The Orchards at Roseville

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2673919.Based on interview and record review, the facility failed to notify the guardian of a change in condition for one resident (#702) out of one resident reviewed for a change in condition. Findings include:It was reported to the State Agency that the facility failed to notify the guardian that R702 had been sent to the hospital. A review of the clinical record revealed R702 was initially admitted to the facility on [DATE] and readmitted on [DATE]. R702's diagnoses included Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease and Chronic Respiratory Failure. R702 has a legal guardian who makes their decisions. Further review of the clinical record revealed on 10/29/25, R702 was sent to a vascular doctor's appointment outside the facility. At the doctor's appointment, R702 complained of chest pain and was sent 911 to the hospital. There was no documented communication in the clinical record regarding R702 being sent to the hospital. On 11/20/25 at 3:15 PM 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2638560. Based on interview and record review, the facility failed to ensure one resident (R700) did not receive discontinued medications out of two reviewed for unnecessary medications. Findings include: A review of the Electronic Medical Record (EMR) revealed R700 was originally admitted on [DATE]. Diagnoses included Fibromyalgia, and schizoaffective disorder. Further review revealed a Brief Interview for Mental Status score of 13/15 which indicated intact cognition. A review of the physician's orders revealed an order on 9/22/25 to discontinue Ultram (Tramadol-pain medication) once Norco (narcotic pain medication) arrives from pharmacy. The Norco arrived on 9/22/25 however the Tramadol was not discontinued. A review of the September 2025 medication administration record showed the Tramadol was administered on the following dates 9/24/25, 9/29/25, 10/1/25, 10/2/25, and 10/3/25, and the Norco was administered on: 9/23/25, 9/26/25, 10/1/25, 10/2/25, 10/4/25, and 10/5/25. R700…

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 2623867.Based on observations, interview, and record review the facility failed to provide wound care as ordered for one sampled resident (R701) of three reviewed for wound care. Findings include: A review of the complaint summary noted, Today (9/18/24) [R701] was seen by [R701's] wound care providers (that [R701] sees every other week) and [R701's] dressings were dated 09/12/2025.On 9/28/25 at 10:24 AM, R701 was observed in their room lying in bed. R701 feet were observed wrapped and dated 9/28/25 and in heel protector boots. R701 was asked about their wound care and offered no complaints. A review of R701's medical record wound consultation noted, 9/18/2025 . Bandage not changed for six days-dated 9/12 !! Not appropriate! A review of R701's treatment record noted. Order: apply betadine and dry dressing to left medial heel. every day shift every 2 day(s) for protection maintain bil (bilateral) heel elevation while in bed. Blank without documentation were September12th, 14th,…

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: MI00153342. Based on observation, interview, and record review, the facility failed to ensure coordination of care between the facility and hospice services, implement a plan of care regarding hospice services, and ensure a signed agreement between all hospice entities and the facility was obtained for three (R's 303, 304 & 305) of three residents reviewed for quality of care. Findings include: R303 On 6/10/25 at 10:39 AM, R303 was observed laying back in a chair in the community room. An interview could not be conducted with the resident due to their cognitive impairment. A review of the medical record revealed R303 was admitted to the facility on [DATE], with a readmission date of 12/29/22 and diagnoses that included: Alzheimer's disease and vascular dementia. A Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognition for R303. R303 was dependent on staff for all Activities of Daily Living (ADLs). A review of a hospice document revealed R303 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 Intake number MI00151441. Based on observation, interview, and record review, the facility failed to maintain a safe, sanitary, comfortable environment for one of one resident (R32), six confidential group residents, with the potential to affect the remaining 107 residents residing at the facility. Findings include: R32 On 4/28/25 at 10:45 AM, R32 was interviewed and asked about their satisfaction with the care and services they were receiving at the facility. R32 indicated every time they received a shower in the 100 south unit shower room, the shower filled up with water and leaked out the door into the hallway. R32 further indicated that because of the large amount of water, the shower room floor could become very slippery. R32 stated, It's not safe. A review of R32's electronic medical record (EMR) revealed that R32 was admitted to the facility on [DATE] with diagnoses that included Seizures, Schizophrenia, and Dementia. R32's most recent minimum data set assessment (MDS) 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.

