Healthsource Saginaw, Inc

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain best practices in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:Facility [NAME], [NAME] (52634) - Kitchen On 7/29/2025 at 9:25AM A kitchen tour was conducted with the Regional Director of Operations I and the General Manager J. On 07/29/2025 at 9:42 AM Record review of the high temp dishwasher log temps had ranges at the rinse temp from 154-193 degrees Fahrenheit. The guidelines for temperature ranges at the top of the document state Rinse 180 degrees Fahrenheit. On 7/29/2025 at 9:45 Observed dishwasher temps at: final temp 184, wash 164, rinse 161, and dual rinse 173 degrees Fahrenheit. On 07/29/2025 at 9:55 AM Observed mixer visibly soiled with residue. In response to the soiled mixer, the Regional Director of Operations I commented Well this looks like it needs to be cleaned. It should be cleaned every day. On 07/29/2025 at 10:05 AM…

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 2564956.Based on observation, interview and record review, the facility failed to implement care plan interventions for fall safety prevention for 2 of 5 residents (R21 & R114) reviewed to be at risk for falls, accidents and hazards, by not consistently ensuring the resident's call light was within reach and the fall mat was in place as outlined in the residents' care plans. Facts and Findings include: Resident #21: Review of the Face Sheet, Care Plans dated 4/25, nursing progress notes and Hospice notes dated 7/25, and care guide for Nursing Assistants/CNA’s found in the closet, revealed Resident #21 was [AGE] years old, admitted to the facility on [DATE], confused, unable to follow simple directions, had poor safety awareness with a history of falls in the facility. The resident's diagnoses included, Dementia, behavioral disturbances, cardiac pacemaker, bipolar disorder, depression, anxiety disorder, Alzheimer’s disease, Dysphagia (difficulty swallowing), stroke and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake Number MI00149682. Based on interview and record review, the facility failed to provide adequate post fall assistance to one resident (R1) of three residents reviewed for falls, resulting in feelings of sadness and tearfulness. Findings include: Resident #1 (R1): R1 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include aphasia, cerebral infarction affecting the right side, anxiety and depression. R1 is non-verbal, however, they can respond to yes/no questions. On 2/7/25 record review of recent falls revealed that R1 sustained an unwitnessed fall on 1/19/25 at 5:50pm. R1 was observed sitting in an upright position on the floor mat next to the bed. On 2/7/25 at 1:01pm, an interview was conducted with Licensed Practical Nurse (LPN). LPN 'F' was asked where they were at during the time R1 was observed on the floor. LPN 'F' stated, I was in the room next to the resident. LPN 'F' was asked what alerted them to go into R1's room. LPN 'F' stated, I heard…

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 MI000147442 and #MI00147989. The facility failed to ensure professional quality of care regarding timely treatment, transfer to acute care for evaluation and treatment of an infected wound for 1 resident (Resident #104) of 3 residents reviewed for pressure ulcers, resulting in sepsis (severe infection throughout body), hospital admission with treatment for infected pressure ulcer, and antibiotic usage. Findings Include: Resident #104: Review of the Face Sheet, care plans and physician orders dated 5/31/24 through 6/29/24, physician and nursing progress notes dated 5/31/24 through 6/29/24, revealed Resident #104 was 57 years-old, alert with communication deficit due to stroke, admitted to the facility on [DATE] and discharged to acute care for evaluation and treatment of an infected coccyx pressure ulcer. The resident's diagnosis included, diabetes, amputation of right leg below knee, Acute respiratory failure with hypoxia, facial weakness, communication deficit, metabolic…

