistance from facility staff with most of their activities of daily living. R70's BIMS score (brief interview for mental status) was nine indicating moderately impaired cognition. A review of R70's 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 observation, interview, and record review, the facility failed to administer tube feeding according to the resident's assessed needs and physician's orders for one (R5) of one resident reviewed for tube feeding. Findings include: On 12/2/25 at 9:44 AM, R5 was observed lying in bed sleeping. A tube feeding pole was observed tucked behind the privacy curtain, but no tube feeding formula was hung or infusing. On 12/2/25 at approximately 12:20 PM, an observation of R5 was made. When spoken to R5 did not respond or make eye contact. No tube feeding was hung in the room at that time. A review of R5's Physician's Orders revealed an active order for .Jevity 1.5 via pump per PEG (Percutaneous Endoscopic Gastrostomy - a tube surgically inserted into the stomach to deliver nutrition) at 65 ml/hr (milliliters per hour) x 18 hours (up at 6pm) or until total volume of 1170 mL is reached daily . On 12/3/25 at 8:13 AM, R5 was observed in bed with no tube feeding hung in the room. On 12/3/25 at 8:30 AM, a review of R5'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 interviews and record review the facility failed to provide ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for one (R6) of one resident reviewed dialysis communication. Findings include:A record review of R6 medical record was conducted, it revealed that R6 was admitted to the facility on [DATE] with the medical diagnosis of End Stage Renal Disease and dependent on dialysis.A review of R6's Order summery revealed that there was a physician's order to receive Hemodialysis on Tuesdays, Thursdays, and Saturdays. The medical record also showed that the facility had initiated a care plan for R6.On 12/4/25 at 11:24 AM, the Director of Nursing(DON) was asked to provide dialysis communication forms for four months between the facility and the dialysis center.On 12/4/25 at 1:23 PM, a review of the communication forms submitted revealed that the facility did not have communication between the facility and the dialysis center for the month of October. 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 ensure a medication error rate less than five percent when two medication errors out of 26 opportunities were observed for two (R78 and R35) of six residents reviewed during the medication administration observation, resulting in a 7.69% error rate. Findings include: On 12/3/25 at 8:37 AM, Licensed Practical Nurse [LPN] E was observed as part of the medication pass task. LPN E prepared five medications for R78, including one Oyster [NAME] Calcium 500 milligrams [mg] tablet. LPN E was then observed enter R78's room and administer all five medications to R78.On 12/3/25 at 8:43 AM, LPN D was observed preparing four medications for R35, including one Docusate Sodium 100 mg tablet. LPN D crushed all four medications, including the Docusate Sodium tablet. LPN D entered R35's room and administered all four medications to R35.On 12/3/25 at 11:10 AM, R35's physician orders were compared to the medications observed to have been given. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 263088. Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for three (R801, R802 and R803) of three residents reviewed for abuse. Findings include:R801 and R802Review of the documentation submitted to the State Agency on 9/21/25 included an incident summary of a resident to resident physical altercation which read, On 9/20/25 at approximately 5:50pm Nurse was at medication cart in the hallway. She heard a commotion and when she turned around she observed [R801] make contact with [R802] in the face with a closed hand.Staff completed a skin and pain assessment on [R802] with notation of slight redness, res (resident) did not resent with any pain. It should be noted that the information submitted as above did not accurately represent the extent of the events that were documented on witness statements and included in…

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

This citation pertains to Intake Number(s): 1290771.Based on observation, interview, and record review, the facility failed to ensure there was sufficient nursing staff to meet the needs of 11 (R804, R805, R806, R807, R808, R809, R810, R811, R812, R813, and R814) of 11 residents reviewed for staffing, resulting in residents not receiving water for two days, residents wandering into other residents' rooms, incorrect meal trays being delivered and/or left in the residents' rooms for extended periods of time, and staff being unaware of their assignments. This had the potential to affect all residents who resided on the second floor. Findings include:On 7/15/25 at 9:34 AM, R805 was observed lying in bed. A breakfast tray was observed on R805's over bed table with a meal ticket dated 7/14/25 with R804's name (a resident who resided in a room across the hall from R805). A meal ticket with R805's name dated 7/11/25 was observed on the table. A disposable cup was observed on R805's nightstand, not within reach of R805 dated 7/13/25 3-11pm, two days prior. When asked, R805 was unable to say…

