The Orchards at Roseville

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00131345. Based on observation, interview, and record review, the facility failed to provide a safe, clean, homelike environment, in eight resident rooms (Room #'s 106, 200, 204A, 207, 210, 212, 214, and 216), resulting in the potential for dissatisfaction in living conditions. Finding include: On 12/07/2022 at 9:21 AM, a tour of the facility was completed. In room [ROOM NUMBER], crumbs were observed on the floor. There were multiple used gloves on the floor and a brown dried substance on the walls. In room [ROOM NUMBER]A, the sheets were observed to be stained with a red substance on them. The wall had a brown dried substance on it as well. In room [ROOM NUMBER], multiple gloves were observed on the floor. Napkins and a cup were observed on the floor. In room [ROOM NUMBER] a pile of dust was observed in the middle of the room. There were multiple used gloves on the floor and the nightstands. In room [ROOM NUMBER], an unknown sticky substance was on the floor. Crumbs 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 Resident 87 (R87) On 12/07/22 at 10:15 AM, R87 was asked about their stay at the facility and explained, the facility needs more help. R87 stated, Yesterday I went to an appointment and when I came back, I was in the wheelchair for a long time. I use a mechanical lift and it took over an hour because they said there was not enough qualified Hoyer staff to help. R87 explained that this has happened before and that they have wounds that are painful if they sit in the chair for long periods of time. On 12/09/22 at 10:31 AM, R87 was asked about their night and stated, It's just so hard to get help from an aide. I waited an hour and 20 minutes. My night did not go well. On 12/09/22 at 12:34 PM, R87's call light was observed to be activated, the HRD (human resources director) was observed to go into R87's room [room [ROOM NUMBER]] at 12:35pm. R87 stated, Tell someone I need to be changed. The staff exited out of the room and the call light was now observed off. At 12:37 PM, medical records staff was overheard talking…

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 MI00130598. Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff were available, affecting three residents (R24, R87 and R23) from a total sample of 39, nine confidential group residents, and potentially all residents residing in the facility, resulting in, unmet care needs, dissatisfaction with the care provided, and lack of resident monitoring with the potential to affect resident safety. Findings include: On 12/7/22 at 3:15 PM, resident council meeting notes for the months of August 2022 through November 2022 were reviewed and revealed the following, October 19, 2022, call lights are not being answered in a timely manner (when they answer the lights they come back 2hrs (hours) later). November 22, 2022, still not answering call lights, if they do they just turn the light off and come back 2 hrs later to assist. On 12/8/22 at 11:13 AM, a confidential group meeting was held with nine confidential group residents 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 Based on observation, interview and record review, the facility failed to maintain dignified chair position and safely transport one resident (R64) of three residents sampled for positioning and mobility, resulting in the potential for injury, and embarrassment utilizing the reasonable person concept. Findings include: On 12/07/2022 at 08:53 AM, R64 was observed in a tan colored, custom high back wheelchair in the busy hallway in front of the lobby. R64 was sitting with their back on the seat portion of the chair, and their legs extended up resting above and over the seat back of the wheelchair. R64's head was upside down resting on the foot pedals of the wheelchair. The resident was being transported down the hallway in that position with an unknown staff member pulling the wheelchair behind them. There were several staff members and residents in the hallway. On 12/09/2022 at 08:13 AM, R64 was observed in the dining room in their wheelchair with their head resting at the foot of the wheelchair and their feet…

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 inform residents, families, and visitors of the location of the survey results (Statement of Deficiencies (Form CMS-2567) and the Statement of Isolated Deficiencies generated by the most recent standard survey and any subsequent surveys) for nine confidential residents who attended a confidential group meeting, resulting in the potential for residents, families, and visitors to be uninformed of the facility's deficient practices. Findings include: During a group meeting that was conducted in the facility on 12/9/22 at 11:13 AM, all nine residents who attended the meeting verbalized that they were unaware of the location of the most recent and past survey results. On 12/8/22 at 4:45 PM, a tour of the facility resulted in the survey binder/survey results unable to be located. On 12/9/22 at 8:30 AM, the Administrator (NHA) was interviewed regarding the location of survey results at the facility and stated, It's in the first floor south dinning room. Other places I've worked at, it's been located up front. 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.

Based on observation, interview, and record review, the facility failed to revise and/or update the plan of care related to falls for one sampled resident (R83) out of one reviewed for falls, resulting in the potential for continued falls and injury. Findings include: On 12/07/2022 at 9:30 AM, R83 was observed received an x ray of the right shoulder. An unidentified nurse stated that R83 was receiving a x ray due to having a recent fall. A review of six months of incident and accident reports for R83 revealed that they had falls on the following dates, 8/25/22,9/26/22,9/30/22,10/18/22,10/21/22, 11/20/22, 12/5/22, and 12/6/22. Further review of the care plan revealed that the interventions were not updated or revised following each fall. On 12/13/2022 at 9:28 AM, an interview was completed with the Director of Nursing (DON) regarding falls in the facility. The DON stated that interventions should be implemented immediately following a fall and the care plan should be updated to reflect those falls. The DON stated that R83's care plan should have been updated with an intervention…

