Great Lakes Rehabilitation Center

Based on observation, interview and record review, the facility failed to administer medications per standards of practice for two residents (Resident #41, Resident #59) of eight residents reviewed during the medication administration task, resulting in a medication error rate of 6.67 percent with the likelihood of further medication errors. Findings include. On 1/13/2026, at 2:28 PM, During medication administration task with Nurse P, Nurse P prepared a Heparin injection for Resident #59. Nurse P drew up the Heparin medication into a 3 cc (cubic centimeter) syringe with a 1-inch needle and walked towards Resident #59's room. Nurse P was asked what medication and what route they were going to administer and Nurse P stated, Heparin IM (intramuscular) and then quickly stated no, sub q (subcutaneous). Outside Resident #59's room, Nurse P reached for Resident #59's door and was asked what size needle whas required for a sub q injection and were they sure of the physician's order. Nurse P clarified the order on Resident #59's electronic medical record and Nurse P again reached for 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 administer medications per standards of practice for two residents (Resident #41, Resident #59) of eight residents reviewed during the medication administration task, resulting in the likelihood of unwanted reactions such as hematoma, severe stomach pain and potentially dangerous, rapid increases in potassium levels in the blood. Findings include. On 1/13/2026, at 2:28 PM, During medication administration task with Nurse P, Nurse P prepared a Heparin injection for Resident #59. Nurse P drew up the Heparin medication into a 3 cc (cubic centimeter) syringe with a 1-inch needle and walked towards Resident #59's room. Nurse P was asked what medication and what route they were going to administer and Nurse P stated, Heparin IM (intramuscular) and then quickly stated no, sub q (subcutaneous). Outside Resident #59's room, Nurse P reached for Resident #59's door and was asked what size needle whas required for a sub q injection and were they sure of the physician's order. Nurse P clarified the order on Resident #59'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 interview and record review the facility failed to administer an influenza vaccine for one resident (Resident #19) of five residents reviewed for immunizations. Findings include:R19 is [AGE] years old and admitted to the facility most recently on 03/25/2025 with diagnoses that include hypertension, dementia, acute kidney failure and muscle weakness. On 01/13/2026 at 2:31PM, record review of influenza, pneumococcal and COVID-19 immunization was conducted for five residents.R19 received an influenza vaccine on 01/30/2024. A scanned influenza immunization consent dated 01/07/2025 indicated that R19 consented to receiving the influenza vaccine. Record review of the EMR revealed that R19 had not received the influenza vaccine in 2025. On 01/13/2025 at 2:55PM, an interview was conducted with Infection Control (IC) nurse B. IC nurse B was asked if R19 had received an influenza vaccine in 2025. IC nurse was unsure if R19 had or not and said they would check. IC nurse B returned a few minutes later and stated…

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 MI00150127. Based on observation, interview and record review, the facility failed give prompt treatment for several fractures related to a roll/fall out of bed for one resident (Resident #301). Findings include: Record review of the facility Abuse Prevention Program policy, dated 1/2025, defined 'Neglect' as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Resident #301: Record review of Resident #301's hospital Emergency Department note, dated 2/3/2025 at 9:17 PM, noted acute left 5th through 10th rib fractures and medial left clavicle fractures. The emergency department noted that the resident was symptomatic with multiple rib fractures and left clavicle fracture and has not achieved medical stability for safe discharge from hospital . the current condition would worsen and an adverse event like worsening pain, pneumonia may occur . Record review of Resident #301's progress notes, dated 1/31/2025,…

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

Based on observation and interview the facility failed to maintain sanitary conditions in the kitchen, resulting in an increased potential for cross contamination of food, foodborne illness and improper kitchen sanitization, potentially affecting all residents who consume meals from the kitchen. Findings Include: On 11/18/2024 at 7:45 AM, initial tour was conducted in the kitchen in the presence of Dietary Manager F, the following expired/outdated items were found: Dry Storage Room: - 3-1-gallon containers of [NAME] Vinegar with expiration date of 7/9/2024 - Manager F stated the vinegar is good for a year after they receive it and the date received was 7/9/2023. Walk-in Cooler: - 6-8 pieces of pureed toast- expiration date 11/16/24 - 1 - Gallon size of brownies with no use by date - Premium Parmesan Cheese- opened 10/9/241 with no use by date - Manger F stated the cheese should have been discarded of after 14 days (10/22/24) Walk-in Freezer: - 1 bag of pecans- expired 11/16/24 - Gallon size bag of marinara sauce- expired 10/18/24 - Gallon size bag of turkey- cooked 9/4/2024- with no…

