Greenfield Rehab and Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the facility assessment staffing was revised upon the reopening of a previously identified closed unit. This has the potential to affect all 87 residents. Findings include:Observations made from 7/23/25 to 7/25/25 revealed the facility had all units being utilized (residents assigned to rooms), including the 2 South unit.Review of the revised Facility assessment dated [DATE] documented under the section for staffing plan ratios by unit as the 2 south unit as not being staffed d/t (due to) census.Page 14 of 14 of the Facility Assessment had a section for Review and Update after Significant Changes - Any changes made within the facility assessment after the initial completion will be initialed and dated at the area of the change as well as documented below. The most recent revision signature was 4/1/25 by the current Administrator. This assessment was not updated to reflect the staffing plan for 2 South now that it was actively being…

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 Minimum Data Set (MDS) Assessments were completed accurately for one (R68) of residents reviewed. Findings include:According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual. Link to the LTCF RAI User's Manual: https://www.cms.gov/files/document/finalmds-30-rai-manual-v1191october2024.pdf: .an accurate assessment requires collecting information from multiple sources .Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician .On 7/22/25 at 10:19 AM, R68 was observed lying in bed. R68's left hand appeared to be contracted with his fingers completely bent at the second knuckle and his fingertips were almost touching the upper most aspect of the palm. R68 was asked if he could open his hand. R68 explained he was not able to move any of his fingers on his left hand. R68 was asked if he could straighten his legs…

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 that resident's call light was within reach for one (R48) one of resident reviewed for call lights, resulting in the potential for unmet response for care needs or fall(s) etc. Findings include: R48R48 was a long-term resident of the facility, originally admitted to the facility on [DATE]. R48's admitting diagnoses included encephalopathy (Encephalopathy is a group of conditions that cause brain dysfunction. Brain dysfunction can appear as confusion, memory loss, personality changes and/or coma in the most severe form-source: https://my.clevelandclinic.org/health/diseases/encephalopathy), Chronic Obstructive Pulmonary Disease (COPD), abnormalities of gait and mobility and adjustment disorder with mixed anxiety and depressed mood. Based on Minimum Data Set (MDS) assessment dated [DATE], R48 needed supervision with toileting, transfers, and moderate assistance with dressing.An initial observation was completed on [DATE] 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.

Based on observation, interview and record review, the facility failed to ensure the window air conditioning (AC) unit was properly sealed to maintain a safe, clean, comfortable environment for two (R15 and R77) of four residents reviewed for environmental concerns. Findings include:On 7/22/2025 at 10:58 AM, R15 was observed lying in bed. A window AC unit was observed to be poorly sealed, and the side and bottom of the unit had gaps that were open to the outside. A green insect with wings was observed on the pillowcase to the left of the resident's head.On 7/24/2025 at 10:33 AM, an observation of the 2 north unit was conducted with the Maintenance Director (Staff 'R'). When asked about who maintains the facility's window AC units, Staff 'R' reported they did. At that time, Staff 'R' was requested to observe several resident rooms with the window AC units.On 7/24/25 at 10:36 AM, the room occupied by R15 and R77 was observed with Staff 'R'. The window AC unit was observed to be in the same manner as observed on 7/23/25. When Staff 'R' was asked about the lack of proper seal, 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 Based on observation, interview and record review the facility failed to report an injury of unknow origin to the State Agency (SA) for one R10 out of three residents reviewed for abuse. Findings include: On 7/2/25 at approximately 9:23 AM, R10 was observed sitting in a wheelchair near the main dining room. The resident was alert but unable to answer questions asked.A review of R10's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Epilepsy, Type II diabetes, recurrent falls and paranoid schizophrenia. A review of the resident Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 0/15 (severely cognitively impaired).Continued review of R10's clinical record revealed the following:4/3/25: Physician Team Progress Note: .seen for facial swelling and bruising, facial bruising and swelling noted on exam.? Recent injury/fall.check facial x-ray, ice compression as tolerated. *It should be noted that there…

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 conduct a care planning review in coordination with a significant change Minimum Data Set (MDS) assessment for one (R62) of one resident reviewed for hospice, resulting in the lack of opportunity for the resident, legal representatives, and hospice to participate in review of interventions which pertained to their care. Findings include:Review of the clinical record revealed R62 was admitted into the facility on 3/28/25, hospitalized on [DATE], readmitted on [DATE] and signed onto hospice on 6/19/25. Diagnoses included: encounter for palliative care, anemia, other asthma, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, other sequelae of cerebral infarction, type 2 diabetes mellitus without complications, obstructive sleep apnea, hyperlipidemia, depression, anxiety disorder, unspecified intracranial injury without loss of consciousness, and bilateral hearing loss.According to the significant Minimum Data Set (MDS)…

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 showers and/or nail care were provided to one (R50) of four residents reviewed for activities of daily living (ADL's). Findings include:On 7/23/25 at approximately 10:05 AM, R50 was observed lying in bed. The resident was alert and able to make needs known. The resident was asked about care provided in the facility and reported that they were upset they had not yet seen a doctor per their request the day prior. They also reported that they had not had a shower since being admitted to the facility as the facility told them they did not have a chair large enough for them to fit in the shower room. R50 reported they were admitted from a sister facility. A review of R50's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Type II diabetes, chronic pulmonary disease and COPD (chronic obstructive pulmonary disease). A review of the R50's MDS noted the resident had a BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #'s 1214456 and 2569467. Based on observations, interviews and record reviews, the facility failed to timely and accurately assess, treat and follow up with a medical provider for change in condition for one resident(R83) of one resident reviewed for a change in condition,resulting in R83 being transferred to the hospital for a cellulitic scalp wound. Findings include: R83 On 7/23/25 a complaint submitted to the State agency was reviewed which alleged R83 had been transferred to the hospital for an infected wound on their head. On 7/23/25 the medical record for R83 was reviewed and revealed the following: R83 was initially admitted to the facility on [DATE] and transferred to the hospital on 7/14/25. A review of R83's MDS (minimum data set) with an ARD (assessment reference date) of /8/25 revealed R83 was dependent on facility staff with most of their activities of daily living. R83's BIMS score (brief interview for mental status) was 15 indicating intact cognition. A 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 Based on observation, interview and record review, the facility failed to ensure timely interventions and treatments for one (R6) of three residents reviewed for pressure ulcers, resulting in R6 acquiring a Stage 3 (full-thickness skin loss) pressure ulcer. Findings include:On 7/22/25 at 10:08 AM, R6 was observed lying in bed. R6 was asked if he had any wounds or sores. R6 explained he wasn't sure.Review of the clinical record revealed R6 was admitted into the facility on 9/11/24 with diagnoses that included: dementia, heart disease and kidney disease. According to the Minimum Data Set (MDS) assessment dated [DATE], R6 had severely impaired cognition. The MDS assessment also indicated R6 had one facility acquired Stage 3 pressure ulcer.Review of a Skin - Total Body Eval dated 6/14/25 by Licensed Practical Nurse (LPN) T read in part, .Does the resident have any skin abnormalities? 1. Yes. Site: wound to coccyx.Review of a Skin/Wound progress note dated 6/16/25 at 10:36 AM by LPN E, who served as the Wound Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake #1214313Based on interview and record review the facility failed to provide proper care for one (R87) out of three residents reviewed for falls, resulting in R87 being transferred to the hospital and examined for injuries. Findings include:A complaint was filed with the State Agency (SA) that alleged the facility staff failed to ensure R87, a noted two-person assist for bed mobility, was properly changed resulting in a fall with injury requiring hospitalization. Hospital (name redacted) records were reviewed and documented, in part: .7/8/25.ED (Emergency Department) Provider Note:.R87 presents with a fall and right arm pain.Fall and associated injuries- Experienced a fall in a rehabilitation facility when only one person was assisting, despite requirement for two-person assist.most likely during midnight shift.Right arm pain localized to the proximal humerus following fall.Mild head pain.x-rays significant for a possible nondisplaced medial humerus fracture.CT (Computed…

