Adira Nursing and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility 1) Failed to ensure proper labeling of medications in 5 of 5 medication carts, and 2 of 2 treatment carts, 2) Failed to properly secure/lock 2 of 2 treatment carts with medical supplies and prescription creams/ointments, 3) Failed to clean up loose medication tablets and debris, and 4) Failed to ensure proper completion of 2 temperature logs for medication refrigerators, resulting in the opened and undated medications, creams/ointments, with the potential for a resident to received medications/treatments with altered/decreased efficacy and potency, drug diversion or ingestion of unlocked medication/treatment carts, cross contamination and inappropriate temperatures. Findings include: Record review of the facility 'Storage of Medications' policy dated 8/2024 revealed that medications and biological's are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only…

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 and operationalize a comprehensive infection control program, encompassing outcome and process surveillance, accurate data collection/documentation/analysis and failed to ensure appropriate hand hygiene and disposal of soiled linens/waste products, resulting in a lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis. and the likelihood for spread of microorganisms and illness to all 84 facility residents. Findings include: Facility line listing documentation since the last annual survey were requested from the facility Administrator and Infection Control (IC) Registered Nurse (RN) P on 10/29/24 at 12:07 PM and 12:10 PM respectively. On 10/29/24 at 12:44 PM, IC RN P provided the line listing documentation for June and July 2024. On 10/29/24 at 2:55 PM, the only requested line listing documentation received was for June and July 2024 and an interview was completed was completed…

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 complete advance directives for seven residents (R19, R24, R29, R30, R36, R39, R50) of seven residents reviewed for advance directives, resulting in missing or incomplete advance directive forms. Findings include: Resident #19 (R19): R19 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include cerebral palsy, dysphagia, anxiety disorder and need for assistance with personal care. R19 has a Brief Interview for Mental Status (BIMS) score of 13, indicating they are cognitively intact. R19 has a guardian due to the inability to make their own medical decisions. On [DATE] at 10:53 AM, record review of the EMR (electronic medical record) for R19 revealed a physician's order for CPR (cardiopulmonary resuscitation), there is an advance directive care plan in place, no signed documents indicating code status were able to be located. Resident #24 (R24): R24 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that reviews and revisions of residents' care plans were made to ensure interventions necessary for care and services were provided for 5 residents (#5, #9, #40, #78, #80), resulting in a lack of showers/bathing, weight loss and/or catheter care, consistently resulting in the potential for unmet care needs. Findings include: Resident #5: Activities of Daily Living: In an interview on 10/28/24 at 10:40 AM with Resident #5 stated that she does have missed her showers. The Resident #5 stated that she requested showers 3 days a week, like she would if she was at home. But the staff will miss her shower day and if she does not remind them and then [NAME] the aides, they will not do it. Record review of Resident #5's Activity of Daily Living (ADL) care plan dated 7/18/2024 noted bathing with 2 assists, prefers to have showers Monday-Wednesday-Fridays. Record review of Resident #5's shower task question #3: Shower, bed bath or tub, 30-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 Based on observation, interview and record review the facility failed to conduct and maintain timely activity assessments for eleven residents (#4, #5, #26, #28, #32, #37, #42, #45,#75,#77, #79) of 11 residents reviewed for assessments and ensure that one resident (#4) was able exercise their right to vote of 1 resident reviewed for voting preferences. Findings Include: During Resident Council meeting held on 10/29/2024 at 11:30 AM, Resident #4 shared she would like to vote in the upcoming Presidential election and does not recall this being addressed with her. On 10/29/2024 at 2:35 PM, Activities Director R was queried regarding the process for residents voting in the upcoming election. Director R explained upon admission each resident is asked about their preference regarding voting. When asked about Resident #4, the Director stated during their voting preference audit in September 2024, she declined to vote and recently informed her that her mother would assist with her voting. Director R was asked if 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 observation, interview and record review, the facility 1) Failed to ensure quality of care to meet residents' needs for diabetic and behavioral care and 2) Failure of facility staff to retrieve medications from the backup source for 11 Residents (#5, #9, #41, #46, #50, #56 #72, #76, #81, #137, #147), resulting in the lack of identification and assessment of changes in condition and delays in treatment. Findings include: Record review of the facility 'Medication Administration' policy dated 11/2023 revealed medications are administered in a safe and timely manner, and as prescribed. (7.) Medications are administered within one (1) hour of their prescribed time, unless otherwise specified Record review of the facility 'Insulin Administration' policy dated 1/2024 revealed characteristics and types of insulin noted three key characteristics of insulin are: Onset of action- (a.) how quickly the insulin reaches the bloodstream and begins to lower blood glucose. (b.) Peak effects- the time when the insulin is…