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: 1290771. Based on observation, interview and record reviews the facility Administration failed to follow the facility's policy regarding grievances and failed to follow up regarding reported concerns for one (R804) of one resident reviewed for grievances. Findings include:A review of a complaint submitted to the State Agency (SA) documented concerns about the Administration staff failure to follow up with the family on multiple occasions regarding verbalized concerns. On 7/15/25 at 9:30 AM, R804 was observed lying in bed. A brief interview was conducted with the resident at that time. A review of the medical record revealed R804 was admitted to the facility on [DATE], with diagnoses that included: epilepsy, dementia and cognitive communication deficit. A review of a Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 9 which indicated moderately impaired cognition and required staff assistance for all ADLs. Further review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number(s): 1290904.Based on observation, interview, and record review, the facility failed to follow their abuse policy to address a witnessed resident to resident physical altercation between two (R801 and R802) of five residents reviewed for abuse, resulting in R815 attempting to intervene and stop the altercation. Findings include:A review of a Facility Reported Incident (FRI) submitted to the State Agency on 6/23/25 revealed there was a resident-to-resident incident between R801 and R802.On 7/15/25 at 10:48 AM, R802 was observed sleeping. Certified Nursing Assistant (CNA) 'G' was observed standing outside of R802's room. CNA 'G' reported R802 was on one to one supervision because I think he punched someone. CNA 'G' reported he stood outside the door and if R802 left the room, he followed him. CNA 'G' stated, I don't know. They didn't give me all the details.On 7/15/25 at 12:34 PM, R801 was observed seated on his bed. When queried about any physical altercations that occurred…

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: 1290771. Based on observation, interview and record reviews the facility failed to provide assistance with grooming for one (R804) of two residents reviewed for Activities of Daily Living (ADLs). Findings include: A review of a complaint submitted to the State Agency (SA) documented concerns about the lack of staff assistance to maintain R804's grooming and hygiene.On 7/15/25 at 9:30 AM, R804 was observed lying in bed. R804 was observed with lots of facial hair and in need of a shave. A brief interview was conducted with the resident at that time. A review of the medical record revealed R804 was admitted to the facility on [DATE], with diagnoses that included: epilepsy, dementia and cognitive communication deficit. A review of a Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 9 which indicated moderately impaired cognition and required staff assistance for all ADLs. Further review of the medical record 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 pertains to intake #s MI000151156 and MI00151228. Based on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for two (R705 and R704) of three residents reviewed for abuse, resulting in R703 punching R704 and R705 on their face with a closed fist. Findings include: Resident to Resident incident on 3/9/25 between R703 and R704: Review of a Facility Reported Incident (FRI) for a Resident to Resident incident submitted to the State Agency (SA) on 3/8/25 documented, in part: .On 3/8/2025 [R703] was walking down the hallway on the 2 North unit towards [Nurse 'A'], reached over her shoulder, and punched Resident [R704] with a closed hand fist in the right side of the face .Resident [R704] revealed she has swelling to the right side of her face near her lower jaw and states it is painful. Resident is unable to give a number from the pain scale rating but states, It hurts, and points to the right side of her face . Further review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure nonpharmacological interventions were implemented and utilized before the administration of pharmacological interventions, failed to implement a person centered behavioral care plan, and failed to provide behavioral health services to one (R702) of three residents reviewed for falls. Findings include: Review of a complaint submitted to the State Agency (SA) documented a concern of multiple falls for R702 that led to hospitalization. A review of the medical record revealed R702 was admitted to the facility on [DATE], with diagnoses of a traumatic brain injury, acute respiratory failure, acute embolism and thrombosis, and major depressive disorder. Review of a care plan titled . risk for falls . documented the following intervention: . When showing increased anxiety offer PRN (as needed) anxiolytic and monitor for safety awareness after administration . Date Initiated: 03/03/2025 . A review of the medical record revealed no diagnosis of anxiety…

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 #MI00149000 Based on interview and record review the facility failed to fully investigate two falls to determine the root cause, ensure correct interventions were in place for one (R804) of two residents reviewed for falls/accidents. Findings include: A complaint was filed with the State Agency (SA) that reported R804 was transferred from the facility to the hospital emergency room (ER) on/or about 12/13/24 due to low blood pressure. At the hospital it was determined the resident had multiple fractures to both their right and left femur. The complainant further noted that the injury/falls were not reported to the hospital ER upon admission. A Facility Reported Incident (FRI) was submitted to the SA that noted on 12/16/24 the facility was made aware that upon admission to the ER the resident was found to have bilateral femur fractures. The facility addressed the concern as an injury of unknown origin. A review of R804's Clinical Record revealed the resident was initially admitted…

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 sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 8/26/24 at 9:10 AM, there was raw chicken observed under running water directly inside the sink basin of the 2 compartment sink. The internal temperature of the chicken was measured to be 67 degrees Fahrenheit. When queried, Dietary Staff M stated the chicken was in the walk-in cooler, but was still frozen, so it was placed in the sink to thaw. No explanation was given as to why the chicken was still in the sink basin with an internal temperature of 67 degrees Fahrenheit. According to the 2017 FDA Food Code section 3-501.13 Thawing Except as specified in (D) of this section, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be thawed: 1. (A) Under refrigeration that maintains the FOOD temperature at 5 ºC (41ºF ) or less; or 2. (B) Completely submerged under running water: 1. (1) At a water temperature of 21 ºC (70ºF )…