Based on observation and interview, the facility failed to ensure all corridor areas used by residents were provided with safe and secure handrails. This deficient practice has the potential to affect all 115 residents who are independently ambulatory with, or without an assistive device, and residents who were able to self-propel in their wheelchairs living in the facility. Findings include: An initial observation of the 2nd floor was completed on 4/28/25 at approximately 12:00 PM. During this observation residents with cognitive impairment were observed walking in the hallway using the handrails as well as residents were using the rails to move around in their wheelchairs. The end caps for the handrails were missing with sharp areas of the handrails exposed in multiple areas throughout the 2nd floor hallway. There were 2 end caps missing near the elevator, near the doorways of rooms 218, 221, outside the unit manager's office. Throughout the survey multiple follow-up observations were completed on 4/28/25, 4/29/25 and 4/30/25 to confirm the initial observation. An interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to offer a mirror of appropriate height visible from a wheelchair level to perform their shaving/grooming for one of one resident (R83) reviewed for accommodation of needs. Findings include: R83 R83 was recently admitted to the facility after hospitalization on 3/19/25. R83's admitting diagnoses included recent left above knee amputation, Chronic Obstructive Pulmonary Disease (COPD), and peripheral vascular disease. Based on the Minimum Data Set (MDS) assessment dated [DATE], R83 had Brief Interview for Mental Status (BIMS) score of 15/15, indicative of intact cognition. An initial observation was completed on 4/29/25 at approximately 7:55 AM. R83 was in their bed. R83 had a wheelchair, parked next to their bed. An interview was completed during this observation. R83 was asked about their care and if they had any concerns. R83 reported that they were unable to stand up because of their recent amputation and they used their wheelchair. They added they were…

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, facility failed to update a care plan timely on transfer (from one surface to anther) ability based on the comprehensive assessment for one (R10) of one resident reviewed for care plans. Findings include: R10 R10 was originally admitted to the facility on [DATE]. R10 had a recent admission to hospital and they were recently readmitted back to the facility on 3/23/25. R10's admitting diagnoses included heart failure, end stage renal failure, conversion disorder with seizures, and protein calorie malnutrition. Based on the Minimum Data Set (MDS) assessment dated [DATE] R10 had a Brief Interview for Mental Status (BIMS) score of 13/15, indicative of intact cognition. Review of R10's care plan revealed that R10 needed a mechanical/total body lift with 2-person for their transfers. During an observation completed on 4/29/24 at approximately 3 PM, Certified Nursing Assistant (CNA) H was observed transporting R10 in a shower chair from room to the shower room.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident showers were provided as scheduled for two residents (R18, R59) of six reviewed for care completions and documentation. Findings include: R18 On 04/28/25 at 1:49 PM, R18 reported they had not received their shower one day last week, Tuesday 04/22/25. A review of the record for R18 revealed R18 was admitted into the facility on [DATE]. Diagnoses included Stroke, Mood Disorder and Chronic Pain. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 13/15 Brief Interview for Mental Status score, and R18 required substantial/maximal assistance of staff for showers/bathing, upper and lower body dressing, and R18 was dependent for personal and toileting hygiene and transfer. A review of the April 2025 shower/bathing task in the Electronic Medical Record (EMR) documented bathing was Monday and Thursday between 7:00 PM and 7:00 AM. The documentation which did not correspond with the designated shower days…