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 provide care and services prevent urinary tract infections for 5 residents (#5, #11, #40, #81, #83), resulting in the potential for recurrent urinary tract infections, and cross contamination with the potential for prolonged illness, antibiotic therapy and/or hospitalizations. Findings include: Record review of facility 'Catheter Care, Urinary' policy dated 5/2024 revealed the purpose of the procedure was to prevent catheter-associated urinary tract infections. Resident #5: In an interview on 10/28/24 at 12:20 PM with Resident #5 revealed that her urinary Suprapubic catheter did not get changed as it should. The resident has to tell staff to change the catheter. Resident #5 stated that the catheter is to be changed monthly and that it is supposed to come up on the computer, but it doesn't get changed. It didn't get changed as it should and that she worries about getting infections. Resident #5 stated that her suprapubic catheter care does not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to consistently offer and provide snacks at bedtime for seven residents (#4, #5, #28, #32, #37, #39, #40) of 7 residents reviewed for nightly nutrition. Resulting in, feelings of frustration, unmet needs and residents going longer than 14 hours between dinner and breakfast. Findings Include: During a confidential Resident Council meeting held on 10/29/2024 at 11:30 AM, the twelve residents in attendance were queried if nighttime snacks are offered by facility staff. Eleven of the twelve residents in attendance stated they are not consistently being offered snacks at night. They shared at times when they request snacks, the staff will say they do not have any available snacks for the residents. On 10/30/2024 at 4:22 PM, Dietary Manager I reported he was aware of resident concerns surrounding nighttime snacks as they have mentioned it during food council meetings. On 10/31/2024 at approximately 8:15 AM, a review was conducted of the last 6…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to implement and maintain an Antibiotic Stewardship Program and failed to ensure accurate and timely monitoring and documentation of antibiotic use resulting in the potential for inappropriate antibiotic utilization and the worsening or non-improving infections for all 84 Residents residing within the facility as well as the potential for antibiotic resistance. Findings include: A review of facility provided Infection Control documentation from December 2023 to October 2024 revealed the facility did not provide line listing documentation and/or Antibiotic Stewardship documentation for January, February, May, and September 2024. An interview and review of facility IC data for July 2024 was completed with IC RN P on 10/31/24 at 8:08 AM. When queried regarding the facility antibiotic stewardship program, IC RN P revealed they track antibiotic use on the monthly line list. A review of the July 2024 Line List revealed 28 antibiotics were ordered and initiated…

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 respect the resident's choice to refuse a room change for one resident (Resident #64) of one resident reviewed for choices, resulting in feelings of sadness and hopelessness. Findings include: Resident #64 (R64): R64 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include hypertension, hyperlipidemia, difficulty walking and hemiplegia and hemiparesis following cerebral infarction. R64 has a Brief Interview for Mental Status (BIMS) score of 15, indicating they are cognitively intact. On 10/28/24 at 10:51 AM, R64 was observed sitting in their wheelchair and watching television. This surveyor asked R64 how long they had been at the facility, R64 stated it had been about six months and they were moved to this room on June 17th. R64 was visibly upset and stated said they did not agree to a room change and they were unhappy about it. R64 stated they were crying about the room change at the time, R64 stated this is…

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 provide adequate notice of non-coverage and maintain documentation for two residents (Resident #76 and Resident #187) of five residents reviewed resulting in the lack of full disclosure related to Medicare rights and inability to appeal the discharge in the time frame allotted by Medicare. Findings include: Resident #76: Review of Resident #76's Notice of Medicare Non-Coverage Form revealed the Resident's current services would end on 7/21/24. The form was signed by the Resident on 7/21/24. Resident #187: Per the facility completed, Beneficiary Notice- Residents discharged Within the Last Six Months form, Resident #187's discharge date was 7/1/24. The Resident's Notice of Medicare Non-Coverage Form was requested from the facility and not provided. An interview was completed with Social Worker J and Social Services Director S on 10/29/24 at 12:39 PM. When queried regarding Resident #187's Notice of Medicare Non-Coverage Form, Social Worker J stated they can't find the form. An interview was completed with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to complete continued assessment and monitoring for physical restraints for one resident (Resident #75) of one resident reviewed for restraints, resulting in Resident #75 having a chest harness with four non-self-release buckles. Finding Include: Resident #75: During initial tour on 10/28/2024 at 1:20 PM, Resident #75 was observed in the common area with other residents and staff. He was seated in a customized chair with a harness seatbelt, that secures in four spots. It did not appear Resident #75 would be able to remove the harness himself. On 10/28/2024, at approximately 1:25 PM, a review was conducted of Resident #75's medical record and it indicated he admitted to the facility on [DATE] with diagnoses that included Cerebral Palsy, Acute Respiratory Failure, Dysphagia, Hypertension and Chronic Obstructive Pulmonary Disease. Further review yielded the following: Physician Order: Custom w/c with custom molded seat back as well as postural…