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 licensed failed to employ a full-time qualified social worker when certified for 126 residents, resulting in multiple deficient practices including the following areas, advance directives, ancillary services, completing Social Service assessments, discharge planning, and Preadmission Screening and Resident Review (PASRR). This deficient practice had the potential to affect all 62 residents who resided in the facility. Findings include: During an onsite annual recertification survey conducted from 8/26/24 through 8/28/24 deficient practices were identified in multiple areas of social services, including the failure to provide the following: effective coordination of advance directives to ensure the residents' desired code status was properly documented in the clinical record, discharge planning resulting in an unsafe discharge without home health care services, completion of PASRR, and facilitation of ancillary services including dental and audiology, and assessment of residents for their social service needs. A review of a Facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews the facility failed to ensure infection control standards and practices were consistently implemented (R58) and ensure an effective infection control prevention and control program was consistently implemented for 62 of 62 residents residing at the facility during the time of the survey. Findings include: A review of the facility's Infection Control Surveillance program provided by the Infection Control Nurse (ICN) J who also served as the facility's Infection Preventionist was conducted and revealed the following: - No monthly Infection Control Analysis report for May, June or July 2024 - No surveillance log for July 2024 Further review of the program revealed inaccurate mapping of infections. Review of the July 2024 antibiotic audit revealed three residents treated with antibiotics for a urinary tract infection and only one resident was identified on the facility's mapping. On 8/28/24 at 11:12 AM, a meeting to review the facility's infection control program…

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 three deficient practice statements (DPS). DPS #1 Based on observation, interview, and record review, the facility failed to identify the root cause of multiple falls and implement effective interventions to prevent falls for one (R22) of two residents reviewed for falls, resulting in multiple falls with injuries including a bruise to the shoulder, a skin tear, and a bump to the head. Findings include: On 8/26/24 at 10:28 AM, R22 was observed lying in bed, chewing on her fingers, and moving around in the bed. R22 did not verbally respond when spoken to. A fall mat was observed on the floor beside the bed. On 8/26/24 at 1:18 PM, R22 was observed seated in a regular wheelchair in the dining room during lunch. R22 was hunched over and sleeping with a plate of food on the table. No staff members were observed seated with the resident at that time. On 8/26/24 at 3:58 PM, R22 was observed lying in bed. A foam wedge was observed next to the resident, which was not present during the earlier…

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 medically related social services were provided for eight residents (R7, R20, R48, R54, R59, R60, R312 and R315) of nine residents reviewed for social services. Findings include: During an onsite annual recertification survey conducted from 8/26/24 through 8/28/24 deficient practices were identified in multiple areas of social services, including the failure to provide the following: effective coordination of advance directives to ensure the residents' desired code status was properly documented in the clinical record, discharge planning resulting in an unsafe discharge without home health care services, completion of PASARR (Preadmission screening and resident review), and facilitation of ancillary services including dental and audiology, and assessment of residents for their social service needs. Resident #59 On 8/28/24 the medical record for R59 was reviewed and revealed the following: R59 was initially admitted on [DATE] and had…

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 reviews the facility failed to maintain and implement an effective antibiotic stewardship program for five (R1, R11, R23, R58, R212) of five residents identified, however this deficient practice had the ability to affect multiple residents that were prescribed and administered antibiotics while residing in the facility. Findings include: A review of the April, May, and June 2024 Infection Surveillance logs revealed no documentation of any of the documented infections to have met or not met the criteria of an infection. Review of the Surveillance logs revealed the following: - April 2024- R23 was prescribed and administered Cephalexin 500 mg (milligram) three times a day for a right arm selling/pain from an IV (intravenous) site from the hospital. Review of the April 2024 infection log documented in part . Started on ATB (antibiotic) as prophy (prophylaxis). Sent to hospital and found to have a GI (gastroenterology) bleed and no infection so DCed (discontinued) ). The antibiotic was signed off until completed, however the resident was sent and admitted…