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 the medications acyclovir (treatment for viral infections) and mupirocin ointment (treatment for skin lesions) as ordered, for one resident (R26) of five reviewed related to medication administration. Findings include: On 04/28/25 at 2:10 PM, R26 reported they had not been consistently treated for their urinary tract infections and impetigo (reddish itchy sores, often around the nose and mouth which may rupture, ooze, and then crust). R26 reported they had not refused any treatments for these conditions. R26 was observed to have two raised areas about the size of a pencil eraser on the forehead. Both were pink in color and one had a scabbed ring around the base. R26 reported the areas itched and had needed to scratch them. On 04/28/25 at 3:04 PM, Licensed Practical Nurse (LPN) C was asked about potential causes of missed medications and reported some history of difficulty with getting medications from the pharmacy and resident…

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

Based on observation, interview, and record review, the facility failed to ensure, insulin and eyedrops were dated when opened, expired insulin discarded, in three of four medication carts and tuberculin was dated when opened and the refrigerator temperature was maintained within normal limits in one of three medication rooms. Findings include: On 04/29/25 at 9:45 AM, the second floor north front medication cart was observed with Licensed Practical Nurse (LPN) B. The cart contained a Lispro insulin pen dated opened 03/16/25. On 04/29/25 at 10:08 AM, the second floor back cart was reviewed with LPN D. A timolol brimonidine eye dropper was out of the box, open and not dated when opened. On 04/30/25 at 12:43 PM, the first floor north front cart was reviewed with LPN C. A Lantus insulin vial was not dated when opened and an Aspart insulin pen was not dated when opened. Three additional insulin pens were undated and undetermined (no plastic wrapper/seal in place) if opened and used. Three of the insulin pens in the cart were stored without the cap on. On 04/30/25 at 12:54 PM, the one…

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 M100148727. Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, home-like environment for one (R704) of three residents reviewed for environmental concerns. Findings include: Review of the facility record for R704 revealed an admission date of 11/30/24 with diagnoses that included Metabolic Encephalopathy, Sepsis and Urinary Tract Infection. R704 was discharged to another facility on 12/06/24. On 01/08/25 at 12:30 PM, R704's former room (room [ROOM NUMBER]) was inspected. The bathroom sink had been caulked along the length of the top and side contact with the wall. This caulk line was broken along the entire length and had the appearance of the sink coming away from the wall. There were multiple holes in the wall with exposed drywall adjacent to the toilet where a toilet paper holder had been removed and not repaired. The heat register on the wall under the windows of the bedroom area was missing the cover plates 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.

This citation pertains to intake M100148727. Based on interview and record review, the facility failed to complete an initial skin assessment and place initial wound care orders for one (R704) of three residents reviewed for wound care services. Findings include: Review of the facility record for R704 revealed an admission date of 11/30/24 with diagnoses that included Metabolic Encephalopathy, Sepsis, and Urinary Tract Infection. R704 was discharged to another facility on 12/06/24. Review of R704's admission Note dated 11/30/24 documented, Patient received on unit at 1800 (6 PM) alert and oriented x 2-3, stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) wound reported on buttock . There was no initial skin assessment, treatment orders, or documentation of wound care provided from 11/30/24 to 12/3/24. Review of the physician orders dated 12/3/24 revealed wound care orders for the sacrum and bilateral buttocks, Cleanse with NS (normal saline)/wound cleanser,…

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 MI00148164. Based on interview and record review, the facility failed to implement interventions to reduce the risk for elopment for one resident (R700) of one reviewed for elopement, resulting in a R700 eloping out fire door to the front of the building and walking to the corner. Findings include: On 11/12/24, a facility reported incident submitted to the State Agency was reviewed and indicated R700 had exited the facility on 11/12/24 at 4:15 AM. Door alarms had alerted staff someone had opened door and possibly left the building. R700 was found outside of the building after setting off alarms and leaving through a fire door. On 11/21/24 the medical record for R700 was reviewed and revealed the following: R700 was admitted to the facility on [DATE] with the diagnoses of dementia, hypertension, hyperlipidemia, insomnia, and diabetes mellitus. A review of the minimum data set assessment (MDS) dated [DATE], R700 brief interview of mental status assessment indicated a score of 6…