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 The facility failed to ensure comfortable room temperatures for two residents (Resident #24, Resident #110) from a census of 52 residents, resulting in Resident #110 becoming upset and disgruntled because he was too cold to eat and sleep. FACILITY Environment Resident #110: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #110 was admitted to the facility on [DATE] with diagnoses: Kidney disease, heart disease, pneumonia, COPD, and a history of falls with a fracture. The MDS assessment dated [DATE] revealed the resident had mild cognitive loss with a Brief Interview for Mental Status/BIMS score of 11/15 and needed some assistance with all care. On [DATE] at 10:53 AM, Resident #110 was observed lying in bed, watching TV. He was awake, alert and talkative. The resident pointed at the heat register in the room; it read 68 degrees Fahrenheit. Resident #110 said he was very cold. He was very upset. He said he kept telling people that he was too cold and they would tell him 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 interview and record review the facility 1) Failed to check blood sugars and administer insulin per physicians' orders for two residents (Resident #30, Resident #158) of two residents reviewed for timely medication administration and 2) Failed to ensure coordination and integration of hospice services for one resident (Resident #51) of one resident reviewed for hospice. Findings Include: Resident #30: During Resident Council on 11/19/2024 at 10:30 AM, Resident #30 shared many times her blood sugar is being checked after she had already completed breakfast. She continued the nurse typically has an excuse as to why it was not checked prior to meal service. On 11/19/2024 at approximately 2:00 PM, a review was conducted of Resident #30's medical record and it revealed she was admitted to the facility on [DATE] with diagnoses that include, Cellulitis, Peripheral Vascular Disease, Type 2 Diabetes Mellitus, Long term use of insulin and Heart Disease. Further review of Resident #30's records revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that food preferences were identified and followed for 2 residents (#8 and #109) of 2 residents reviewed for food or choices, resulting in both Resident #8 and #109 becoming upset, and discouraged that they did not receive the food that they had requested. Findings Include: Resident #109: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #109 was admitted to the facility on [DATE] with diagnoses: Cirrhosis of the Liver with ascites, vitamin/mineral deficiency, dehydration, history of falls, left hip pain, hypertension, COPD, depression, Panic disorder, GERD and arthritis. The MDS assessment dated [DATE] indicated Resident #109 had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and needed some assistance with care. The MDS section K identified the resident was receiving a Therapeutic diet. On 11/19/2024 at 9:20 AM, Resident #109 was viewed sitting in 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 complete a Minimum Data Set/MDS Comprehensive Assessment for 2 residents (#35 and #45) of 15 residents reviewed for Comprehensive Assessments, resulting in the potential for the misidentification of resident needs, treatments and services for Resident #35 and Resident #45. Findings Include: FACILITY Resident Assessment Resident #35: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including: Dementia, heart disease, diabetes, kidney disease, depression and hypothyroidism. On 11/18/2024 at 10:27 AM, during a review of the MDS assessments for Resident #35 identified an admission assessment on 10/31/2023 and 4 quarterly assessments dated: 1/31/2024, 5/2/2024, 8/2/2024 and 11/2/2024. At the top of the MDS screen in the electronic medical record/EMR, identified Next Full: ARD (assessment reference date: 10/31/2024, 5 days…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to update/revise individualized, person-centered care plans to reflect changing care needs for 2 residents (Resident #10, Resident #109), of 15 residents reviewed for care plans, resulting in the potential for unmet care needs. Findings Include: Resident #10: A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #10 indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Alzheimer's dementia, history of falls with right leg fracture, respiratory failure, history of a stroke and heart disease. The MDS assessment dated [DATE] indicated the resident had severe cognitive impairment with a Brief Interview for Mental Status/BIMS score of 0/15 and the resident needed assistance with all care. On 11/19/2024 at 9:50 AM, Resident #10 was observed sitting in the day room looking out the window. Her face was observed to have several very dry and scaly patches. A review of a skin…