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 observations interview and record review the facility failed to ensure that oxygen was administered according to physician's orders for one resident (Resident #39) of one reviewed for respiratory care. Findings include:On 7/22/25 at 9:54 AM, Resident #39 was observed lying in bed with a nasal cannula in their nose. Resident #39, was asked, did they normally use oxygen and how many liters where they on. Resident #39 reported that they used oxygen and that it should be on 2 liters. An observation of the concentrator in room was on , but set to administer 0 liters of oxygen. There was no audible sound coming from the concentrator to indicate that it was running. On 7/22/25 at 10:00 AM, Nurse A, was asked to come to Resident #39's room and observed the oxygen concentrator. Nurse A was then asked was Resident #39 supposed to be on oxygen and if so, why wasn't the concentrator working. Nurse A reported that Resident #39 was to be on oxygen and that the concentrator was not plugged in. Nurse A then plugged in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the timely acquisition and administration of medication for one (R13) of one resident reviewed for pharmacy services. Findings include:Review of the clinical record revealed R13 was admitted into the facility on 8/10/23, and readmitted on [DATE] with diagnoses that included: Alzheimer's disease, adjustment disorder with mixed disturbance of emotions and conduct, dementia with agitation, and anxiety disorder.According to the Minimum Data Set (MDS) assessment dated [DATE], R13 had severe cognitive impairment and received antipsychotic medication on a routine basis.Review of the current physician orders included two separate orders for quetiapine (Seroquel - an antipsychotic medication). One order started on 1/31/25 to have 25 MG (Milligrams) one tablet by mouth at bedtime; and the second order started on 5/14/25 to have 0.5 MG tablet by mouth one time a day (scheduled for 2:00 PM).Further review of the Medication Administration Records (MARs)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow infection control practices related to implementation of enhanced barrier precautions (EBP) upon identification of a new wound for one (R62) of three residents reviewed for pressure ulcers. Findings include:On 7/22/2025 at 10:19 AM, the hallway outside of R62's room had a cart with some personal protective equipment (PPE), however there was no signage posted to indicate if anyone in the shared room was on any infection control precautions. Other rooms throughout the hallway were observed to have signage that indicated they were on EBP. Upon entering the room, R62 was observed lying in a bed with a low air loss mattress. The resident did not wake up when approached.Review of the clinical record revealed R62 was admitted into the facility on 3/28/25, hospitalized on [DATE], readmitted on [DATE] and signed onto hospice services on 6/19/25. Diagnoses included: encounter for palliative care, anemia, other asthma, chronic obstructive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number(s): MI00152130. Based on observation, interview, and record review, the facility failed to ensure call lights were within reach of five (R605, R606, R607, R608, and R609) of six residents reviewed for accommodation of needs. Findings include: A review of a complaint submitted to the State Survey Agency revealed an allegation of call lights not being accessible to a resident. On 4/24/25 at 9:25 AM, R605 was observed lying in bed, crying. R605's call light was observed hanging from the head of the bed out of reach from the resident. At that time, Licensed Practical Nurse (LPN) 'F' entered R605's room to speak with the resident. LPN 'F' did not ensure the call light was placed within reach of the resident prior to exiting the room. Then, Registered Nurse (RN) 'G' entered R605's room to assess what was going on. RN 'G' did not ensure the call light was placed within reach of the resident prior to exiting the room. On 4/24/25 at 10:39 AM, R606 was observed in bed sleeping.…

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

This citation pertains to Intake Number: MI00149259. Based on observation, interview, and record review, the facility failed to ensure a resident bathroom was maintained in a clean, comfortable, and safe manner for one (R803) of three residents reviewed for the environment, resulting in the resident having to change their clothing often due to leaking water, having to wait for a community bathroom, and feeling frustrated. Findings include: On 1/15/25 at approximately 8:55 AM, R803 was observed walking in the hallway of the 1 South Unit. R803 asked, When will my toilet be fixed? It has been seven days like this and now we don't have a toilet to use. At that time, R803 was interviewed regarding their concerns about the toilet. R803 reported seven days ago, the ceiling over the toilet began leaking onto the resident and their roommate when they were seated on the toilet. R803 said every time they used the toilet they had to change their clothing because it would get wet from whatever was leaking from above. R803 stated, The toilet drains on you. R803 reported as of the previous day,…

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 #MI00149259 Based on observation interview and record review, the facility failed to ensure medications were administered per the Physician's orders for one resident (R801) of two residents reviewed for medication administration. Findings include: On 1/15/25 a concern submitted to the State Agency was reviewed and alleged R801 was not receiving their medications as ordered. On 1/15/25 at approximately 8:23 a.m., R801 was observed in the hallway, up in their wheelchair. R801 was asked if they had any concerns regarding receiving their medications and they reported they did and that the facility keeps missing their medications because another Nurse on the other side has to give them. R801 reported they were not given their Synthroid or their regular Tylenol that morning and that the issue happens frequently. On 1/15/25 the medical record for R801 was reviewed and revealed the following: R801 was initially admitted to the facility on [DATE] and had diagnoses including Hypothyroidism…