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

Based on observation, interview and record review, the facility failed to ensure that previous survey results, State Hotline and Ombudsman contact information were accessible for all residents, resulting in the potential for all residents to be frustrated and/or uninformed of the previous survey results and unsure how and who to complain to. Findings include: On 8/6/24, at 4:00 PM, During Resident Council, group members complained they did not know where the survey results were located. The resident council president reminded the group that the book was in the front lobby and the following complaint was made by members not everyone gets to the lobby. During Resident Council, group members complained they didn't know how to get a hold of the ombudsman and was not sure how to get the state hotline number. The following complaint was made: they were in the hallway, but I think they took them down I know someone in here that has the number On 8/7/24, at 8:45 AM, a measurement of the main corridor hallway from the 500 hallway/nursing unit to the lobby where the survey results binder 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 ensure that the daily staff posting was accessible for all residents, resulting in the potential for all residents to be frustrated and/or uninformed of the daily available staff. Findings include: On 8/7/24, at 8:45 AM, a measurement of the main corridor hallway from the 500 hallway/nursing unit to the lobby where the staff posting was located revealed .11 miles/580 feet. On 8/07/24, at 9:43 AM, an interview with the Director of Nursing (DON) was conducted regarding the posting of the daily staff. The DON stated the staff posting was at the front desk. The DON was asked if the staff posting at the front desk was for the entire building and the DON stated, yes. The DON was asked for clarification if each of the nursing units had their own staff posting and the DON stated, no. On 8/08/24, at 2:05 PM, Central Staffing (CF) Z was interviewed regarding the staff posting and CF Z stated, they fill it out and email it to the switchboard operator each day. On 8/08/24, at 2:07 PM, a record review of the staff posting…

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 ensure that the Arbor Cafe's refrigerator was clean and sanitary, and 2) Failed to ensure a clean and sanitized kitchen for a census of 162 residents who eat from the kitchen, resulting in the likelihood for resident illness from cross contamination, unsafe food items and weight loss. Findings Include: On 8/05/24 at 9:15 a.m., during the initial kitchen tour accompanied by Chef F and VP of Dietary G, the following observations were made: -At 9:43 a.m., a large trash bin with trash up to the top was found sitting next to the grill, with no lid on it. -At 9:44 a.m., the microwave was found to have dried food particles on the inside top, sides and door. -At 9:45 a.m., the large can opener had dried food on it and the paint was chipping off the blade. -At 9:46 a.m., a clean and ready for use silver metal pan was stacked inside another pan and it was found to be wet inside. -At 9:47 a.m., in the backing area several staff members were making cookies and the large trash bin that was sitting directly behind 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 a clean and safe environment for 3 Units (Wheel's, Patriot, and Garden) of 4 units observed and failed to ensure that one resident's refrigerator (room [ROOM NUMBER]) was clean and all food items were dated, resulting in the likelihood for cross contamination, resident illnesses, cluttered resident rooms, and an unsafe environment. Findings Include: Environmental tour done on 8/7/24 starting at 10:28 a.m., accompanied by the Director of Nursing/DON, Director of Maintenance C, and the Director of Housekeeping A. During the tour, the following concerns were found: On Wheels Neighborhood starting at 10:30 a.m.: -In room [ROOM NUMBER], the CPAP (continuous positive airway pressure) was sitting on the nightstand, not in the clear plastic bag next to the CPAP machine. The CPAP and tubing were also found to be dirty. Review of the facility CPAP policy (dated February 2023) revealed the CPAP should be cleaned and disinfected by staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Numbers MI00143547 and MI00144442. Based on observations, interviews and record review, the facility 1) Failed to ensure that privacy was maintained for one resident (Resident #56), 2) Failed to ensure that residents are receiving timely, polite, and dignified assistance, 3) Failed to ensure that female residents with facial hair were shaven, 4) Failed to ensure that call lights are within reach, and 5) Failed to respond timely to call lights for nine residents (#6, #11, #12, #26, #28, #56, #78, #135, and #136) and the Confidential Resident Group meeting conducted on 08/06/24, resulting in verbalizations of concern and anger, an unsafe environment, and the likelihood for decreased self-esteem, shame and isolation. Findings Include: Resident #6: Review of the Face Sheet and care plans, revealed Resident #6 was [AGE] years old, admitted to the facility on [DATE], alert and able to make own healthcare decisions, and dependent on staff for assistance with Activities of Daily Living…