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

Based on observation, interview and record review, the facility failed to ensure 1) Appropriate narcotic medication practices including, prevention of discrepancies in the narcotic log count for one resident (Resident #49) from the 300 hall medication cart of 2 carts reviewed for narcotics administration, and 2) Storage and handling of medications for one medication room of one reviewed and one of two medication carts reviewed, in accordance with acceptable pharmaceutical standards of practice, resulting in the potential for inappropriate access to narcotic medications, residents not receiving medications as ordered and a lack of therapeutic benefits of medication. Findings Include: FACILITY Medication Storage and Labeling On 11/19/2024 at 1:59 PM, the 300 hall medication cart was reviewed with Nurse M. While reviewing the Narcotics log and narcotics medication cassettes, it was observed that Resident #49's Narcotic log for Norco 7.5-325 mg (Hydrocodone-Acetaminophen) tablet: Give one tablet by mouth every 6 hours as needed for Pain, did not match the cassette the medication 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 post in a prominent location for public viewing the actual hours worked by categories of nursing staffing and the census for each day resulting in the public and the 49 residents of the facility being unaware of the nursing staff available to care for residents. Findings include: Record review of the facility 'Staffing' policy dated 2/2023 revealed that the facility provides adequate staffing to meet needed care and services for the resident population. (4.) The facility furnishes information from payroll records as required by Payroll Based Journal or determine the numbers of staffing personnel per shift on a daily basis as required by state guidelines. In addition, this information is posted daily for public viewing at the central nurses' station. FACILITY: Observation on 12/03/23 at 09:46 AM the state surveyor Observation of clear plastic upward standing document holder on the far west end of the nursing station noted posted staffing of daily staffing sheets dated Friday 12/1/2023 and on the back side was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain sufficient dietary staff to provide dietary services consistently for residents consuming foods from the kitchen, resulting in low dietary staffing, meals being served in Styrofoam containers with plastic utensils, and complaints of cold food. Findings include: On 12/3/2023 at 7:50 AM, the initial tour of the kitchen was completed and at the time of the tour there were only two dietary staff working in the facility. CDM (Certified Dietary Manager) C was cooking, and Dietary Aide J was plating and serving residents in the dining room and passing resident room trays. There were multiple undated and expired food found during the tour in the refrigerator, dry storage area and walk in cooler. During initial tour Dietary Aide J was observed passing meal trays on 300 and 400 halls. Aide J stated she was the only Dietary Aide in the facility and was responsible for completing meal service in the dining room and passing room trays. 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.

On 12/4/23 at 10:18 AM, encrusted food debris was observed on the digital probe thermometer. At this time, the thermometer was in it's sheath and food debris was observed in the sheath. CDM C proceeded to instruct staff to clean the thermometer and sheath. According to the 2017 FDA Food Code Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 12/4/23 at 10:20 AM, a container of raw hamburger patties were observed to be dated 11/28 to 12/3. At this time, [NAME] L was observed to pull out a burger and place it in a cooking pan. During an interview, [NAME] L stated that they intended on cooking the burger. [NAME] L was then informed of the expiration date on the container and stated that they won't…

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 the facility's Second Quarter 2023 third party payroll services submitted Payroll-Based Journal (PBJ) data timely, resulting in the second quarter (April/May/June) 2023 payroll submission to trigger by CMS for staffing concerns with the likelihood to affect all residents residing within the facility. Findings include: Record review of the facility 'Staffing' policy, dated 2/2023, revealed that the facility provides adequate staffing to meet needed care and services for the resident population. (4.) The facility furnishes information from payroll records as required by Payroll-Based Journal to determine the numbers of staffing personnel per shift on a daily basis as required by state guidelines. In addition, this information is posted daily for public viewing at the central nurses' station. Record review of the Centers for Medicare & Medicaid Services (CMS) PBJ Staffing Data Report FY Quarter 3 2023 (April 1-June 30) run date 11/21/2023 noted: One-star staffing rating: Triggered. Excessively low weekend staffing:…