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: MI00148850. Based on observation, interview, and record review, the facility failed to ensure recommendations from the orthopedic specialist were implemented for one (R802) of one resident reviewed for coordination of care to outside appointments. Findings include: A review of a complaint submitted to the State Agency revealed an allegation that the facility was not properly coordinating and assisting R802 with appointments with outside providers. On 1/15/25 at 8:30 AM, R802 was observed lying on their bed. When R802 attempted to reach for the remote control for the television, they appeared to have difficulty moving their arm. When queried about any concerns they had with their care in the facility, R802 reported their main issue was with the facility not following through with recommendations and orders from medical specialists. R802 reported that she went to an outside provider who recommended a brace for their foot. R802 explained that the braces were never…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake(s): MI00147253 and MI00147444 Based on observation, interview and record review, the facility staff failed to timely report allegations of sexual abuse to the Administrator/Abuse coordinator to ensure timely reporting to the State Agency for one (R901) out of three residents reviewed for abuse. Findings include: A complaint and FRI (facility reported incident) were reported to the State Agency (SA) that alleged on or about 9/25/24 an outside male visitor entered R901's room and allegedly engaged in oral sex with the resident. R901 was noted as suffering from dementia, memory deficit and had a court appointed guardian. On 10/22/24 at approximately 12:44 PM, R901 was observed sitting in their wheelchair. The resident was alert but not able to answer regarding the allegation noted above. A review of R901's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: dementia, psychotic disorder with delusions and memory…

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 # MI00146550. Based on observation, interview, and record review, the facility failed to maintain an effective pest control program, resulting in the presence of gnats, house flies and sewer flies throughout the facility. This deficient practice had the potential to affect all residents in the facility. Findings include: Review of complaints reported to the State Agency included allegations that the facility had bugs/ants getting in. On 9/18/24 from 9:00 AM to 11:45 AM, multiple observations of several flying insects including house flies, sewer flies, and gnats were observed throughout each floor of the building, including the basement. At 9:23 AM, the bottom door seal to the emergency exit/delivery door on the first floor north hallway was observed to be missing. Outside light was visible along the entire bottom of the door (in which bugs/insects were able to enter). At 10:00 AM, an interview and observation of the facility was conducted with the Maintenance Director (Staff 'E') who reported they had been in their role since 2022. They were asked…

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 # MI00146550. Based on observation, interview and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment, affecting multiple residents throughout the facility. Findings include: Review of complaints reported to the State Agency (some as recent as 9/10/24) included allegations that the facility was not clean, had mold, bugs/ants getting in, and had electrical issues with cords. On 9/18/24 at 8:30 AM, the outside of the facility's north parking lot was observed to have several loose wires hanging down from the building and were connected to a large rectangular box that had more loose wires that hung down. The bottom of these wires were observed hanging just next to an external water spout that had visible water drainage coming from the spout. Another area outside the facility, near the emergency exit/delivery area was observed to have long, black, loose cords that hung down from the side of the building. At 9:10 AM, the lower wall heater…

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 that a portable oxygen tank was properly secured while left unattended for one (R405) of one resident reviewed for oxygen use, resulting in the potential for the tank to be knocked over, causing a potential rocketing of the cylinder and injury to residents in the immediate area. Findings include: On 9/18/24 at 9:10 AM, R405 was observed laying in bed, naked from the waist up. The roommate's privacy curtain was drawn so the resident was not visible from the hallway. There was an oxygen concentrator in use with a nasal cannula and was set to three liters. There were two portable oxygen tanks stored next to the resident's bed. One oxygen tank was secured in a metal holder/stand with two wheels, and the other oxygen tank was free-standing right next to the resident's head of bed. The resident reported that tank was empty and unsure of how long it had been like that. On 9/18/24 at 9:14 AM, Nurse 'D' was at their med cart a few doors away and was asked to observe R405's room. Nurse 'D' confirmed the unsecured…

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 resident medications were not left at the bedside for one (R406) of one resident reviewed for medication storage. Findings include: On 9/18/24 at 9:30 AM, R406's bedside table was observed to have a single white circular pill stored on top. The resident was not in the room. On 9/18/24 at 9:33 AM, Nurse 'C' was observed at the medication cart a few rooms down. When asked to observe R406's room, upon entry to the room, Nurse 'C' confirmed the pill on the bedside table and proceeded to don a glove and remove it. They reported they weren't sure who put that there, and it could've been from midnights since they had given the resident their medication earlier in the hallway, and that resident was now in the therapy room upstairs. Nurse 'C' was asked to verify what the medication was and upon reviewing R406's blister packs in the medication cart, it was confirmed the pill was carvedilol (a pill for high blood pressure) which was to be…

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 # MI00145182. Based on observation, interview, and record review facility failed to complete appropriate assessment(s) and provide appropriate interventions and follow the standard(s) of care for Activities of Daily Living (ADL's) resulting in a fall from bed for one (R801) of one Resident reviewed for falls. Findings include: A complaint received by the State Agency alleged R801 had a fall while staff were providing care. R801 R801 was long term resident of the facility originally admitted on [DATE]. R801's admitting diagnoses included: osteoarthritis, stroke, and benign (non-cancerous) brain tumor. R801's Minimum Data Set (MDS) assessment dated [DATE], was reviewed and revealed R801 had a Brief Interview of Mental Status (BIMS) score of 15/15, indicative of intact cognition. An initial observation was completed on 7/1/24, at approximately 11:30 AM. R801 was not in their room. R801 had a regular size bed with regular mattress. There was chair (with an arm rest) on the right side…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number(s): MI00140123 and MI00144352. Based on interview and record review, the facility failed to report actual and alleged physical and verbal abuse to the Abuse Coordinator, law enforcement, and/or the State Agency within the required time frame for six (R7, R21, R33, R35, R50, and R61) of 11 residents reviewed for abuse, resulting in an approximately six month delay in investigating physical abuse of R33 by a staff member who continued to work in the facility during that time. Findings include: R50 and R35 A review of a complaint submitted to the State Survey Agency revealed multiple allegations of resident to resident abuse, including an allegation that R50 physically assaulted R35 by hitting him 5 times in the head. A review of an Incident Note dated 3/27/24 at 4:11 AM, written by Registered Nurse (RN) 'M', revealed, Resident involved in physical altercation at approximately 0325 (3:25 AM) with roommate .Room changed . A review of an incident report for R35 dated 3/27/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number(s): MI00144325 and MI00143575. Based on observation, interview, and record review the facility failed to investigate witnessed and alleged resident to resident physical and verbal abuse and failed to thoroughly investigate a bruised eye of unknown origin for five (R21, R35, R50, R61, R66) of 11 residents reviewed for abuse. Findings include: R50 and R35 A review of a complaint submitted to the State Survey Agency revealed multiple allegations of resident to resident abuse, including an allegation that R50 physically assaulted R35 by hitting him 5 times in the head. A review of an Incident Note dated 3/27/24 at 4:11 AM, written by Registered Nurse (RN) 'M', revealed, Resident involved in physical altercation at approximately 0325 (3:25 AM) with roommate .Room changed . A review of an incident report for R35 dated 3/27/24 at 3:30 AM, completed by RN 'M', revealed, CENA (Certified Nursing Assistant) heard a noise entered the room to investigate sound observed (R50) strike…