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 obtain weights timely for 2 Residents (#9, #80), resulting in unassessed weight loss with the potential of unmet care needs. Findings include: Resident #9: In an interview on 10/28/24 at 10:27 AM with Resident #9 in his room revealed that he had lost weight and that he did not know why. Resident #9 stated that he did have a peg tube that that staff used for his formula stuff feed. Record review of Resident #9's weight log revealed weight on 10/2/24 of 147.2 pounds, and on 10/18/24 a weight of 130.1 pounds. That was a 17.1-pound loss in 16 days. Weight loss percentage of 11.62% loss. Record review of Resident #9's care plans pages 1-34 revealed care plan revision date of 8/28/2024 for malnutrition related to dysphagia with latest intervention dated 9/27/2024 of supplements as ordered: 30ml Critical Care Pro-heal TID (three times daily) via peg tube. Resident #80: Observation on 10/28/24 during the initial tour of the facility revealed Resident #80 was lying in bed and thin in appearance. The Resident #80 made eye contact…

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 accuracy of enteral feeding orders for one resident (#80), resulting in Resident #80's enteral feeding material order to be incomplete, with the potential for enteral tube malfunction/weight loss. Findings include: Resident #80: Observation on 10/28/24 during the initial tour of the facility revealed Resident #80 was lying in bed and thin in appearance. The Resident #80 made eye contact but did not say anything at that time. Observation of Peractive tube feeding solution was infusing at 60cc/hr. Observation on 10/29/24 at 08:12 AM with Registered Nurse (RN) F during medication pass revealed that Resident # 80's peg tube pump was beeping alerted nurse and state surveyor in hallway. Observation of Resident #80's room revealed an empty bottle hanging at bed side dated 10/28/24 at 12:00 PM noon. The tube feeding bottle was empty and new bottle is set on overbed table not labeled. RN F stated that the night shift just leaves the full bottle at the bedside and do not hang it. To do the math 1000cc bottle to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a procedure for effective communication and coordination of care with dialysis for one resident (Resident #41) of one resident reviewed, resulting in a lack of communication regarding vaccine administration, Resident #41 receiving duplication vaccinations, and the potential for side effects, ongoing lack of communication, and duplicate medication therapy. Findings include: Resident #41: Record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses which included dementia, legal blindness, arthritis, falls, diabetes mellitus, and end stage renal disease with dialysis dependence. Review of the Minimal Data Set (MDS) dated [DATE] revealed the Resident was severely cognitively impaired and required maximum to total assistance to complete Activities of Daily Living (ADL). Review of Resident #41's Electronic Medical Record (EMR) revealed the Resident received dialysis two times a week. Resident #41 had a care plan in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that three residents (#75, #80 and #82) of 5 residents reviewed for unnecessary medications had adequate indications for usage, care plan implementation and appropriate monitoring, resulting in the increased potential for serious adverse side effects and adverse reactions, and the inability to monitor the effectiveness of antipsychotic and hypnotic medication treatment due to lack of documented supporting evidence. Findings Include: Resident #75: During initial tour on 10/28/2024, Resident #75 was observed in the common area with other residents and staff. On 10/28/2024, at approximately 1:25 PM, a review was conducted of Resident #75's medical record and it indicated he admitted to the facility on [DATE] with diagnoses that included Cerebral Palsy, Acute Respiratory Failure, Dysphagia, Hypertension and Chronic Obstructive Pulmonary Disease. Further review yielded the following: Physician Orders: Medication Class:…