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 effective facility communication for honoring advanced directives for two residents (R48 and R315) of four residents reviewed for advanced directives. Findings include: On [DATE] at approximately 9:33 a.m., R48 was observed in their room, laying in their bed. R48 was observed to be thin and weak. On [DATE], R48's medical record was reviewed and revealed the following: R48 was initially admitted to the facility on [DATE] and had diagnoses including Dementia and Anxiety. R48's Code status (advanced directives) was documented as Full Resuscitate A facility document titled Advanced Directives/Medical Treatment Decisions revealed the following:I have chosen to formulate and issue the following Advanced Directives (checked) .Do Not Resuscitate (DNR) (checked) Further review of the document revealed it was signed by R48's POA (Power of attorney) on [DATE]. A facility document titled Do Not Resuscitate Order signed by R48's Physician and their POA 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 interview and record review, the facility failed to report an allegation of abuse to the State Agency for one resident (R11) of two residents reviewed for abuse/neglect/mistreatment. Findings include: On 8/26/24 the medical record for R11 was reviewed and revealed the following: R11 was initially admitted on [DATE] and had diagnoses including Psychotic disorder with delusions, Anxiety and Dementia. A review of R11's progress notes revealed the following: 7/9/2024 .Nurses' Notes: Heard loud commotion from the dining room. Entered dining room to see [R11] standing over another resident (R37) pouring coffee and grabbing at her. Residents were separated. Assessed resident that the coffee was poured onto for any injuries. Abrasion to right side cheek. and discoloration to lower right arm. Notified both family party. Notified unit nurse. Notified administrator. Notified MD (Medical Doctor). On 8/28/24 at approximately 1:55 p.m., Nurse E was queried regarding their progress note and the incident with R11…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a thorough investigation into allegations of abuse were completed for two residents (R11 and R25) of two residents reviewed for abuse/neglect/mistreatment. Findings include: R11 On 8/26/24 the medical record for R11 was reviewed and revealed the following: R11 was initially admitted on [DATE] and had diagnoses including Psychotic disorder with delusions, Anxiety and Dementia. A review of R11's progress notes revealed the following: 7/9/2024 .Nurses' Notes: Heard loud commotion from the dining room. Entered dining room to see [R11] standing over another resident (R37) pouring coffee and grabbing at her. Residents were separated. Assessed resident that the coffee was poured onto for any injuries. Abrasion to right side cheek. and discoloration to lower right arm. Notified both family party. Notified unit nurse. Notified administrator. Notified MD (Medical Doctor). 5/27/2024 .Nurses' Notes: Resident reported abuse by roommate .writer reported 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 reviews the facility failed to ensure a Level II screening was completed for one resident (R54) of four residents reviewed for PASAR (PAS - Preadmission Screening - ARR - Annual Resident Review). Findings include: On 8/26/24 at 9:44 AM, R54 was observed walking the unit hallways. R54 asked the surveyor multiple times if they wanted to hug. An interview was conducted with R54 at that time. A review of the medical record revealed R54 was admitted to the facility on [DATE] with diagnoses that included epilepsy and dementia. Review of a level I Screening dated 2/16/24, documented a Hospital Exemption Discharge . Mental Illness . The person has routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days . Review of a Level II Screening dated 2/16/24, documented in part Hospital Exempted Discharge . is being admitted after a hospital stay . requires nursing facility services for the condition for which he/she received hospital…

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

Based on observation, interview and record review the facility failed to implement adequate care plan interventions for a language barrier/communication problem for one (R3) of 16 sampled residents reviewed for care plans. Findings include: R3 On 8/26/24 at 9:59 AM, R3 was observed sitting in their wheelchair with a head wrap on. An interview was attempted however unsuccessful. R3 was identified to only speak Arabic. Certified Nursing Assistant (CNA) K confirmed that R3 only speaks in Arabic. CNA K who stated they were R3's assigned CNA for the day, was asked how they communicated with R3 and CNA K stated they used an activities aide who speaks Arabic or the resident's family. CNA K was asked to have the activities aide assist in translating for the surveyor and CNA K stated the activities aide was off duty this day. Review of a care plan titled I am at risk for impaired communication related to cognitive impairment, As evidenced by: difficulty making self-understood, As evidenced by: difficulty understanding others, As evidenced by: language barrier; English is not resident'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.

This citation pertains to Intake #MI00145963 Based on interview and record review the facility failed to facilitate a safe and coordinated discharge for one resident (R312) out of three reviewed for discharge. Findings include: A complaint was submitted to the State Agency with the allegations of an improper discharge of a trach and peg tube resident into the community with no home health care or adequate nutrition for the resident's needs. On 8/28/24 at 1:12 PM the Director of Nursing (DON) was interviewed and asked who was in charge of the discharge planning process and what home health agency was used for R312. The DON explained that in most cases the discharging of residents usually goes through the interdisciplinary team (IDT) and is discussed what a resident will need, the community tools and any additional medical providers may need to conduct a safe discharge. However, at that time, the facility did not have a social worker to help facilitate outside agencies effectively. Upon further discussion, it was expressed to the DON that there was no discharge progress note nor a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two deficient practice statements (DPS). DPS #1 Based on observation, interview, and record review, the facility failed to coordinate follow up cardiology, pulmonology, and gastrointestinal (GI) appointments for two (R57 and R58) of two residents reviewed for appointments. Findings include: Resident #57 (R57) On 8/26/24 at 10:00 AM, R57 was observed lying in bed. During an interview, R57 presented with pursed breathing and appeared uncomfortable. When queried, R57 reported he had trouble breathing when he was worked up. R57 was receiving three liters of oxygen via nasal cannula at that time. R57 reported he recently went to the hospital for his breathing and he was supposed to follow up with a doctor so he could find out what was going on. R57 reported the facility has not assisted with making that follow up appointment. On 8/26/24 at 3:53 PM, R57 was observed lying in bed. When asked how he was doing, R57 stated, Not well. When queried about what was wrong, R57 reported he was having trouble…

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 up on the audiology recommendations and services timely for one R7 of one resident reviewed for audiology services. Findings include: On 8/26/24 at 9:31 AM, R7 was observed lying in bed reading a book. An interview was attempted, however the resident stated they were hard of hearing. The surveyor then questioned the resident up close to their left ear and the resident was able to proceed with the interview. R7 explained they tried getting hearing aides at the facility but no one would direct them on who to talk to or where to go. A review of the medical record revealed R7 was admitted to the facility in 2016, with diagnoses that included major depressive disorder and Parkinson's disease. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Review of the medical record revealed no consultations of an audiology assessment and/or examination.…