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 the resident's active Durable Power of Attorney (DPOA) wishes for their family member's code status was accurately followed for one (R34) out of five residents reviewed for advanced directive/code status. Findings include: On [DATE] at 8:35 AM, R34 was observed walking around in their room. The resident was alert, but not able to answer any questions asked. Review of R34's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Parkinsonism, vascular dementia and depressive disorder. A review of the resident's Minimum Data Set (MDS) dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 1/15 (significantly impaired cognition). The face sheet noted that R34 was a FULL CODE. Continue review of the clinical record documented, the following: [DATE]: DPOA Paperwork: Indicated that R34 had nominated Family Member 1 as their DPOA for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake# MI00142649 Based on observation, interview and record review the facility failed to inform the resident's family/legal guardian of a room change, physician recommendations and enquire as to vaccination recommendations for one (R38) out of two residents reviewed for change in condition. Findings include: A complaint was filed with the State Agency (SA) that alleged that the facility was not informing them as to why the resident was changing rooms, not providing complete medical information and generally not answering and/or returning calls. On 5/13/24 at approximately 8:41 AM, R38 was observed lying in bed. The resident was alert but not able to answer many questions asked. A review of the resident's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Parkinsons Disease, Dementia and falls. Review of the resident's Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) for one resident (Resident #76) of three residents reviewed for Beneficiary Notices, resulting in the resident and/or the representative not being informed of the right to appeal and the potential for undue emotional and financial hardships. Findings include: Record review revealed R76 was admitted for skilled rehabilitation and nursing services after hospitalization on 2/22/24. R76's admitting diagnoses included sepsis, acute respiratory failure, and muscle weakness. Based on the Minimum Data Set (MDS) assessment dated [DATE], R76 had a Brief Interview for Mental Status score of 8/15, indicative of moderate cognitive deficits. During an observation on 5/13/24, at approximately 9:30 AM, in their room R76 reported to the surveyor that they would like to get stronger and walk. Their therapy services ended last week due to their insurance. Review of R76's Electronic Medical Record (EMR) revealed 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.

Based on observation, interview, and record review, the facility failed to appropriately store resident property for two residents (R9, R67) of two reviewed for personal property, allowing for the potential loss and or theft of personal possessions. Findings include: On 5/15/24 at 8:35 AM, A medication storage observation was conducted with Licensed Practical Nurse (LPN) Y with the One South Back medication cart. Observation in the narcotic box identified a Ziplock baggie with black writing identified with R9's name and room number. A Ziplock bag was observed to have one ten-dollar bill on one side, and when turned over, a one-dollar bill. More bills were layered in between but the denominations were not observed. Placed next to the bag of cash, a small black cell phone encased in a black phone case was identified with a return address sticker identifying as a relative of R67. LPN Y acknowledged that resident's money and personal items should not be stored in the medication cart. LPN Y was unclear what the facility policy was for personal property storage, but indicated money was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate assessments were completed for one (R50) of 32 residents reviewed for Minimum Data Set (MDS) assessments. Findings include: On 5/14/24 at 7:42 AM, a review of R50's clinical record revealed R50 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Wernicke's encephalopathy (a neurological disorder). A review of R50's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R50 had no behaviors, including no rejection of care in the seven day look back period from 3/12/24 through 3/18/24. A review of R50's previous comprehensive annual MDS assessment dated [DATE] revealed R50 had no behaviors, including no rejection of care in the seven day look back period from 12/10/23 through 12/16/23. A review of R50's progress notes revealed the following: On 12/11/23, R50 refused medication x 3. On 12/25/23, R50 refused vitals .Resident noncompliant with medication intake and ADL…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a level I Preadmission Screening (PAS)/Annual Resident Review (ARR) Mental Illness/Intellectual Disability/Related Conditions Identification was completed on admission and/or annually and sent to local community mental health for a level II OBRA (Omnibus Budget Reconciliation Act of 1993) evaluation for two (R7 and R67) of three residents reviewed for PASARR. Findings include: A review of R7's clinical record revealed R7 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Schizophrenia, dementia with other behavioral disturbance. A review of R7's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the following: Section A1500 for Preadmission Screening and Resident Review (PASRR) was marked No for the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? . It was documented in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to consistently monitor blood pressure for one (R7) of one resident reviewed for a change in condition who was prescribed multiple medications to treat high blood pressure. Findings include: A review of R7's clinical record revealed R7 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: lupus (an autoimmune disorder) and hypertension. R7 was transferred to the hospital on 4/25/24. A review of a progress note dated 4/25/24 revealed the following regarding R7 on that date, Writer attempted to wake resident up for breakfast and noticed resident unable to respond to verbal commands. Once writer attempted to reposition resident, she was unable to sit upright in bed. Vitals obtained BP (blood pressure) 189/93 (mmHg - millimeters of mercury) (According to the guidelines of American Heart Association - AHA, a systolic blood pressure - top number - higher than 180 indicates a hypertensive crisis requiring emergent care)…

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

This citation pertains to Intake MI00137192 and MI00140349 Based on observation, interview and record review, the facility failed to implement preventative interventions and timely assess and identify formation of pressure ulcers for one (R75) of five residents reviewed for pressure ulcers resulting in R75 acquiring one Stage 2 (partial-thickness loss of skin with exposed dermis) and two Stage 3 (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer) pressure ulcers. Findings include: On 5/13/24 at 10:35 AM, R75 was observed lying in bed with dressing on both of their ears. R75 did not respond in any way to questions asked. Review of the clinical record revealed R75 was admitted into the facility 2/18/24 with diagnoses that included: metabolic encephalopathy, altered mental status and diffuse traumatic brain injury. According to the Minimum Data Set (MDS) assessment, dated 3/29/24, R75 had severely impaired cognition and was dependent on staff for all activities of daily living (ADL's). Review of R75's progress notes revealed: A Skin/Wound Note by Wound…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the recommendations and physician orders for assistive devices to maintain range of motion and positioning for two (R12 and R30) of three residents reviewed for positioning resulting in the potential for decline in range of motion and worsening of contractures. Findings include: R12 R12 was a long-term resident of the facility. R12 was originally admitted to the facility on [DATE]. R12's admitting diagnoses included hemiplegia (paralysis of one side of the body) due to stroke, contracture of joints, dementia, and anxiety. Based on the Minimum Data Set (MDS) assessment dated [DATE], R12 had a brief Interview for Mental Status (BIMS) score of 00/15, indicative of severe cognitive deficits. An initial observation was completed on 5/13/24 at approximately at 10:50 AM, R 12 was observed sitting in their wheelchair watching TV. R12's left elbow was bent, wrist bent, and fingers bent in the closed fist position with their fingertips…