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 timely complete a mental health evaluation for one resident (Resident #26) reviewed and eight unsampled residents, reviewed for screening of mental and intellectual disabilities, after surpassing the 30-day exemption period, resulting in the likelihood for missed specialized behavior health services from the local Community Mental Health Organization. Findings include: Record review of the facility 'Facility Assessment' annul review date 1/2023 revealed a facility that had a total of 55 licensed beds. The facility resident profile included common diagnosis/conditions of psychiatric/Mood with impaired cognition, depression, anxiety disorder, behaviors that need interventions. Facility assessment on acuity/special treatments and conditions section revealed mental health/behavioral health needs was assessed as number/average or range of residents as approximately 35% of the resident population. Part 2: Services and care offered based on residents' needs-…

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 Resident #23's dignity and thoroughly investigate a customer service complaint, resulting in Resident #23 reporting offensive statements made to her by CNA (Certified Nursing Assistant) N with inadequate facility follow-up and feelings of frustration, unimportance, and betrayal. Findings Include: Resident #23: During initial tour on [DATE], Resident #23 was observed resting in their reclining chair. She was in good spirits and spoke about her overall physical progress since admitting to the facility. Resident #23 reported about 1.5 months ago she pressed her call light and it took about 40 minutes for a CNA to respond. The CNA that responded was training a new aide as well and upon entering her room said curtly, what do you need? Resident #23 responded that she needed to use the restroom and the aide told her she wasn't going to be ready by the time she returned with her wheelchair (which was in the bathroom) as you don't even have…

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/update interventions of offering and documenting bedtime snacks for two residents (Resident #31, Resident #32) with noted weight loss, resulting in Resident #31 to experience weight loss and Resident #32 to have a decline in weight and not receive any bedtime snacks between meals with a diagnosis of diabetes. Findings include: Record review of the facility 'Care Plans, Comprehensive Person-Centered' policy dated 2/2023 revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. (14.) the interdisciplinary team must review and update the care plan: (a.) When there has been a significant change in the resident's condition . Record review of the facility 'Frequency of Meals' policy dated 2/2023 revealed that each resident shall receive at least three meals daily, at times…

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 1. Ensure medication administration for Resident #252; 2. Effectively assess, monitor, and implement timely interventions for hearing loss and wax build up for Resident #4; and 3. Assess and monitor ICD (Implantable cardioverter-defibrillator) after implantation and monitor usage of [NAME] Heart Transmitter for Resident #38, resulting in, Resident #252's blood pressure and intravenous antibiotics not being administered, Resident #4 ears being severely wax compacted and causing hearing loss without timely facility interventions and inability to monitor Resident #38's cardiac status as they failed to recognize his ICD implantation and usage of [NAME] Heart Transmitter. Findings Include: Resident #4: On 12/2/2023 during initial tour, Resident #4 was observed taking a nap in her wheelchair and was not able to be aroused. Her hearing aides were observed charging on the dresser. During Resident Council on 12/4/2023 at 11:30 AM, Resident #4…

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 Observation, interview and record review, the facility failed to monitor weight fluctuations and offer cueing with meals for two resident (Residents #31, Resident #32), resulting in weight loss and likelihood for further weight loss and a decline in overall health and wellbeing. Findings include: Record review of facility provided 'Snack List' undated listed: Oranges, apples, Oatmeal cookies, Sugar-free cookies, [NAME] crackers, Peanut Butter crackers, Potato chips, Fritos, reduced fat Cheeto puffs, Chex mix, Applesauce, Fruit cups, Uncrustable peanut butter and jelly sandwiches. (Very few protein snacks noted on list). Record review of the facility 'Frequency of Meals' policy dated 2/2023 revealed that each resident shall receive at least three meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs, preferences, requests, and plan of care. The facility will serve at least three meals or their equivalent daily at scheduled times. There will not be more than…

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 water flush tubing was utilized within a 24 hour period and maintain the head of bed (HOB) at 45 degrees per care plan for one resident (Resident #9), resulting in decreased elevation of the HOB and old water flush tubing with the likelihood of aspiration and infection. Findings include: Resident #9: On 12/03/23, at 7:53 AM, Resident #9 was lying in their bed. Their Jevity 1.5 tube feeding solution was hooked to them and running. The water flush bag was dated 12-1 1930 (7:30 PM). On 12/04/23, at 9:00 AM, a record review of Resident #9's electronic medical record revealed a readmission on [DATE] with diagnoses that included Unspecified fracture of right femur, stroke and Alzheimer's. Resident #9 required extensive assistance with all Activities of Daily Living and had severely impaired cognition. A review of the Focus (the resident) is NPO (nothing by mouth) and requires PEG tube feeding . r/t (related to): Dysphagia .…