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 oxygen was administered as ordered by the physician for one R315 of three residents reviewed for respiratory care. Findings include: On 8/27/24 at 8:15 AM, Licensed Practical Nurse (LPN) A was observed administering R315's morning medications. LPN A was observed to have administered R315's medications and signed them as completed in the electronic record. LPN A was observed to document R315's 02 Sat (oxygen saturation) level as 97% on 4L (liters) of oxygen. An observation was conducted of R315's oxygen concentrator and was observed at 5L of oxygen being administered. At 8:53 AM, LPN A was asked to accompany the surveyor into the room of R315 and an observation was made of the residents oxygen concentrator. LPN A was asked to report the level of oxygen being administered. LPN A then stated it was 5L but it's 4L now, while being observed decreasing the oxygen to 4L. LPN A was then asked why they had signed off that R315 was receiving oxygen at 4L without checking and verifying the administration level 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 ensure there was physician oversight for one (R58) of two residents reviewed for pressure ulcers, resulting in the lack of medical evaluation for a stage 2 (partial-thickness skin loss with exposed dermis) facility acquired pressure ulcer that worsened to a Stage IV pressure ulcer (Full-thickness skin and tissue loss) with acute osteomyelitis (bone infection). Findings include: On 8/26/24 at 10:34 AM, R58 was observed positioned on his back in bed with his neck tilted to the right side with a tracheostomy tube (a tube inserted into the windpipe to provide breathing assistance) and a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube inserted into the stomach to directly provide nutrition). When spoken to, R58 did not make eye contact and did not verbally respond to questions. A review of R58's clinical record revealed R58 was admitted into the facility on 6/10/24, and readmitted on [DATE] with diagnoses that included: diffuse…

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 (R58) of 16 residents reviewed for physician visits was seen at least once every 30 days for the first 90 days after admission by a physician or physician extender. Findings include: A review of R58's progress notes since his admission into the facility on 6/11/24 revealed R58 was seen by a physician covering for Physician 'K' on 6/20/24 for a competency evaluation and by Physician 'I' on 6/26/24 for a History and Physical (H&P). On 6/26/24, a Medical Practitioner H&P progress note, written by Physician 'I' documented, I was asked to evaluate patient secondary to copious secretion, patient is unresponsive .positive for left-sided skull deformity .trachestomy with trach mask .PEG tube in place .Copious secretion .likely tracheitis (infection in trachea) .Start Levaquin (an antibiotic) .monitor clinically .seizure .continue Keppra (an anticonvulsant medication) .Diabetes .Continue insulin sliding scale . Further review of R58'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 observation, interview, and record review, the facility failed to ensure one (Certified Nursing Assistant - CNA 'H') of five CNAs reviewed for competency was evaluated for skills and techniques to care for residents' appropriately, resulting in CNA 'H' providing care to R58 in an unsafe manner and not according to assessed needs. Findings include: On 8/26/24 at 10:34 AM, R58 was observed positioned on his back in bed with a tracheostomy tube (a tube inserted into the windpipe to provide breathing assistance) and a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube inserted into the stomach to directly provide nutrition). When spoken to, R58 did not make eye contact and did not verbally respond to questions. A review of R58's clinical record revealed R58 was admitted into the facility on 6/10/24, and readmitted on [DATE] with diagnoses that included: diffuse traumatic brain injury with loss of consciousness, acute respiratory failure with hypoxia, type 2 diabetes, and seizures. A review of an…

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

Based on observation, interview and record review the facility failed to establish and implement an effective system to receive, dispense, administer and disposition of controlled medications account for two (R's 59 & 315) of five residents reviewed for medications, this deficient practice resulted in the inaccurate documentation of a controlled medication and had the ability to result in the diversion of medication not accounted for. Findings include: On 8/27/24 at 8:24 AM, Licensed Practical Nurse (LPN) A was observed preparing the morning medications for R315. LPN A was observed to obtain a morphine sulfate bottle, inside of a plastic bag with a folded controlled form for the morphine medication. The form was reviewed with LPN A and was observed to be blank. LPN A was asked how they were accounting for the unopened morphine medication if the document was blank. LPN A stated they don't account for the medication until they open the bottle. LPN A was asked to provide the current Morphine controlled form in use. Review of the Morphine controlled form that was in use 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.

Based on observation, interview and record review the facility failed to follow the facility's policy on the maintenance and storage of medications and foods for one of one medication storage rooms observed. Findings include: On 8/27/24 at 8:20 AM, an observation of the medication back up storage room refrigerator was conducted. A refrigerator temperature check list was observed with the date of 8/20/24 to have been the last date staff had checked the temperature of the refrigerator. Two applesauce containers were found in the refrigerator next to medications and insulins that were also stored in the refrigerator. The Director of Nursing (DON) was asked to confirm the findings and stated the nightshift nurses are responsible for checking the refrigerator temperature. The DON stated they would start education with their staff. The DON also stated there should be no food stored in the refrigerator with the residents medications and if so, should be separated. Review of a facility policy titled Medication Access and Storage review date of 8/1/24, documented in part . It is the 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 observation, interview and record review, the facility failed to ensure a dental oral surgery referral was made for one resident (R20) of one residents reviewed for dental services. Findings include: On 8/27/24 at approximately 11:03 a.m., R20 was observed in the group meeting and indicated that they were supposed to have their tooth taken out in January but had no assistance from the facility in getting the procedure completed. On 8/27/24 at approximately 3:04 p.m., R20 was observed in the hallway, up in their wheelchair and expressed concerns about their tooth hurting and needing to be pulled. R20 indicated again that nobody was going to do anything about it. On 8/27/24 the medical record for R20 was reviewed and revealed the following: R20 was initially admitted to the facility on [DATE] and had diagnoses including Pain and Dysphagia. A review of R20's MDS (minimum data set) with an ARD (assessment reference date) of 7/20/24 revealed R20 needed assistance from facility staff with most of their…