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

Based on observation, interview and record review, the facility failed to ensure that grievances were followed up timely and ensure that all residents were invited to the Resident Council meeting for a confidential group of residents, resulting in feelings of being left out, frustration, crying, continued complaints of staff being loud, rude, slow and disrespectful call light responses. Findings include: On 8/6/24, at 4:00 PM, during Resident Council, the group complained that the facility doesn't follow up on their complaints. The group complained that they often complain about loud staff in the hallways and nothing has changed at all or nothing gets done about it. They also complained that the staff continue to answer their call lights rudely and say what do you want; don't answer them timely and/or cancel them and don't come back. The following complaints were voiced: they will come in a grab my tray, but leave me in my mess (referring to bowel movement) They will tell you to start going and will help you, but they don't They say I have to go to bed now because they're short…

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 a clean, comfortable and home like environment to ensure that residents' rooms, dining rooms and other facility areas were 1) Clean, uncluttered and in good repair including Rooms 383, 422 and 449; 2) Without pests; 3) Cleaning supplies were stored properly; and 4) A Confidential group of residents received proper silverware, resulting in an unclean and non-homelike physical environment, resident dissatisfaction and complaints. Findings Include: FACILITY Environment On 8/5/2024 at 9:58 AM, during a tour of the building room [ROOM NUMBER] was observed to have a yellow, urine-soaked wash rag, laid out flat on the floor in front of the toilet. The room smelled strongly of urine. On 8/05/2024 at 2:40 PM, during a tour of the facility large bags of clothes were observed in a laundry basked under the sink in the bathroom in room [ROOM NUMBER]. There was also a plastic storage container next to the toilet. Unit Manager JJ was interviewed…

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 Activities of Daily Living (ADL) care for five dependent residents (Resident #59, Resident #60, Resident #62, Resident #117 and Resident #135) of eight residents reviewed for ADL's resulting in long, dirty fingernails, female residents having facial hair, lack of assistance with oral care and timely assistance with toileting. Findings include: Resident #135 (R135): Resident #135 is [AGE] years old, non-verbal and admitted to the facility on [DATE] with diagnoses that include dementia, aphasia, depression and cognitive communication deficit. On 08/06/24 at 11:18 AM, R135 was observed sitting in the dining room on the 500 unit, R135 was observed to have facial hair on the chin and upper lip and dirty nails. On 08/07/24 at 10:40 AM, R135 was observed during an activity and noted to still have facial hair and dirty nails. On 08/07/24 at 10:43 AM, an interview was conducted with Activity Aide O. Activity Aide O was asked who 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 to ensure that residents' food preferences were honored for four residents (Resident #23, Resident #26, Resident #42, and Resident #79) of 7 residents reviewed for food and nutrition, resulting in residents' feelings of anger, frustration and dissatisfaction with the meal experience, which could lead to decreased nutritional intake and weight loss. Findings Include: Resident #23: Food A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #23 was admitted to the facility on [DATE] with diagnoses: history of a stroke, left sided weakness, GERD, depression weakness, epilepsy and hypertension. The Minimum Data Set assessment (MDS) dated [DATE] revealed the resident had mild cognitive deficit with a Brief Interview for Mental Status (BIMS) score of 12/15 and the resident needed assistance with all care. On 8/05/2024 at 1:39 PM, during an interview with Resident #23, she said she was upset because she did not…