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: MI00145649 Based on interview and record review, the facility failed to ensure an allegation of abuse was immediately reported to the State Agency (SA) for one resident (R902) of one resident reviewed for abuse. Findings include: A review of intake: MI00145649 revealed the following, [R902] was at a dialysis appointment today and she called police due to one of her caretakers assaulting her. The caretaker's name is [Certified Nursing Assistant (CNA) A .] A review of R902's medical record revealed they were initially admitted into the facility on 3/7/24 with diagnoses that included Chronic Respiratory Failure with Hypoxia, Heart Failure, End Stage Renal Disease, and Schizoaffective Disease. The medical record revealed R902 was cognitively intact and required one person assistance for bathing, bed mobility and toilet use. A review of the police report dated 7/12/24 from the local police agency where dialysis occurs revealed the following: .met with caller who was identified as…

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

This citation pertains to Intake: MI00145702 Based on observation, interview, and record review the facility failed to consistently complete and document ordered wound care treatment, and timely implement treatment interventions for one Resident (R901) of one resident reviewed for pressure ulcers. Findings include: A review of Intake MI00145702 revealed the following, .the facility isn't getting the resident out of bed or turning him, so [they are] concerned that the bed sores are no longer healed and could potentially be getting worse . On 7/23/24 at 9:38 AM, R901 was observed lying in bed on their back, head elevated, feet flat on the mattress. R901 was asked if they ever get repositioned and they stated, No. There were no pillows or wedges observed in the resident's room. A review of R901's medical record revealed that they were admitted into the facility on 3/4/22 with diagnoses of heart failure, dementia, and gastrotomy status. The medical record revealed R901 was moderately cognitively impaired and required extensive assistance for bed mobility. A review of the Progress Notes…

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 MI00145171. Based on observation, interview, and record review, the facility failed to ensure resident rooms and shower rooms were maintained in a homelike/sanitary manner for four residents (R1, R111, R89, R87) of four whose environment was reviewed. Findings include: On 07/02/24 at 8:25 AM, an odor of urine was noted at the middle to end of the low north hall. The shower was observed to have a wet washcloth on the floor at the doorway, two upside down loose tiles in the left corner and black spots from pin to pencil eraser size (which appeared to be mildew or black mold), along the base tiles along the back and sides of the shower area. A larger golf ball size area of the black mildew like substance was noted on the right side base tiles. The two curtains which hung across the entry to the shower area had the similar black mold like substance continuously along the bottom seam and up the curtains around two to three inches in places. The floor threshold for room the room of R89…

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 MI00145171. Based on observation, interview, and record review, the facility failed to ensure care needs and or incontinence care was provided for nine residents (R105, R87, R71, R95, R48, R34, R22, R1, R2) of 13 reviewed for activities of daily living (ADLs). Findings include: On 07/02/24 at 8:25 AM, an odor of urine was noted at the middle to end of the low north hall. R105 On 07/02/24 at 9:55 AM, R105 reported the facility needs more help because they wait a long time to get to get cleaned up when they are wet and soiled. At 12:23 PM, R105 was observed to be slouched over to the left side of the bed asleep. R105 reported they were wet with urine and had put their light on and no one came and must have fallen asleep. R105 did not recall the time they were last checked. At 2:32 PM, R105 was observed to be slouched to the left in bed asleep. A record review for R105 reveals that R105 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure. Further record…