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 inttake MI00130598. Based on interview and record review, the facility failed to complete weekly skin assessments for one resident (36) out of two reviewed for skin assessments, resulting in the potential for missed skin alterations. Findings Include: On 12/07/2022 at 9:37 AM, an interview was conducted with R36 regarding their care in the facility. R36 stated that they thought that they were developing bedsores, but no one will tell them anything. R36 was queried as to if the staff checks their skin weekly. R36 stated that this does not happen. A review of the medical record revealed that R36 had skin assessments completed on the following dates in 2022, 3/2, 3/23,7/4, 7/6,9/23, and 11/1. On 12/09/2022 at 12:31 PM, an interview was conducted with the Wound Care Nurse (WCN) H regarding skin assessments being completed in the facility. WCN H stated that floor nurses are responsible for completing skin assessments. WCN H stated that skin assessments should be completed weekly, and that it has been identified as a problem in the facility. WCN H stated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to complete weekly skin assessments and/or apply a heel boot consistently for two residents (R97 and R23) of three reviewed for pressure ulcers, resulting in the potential for unassessed, worsened, or new wounds. Findings include: Resident 97 (R97) On 12/07/2022 at 09:29 AM, R97 was observed awake in bed. The resident had clear speech and answered questions appropriately. R97 was asked about the condition of their skin and explained that they had a wound on their left hip. The resident further explained that the wound had been there for awhile and that it caused pain occasionally. A record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed R97 was independent with decision making and needed extensive assistance with bed mobility and transfers. R97 was most recently admitted to the facility on [DATE] with the diagnoses of Anxiety and Depression. A record review of the Physician Orders for R97 revealed the following: Apply…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain safety during care, for two sampled residents (R23 and R83) of four reviewed for accidents, resulting in a fall from bed and shoulder pain. Findings include: On 12/07/22 at 12:19 PM, R23 reported that they fell out the bed about 3 weeks ago. R23 was asked if they were alone when the fall happened and R23 stated, No I was with a CNA(Certified Nursing Assistant). R23 asked how the fall happened and stated, I fell off the bed. [CNA ] was washing me up. R23 explained that they hit their head. A review of R23's incident report revealed, Date: 11/10/22. Type: Fall. Incident Description: CNA said resident rolled out of bed during care. Resident observed on floor on left side facing window. Did not hit head. c/o (complaint of) left arm pain and left humorous pain rates, a 6 on scale 1-10. Moves all extremities, no neur deficits. [Physician] notified of fall and ordered x rays. Resident Description: I rolled out of bed. my left arm and…

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

Based on observation, interview and record review, the facility failed to provide one resident (R26) with their ordered therapeutic diet out of one reviewed for nutrition, resulting in the potential for aspiration. Findings include: On 12/07/2022 at 1:31 PM, R26 lunch was observed. A review of their meal ticket noted that R26 was on a mechinal soft diet and had been served a piece of ham that was cut into pieces by the certified nursing assistant. On 12/8/2022 at 12:42 PM, an interview was conducted with Dietary Manager G who stated that R26's ham should have been ground up when it came up from the kitchen and would look into it. A review of a facility policy titled; Nutritional Care did not address therapeutic diets.

Based on observation, interview and record review, the facility failed to maintain an nebulizer mask in a sanitary manner, for one Resident (R69), resulting in the likelihood for infection. Findings include: On 12/07/22 at 9:21 AM, R69 was observed in bed and on the overbed table was a nebulizer and tubing next to the breakfast tray. On 12/07/22 at 12:41 PM, R69's overbed table was on the side of the bed with the nebulizer mask not in a bag laying on the table. On 12/08/22 at 9:40 AM, R69's nebulizer mask was on the overbed table, in the same position. On 12/13/22 at 2:36 PM, the Director of Nursing was asked the facility's process for nebulizer mask not in use and stated, Should be in a bag.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake #MI00131359. Based on observation, interview and record review, the facility failed to administer available pain medication as ordered to two residents (R321 and R97) of two residents reviewed for pain management, resulting in unnecessary prolonged pain. Findings include: Resident 321 (R321) A record review of the Electronic Medical Record (EMR) for R321 revealed the resident was admitted to the facility following a motor vehicle accident (MVA) on 09/15/2022 with the diagnoses of Right Pubis Fracture, Fracture of the 5th Metacarpal Bone of the Right Hand, Left Fibula Fracture and Multiple Right Rib Fracture. R321 discharged from the facility (per their initiation) on 09/19/2022. The Minimum Data Set (MDS) assessment dated [DATE] revealed that R321 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognition and needed minimal assistance with activities of daily living. A record review of the hospital discharge record prior to R321's admission to 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 interview and record review the facility failed to ensure that two confidential group residents were offered bedtime snacks of nine residents reviewed for snacks, resulting in resident dissatisfaction and the potential for nighttime hunger. Findings include: On 12/8/22 at 11:13 AM, a group meeting was held with nine confidential group residents and the group was asked about being offered bedtime snacks. The group indicated that bedtime snacks were typically brought to the unit, placed on the counter and Residents who are able to get to the counter get snacks, residents who are in bed and unable to get out of bed do not. All group members expressed dissatisfaction with this arrangement regarding the distribution of bedtime snacks. On 12/9/22 at 9:15 AM, all nine confidential group residents' electronic medical records (EMR) were reviewed over the past thirty days for documentation of bedtime snacks being offered to them. Results of the EMR review revealed that two confidential group residents had no documentation in their EMR of having been offered bedtime snacks. On 12/9/22…

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 document and/or offer the pneumonia vaccine for three residents (R97, R39, R34) of five residents reviewed for vaccinations, resulting in the potential for infection. Findings include: Resident 39 (R39) On 12/07/2022 at 10:19 AM, R39 was observed awake in bed with their eyes open wearing a shirt. The resident had clear speech and was able to answer questions appropriately. R39 was asked about the care received in the facility and explained that they were waiting to get out of bed for the day, but needed help from staff first. A record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed R39 was most recently admitted to the facility on [DATE] with the diagnoses Anemia and Hypertension. R39 needed extensive assistance with bed mobility and transfers. R39's Brief Interview for Mental Status (BIMS) score was not assessed. A review of the immunizations for R39, revealed no pneumonia vaccination record. Resident 97 (R97) On 12/07/2022 at…

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