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

Based on observation, interview and record review, the facility failed to provide snacks, including bedtime snacks, for a confidential group of residents, resulting in complaints of the unit refrigerators being empty of snacks, no availability for snacks, no personal choice of snacks, familiy and friends having to purchase snacks with the feelings of frustration, sadness and hunger. Findings include: On 8/6/24, at 4:00 PM, During Resident Council Task, all attendees complained of not getting snacks. The following complaints were voiced: Being a diabetic, you'd think you'd get healthy snacks like apple sauce, peanut butter and jellies, fruit or cheese our family has to bring us snacks you have to ask every afternoon with us being diabetic, they should give a snack for us at bedtime I save my chips from dinner so I have a bedtime snack my son brings me snacks I don't eat all my chips at dinner and save half the bag for nighttime I have my family bring me snacks my family brings me in fresh fruit because they don't give us any we only get 1 banana for breakfast on Sundays it would be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number MI00143547. Based on observation, interview and record review the facility failed to ensure Infection Prevention and Control standards of practice were followed for 1) Personal Protection Equipment/PPE use, 2) Hand Hygiene for Residents #56 and #143 and 3) Linen transport for a census of 162 residents, resulting in the potential for the spread of infection. Findings Include: On 8/05/24, at 1:35 PM, the in-room sanitizer for room [ROOM NUMBER] was not working. Resident #56: On 8/07/24, at 8:55 AM, an observation of Resident #56's incontinence care along with CENA X was conducted. CENA X had gloves on and assisted the resident with perineal care and placed a new incontinent brief on the resident. Resident #56 asked for a drink and CENA X picked up the bedside cup with their gloved hand and offered the bedside cup to the resident. CENA X did not remove their dirty gloves and perform hand hygiene prior to assisting with the fluids. On 8/05/24, at 2:08 PM, an observation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a Preadmission Screening and Annual Resident Review (PASARR) Level II completed by Community Mental Health with recommendations for specialized mental health services was incorporated into the residents' plan of care for two residents (Resident #26 and Resident #59) of 2 residents reviewed for PASARR, resulting in the potential for absence of available services for mental health disorders . Findings Include: Resident #26: PASARR A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #26 was admitted to the facility on [DATE] with diagnoses: Guillain-Barre syndrome, quadriplegia dysphagia, bipolar disorder, pneumonia, pain, depression, and hypertension. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 15/15; the resident had functional limitations in bilateral upper and lower extremities and the needed assistance with all…

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

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 three residents (Resident #12, Resident #16, and Resident #117), of 32 residents reviewed for care plans, resulting in the potential for unmet care needs. Findings Include Resident #16: Pressure Ulcer/Injury A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #16 was admitted to the facility on [DATE] and the most recent readmission of 4/16/2024 with diagnoses: History of brain injury, quadriplegia, seizures, hydrocephalus, dysphagia, multiple pressure ulcers, and anxiety. The MDS assessment dated [DATE] revealed the resident had severe cognitive decline and was dependent with all care. On 8/06/24 at 9:53 AM, Resident #16 was observed lying in bed. He had an air mattress set at 400 normal pressure; on the static setting. The resident was awake and alert, but unable to answer questions. On 8/08/24 at 12:28 PM,…