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

This citation pertains to MI00137527. Based on observation, interview, and record review, the facility failed to maintain the kitchen, equipment, and the first floor resident refrigerator in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 3/18/24 at 10:00 AM, in the 1 South resident refrigerator, there was an undated food container of corned beef, an undated bag with tuna salad and 2 foil wrapped sandwiches, an undated chef salad, and an orange liquid pooled at the bottom surface of the refrigerator. According to the facility's policy Food From Outside Sources dated 12/28/17, 2. All food brought in must be .labeled with the resident's name and date the food was processed/cooked and the date it is to be discarded . On 3/18/24 at 11:30 AM, the 2nd floor ice machine was observed with a black mold-like substance along the bottom edge of the ice chute. According to the 2017 FDA Food Code section 4-602.11 Equipment Food-Contact Surfaces and Utensils, (E) Except when dry cleaning methods are used…

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 in part to Intakes MI00237527 and MI00139246. Based on observation and interview, the facility failed to maintain a clean, safe environment, in multiple resident rooms and bathrooms. Findings include: On 3/18/24 between 9:45 AM-10:30 AM, during a tour of the facility with Maintenance Supervisor K, the following items were observed: room [ROOM NUMBER]- Bathroom ceiling vent cover dusty, toilet riser rusty, stained ceiling tiles, missing ceiling tiles room [ROOM NUMBER]- The bathroom ventilation system was non functional. This was tested by placing a toilet tissue square against the ventilation grate. There was no suction observed, and the toilet tissue did not suction to the vent grate. Maintenance Supervisor K confirmed the vent was non-functional and stated he was unaware of any issues. 1 North Shower room- There were numerous missing and cracked floor tiles. Maintenance Supervisor K provided no explanation. room [ROOM NUMBER]- There were large areas of torn wallpaper, and a dusty…

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: MI00140563. Based on interview and record review, the facility failed to honor a resident's right to smoke for one sampled resident (R211) of two residents reviewed for smoking. Findings include: A review of Intake MI00140563 revealed the following, The DON (Director of Nursing) lied to the physician and told the physician the resident was unsafe to go on an LOA (leave of absence) alone. This was not a true statement, resident was independent and was previously going on LOAs alone per PT (physical therapy) and physician. The DON was upset because the resident was smoking outside on the premises and took [their] rights away. When the resident tried to explain that [they] had an appointment scheduled the DON forced [them] and documented it as being an AMA (against medical advice). No paperwork was signed, the resident called the facility multiple times trying to return and the DON would not let [them]. A review of R211's medical record revealed that they were admitted into the facility on 9/6/23 with diagnoses that include Heart Failure, Diabetes,…

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 M100141520 and MI00137527. Based on interview and record review, the facility failed to prevent the misappropriation of resident funds by a staff member for one (R61) of six residents reviewed. Findings include: Review of the facility record for R61 revealed an admission date of 04/03/23 with diagnoses that included Rheumatoid Arthritis, Chronic Obstructive Pulmonary Disease and Osteoarthritis. The Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 13/15 indicating intact cognition. On 03/17/24 at 10:32 AM, R61 was interviewed in their room. R61 reported that on 12/02/23 they had given Certified Nurse Assistant (CNA) G their bank card and asked them to withdraw two hundred dollars from the ATM for them. R61 stated that CNA G had withdrawn money for them multiple times and that they trusted them and they would give CNA G a ten dollar tip for the assistance. R61 reported that after CNA G gave them the two hundred dollars they…

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: MI00137527. Based on observation, interview and record review, the facility failed to report allegations of abuse to the State Agency (SA) within required regulatory timeframe's for one sampled resident (R3) of four residents reviewed for abuse. Findings include: On 3/17/24 at 10:13 AM, R3 was observed lying in bed and asked about their stay in the facility. They explained that they had been punched in the stomach by a facility staff member approximately 5-6 weeks ago however, they had not seen that staff member since. A review of R3's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that include Post-Traumatic Stress Disorder (PTSD), Depression, and Chronic Pain Syndrome. Further review of R3's medical record revealed that the resident was cognitively intact, and required extensive to total dependence with Activities of Daily Living. Further review of the medical record revealed the following progress notes: 12/28/2023 16:56 (4:56pm)…