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 plan of care for hospice services being provided was coordinated and documented in the resident's clinical record for one (R315) of one sampled resident reviewed for hospice services, resulting in a lack of coordination of comprehensive services and incorrect code status. Findings include: On 8/25/24 at 10:20 AM, R315 was observed lying in bed with a family member present. An interview was held with R315. R315 was then asked how the care was received at the facility and stated that they were only here for a short period of time because they were a hospice respite patient (at the facility for a short period of time). On 8/27/24 at 3:00 PM, the Director of Nursing (DON) was interviewed and asked how the facility communicated with the hospice company for R315. DON replied that we have been doing everything verbally, there is no actual book or log (to communicate with hospice) at this moment. The DON continued by stating , I have told the administrator (about the communication concern), and they will…

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 establish an effective Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) plan that identified issues of harm. This deficient practice had the potential to affect all 59 residents in the facility. Findings include: A review of a facility provided policy titled, Quality Assessment & Assurance Program revised 9/18/29 was conducted and read, .Quality Assurance is a continuous process towards quality management .Each person's effort contributes to improving resident outcomes .The Quality Assessment and Assurance (QAA) Committee provides leadership and guidance for ongoing continuous quality and performance improvement . On 10/9/24 at 12:27 PM, an interview was conducted with the facility's Director of Nursing regarding concerns identified with pressure ulcers. The DON acknowledged the concerns and the facility's ongoing audits that indicated no concerns despite concerns identified during the re-visit survey. On 10/9/24 at 1:00 PM, an interview with the facility's Administrator 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 interview and record review the facility failed to provide education and offer the pneumococcal immunization for two R's 26 & 58 of five residents reviewed for the Pneumococcal immunization. Findings include: R26 Review of R26's medical record revealed no documentation of the resident and/or representative to have been educated and offered the pneumococcal immunization. Further review of the medical record revealed no documentation of the immunization to be medical contraindicated or noted the resident to already be immunized. R26 was admitted to the facility on [DATE]. R58 Review of 58's medical record revealed no documentation of the resident and/or representative to have been educated and offered the pneumococcal immunization. Further review of the medical record revealed no documentation of the immunization to be medical contraindicated or noted the resident to already be immunized. R58 was admitted to the facility on [DATE] and had a readmission date of 7/23/24. Review of the facility's 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 provide education and offer the Covid-19 vaccine and/or booster for two R's 26 & 58 of five residents reviewed for the Covid-19 vaccine. Findings include: R26 Review of R26's medical record revealed no documentation of the resident and/or representative to have been educated and offered the Covid-19 Vaccine. Further review of the medical record revealed no documentation of the vaccine to be medical contraindicated or noted the resident to have already received the vaccine and/or booster. R26 was admitted to the facility on [DATE]. R58 Review of 58's medical record revealed no documentation of the resident and/or representative to have been educated and offered the Covid-19 Vaccine. Further review of the medical record revealed no documentation of the vaccine to be medical contraindicated or noted the resident to have already received the vaccine and/or booster. R58 was admitted to the facility on [DATE] and had a readmission date of 7/23/24. Review of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00145585. Based on interviews and record reviews the facility failed to ensure effective tracheostomy/supervision interventions were implemented for one (R303) a resident with a tracheostomy (trach) of two residents reviewed for tracheostomy care. Findings include: Review of a complaint submitted to the State Agency (SA) documented concerns of the facility's failure to provide adequate tracheostomy care leading to R303's death. Review of the medical record revealed R303 was admitted to the facility on [DATE] with diagnosis that included: Respiratory failure, dysphagia (difficulty swallowing), tracheostomy status and autistic disorder. R303 was documented to have severely impaired cognition and required staff assistance for all Activities of Daily Living (ADLs). Review of a Nursing note dated [DATE] at 1:03 PM, documented in part . 8:10 pm RN (Registered Nurse) went to his (R303) room observed resident lying in <sic> floor while holding his Ipad. Family of (room number) at the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake # MI00143422 Based on interview and record review, the facility failed to establish and maintain a system that assures complete and separate accounting for Resident's Trust Funds from the facility's operating account, according to the generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf; and failed to provide timely financial statements for one (R701) of three Residents reviewed for Resident's Trust Fund resulting in resident/resident's representative being uninformed about their personal funds and potential for misuse of resident funds. Findings include: R701 A complaint received by the State Agency in March-2024, read in part, Since Dec of 2023 I have asked every week almost and keep getting excuse after excuse. 1st it was she only has $15 with $60 pending for December. OK I ask for a printout so I can audit my (relationship omitted) account. Was told I'd have by next week. 2 weeks later I still got…