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 appropriate supervision and/or positioning during showers and therapy for cognitively impaired residents for two (R436 and R11) of four residents reviewed for falls, resulting in R436 sustaining a compression fracture to the thoracic vertebrae and R11 hitting their head. Findings include: R436 On 5/13/24 at 8:38 AM, R436 was observed lying in their bed. A back brace was observed hanging on the headboard. R436 was asked about the back brace. R436 indicated they had fallen in the shower and needed the back brace now. Review of the clinical record revealed R436 was admitted into the facility on 1/20/24 and readmitted on [DATE] with diagnoses that included: stroke, fracture of first thoracic vertebra and wedge compression fracture of T11-T12 vertebra. According to the Minimum Data Set (MDS) assessment dated [DATE], R436 had severely impaired cognition and required the supervision of staff for showers and/or bathing. Review of R436's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement recommendations made by the contracted behavioral health provider for one (R67) resident reviewed for behavioral health services. Findings include: On 5/13/24 at approximately 8:30 AM, R67 was observed in her room. R67 was pleasant and participated in an interview. R67 talked about her love for playing bingo and spoke about the recent prizes she won. A review of R67's clinical record revealed R67 was admitted into the facility on 9/1/22 and readmitted on [DATE] with diagnoses that included: dementia with psychotic disturbance, anxiety disorder, adjustment disorder, psychotic disorder with hallucinations, and major depressive disorder. A review of R67's Minimum Data Set (MDS) assessment dated [DATE] revealed R67 had intact cognition with no behaviors, hallucinations, or delusions. A review of a Psychiatric Evaluation & Consultation reported dated 3/25/24 revealed the following documentation: Chief Complaint: 'I'm scared and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to evaluate the competency and obtain guardianship for a resident with severely impaired cognition who did not have a resident representative for one (R35) residents reviewed for social services. Findings include: On 5/13/24 at approximately 9:00 AM, R35 was observed seated on the side of his bed eating breakfast. R35 appeared disheveled, wearing stained clothing and with a scruffy beard. R35 was interviewed and when asked questions, R35 did not always answer in a way that was relevant to the question asked. R35 appeared confused. A review of R35's clinical record revealed R35 was admitted into the facility on [DATE] with diagnoses that included: vascular dementia. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R35 had severely impaired cognition. Further review of R35's clinical record revealed no paperwork that indicated R35 had a legal guardian or advance directive that named a decision maker in the event R35 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.

Based on observation, interview, and record review, the facility failed to accurately document and reconcile two controlled medications observed in a random surveillance of the narcotic drawer for one resident (R9) of one reviewed during medication storage and labeling observation. Findings include: On 5/15/24 at 8:35 AM, a medication storage observation was conducted with Licensed Practical Nurse (LPN) Y with the One South Back medication cart. A random selection from the controlled substance drawer identified R9 with Gabapentin (an anticonvulsant medication to treat seizures and neuropathic pain) 100 milligram (mg) capsules. The blister pack was observed and contained 11 capsules. The narcotic binder documented Gabapentin 100 mg remained with 12 capsules. A second controlled blister pack medication was pulled for R9 and identified as Clonazepam (a medication to treat seizures, panic disorders, bi-polar, and anxiety) 0.5 mg. The blister pack was observed with 12 tablets. The narcotic binder documented Clonazepam with 13 tablets remaining. LPN Y acknowledged that both medications…

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 schedule follow up dental services for one resident (R236) of two residents reviewed for dental services. Findings include: R236 was a long-term care resident, originally admitted to the facility on [DATE]. R236 was recently hospitalized and readmitted back to the facility on 5/8/24. R236's admitting diagnoses included dementia, anxiety and mood disorder, and recent pneumonia due to flu. Based on the Minimum Data Set (MDS) assessment dated [DATE], R236 had a Brief Interview for Mental status score of 10/15 indicative of moderate cognitive impairment. An initial observation was completed on 5/13/24 at approximately 1:45 PM. R236 was observed in their bed and they were receiving oxygen. R236 had multiple fractured teeth. On 5/14/24, at approximately 10:15 AM during a follow-up observation, R236 was queried about their breakfast that morning and their teeth. R236 reported that I don't have all of them. Little blood comes out. R236 asked 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 provide timely skilled rehabilitation (physical therapy) services as ordered for one (#33) of one sampled resident reviewed for rehab/restorative services resulting in the delay in evaluation for physical therapy services to address the change in mobility and feelings of frustration. Findings include: A record review revealed R33 was a long-term resident of the facility originally admitted on [DATE]. R33 had had hospitalization during their stay at the facility and was most recently readmitted to the facility on [DATE]. R33's diagnoses included polyneuropathy, liver failure, spinal stenosis, and osteoarthritis. Based on the most recent Minimum Data Set (MDS) assessment dated [DATE], R33 had a Brief Interview for Mental Status (BIMS) score of 10/15, indicative of moderate impairment with their cognition. An initial observation was completed on 5/13/24, at approximately 12:45 PM. An interview was completed during this observation. During…

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 MI00142547 Based on interview and record review, the facility failed to ensure vaccine consent/declination was signed by a resident's legal guardian, and ensure accurate tracking and administration of the pneumococcal vaccinations for residents residing in the facility for three (R38, R1 and R216) of five residents reviewed for influenza and pneumococcal vaccinations. Findings include: Review of a facility policy titled, Vaccination - Influenza dated 10/13/23 read in part, .Prior to the vaccination, the resident or the resident's legal representative will be provided information and education regarding the benefits and potential side effects of their influenza vaccine which will be documented in the resident's medical record . Individuals receiving the influenza vaccine, or their legal representative, will provide informed consent to the administration of the vaccine which will be documented in the resident's medical record . R38 Review of the clinical record revealed R38 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.