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 1) Failed to prevent pre-set up medications to be found in 2 of 5 medication carts, 2) Failed to prime a new insulin pen prior to administration, and 3) Failed to provide insulin administration timely and per a physician's order for 1 resident (Resident #5), resulting in a medication error rate greater than 5%, and the potential for wrongful administration of pre-set up medications and unmanaged medical conditions requiring therapeutic drugs with the potential for complications and increased blood glucose levels. Findings include: Record review of the facility 'Medication Administration' policy dated 11/2023 revealed medications are administered in a safe and timely manner, and as prescribed. (7.) Medications are administered within one (1) hour of their prescribed time, unless otherwise specified Record review of the facility 'Insulin Administration' policy dated 1/2024 revealed characteristics and types of insulin noted three key characteristics of insulin are: Onset of action- (a.) how quickly the insulin reaches 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 interview and record review the facility failed to provide dental services to one resident (R19) of one resident reviewed for dental services, resulting in the resident not receiving routine dental services since admission. Findings include: Resident #19 (R19): R19 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include cerebral palsy, dysphagia, anxiety disorder and need for assistance with personal care. R19 has a BIMS (brief interview for mental status) score of 13, indicating they are cognitively intact. R19 has a guardian due to the inability to make their own medical decisions. On 10/29/24 at 09:27 AM, R19 was asked if they had any concerns they would like to discuss. R19 stated they would like to see the dentist. R19 stated they have no issues with their teeth, but they have some fake teeth. R19 was asked if they had seen the dentist since being in the facility. R19 stated they haven't seen the dentist since being here. On 10/30/24 at 03:38 PM, an interview 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 interview and record review, the facility failed to implement and operationalize policies and procedures for vaccination administration for three residents (Resident #1, Resident #56, and Resident #75) of five residents reviewed, resulting in the lack of administration of desired and appropriate vaccinations, and the potential for disease acquisition, transmission, and decline in overall health status. Findings include: A review of the facility vaccination program was completed with Infection Control Registered Nurse (RN) P on 10/31/24 at 8:08 AM. When queried regarding facility policy/procedure related to vaccination administration, RN P revealed they obtain all vaccine consents and review prior vaccination administration. Resident #1: Review of Resident #1's immunization consent documentation revealed the Resident wanted the Influenza and Pneumonia vaccinations. The Resident's Immunization administration documentation in the Electronic Medical Record (EMR) revealed the Resident had received the Influenza vaccine but did not receive the Pneumonia vaccine. When queried why…

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 MI00146372. Based on interview and record review, the facility failed to implement and operationalize abuse prohibition policies and procedures to ensure adequate supervision to prevent non-consensual sexual behaviors and actions for two residents (Resident #705 and Resident #706) of five residents reviewed for abuse. This deficient practice resulted in a lack of timely reporting and comprehensive investigation of abuse allegations, a lack of supervision to prevent non-consensual sexual actions between cognitively-impaired residents in the locked Dementia Unit of the facility. Resident #705 and Resident #706 were found partially naked in bed with genitals exposed by staff. Resident #705 was displaying ongoing inappropriate sexual behaviors with the likelihood for psychosocial distress using the reasonable person concept. Findings include: Review of Facility Reported Incident (FRI) documentation dated as received 7/11/24 at 3:38 PM and Facility Investigation Report received…

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 Numbers MI00142793 & MI00143087. Based on the interview and record review, the facility failed to honor the resident's wishes and identify the designated patient advocate, despite legal documentation brought in by the family, upon admission to clearly establish the resident's wishes of Do Not Resuscitate (DNR) for one resident (Resident #801) of three sampled residents reviewed for residents' rights and honoring the resident's and designated patient advocate's wishes for Do Not Resuscitate (DNR) resulting in Resident #801 receiving Cardiopulmonary Resuscitation (CPR) for approximately over an hour and later dying as witnessed by Resident #801's Designated Patient Advocates who were present to witness Resident #801 receiving CPR until Resident #801 was pronounced dead by the Emergency Medical Team (EMT) Ambulance who responded to the 911 call. Findings include: Resident #801 (R801): Resident R801 was admitted on [DATE] with the diagnosis of Encephalopathy, Essential (Primary)…

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 MI00145334 Based on interviews and record review, the facility failed to follow the facility policy to immediately report, conduct an investigation, and inform the local authorities, per facility policy, for one missing resident (Resident #802) of one sampled resident, whose whereabouts were unknown over 24 hours, resulting in the potential for harm from not receiving scheduled medications. Findings include: Resident #802 (R802): On 7/8/24 at 10:30 AM, a review of EMR records revealed R802 was admitted to the facility on [DATE] with a diagnosis of osteomyelitis of the left ankle and left foot requiring Intravenous (IV) antibiotic therapy. Other diagnosis listed were Diabetes Mellitus, Diabetic Neuropathy, Immunodeficiency Virus (HIV) Disease, Essential Hypertension, and Major Depressive Disorder in addition to other diagnoses. R802's discharge plan was to complete treatment regimen of IV antibiotics through the Intravenous (IV) Percutaneous Indwelling Central Catheter…