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 MI00143547. Based on interview and record review the facility failed to monitor and treat blood glucose levels for one resident (Resident #165) of five residents reviewed for medication management, resulting in Resident #165 developing a change of condition due to low blood glucose levels and being transferred to the hospital. Findings Include: Resident #165: Hospitalization A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #165 was admitted to the facility on [DATE] with diagnoses: Diabetes, end stage kidney disease, renal dialysis, Alzheimer's disease, GERD, COPD, hypothyroidism, and hypertension. The MDS assessment dated [DATE] indicated the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 14/15 and needed assistance with all care. On 8/07/24 at 2:00 PM, during an interview with the Assistant Director of Nursing/ADON BB related to a facility reported incident for Resident #165, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that management and monitoring of a left arm splint was provided for one resident (Resident #78), of 1 resident reviewed for splint use, resulting in Resident #78 having a soiled hand splint, that had not been laundered. Findings Include: Resident #78: Position, Mobility A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #78 was admitted to the facility on [DATE] with diagnoses: Dementia, history of a stroke, diabetes, depression, weakness, COPD, obesity, pain, seizure disorder, dysphagia and left sided weakness. The MDS assessment dated [DATE] revealed Resident #78 had full cognitive abilities with a BIMS score of 15/15 and needed assistance with all care. On 8/05/24 at 1:28 PM, Resident #78 was observed sitting in a chair in his room. He showed his left-hand splint sitting on top of a table. The splint had a cream-colored soft material on the inside and was very soiled, brown. The resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the safety for one resident (Resident #12) of 4 residents reviewed for accidents and falls, resulting in a left eyebrow laceration, pain and the likelihood of further injury. Findings include: Resident #12: On 8/6/24, at 1:00 PM, a record review of Resident #12's electronic medical record revealed an admission on [DATE] with diagnoses that included Dementia, Parkinson's Disease and Alzheimer's. Resident #12 had severely impaired cognition and required assistance with all Activities of Daily Living (ADL's). A record review of the Problem Start Date: 11/24/2022 Category: ADL's Functional Status . (the resident) is limited in ability to perform ADL's/hygiene/transfers related to: Dementia; Parkinson's . Approach Start Date: 01/09/2024 Staff to use 2 assist with ADL's and hygiene when resident is exhibiting behaviors to help decrease risk for injury as needed . A review of the Problem Start Date: 07/22/2024 (the resident) has periods of swinging at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, interview and record review, the facility failed to document food acceptance, provide suitable utensils, and assess, monitor and notify the physician of a weight loss for one resident (Resident #143) of three residents reviewed for nutrition, resulting in a significant weight loss and numerous undocumented meal consumptions. Findings include: Resident #143: On 8/06/24, at 9:08 AM, Resident #143 was sitting in bed. Their breakfast tray was on the overbed table and appeared untouched. There was 2 slices of bacon and pile of scrambled eggs. There was a medal fork, a plastic spoon and a plastic knife. There was no staff assistance. Resident #143 was asked if they needed help or could take a bite of eggs on their own. Resident #143 picked up the fork with a shaky hand and forked a bite of eggs. Resident #143 used their right hand with the fork and with their left hand pushed the fork of eggs into their mouth. It took the resident 2 full minutes to get a bite of eggs and chew it. The resident 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 ensure that oxygen equipment for two residents (Resident #2 and Resident #60) and one continuous positive airway pressure (CPAP) mask and tubing for one resident (Resident #624) were clean, sanitized and stored properly after use of 4 residents reviewed for oxygen and CPAP equipment, resulting in the likelihood for cross contamination, respiratory illnesses/disease and increased antibiotic usage. Findings Include: Resident #624: Review of the Face Sheet, physician orders and care plans dated 8/2/24, revealed Resident #624 was [AGE] years old, admitted to the facility on [DATE], was alert and required staff assistance with Activities of Daily Living. The resident's diagnosis included fracture of left lower leg, fall, degenerative disease of nervous system, diabetes, peripheral vascular disease, sleep apnea and heart disease. During the environmental observation done on 8/7/24 at 10:00 a.m., Resident #624's CPAP was sitting out on 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 assess and monitor the dialysis port for one resident (Resident #54) of one resident reviewed for dialysis resulting in the resident starting on antibiotics. Findings include: Resident #54 (R54): Resident #54 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include end stage renal disease, hypertensive chronic kidney disease, heart failure and dependence on renal dialysis. On 08/07/24 at 02:23 PM, R54 was observed in their room, a dressing was noted on the upper right chest area where the dialysis port is located. On 08/07/24 at 02:24 PM, an interview was conducted with R54. R54 states they go to dialysis on Monday, Wednesday and Friday. R54 stated they were a bit tired after dialysis today but overall feeling good. On 08/07/24 at 02:29 PM, record review revealed there was no physician order to assess and monitor the dialysis port for any changes. On 08/08/24 at 10:46 AM, an interview was conducted with R54. R54…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview, the facility failed to ensure that 3 of 8 medication carts were free of crushed pills, pieces of loose paper, silver shards of foil from medication cartridges and dust on the bottom of the drawers, and one set-up of a resident's medications (room [ROOM NUMBER]) in a medication cup, resulting in the likelihood for cross contamination, low medications count with increased cost and missed resident medications. Findings Include: During observation of Patriot units cart 2 of 300 hall medication cart done on 8/5/24 at 1:43 p.m., accompanied by Nurse, RN I, revealed the second, third and fourth drawers were found to have crushed white pills, pieces of paper and dust on the bottoms of the drawers. During an interview done on 8/5/24 at 1:45 p.m., Nurse I stated I just cleaned this out last week, I am not sure who cleans the carts. During a second observation of Patriot units cart 1 of 300 hall medication cart done on 8/5/24 at 2:36 p.m., accompanied by Nurse, LPN J, 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 interview, and record review the facility failed to ensure that antibiotic orders identified the reason for use and antibiotic use was tracked for two residents (Resident #23 and Resident #79) of 3 residents reviewed for antibiotic use, resulting in the potential for inappropriate antibiotic use that could contribute to adverse effects, antibiotic resistance and the spread of infection. Findings Include: FACILITY Infection Control Resident #23: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #23 was admitted to the facility on [DATE] with diagnoses: history of a stroke, left sided weakness, GERD, depression weakness, epilepsy and hypertension. The Minimum Data Set assessment (MDS) dated [DATE] revealed the resident had mild cognitive deficit with a Brief Interview for Mental Status (BIMS) score of 12/15 and the resident needed assistance with all care. A review of the physician orders for Resident #23 indicated the resident had an order for Doxycycline (an…