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: MI00137527. Based on observation, interview, and record review, the facility failed to operationalize policies and procedures and thoroughly investigate an allegation of abuse for one resident (R3) of four residents reviewed for abuse. Findings include: On 3/17/24 at 10:13 AM, R3 was observed lying in bed and asked about their stay in the facility. R3 explained that they had been punched in the stomach by a facility staff member approximately 5-6 weeks ago. R3 explained that they believed that there was another resident who also disclosed that the same staff member had become physical with them as well. A review of R3's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that include Post-Traumatic Stress Disorder (PTSD), Depression, and Chronic Pain Syndrome. Further review of R3's medical record revealed that the resident was cognitively intact, and required extensive to total dependence with Activities of Daily Living. 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 Intakes: MI00137973, MI00143112, MI00143340, MI00237527, and MI00139246. Based on observation, interview and record review the facility failed to ensure provide timely response to (activities of daily living) ADL needs was provided and or documented for three residents (R88, R91, R27) of three reviewed for services. Findings include: R88 On 03/17/24 at 1:25 PM, R88 was observed to be in bed and dressed in a hospital style gown. The head of the bed was up around 45 degrees and R88 leaned toward the right side of the bed. Attempts to sit more up right were not observed. R88 reported they had a history of stroke and right sided weakness. R88 further reported along with their visitor they were not getting changed timely and at times it would be more than an hour once they asked to be changed. R88 also reported there had been times they received a bed bath instead of their preferred shower in the shower room and that it was due staffing. On 03/17/24 at 4:37 PM, R88 was observed to bed,…

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 MI00137527 and MI00141187. Based on observation, interview and record review, the facility failed to provide and or document wound care treatment for two sampled residents (R72 and R160) of five residents reviewed for skin management. Findings include: R72 On 3/17/24 at 8:49 AM, R72 was observed lying in bed and asked about their stay in the facility, and the care received for their pressure ulcers. R72 explained that they have a wound on their hip that isn't healing, and that wound care treatment is completed every other day. A review of R72's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included with diagnoses that Hemiplegia and Hemiparesis following Cerebral Infarction, Diabetes, Anxiety, and Hypotension. Further review revealed the resident was cognitively intact and required extensive with Activities of Daily Living. Further review of R72's medical record revealed the resident has a left hip chronic stage IV (four) pressure…

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 restorative care was provided and documented for three residents (R88, R91, R27) of three reviewed for services. Findings include: R88 On 03/17/24 at 1:25 PM, R88 was observed to be in bed and dressed in a hospital style gown. The head of the bed was up around 45 degrees and R88 leaned toward the right side of the bed. Attempts to sit more up right were not observed. R88 reported they had a history of stroke and right sided weakness and had some physical therapy but due to insurance it was discontinued and there had been subsequent delays in getting therapy started again. R88 was not observed to be out of bed or dressed in clothes during the three days of the survey. On 03/18/24 at 11:26 AM, Physical Therapist (PT) J reported therapy had been waiting on authorization for a while and had just done an evaluation on 03/12/24. R88 was then referred to restorative pending authorization for more visits. The last documented physical therapy…

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 label and date tuberculin vials when opened in three of three medication rooms and inhalers in three of four medication carts. FIndings include: On 03/18/24 at 9:17 AM, in the south unit medication cart, a fluticasone/salmeterol inhaler for R63 was not dated when opened and did not have a resident identifier on the inhaler. On 03/18/24 at 9:54 AM, in the north middle medication cart, an Incruse inhaler for R41 had no name or date on the actual inhaler and a fluticasone/salmeterol inhaler for R59 did not have a date opened on the actual inhaler. On 03/18/24 at 10:24 AM, in the north front medication cart, a Trelegy inhaler for R49 did not have a resident identifier nor a date opened on the inhaler and a fluticasone/salmeterol inhaler for R19 was not dated when opened on the box nor the inhaler. A resident identifier was not on the acutal inhaler. On 03/18/24 at 10:31 AM, the one north med room refrigerator was observed with the unit manager and two tuberculin vials were not dated when opened on the box nor 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.