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 Numbers MI00142793, MI00143087, MI00143556, and MI00145334. Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for two residents (Resident #801 and Resident #802) reviewed for care planning by 1) Failing to address Resident #801's Advanced Directive and 2) Failing to address Resident #R802's frequent Leaves of Absence out of the facility, resulting in lacking a care plan with resident-specific interventions, staff actions, resident's/advocate's preferences of advanced directives (R801) and leave of absence status (R802) and a lack of clarity and directions specific to staff actions and interventions to deliver patient-centered care. Findings include: Resident #801 (R801): Resident R801 was admitted on [DATE] with the diagnosis of Encephalopathy, Essential (Primary) Hypertension, Type 2 Diabetes Mellitus with Diabetic Mononeuropathy and History of Transient Ischemic Attack (TIA), Cerebral Infarction, and Cerebral Edema 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 This Citation pertains to Intake Number MI00143087. Based on interview and record review, the facility failed to follow the wishes of one resident (Resident #801) pertaining to Do Not Resuscitate (DNR) of 5 residents reviewed for Code Status, resulting in Resident #801 receiving a Full Code status not honoring the resident/patient advocate's wishes due to delay caused by the facility and potential for injury, pain and suffering for the resident to experience Cardiopulmonary Resuscitation (CPR) and the resident's family DPOA to witness CPR given to Resident #801 against their wishes. Findings include: Resident #801 (R801): On [DATE] at 12:15 PM, a review of the Nursing Clinical Progress notes dated [DATE] at 18:39 revealed that resident (R801) was found by Nurse C unconscious in her room around 5:40 PM on [DATE]. Staff called 911, and immediately started Cardiopulmonary Resuscitation (CPR). Staff reported giving seven (7) rounds of CPR until the ambulance people arrived at 5:47 PM and took over and continued…

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 #MI00139971 Based on observation, interview, and record review the facility failed to ensure that food was served and held at a palpable temperature. Resulting in the potential to affect all residents (total facility census of 81) that consume food from the kitchen. Findings Included: Resident #25 (R25) Review of the medical record demonstrated that R25 was admitted to the facility 10/04/2022 with diagnoses that included type 2 diabetes, malignant neoplasm (cancer) of the endometrium (lining of the uterus) , atrioventricular block (heart block), anxiety, muscle wasting and atrophy, depression, cerebral infarction (stroke), hemiplegia (paralysis) of the left side, anemia (low red blood cell count), gout (build up of uric acid in joints), hyperlipidemia (high fat amount in blood), and hypertension. During observation and interview on 11/27/2023 at 09:27 a.m. R25 was observed siting at the side of her bed in a wheelchair. When R25 was questioned regarding the food at 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 MI00139969 Based on observation, interview and record review, the facility failed to develop and implement care plans for 5 residents (R# 4, #23, #38, #60 and #76) of 19 reviewed, resulting in the potential for unmet care needs. Findings include: Resident #4 Review of the clinical record, including the Minimum Data Set, dated and 9/30/23, R4 was admitted to the facility with diagnosis that included multiple sclerosis, R4 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). During the initial screening process on 11/27/23 at approximately 1:00 pm, R4 was observed resting in bed and was interviewed at bedside, when queried about her antibiotic use, R4 reported she did not know why she was prescribed the antibiotic. Further review of the R4's clinical record reflected a physician order was written on 11/09/23 for Bactrim Oral Tablet 400-80 milligram one time daily for prophylactic due to recurrent urinary tract infections until 12/20/23. Further review of the clinical record reflected there was no care plan in place…