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 report an allegation of resident to resident physical abuse to the State Agency (SA) for one (R703) of three residents reviewed for abuse. Findings include: Review of a facility policy titled, Abuse, Neglect and Exploitation revised 1/10/24 read in part, .Physical Abuse includes, but is not limited to hitting, slapping, punching, biting and kicking . Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated . Reporting of alleged violations to the Administrator, state agency . within specified timeframes as required by state and federal regulations: a. Immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury . On 5/29/24 at 10:47 AM, R703 was observed sitting on the side of their bed. R703 did not answer any questions asked however, R703…

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 medically related social services to three (R38, R39, and R50) residents reviewed for social services, with the potential to affect all facility residents. This deficient practice resulted in insufficient/ineffective mood and behavior monitoring, a lack of social service assessments to effectively monitor and/or address changes in mental and psychosocial health needs, coordination of ancillary services, and assistance with discharge planning. Findings include: According to the facility's Social Services policy dated 1/1/2022: .The facility, regardless of size, will provide medically-related social services to each resident, to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .The social worker, or social service designee, will complete an initial and quarterly assessment of each resident, identifying any need for medically-related social services of the resident. Any need for…

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

Based on observation, interview, and record review, the facility failed to store utensils in a sanitary manner, failed to maintain the dry storage room in a sanitary manner, and failed to store food in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 7/11/23 during an initial tour of the kitchen between 8:45 AM-9:30 AM, the following items were observed: The ice scooper was observed resting directly on the top surface of the ice machine. There was dust and visible debris on the top surface of the ice machine. On 7/11/23 at 11:15 AM, Dietary Manager (DM) AA confirmed the ice scooper should not be stored on top of the ice machine. According to the Food & Drug administration (FDA) 2017 Model Food Code, Section 3-304.12 In-Use Utensils, Between-Use Storage, During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: .(E) In a clean, protected location if the utensils, such as ice scoops, are used only with a food that is not potentially hazardous…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #s: MI00131097, MI00131393, and MI00134314. Based on observation, interview, and record review the facility failed to provide a clean, comfortable and home-like environment to ensure that hallways, resident rooms, floors and other facility areas and equipment were clean (R28), and in good repair (R48 and R55) resulting in an unclean physical environment, resident dissatisfaction and complaints regarding the lack of cleanliness and upkeep. This deficient practice had the potential to affect all residents that reside within the facility. Findings include: Complaints were filed with the State Agency (SA) that alleged issues pertaining to the cleanliness of the facility, including but not limited to foul odors, damaged walls, missing paint, soiled floors, and equipment. According to the facility's policy titled, Safe and Homelike Environment dated 1/1/2022: .The facility will create and maintain, to the extent possible, a homelike environment that de-emphasizes the institutional…

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 #MI00134531 Based on interview and record review, the facility failed to report narcotic count discrepancies to the Director of Nursing/Administrator for one resident, (R312) of one resident reviewed for misappropriation, resulting in the potential for future discrepancies. Findings include: A review of a facility provided policy titled, Abuse, Neglect and Exploitation revised 10/24/22 was conducted and read, .VII. Reporting/Response .1. Reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies . On a 7/12/23 12:00 PM, a review of R312's clinical record was conducted and revealed they admitted to the facility on [DATE], was sent out to the emergency room, re-admitted on [DATE], and discharged on 1/23/23. R312's diagnoses included: schizophrenia, delirium, unspecified intellectual disabilities, adjustment disorder with mixed anxiety, fibula fracture and repeated falls. 312's Minimum Data Set assessment dated…

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 to ensure sufficient staffing/supervision was provided for four residents (R31, R38, R40 and R264) of four residents reviewed for behavioral health needs/cognitive impairments. This deficient practice has the potential to affect all residents residing on the second floor of the facility. Findings include: Resident #31 On 7/12/23 at approximately 9:12 a.m., R31 was observed laying on the floor in the middle of the hallway located past the closed double doors that divided the hall. No staff were observed to be aware of R31 on the floor or assisting them. On 7/11/23 the medical record was reviewed. R31 was initially admitted to the facility on [DATE] and had diagnoses including Delusional disorder, Anxiety disorder and Dementia. A review of R31's MDS (Minimum data set) with an ARD (Assessment Reference Date) of 4/21/23, revealed the Resident needed assistance with most of their activities of daily living. R31 was coded as needing supervision while…

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 properly follow a physician order for an antibiotic for one (R213) of five residents reviewed for unnecessary medication. Findings include: On 7/13/23 at approximately 9:11 AM, R213 was observed sitting in a wheelchair near their bed. The resident was alert and able to answer some questions asked. The resident reported that they had been at the facility for few days following a stay at the hospital for Bursitis. R213 reported that it was their first time at the facility. A review of R213's clinical record noted the resident was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included: vascular dementia, bursitis of the knee and type II diabetes. A review of the resident's Minimum Data Set (MDS) revealed the resident was cognitively intact and required one to two person assist for most activities of daily living (ADLs). Continued review of the resident's record noted, in part, the following: Nurse'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.