Based on interviews and record reviews the facility failed to consistently implement their Compliance and Ethics Program, for two (R's 704 and 705) of five residents reviewed for abuse/mistreatment and had the potential to affect all 81 residents that resided in the facility, Resulting in the failure of the Administration staff to report suspected violations, prohibit the retributions of employees who report suspected violations (Unit Manager- UM I), failed to consistently identify and respond to violations, and implemented appropriate disciplinary mechanisms for reportable violations (Certified Nursing Assistant- CNA K). Findings include: Review of the facility policy titled Compliance and Ethics Program Policy with the issue date of 11/1/2019, documented in part . This facility is committed to compliance and high ethical standards. The facility has designed, implemented, and enforced a Compliance and Ethics program for promoting quality of care and preventing and detecting criminal, civil and administrative violations . As part of the facility's culture of compliance, the facility…

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

This citation pertains to intake: MI00144245. Based on interviews, and record reviews the facility failed to ensure the signage of employee rights related to retaliation against the employee for reporting a suspected crime was posted in the facility and failed to prohibit and prevent the retaliation of one employee (Unit Manager- UM I) who was terminated during the investigation conducted for an alleged allegation of abuse for (R704) and an alleged verbal allegation of abuse for (R705) two of five residents reviewed for Abuse/Mistreatment, resulting in the likelihood for mistreatment and/or abuse to occur, the termination of UM I and the likelihood of unreported mistreatment and/or abuse to be reported by the facility staff in fear of retaliation from the facility Administration. Findings include: On 5/1/24 at approximately 1:55 PM, the Assistant Director Of Nursing (ADON) was asked to complete a walk through of the facility with the surveyor and show every staff break room and boards of the facility where signage is hung for the staff to review. The second-floor signage boards,…

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

This citation pertains to intake(s): MI00144212 & MI00144245. Based on interviews, and record reviews the facility failed to develop and/or implement policies and procedures for ensuring the timely reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act, for an injury of unknown origin (R704), failed to report an allegation of a suspicion of verbal abuse (R705), failed to report an allegation of physical abuse (R708) and failed to report an accurate investigation to the State Agency regarding an injury of unknown origin (R704), for three of five residents reviewed for abuse. Findings include: Review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) on 4/25/24 documented in part the following, . Resident Name: (R704) . Was Harmed? Yes . Type of Injury/Harm: Physical . Type of Alleged Perpetrator: Unknown . Type of Alleged Incident: Injury of unknown Source . Suspected Crime: No . Date/Time Incident Discovered: 4/25/2024 10:00 AM . Incident Summary: Nurse reported a swollen hand. Resident was assessed for pain. X-ray was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to provide appropriate and consistent interpreter and/or translation services for three (R's 704, 708 & 711) of five residents reviewed for abuse/mistreatment. Findings include: R704 Review of the medical record revealed R704 was initially admitted to the facility in 2017, with a readmission date of 10/7/21 and diagnoses that included: dementia, hemiplegia and hemiparesis affecting the right dominant side, chronic kidney disease and most recently a fracture of the fourth metacarpal bone. A Brief Interview for Mental Status (BIMS) score completed on 4/25/24 documented a score of 3, which indicated severely impaired cognition. R704 required staff assistance for all Activities of Daily Living (ADLs). Review of a care plan titled Alteration in Communication r/t (related to) Language barrier documented in part . My primary language is Arabic/Chaldean and I also speak English . Communication board have been provided . The care plan documented…

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: MI00144212. Based on observation, interviews, and record reviews the facility failed to consistently implement preventative interventions to prevent falls for one (R708) of one resident reviewed for falls. Findings include: Review of a complaint submitted to the State Agency (SA) documented concerns frequent falls for R708 and unreported injuries. Review of the medical record revealed R708 was admitted to the facility initially in 2011, with a readmission date of 3/15/23 and diagnoses that included: dementia, falls and epilepsy and required staff assistance for all ADLs. Review of the Facility Incident reports for falls, compared to R708's progress notes, revealed the following: On 1/7/24 at 10:52 PM, an unwitnessed fall, that resulted in a deep cut to the left eye. The IDT (Interdisciplinary team) implemented a scoop mattress on 1/8/24 identifying the root cause as seizures. On 1/10/24 at 12:15 PM, an incident of an unwitnessed fall. The IDT team implemented frequent rounding and to complete a urinalysis and culture and sensitivity test. On 1/13/24…

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 #MI00144005. A complaint was received by the State agency that alleged a Certified Nurse Aide (CNA) neglected their patients. Based on interview and record review the facility failed to ensure an allegation of abuse by a staff member was reported to the abuse coordinator for two residents (R#'s 602 and 603) of seven residents reviewed for abuse. Findings include: A review of a facility provided policy titled, Abuse updated 5/2023 was conducted and read, .Identification: .Possible indicators of abuse include, but are not limited to: Resident, representative, or staff reports of abuse .Initial Reporting: The facility will ensure that all allegations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, and crimes are reported immediately to the Administrator . On 4/23/24 at 3:20 PM, a phone interview was conducted with the complainant and they alleged CNA 'B' neglected their patients on the night shift (11PM-7AM) of 4/6/24 into 4/7/24. They said CNA 'B' did not do their rounds, did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00144005 A complaint was received by the State Agency a resident was improperly transferred and suffered a fall. Based on observation, interview, and record review the facility failed to ensure a proper transfer for one resident (R606) of three residents reviewed for accidents resulting in a fall. Findings include: On 4/24/24 at at 9:54 AM, a review of R606's clinical record revealed a progress note dated 3/26/24 at 3:46 PM that read, Writer was at medication cart by nursing station when I heard screaming. Writer ran down hall to see where the screaming was coming from. As writer got to residents room the door was closing. Writer pushed door open and observed resident laying on her right side and CENA (Certified Nurse Aide) was standing across from her. Writer assessed resident and assisted CENA with placing resident in her wheelchair. A review of R606's care plans and [NAME] (CNA care guide) were reviewed and revealed R606 required a Hoyer lift with assistance from two staff…

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

Based on interview and record review the facility failed to ensure sufficient nursing staff for the residents that resided in the facility on multiple dates in October 2022, resulting in the potential for unmet care needs, inadequate supervision and monitoring of the residents that resided in the facility at that time. Findings include: Review of a Centers for Medicare & Medicaid Services (CMS) Payroll-Based Journal (PBJ) report documented the facility to have triggered for One Star Staffing Rating, Excessively Low Weekend Staffing and Failed to have Licensed Nursing Coverage 24 Hours/Day for multiple dates in October 2022. Review of the facility's Nursing assignments, timesheets, Nursing agency invoices and the facility census audits revealed the following: The nursing staff that worked on 10/2/22 was documented as: Night shift- 2 Certified Nursing Assistants (CNA) Day shift- 1 LPN (licensed practical nurse) & 1 RN (registered nurse) Evening shift- 3 CNA's, 1 LPN, 1 RN Review of the census report for 10/2/22 revealed 70 residents identified in the facility. This resulted in 35…