This citation pertains to Intake MI00137527. Based on observation, interview and record review, the facility failed to provide resident food preferences for two (R96, R261) of six residents reviewed. Findings include: R96 Review of the facility record for R96 revealed an admission date of 09/01/23 with diagnoses that included Diabetes Mellitus with Diabetic Neuropathy, Morbid Obesity and Hypertension. On 03/17/24 at 9:53 AM, R96 reported that they are diabetic and they receive large amounts of carbohydrates. The breakfast meal ticket was observed to indicate prefers sugar free condiments; large portions of protein, smaller portions of starches. The breakfast tray was observed to have oatmeal which was served with sugar already poured into it, three french toast sticks with powdered sugar and syrup which R96 indicated was not sugar-free. R96 stated that they often do not receive requested alternate menu items such as salads and instead receive grilled cheese sandwiches. Review of R96's care plan dated 01/03/24 revealed a Focus area addressing nutritional risk which included 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.

This citation pertains to Intake MI00137527. Based on observation and record review, the facility failed to clean multi-use equipment between resident use or perfrom hand hygeine during meal services for one resident (R106) of one reviewed for mutiuse equiment . Findings include: On 3/18/24 at 9:00 AM, Nurse B did not clean the Electronic Wrist Blood Pressure/Pulse machine after use with R21. On 3/18/24 at 9:35 AM, Nurse B did not clean the Electronic Wrist Blood Pressure/Pulse machine after use with R106. When it did not work, Nurse B obtained an upper arm Electronic Blood Pressure/Pulse machine from another medication cart. Nurse B did not clean the machine before or after use. On 3/18/24 at 8:38 AM during a dining room observation, it observed that the CNA passing trays to residents, did not perform hand hygiene between providing trays to each resident. During this same time, a different CNA was going from one resident to another, removing the cover and cutting resident's food without performing hand hygiene between residents. On 3/20/24 at 1:00 PM, during a meeting with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intakes MI00136068 and MI00138028. Based on observation, interview and record review, the facility failed to ensure a safe, clean and sanitary environment was maintained on the north unit and for the north exit door potentially affecting the 52 residents who reside on the north unit. Findings include: On 11/07/23 at 1:00 PM, a resident who asked to remain anonymous (R X) reported to the surveyor that the first floor north shower room does not drain well and has mildew or mold growing in it. On 11/07/23 at 1:11 PM, observation of the first floor north shower room revealed: the metal drain cap in the shower was loose and not secured to the floor. The four inch drain pipe was therefore open and could allow a shower chair wheel to slip into the hole. The were nine 2 x 2 inch tiles missing around the drain hole. The ridge for water retention in the shower had missing or cracked tiles. A black mildew like substance covered an area of 12 tiles at the left side of the retention ridge.…

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 MI00138028. Based on observation, interview and record review, the facility failed to ensure that one (R905) of one residents end of life wishes were followed, resulting in a transfer to a local hospital for a change in condition. Findings Include: A review of the Intake noted, [R905] resided at (name of) nursing home for 7 years until [R905's] death . [R905] had been under hospice care for weeks. [R905's] grandson . was [R905's] medical POA (Power of Attorney). There was a DNR (Do Not Resuscitate ) put in place due to [R905's] declining health. A copy of it was provided to the nursing home. On [DATE], [R905] began to make [their] transition. The facility wanted to provide CPR (Cardiopulmonary Resuscitation) to [R905] . Hospice care advised the staff at the facility not to provide CPR to [R905]. The staff at the facility advised that they could not find their copy of the POA and they were sending [R905] to the hospital On [DATE] at 2:31 PM, Licensed Practical Nurse (LPN) A 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.