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 1. Dispose of expired medications in 3 of 4 medication carts; and 2. Label a Tuberculin vial with an open date in 1 of 2 medication rooms reviewed for medication labeling and storage, resulting in the potential for decreased medication efficacy and side effects. Findings include: On 11/29/23 at 8:14 AM, Bay 2 Medication Cart was reviewed in the presence of Licensed Practical Nurse (LPN) MM. During the review, both an opened box of Latanoprost 0.005% Eye Drops and an open bottle within the box was noted to contain a pharmacy label reflecting Resident #70's (R70's) name. A handwritten open date of 9/28/23 was noted on the box as well as a printed pharmacy label which stated, Refrigerate unopened. Store opened at room temp. [temperature]. Discard after 6 weeks. LPN MM confirmed the 9/28/23 open date on the eye drops, stated that she believed that the eye drops were good for 4 to 6 weeks after opening and therefore were expired, would be discarded, and a new one ordered from pharmacy. Review of R70's medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow acceptable infection control guidelines for hand washing and failed to follow adhere to Enhanced Barrier Precautions resulting in the potential spread of infection and disease to all 81 residents at the facility. Findings Included: During observation on 11/27/2023 at 12:10 pm observed Certified Nursing Aide (CNA) I pass a food tray to room [ROOM NUMBER] and then passed food tray to room [ROOM NUMBER]. CNA I was not observed washing or sanitizing her hands between tray passes. Then CNA I was observed passing at room tray to room [ROOM NUMBER] and was observed moving his box of Kleenex, removing a lid to his drink container then exiting the room without washing or sanitizing her hands and proceeded to pass another food tray to room [ROOM NUMBER]. At no time between passing food trays between rooms was CNA I observed to wash or sanitize her hands. During observation on 11/27/2023 at 12: 18 p.m. observed Certified Nursing Aide (CNA) J…

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, observation and record review, the facility failed to maintain an effective antibiotic stewardship program, including ongoing monitoring of antibiotic use protocols and an ongoing system to monitor antibiotic use. This deficient practice resulted in the potential for the development of Multi Drug Resistant Organisms (MDRO's) within the entire vulnerable facility's population, family members of the facility population, staff, volunteers, contractual providers, and the surrounding community. Findings include: During and interview and observation on 11/29/23 at 11:45 AM, RN-I/C/ Staff Development H stated that she had been reviewing the previous infection surveillance plan, there want one in place, but not previously being implemented as evidence of not following the McGeer criteria and residents were taking antibiotics with no rational for use. Record review revealed a high rate of urinary tract infections and vaginal infections in June 2023,18 out of 14 residents had at least one of both infections. Record review did not reveal any education provided to caregivers…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a call light within reach for 1 resident (#60) and positioned per resident preference for 1 resident (#6) of 19 residents reviewed for accommodation of needs, resulting in impaired resident access to request and receive assist. Findings include: Resident #60 Review of the medical record revealed that Resident #60 (R60) was admitted to facility 11/16/2022 with diagnoses including mild dementia, type 2 diabetes mellitus, generalized osteoarthritis, chronic systolic heart failure, and pressure-induced deep tissue damage of sacral region. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/18/23 revealed that R60 was understood by others and able to understand others with a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 6 (severely impaired cognition). Review of the MDS dated [DATE] reflected that R60 required one-person extensive assist with bed mobility and dressing 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 utilize and maintain complete grievance documentation resulting in grievances not being documented, tracked, and the results of conclusions and/or resolutions not being recorded. This deficient practice has the potential to affect all 81 residents that reside in the facility. Findings include. During an interview on 11/30/23 at 10:05 AM, a resident council group wanted to remain anonymous. 1) Food- up to 45 minutes late, on a daily base's meals are served late and it is cold. Several complains have been filed, but no resolved. 2) Food- no flavor, requested Mrs. Dash for meals, told it was too expensive. 3) Snack- No night snacks available. Diabetics are not offered a night snack. Some items in the refrigerator, 1/2 P & J sandwich, cookies, and crackers if they don't run out. 4) Requested to have lemonade or juices available during all hours of the day. 5) Want to include the Ombudsman, and Owner to attend future meetings. 6) Laundry- Still missing clothes, getting laundry delivered to their room that belongs to another…