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 a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week resulting in the potential for inadequate coordination of emergent and routine care with negative clinical outcomes and clinical supervision of Licensed Practical Nurses (LPN) for the date of 10/7/22 affecting all 75 residents that resided in the facility at that time. Findings include: Review of a Centers for Medicare & Medicaid Services (CMS) Payroll-Based Journal (PBJ) report documented the facility to have triggered for One Star Staffing Rating, Excessively Low Weekend Staffing and Failed to have Licensed Nursing Coverage 24 Hours/Day for multiple dates in October 2022. Review of the facility's Nursing assignments, timesheets, Nursing agency invoices and the facility census audits revealed the following: The Nursing staff that worked on 10/7/22 was documented as: Midnight shift: 3 LPN's (licensed practical nurse) & 4 Certified Nursing Assistants (CNA's) Day shift: 3 LPN's & 5 CNA's Evening shift: 2 LPN's & 4 CNA's The…

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

Based on observation, interview, and record review, the facility failed to ensure potentially hazardous food items were cooled to 41 degrees Fahrenheit or less within 6 hours, and failed to ensure an open window in the kitchen area was screened. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 5/2/23 at 9:00 AM, during an initial tour of the kitchen with Dietary Manager (DM) A, in the walk-in cooler, there was a shallow pan with 2 whole beef roasts tightly covered with foil. The roasts were dated 5/1-5/2. DM A was queried about the roasts, and stated that they had been cooked on 5/1 and were going to be served for dinner on 5/2. The internal temperatures of both roasts were measured and found to be 48 degrees Fahrenheit and 52 degrees Fahrenheit. DM A was queried if staff utilized cooling logs, to ensure potentially hazardous food items are cooled from 135 degrees Fahrenheit to 41 degrees Fahrenheit or less within 6 hours, and stated they did not. According to the 2017 FDA Food Code section 3-501.14 Cooling,…

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 five Certified Nursing Assistants (CNAs- Q, R, S, T & U) of five CNAs reviewed for the required annual in-service education, had the required 12 hours of in-service training within the required time period and/or the initial trainings of a new hire which included abuse prevention and dementia care, resulting in the potential for unidentified abuse, inadequate care and unmet resident care needs. Findings include: On 5/3/23 at 10:41 AM, the Human Resource director (HR) V (who also served as the facility's admission director) and Administrator was asked to provide the education, required trainings and competencies completed for CNAs Q, R, S, T & U. HR V stated they would look into it and provide the requested documentation. Review of the documentation provided revealed the following: CNA Q- Full time employee, hired on 11/8/22- No competencies or trainings on file, including the required abuse prevention and dementia care trainings. CNA R- Part time employee, hired on 9/29/22- No competencies or trainings on file,…

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 free movement throughout the building for four residents (R#'s 9, 17, 40, and 88) of four residents reviewed for self-determination, resulting in a complaint of not being able to leave the 2 North unit without staff keying in a door code. This deficient practice had the potential to affect all resident's on the 2 North unit. A review of a facility provided policy titled, Resident Rights under the Michigan Public Health Code dated 11/20/17 was reviewed and read, .The resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility, including those specified in this section . On 5/2/22, 5/3/22 and during the morning of 5/4/22 it was observed a numerical door code was required to enter and exit the 2 North unit. It was observed no signage on the door indicated in the event of emergency the door would automatically unlock if the handle was pulled…

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 unrestricted, 24-hour visitation affecting all 87 residents residing in the facility, resulting in resident verbalizations of family/visitors unable to enter the facility to visit and potential for decreased psychosocial well-being and quality of life. Findings include: According to the facility's undated policy titled, Resident Right to Access and Visitation: It is the policy of this facility to support and facilitate the resident's right to receive visitors of their choosing, at the time of their choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of other residents. Visitation will be person-centered, consider the residents' physical, mental, and psychosocial well-being, and support their quality of life .The facility will provide immediate access to a resident by immediate family and other relatives of the resident, subject to the resident's right to deny or withdraw consent at the time. Resident's family members are not…