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 pharmacy services that included acquisition and provision of medications as ordered by a physician were provided to two residents (Resident #19, Resident #24) reviewed for pharmacy services, resulting in multiple missed doses of ordered medications and likelihood for prolonged illness. Findings include: Record review of facility 'Pharmacy Services Agreement' dated 1/30/2023 revealed pharmacy services shall supply to the facility and its resident with FDA approved pharmaceuticals, IV medications, and supplies as ordered by residents' physicians, under the terms and conditions of this agreement and in compliance with all federal and state law and/or regulations. Record review of the facility 'Facility Assessment' annul review date 1/2023 revealed a facility that had a total of 55 licensed beds. The facility resident profile included common diagnosis/conditions of psychiatric/Mood with impaired cognition, depression, anxiety disorder, behaviors that need interventions. Facility assessment on acuity/special…

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 administer medications timely for one resident (Residents #24), resulting in missed medication administrations resulting in 3 errors during medication administration reviews with a medication error rate of 10%. Findings include: Record review of facility 'Pharmacy Services Agreement' dated 1/30/2023 revealed pharmacy services shall supply to the facility and its resident with FDA approved pharmaceuticals, IV medications, and supplies as ordered by residents' physicians, under the terms and conditions of this agreement and in compliance with all federal and state law and/or regulations. Record review of the facility 'Facility Assessment' annul review date 1/2023 revealed a facility that had a total of 55 licensed beds. The facility resident profile included common diagnosis/conditions of psychiatric/Mood with impaired cognition, depression, anxiety disorder, behaviors that need interventions. Facility assessment on acuity/special treatments and conditions section revealed mental health/behavioral health needs…

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 prevent a significant medication error for one resident (Resident #4), resulting in Resident #4 receiving an additional 43 doses of Debrox (ear wax removal treatment) when the practitioner prescribed for five days. Findings Include: Resident #4: On 12/2/2023 during initial tour, Resident #4 was observed taking a nap in her wheelchair and was not able to be aroused. Her hearing aides were observed charging on the dresser. During Resident Council on 12/4/2023 at 11:30 AM, Resident #4 expressed frustration with being unable to hear what was being said and was going to leave the meeting. This writer was able position themselves next to the resident and repeat the questions to ensure inclusion and that her concerns were voiced. Resident #4 shared her hearing aides had been checked multiple times and are working but she is still unable to hear because her ears are full of wax. She continued she does not know why there is so much build up nor…

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 3 out of 4 medication carts contained medications with no labels of resident names and/or the date that medications were opened in the 100/200/400 Hall Medication Carts and the facility failed to label back up stock insulin in a multi-dose bottle, resulting in the likelihood of cross contamination and ineffective medications. Findings include: Record review of facility 'Medication Labeling and Storage' policy, dated 10/2023, revealed medication storage: (1.) Medications and biologicals are stored in the packaging containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. Medication labeling: (2.) The medication label includes, at a minimum: (a.) medication name (generic and/or brand). (b.) prescribed dose. (c.) strength. (d.) expiration date, when applicable. (e.) resident's name. (f.) route of administration. (g.) appropriate…

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 care plan and provide documented collaborated visits with Hospice Service for one resident (Resident #7), resulting in the likelihood of unmet needs and confusion as to what services hospice provided. Findings include: Resident #7: On 12/4/23, at 10:00 AM, a record review of Resident #7 revealed an admission to hospice services on 12/28/2022 with diagnoses that included altered mental status, congestive heart failure and Diabetes Mellitus. A review of the miscellaneous tab revealed the last HOSPICE NURSE NOTE was for 11/27/23. A review of the Hospice care plan revealed no schedule nor services hospice provided. On 12/04/23, at 1:25 PM, Unit Manager (UM) E was asked how the facility communicated with Resident #7's hospice group and UM E stated, the nurse usually meets with the floor nurse for order changes etc. UM E was asked regarding Resident #7's recent injury to their leg and where the hospice nurse documented that they have assessed it and UM E I know they needed to stitch it up and would assist if finding…

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.