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 complete the Minimum Data Set (MDS) assessment for 1 (Resident #23) of 19 reviewed, resulting in an inaccurate MDS assessment and the potential for unmet care needs. Findings include: Review of the medical record revealed that Resident #23 (R23) was readmitted to facility on 10/19/2022 with diagnoses including cerebral infarction, metabolic encephalopathy, dysphagia, and chronic respiratory failure with hypoxia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/30/23 revealed that R23 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 12 (moderate cognitive impairment). Section O of the same MDS revealed that R23 had not used oxygen while a resident during the 14-day assessment period (9/17/23-9/30/23). In an observation and interview on 11/17/23 at 11:52 AM, R23 was observed lying in bed, on back, with the head of the bed positioned at an approximate 60-degree angle. R23 was observed to have oxygen in place at 4 liters per minute 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 complete the 3878 portion of the Preadmission Screening (PAS)/Annual Resident Review (ARR) and/or failed to notify the State Agency Health Authority for 1 (Resident #9) of 2 residents reviewed for PAS/ARR from a total sample of 19, resulting in the potential for unmet mental health treatment and services. Findings include: Review of the medical record revealed that Resident #9 (R9) was initially admitted to the facility on [DATE] with diagnoses including anoxic brain damage, suicide attempt, major depressive disorder, mild unspecified dementia, bipolar disorder, generalized anxiety disorder, and history of traumatic brain injury. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/24/23 revealed that R9 had clear speech, was understood by others, and was able to understand others with a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 10 (moderately impaired cognition). Section N…

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 Pertain To Intake MI000139969 Based on observation, interview and record review the facility failed to revise care plans for 2 residents ( #6, and #76) of 19 residents reviewed for care plan revisions, resulting in the potential for unmet needs. Findings include : Resident #76 (R76) Review of the medical record revealed R76 was admitted to the facility 09/13/2023 with diagnoses that included acute and chronic respiratory failure with hypoxia (low oxygen level), chronic obstructive pulmonary disease (COPD), pulmonary fibrosis (scaring of lungs) , muscle wasting and atrophy, interstitial pulmonary disease (cause scaring of lungs), ischemic cardiomyopathy (heart attack), chronic kidney disease, dependence on supplemental oxygen, malaise (general feeling of discomfort, illness, or lack of wellbeing), nicotine dependence, peripheral vascular disease (PVD), hypotension, atherosclerotic heart disease (plaque build-up in the wall of arteries), pulmonary hypertension, atherosclerosis of renal artery,…

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 oral care to one resident reviewed for maintaining activities of daily living (Resident #45), resulting in poor oral hygiene and the potential to decline in other activities of daily living abilities. Findings include: Resident #45 (R45) Review of the medical record revealed Resident #45 (R45) was admitted to the facility initially on 08/25/21, then readmitted on [DATE] with diagnoses that included Pneumonia, Septicemia, Urinary Tract Infection, Dementia and Malnutrition. R45 uses a wheelchair to move through the facility. According to Resident #45 (R45)'s Minimum Data Set (MDS) dated [DATE], revealed R45 scored 11 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. According to Section GG; Functional Abilities and Goals, GG0130. Self-Care scored R45 03=Partial/moderate assistance, helper does less than half the effort. During an interview and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake: MI00139969 Based on observation, interviews, and record review the facility failed to provide Activities of Daily Living (ADL), including bathing/showering and oral care, for two dependent residents (#6, #76) out of four resident reviewed for ADL completion resulting in missed bathing/showers, inadequate oral care and potential feelings of embarrassment. Findings Included: Resident #76 (R76) Review of the medical record revealed R76 was admitted to the facility 09/13/2023 with diagnoses that included acute and chronic respiratory failure with hypoxia (low oxygen level), chronic obstructive pulmonary disease (COPD), pulmonary fibrosis (scaring of lungs) , muscle wasting and atrophy, interstitial pulmonary disease (cause scaring of lungs), ischemic cardiomyopathy (heart attack), chronic kidney disease, dependence on supplemental oxygen, malaise (general feeling of discomfort, illness, or lack of wellbeing), nicotine dependence, peripheral vascular disease (PVD), hypotension,…

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 MI00138918 and MI00139969 Based on interview and record review the facility failed to adequately assess the root cause analysis of resident falls and place appropriate fall prevention interventions, after falls, for two residents (#75, #76) of four residents reviewed for accidents and hazards resulting in continued falls and the potential for resident injury. Findings Included: Resident #75 (R75) Review of the medical record revealed R75 was admitted to the facility 04/07/23 with diagnoses that included pressure ulcer of the sacral region, cognitive communication deficit, lack of coordination, dysphagia (difficulty swallowing), acute respiratory failure, congestive heart failure (CHF), cardiomyopathy (enlarged heart), nontraumatic intracerebral hemorrhage (brain bleed), paraplegia (paralysis of the legs and lower body), osteoarthritis (degeneration of cartilage in joints), depression, anemia (low red blood cells), hyperlipidemia (high fat amount in blood), and degenerative…