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

Based on interview and record review, the facility failed to implement its policies and procedures related to screening procedures for work eligibility in a nursing home prior to employment for two (Certified Nursing Assistant- CNAs- Q & U) of five CNAs reviewed. Findings include: Review of the facility's policy titled Criminal Background Checks (reviewed 4/18/19), documented in part . This facility shall conduct and/or require a criminal background check for all employees, those requesting clinical privileges who will have direct access to or will provide regular direct services to resident, students whose clinical training will exceed 120 days at the facility , and any other individuals required by the Michigan Public Acts . If the Facility determines it is necessary to employ or grant clinical privileges to an applicant before receiving the results of the applicant's fingerprint results, the Facility may conditionally employ or grant conditional clinical privileges to the individual if all of the following apply . If the employee will not have direct access to patients or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a meaningful program of activities for two residents (R#'s 82 and 83) of two residents revealed for activities. This deficient practice had the potential to affect all 17 residents on the 2 North unit. A review of a facility provided policy titled, Activities dated 1/2020 was conducted and read, It is the policy of this facility to provide an ongoing program of activities designed to meet the interest choice and preferences as well as to meet the interest of and support the physical, spiritual, mental and psychosocial well-being of each resident, encouraging both independence and interaction in the community . On 5/2/22, 5/3/22 and during the morning of 5/4/22 it was observed a numerical door code was required to enter and exit the 2 North unit. It was observed no signage on the door indicated in the event of emergency the door would automatically unlock if the handle was pulled for a set amount of time. On 5/2/23, 5/3/23, 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 interview and record review, the facility failed to ensure nursing staff had the required certification and competency evaluations to provide nursing care and failed to follow up to ensure one (CNA- Certified Nursing Assistant Q) of five CNA's reviewed became registered, resulting in the potential for unmet care needs to have been provided by an uncertified and potentially incompetent nursing assistant. Findings include: On 5/3/23 at 4:17 PM, certifications for five nursing assistants were reviewed. One sampled CNA Q was identified as not having a valid CNA certification. Review of CNA Q employee profile revealed no documentation of a nursing aide certification. Further review of CNA Q employee profile revealed a Certificate of Completion for a 75-hour Nursing Assistant & Home Health Aide Training program, dated 10/7/2022. Further review of the employee profile revealed no documentation of competency evaluations to have been completed when hired. Review of the registry verification system documented that CNA Q did not have a valid certification. On 5/4/23 at 9:13 AM, 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 Based on observation, interview and record review, the facility failed to ensure accurate advance directive information was in place and all components of their Do-Not-Resuscitate (DNR) process was implemented for two (R70 and R43) of three residents reviewed for advance directives, resulting in the potential for unwanted or unmet health care decisions and the increased likelihood for the residents' end of life wishes and preferences not being considered and/or honored. Findings include: According to the facility's policy titled, Advanced Directive dated 1/2023: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive .Advance care planning is a process used to identify and update the resident's preferences regarding care and treatment at a future time including a situation in which the resident subsequently lacks the capacity to do so . R70 Review of the clinical record revealed R70…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a level I Preadmission Screening (PAS)/Annual Resident Review (ARR) Mental Illness/Intellectual Disability/Related Conditions Identification was completed accurately and sent to local community mental health for a level II OBRA (Omnibus Budget Reconciliation Act of 1993) evaluation for one (R21) of one resident reviewed for PASARRs. This deficient practice resulted in the potential for the resident to be excluded from receiving necessary care and services appropriate to meet their mental health and intellectual disability needs. Findings include: According to the facility's policy titled, PASARR dated 4/2022: .The PASARR process must be completed .PRIOR to admission to a nursing facility .Not less than annually .When rehabilitative services for a mental disorder and/or intellectual disability or services of a lesser intensity, are required in the resident's comprehensive plan of care, the facility must obtain the required services form 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 Based on observation, interview, and record review, the facility failed to ensure coordination of care and timely communication with the hospice provider for the use of bed bolsters for one (R43) of two residents reviewed for hospice care, resulting in the the potential for discomfort and decline in quality of life. Findings include: A record review revealed R43 was initially admitted to the facility on [DATE], and most recently re-admitted on [DATE] after hospitalization. R43's medical diagnoses included: hepatic encephalopathy, metabolic encephalopathy, post COVID condition, liver cirrhosis with ascites, and history of multiple falls. R43's most recent BIMS (Brief Interview for Mental Status) score was 9, indicative of moderate cognitive impairment. R43 was receiving hospice services after their recent readmission to the facility. An initial observation was completed on R43 on 5/2/23, at approximately 2:30 PM. R43 was laying in their bed with their eyes closed. R43 had a perimeter mattress with two bolsters (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents with limited mobility were assessed for appropriate assistive devices to maintain or improve functional mobility for one (R39) of three residents reviewed for mobility and assistive devices resulting in the potential to decline in bed mobility, decreased ability to assist during self-care,dissatisfaction and frustration with the care. Findings include: A record review revealed R39 initially admitted to the facility on [DATE] and most recently readmitted to facility after hospitalization on 2/21/23. R39's diagnoses included: chronic respiratory failure, heart failure, muscle weakness, and history of musculoskeletal and connective tissue diseases. R39's most recent BIMS (Brief Interview of Mental Status) score, dated 1/29/23, was 14, indicative of intact cognition. An initial observation of R39 was completed on 5/2/23, at approximately, 11:45 AM. R39 was observed in their bed watching television. R39 was on oxygen via…

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 appropriate treatment and services for indwelling urinary catheters for one resident (R82) of two residents reviewed for urinary catheters, resulting in the potential for injury and urinary tract infections. Findings include: A review of a facility provided policy titled, Indwelling Catheter-Insertion, Care Removal dated 6/2022 was conducted but did not address the use of anchors or securing devices, or keeping the drainage bag off the floor, however; an article from Healthcare Infection Control Practices Advisory Committee at https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf was reviewed and read, .II. Proper Techniques for Urinary Catheter Insertion .E. Properly secure indwelling catheters after insertion to prevent movement and urethral traction .III. Proper Techniques for Urinary Catheter Maintenance .B. Maintain unobstructed urine flow .2. Keep the collecting bag below the level of the bladder at all…

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

Based on observation, interview and record review the facility failed to ensure an opened Tuberculin solution vial was dated and/or discarded per the manufacturer's instructions from one of two medication rooms reviewed. Findings include: On 5/3/23 at 8:51 AM, an observation was completed with Licensed Practical Nurse (LPN) B of the 1 South medication storage room. Identified in the medication refrigerator was an opened and undated Tuberculin solution vial. LPN B reviewed the vial and acknowledged the vial was opened and the vial nor box was dated. LPN B stated staff should have dated and initialed it after they opened the vial. LPN B was unsure when the Tuberculin solution was initially opened. LPN B placed the Tuberculin vial back inside the medication refrigerator and returned to the unit. Review of a . Tuberculin Purified Protein Derivative package insert documented the following, . a vial of TUBERSOL which has been entered and in use for 30 days should be discarded . On 5/3/23 at 12:52 PM, the Director of Nursing (DON) was asked the facility's protocol on opening a Tuberculin…

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 maintain complete and accurate medical records for one (R70) of one resident reviewed for complete/accurate clinical record, resulting in the increased potential for delayed or omitted notification/involvement of the legal representatives and the potential for providers not having an accurate picture of the resident's condition. Findings include: According to the facility's policy titled, HIM (Health Information Management)/Medical Record Department dated 4/1/2018: .Resident Clinical Record .The record shall be current and entries shall be signed, timed and dated. This includes paper and EHR (Electronic Health Record). The clinical record shall include, at a minimum, all of the following information .Name, address and telephone numbers of .legal guardian .Name, address and telephone number of the person or agency responsible for the resident's care and maintenance in the Facility . On 5/3/23 at 2:40 PM, an interview was conducted with R70 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.

Based on interview and record review, the facility failed to ensure residents/resident's guardians understood the purpose of binding arbitration agreements (an out-of-court alternate form of dispute resolution) for two residents, (R#'s 41 and R55) of three residents reviewed for arbitration. Findings include: On 5/3/22 at 10:30 AM, an interview was conducted with Human Resources (HR) Director 'V'. They were asked if anyone had signed an arbitration agreement and said they were not aware of any. HR Director 'V' was asked to explain the admission process and said a copy of the admission agreement and all forms were either e-mailed or printed and provided to residents/guardians; they went through them, signed them and returned them. On 5/3/23 at 10:30 AM, a group meeting was conducted. During the meeting, the 12 participants (including R41) were asked about their knowledge and understanding of arbitration agreements. None of the 12 participants knew about arbitration agreements or their use and purpose. On 5/3/23 at approximately 11:30 AM, a review of R55's scanned documents in 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.