This citation pertains to intake #s: MI00131393 and MI00134314. Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices related to medication administration for three residents (R#'s 10, 40 and 38) of 9 residents reviewed for infection control and ensure a chair that had been urinated on was cleaned in a timely manner. This deficient practice had the potential to affect multiple residents who reside in the facility. Findings include: On 7/12/23 at 8:36 AM, Nurse 'S' was observed in the hallway midway through preparing medications for R10. Nurse 'S' was observed to pop the pills from the medication cartridge into their bare hand and place them in a medication cup. At the conclusion of preparing the medications Nurse 'S' was then observed to dump the cup of pills into the palm of their bare hand and place them in a plastic bag for crushing. After crushing the pills, they were placed back in the medication cup. Nurse 'S' was then observed to open a capsule with their bare hand and dump the capsule contents into 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 ensure one resident (R163) was treated in a dignified manner while care was being provided for one resident reviewed for dignity. Findings include: On 7/12/23 at approximately 2:12 p.m., R163 was observed in the tub room on the 2nd floor with Certified Nursing Assistant A (CNA A). CNA A was heard talking on their cell phone for multiple minutes while providing care to R163. On 7/12/23 at approximately 2:16 p.m., Nurse B was notified of CNA A being on their phone while providing care to R163 and indicated it was not appropriate and was then observed going into the tub room and speaking with CNA A regarding their cell phone use. On 7/13/23 at approximately 11:03 a.m., during a follow-up conversation with Nurse B pertaining to CNA A being on their cell phone while giving care to R163 in the tub room, Nurse B reported when they went into the tub room and asked CNA A if they were talking on their phone while caring for R163 and CNA A informed…

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 #MI00134531 Based on interview and record review, the facility failed to prevent misappropriation of property for one resident (R312) of one resident reviewed for misappropriation, resulting in missing controlled substance medications. Findings include: A review of a facility provided policy titled, Abuse, Neglect and Exploitation revised 10/24/22 was conducted and read, Policy: It is the policy of this facility to provide protections for health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property . On 7/12/23 at 12:00 PM, a review of R312's clinical record was conducted and revealed they admitted to the facility on [DATE], was sent out to the emergency room, re-admitted on [DATE], and discharged on 1/23/23. R312's diagnoses included: schizophrenia, delirium, unspecified intellectual disabilities, adjustment disorder with mixed anxiety,…

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 # MI00134314. Based on interview, and record review, the facility failed to develop comprehensive care plans which addressed actual non-pressure wounds for one (R162) of one resident reviewed for care planning. Findings include: Review of the clinical record revealed R162 was admitted into the facility on 8/16/22 and discharged to the hospital on 2/4/23 and had not returned to this facility. Diagnoses included: edema, chronic kidney disease stage 3B, and hypokalemia. According to the Minimum Data Set (MDS) assessment dated [DATE], R162 had mild cognitive impairment (scored 12/15 on brief mental status exam), had physical behavioral symptoms directed towards others which occurred 4 to 6 days during this assessment period of 14 days; required limited assistance of one person physical assist for bed mobility, dressing, and personal hygiene; was at risk of pressure ulcers/injuries but had no unhealed pressure ulcers/injuries, and had no venous and arterial ulcers. Review 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 This citation pertains to intake #s: MI00136363, MI00134314, and MI00134531. Based on interview, and record review, the facility failed to perform skin and wound assessments consistently, administer wound treatments and diagnostic testing according to physician's orders for one (R162) of one resident reviewed for non-pressure skin conditions. Findings include: Review of a complaint reported to the State Agency included allegations that wound care was not being provided as ordered or per plan of care. Review of R162's hospital records included: A emergency department report on 2/4/23 read, .Upon arrival .have significant swelling and erythema to her lower extremities .The patient will be started on IV (Intravenous) antibiotics and require admission .Final Impression: 1. Acute lower extremity cellulitis . A History and Physical report on 2/4/23 read, .presents to the ED (Emergency Department) due to concerns of increased leg swelling with weeping ulcers .Patients daughter explains that the onset of swelling 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 one resident (R9) was provided with a timely dental consult of two residents reviewed for dental services. Findings include: On 7/11/23 at approximately 9:49 a.m., R9 was observed in their room, laying in their bed. R9 was observed and appeared to have multiple broken teeth showing some decay at the base of the gums. R9 was queried if they have seen a dentist at the facility and they indicated they have not but that they needed to because they have had tooth pain. On 7/12/23 the medical record for R9 was reviewed and revealed the following: R9 was initially admitted to the facility on [DATE] and had diagnoses including Dementia, Heart failure and Disorder of teeth and supporting structures. A review of R9's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4/20/23 revealed R9 needed assistance from facility staff with most of their activities of daily living. R9's BIMS score (brief interview of mental status) was 15…

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.