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: MI00139969 Based on interview and record review the facility failed to follow physician orders for constant oxygen therapy and provide appropriate oxygen tubing for one resident (#76) of three residents reviewed for respiratory care resulting in the potential for respiratory complications. Findings Included: Resident #76 (R76) Review of the medical record revealed R76 was admitted to the facility 09/13/2023 with diagnoses that included acute and chronic respiratory failure with hypoxia (low oxygen level), chronic obstructive pulmonary disease (COPD), pulmonary fibrosis (scaring of lungs) , muscle wasting and atrophy, interstitial pulmonary disease (cause scaring of lungs), ischemic cardiomyopathy (heart attack), chronic kidney disease, dependence on supplemental oxygen, malaise (general feeling of discomfort, illness, or lack of wellbeing), nicotine dependence, peripheral vascular disease (PVD), hypotension, atherosclerotic heart disease (plaque build-up in the wall of…

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

Based on interview and record review the facility failed to ensure that one Certified Nursing Aides (J) completed 12 hours of in-service education per year and failed to ensure that two Certified Nursing Aide (J and K) had competency evaluations completed on hire/annually of four Certified Nursing Aides competency and in-service records reviewed resulting in the potential for staff to lack the necessary in-service education to adequately meet the needs of the 81 Residents that currently reside at the facility. Findings Included: Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) J was hired 10/21/2021. CNA J CNA Competency Check List was completed 11/06/2022. Review of CNA J in-service record demonstrated that she only had nine educations in the last year of employment. The record did not demonstrate how many hours those educations were completed in. Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) K was hired 03/07/2023. Review of her personnel file did not demonstrate that CNA K every had a CNA…

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 appropriate clinical justification for the use of antibiotic medication and the continuance of an unnecessary antibiotics for one (#4) of 5 reviewed for unnecessary medication use, resulting in the potential continued use of unjustified antibiotic usage. Findings include: Review of the clinical record, including the Minimum Data Set, dated and 9/30/23, R4 was admitted to the facility with diagnosis that included multiple sclerosis, R4 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). During the initial screening process on 11/27/23 at approximately 1:00 pm, R4 was observed resting in bed and was interviewed at bedside, when queried about her antibiotic use, R4 reported she did not know why she was prescribed the antibiotic. Further review of the R4's clinical record reflected a physician order was written on 11/09/23 for Bactrim Oral Tablet 400-80 milligram one time daily for prophylactic due to recurrent urinary tract infections until 12/20/23. Further review of…

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

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent when seven medication errors were observed from a total of twenty-eight opportunities for one (Resident #23) of four residents reviewed for medication administration when 7 medications were crushed, dissolved, and administered together via PEG (percutaneous endoscopic gastrostomy-a feeding tube) tube resulting in a medication error rate of 25 percent and the potential for reduced efficacy of medications and increased risk of adverse reactions/side effects. Findings include: Review of the medical record revealed that Resident #23 (R23) was readmitted to facility on 10/19/2022 with diagnoses including cerebral infarction, metabolic encephalopathy, dysphagia, and chronic respiratory failure with hypoxia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/30/23 revealed that R23 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 12 (moderate cognitive impairment). Section K of the same 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 coordinate hospice services for one resident (#38) out of one resident reviewed for coordination of hospice services resulting in the potential for care note being provided to resident receiving hospice services and the potential for residents not be fully informed of hospice services provided. Findings Included: Resident #38 (R38) Review of the medical record revealed R38 was admitted to the facility 03/02/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD), type 2 diabetes, diabetic neuropathy (nerve damage caused by diabetes), right above the knee amputation, nicotine dependence, alcohol abuse, benign prostatic hyperplasia (enlarged prostate), hypothermia (low body temperature), absence of left toes, protein calorie malnutrition, muscle wasting and atrophy, dysphagia (difficulty swallowing), hypertension, atrial fibrillation, hypothyroidism (low thyroid hormone), cerebral infarction (stroke), peripheral…

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 call system was functioning for one (R6) of 19 sampled residents, resulting in decreased emergent response time and potential resident adverse clinical outcomes. Findings Include Resident #6 (R6) Review of the medical record revealed Resident #6 (R6) was admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis, Quadriplegia, Neurogenic Bladder, feeding tube, Cardiovascular Accident and Depression. According to Resident #6 (R6)'s Minimum Data Set (MDS) dated [DATE], revealed R6 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R30 is dependent of all activities of daily living, is bedbound and requires all hydration and medication administration to be through her feeding tube. During an observation and interview on 11/28/23 at 08:06 AM, R6 stated that her call light did not work, so she had to yell, and she…

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.