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

Based on interview and record review, the facility failed to notify the local ombudsman's office of a discharge for one resident (Resident #159), resulting in the lack communication to the local ombudsman office. Findings include: Resident #159: On 8/23/23, at 3:24 PM, the Administrator was asked to provide the discharge notification to the local ombudsman for Resident #159. On 8/24/23, at 9:20 AM, the Administrator was again asked for the discharge notification to the local ombudsman for Resident #159. On 8/24/23, at 10:30 AM, the Administrator was again asked for discharge notification to the ombudsman. The Administrator offered that's not anything they have ever done and that they placed a phone call to their local ombudsman for clarification. On 8/24/23, at 2:06 PM, the Administrator forwarded the email conversation with the local ombudsman office which revealed the following: (the facility) is currently going through annual survey. They would like to exit today and need to have all needed information by 2 PM. I have been the CEO but have just started as the NHA on August 3rd…

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) maintain food preparation and kitchen equipment in a sanitary and good working condition, and 2) ensure kitchen freezer door were properly maintained, resulting in an increased likelihood for food borne illness with hospitalization, and cross contamination affecting 151 residents who consumed oral nutrition from the facility kitchen of a total census of 165 residents. Findings Include: During the initial kitchen tour done on 8/22/23 at 11:00 a.m., accompanied by Dietary Manager/Chef U, the following observations were made: -At 11:00 a.m., a plastic cup with liquid in it was found in cooler #8; no name or date on it (it was a staff member drink). -At 11:04 a.m., the resident microwave was observed to have dried on food and drips inside on top and sides, and on the door. There were an excessive amount of crumbs found under the microwave. -At 11:05 a.m., the clean and ready for use Robot Coupe had the top on it and was found to be wet inside. Moisture in a covered container increases bacterial growth. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive Infection Control (IC) program including outcome and process surveillance, data analysis and reporting, hand hygiene performance, environmental and equipment cleaning/sanitization processes/procedures for all 165 facility Residents resulting in lack of PPE use for a resident diagnosed with Clostridioides difficile (C-diff- contagious gram positive, spore-forming, anaerobic bacillus which causes severe diarrhea), lack of cleaning/sanitization of shared blood glucometers, cross contamination from exposed, bloody towels on the floor, lack of surveillance for potential infections, lack of consistent documentation and utilization of McGeer Criteria, incomplete infection analysis, and the likelihood for the development and transmission of communicable diseases and infections for all residents. Findings Include: On 8/22/23 at 2:00 PM and 8/24/23 at 8:31 AM, the hand sanitizer dispenser near room [ROOM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #73: Record review of Resident #73's electronic medical record revealed that the resident was receiving hospice services and was care planned to encourage the resident to verbalize feelings and concerns. Resident #73 requires hospice and was care planned to experience death with dignity and comfort. An interview on 08/22/23 at 10:42 AM with Resident #73 revealed the call light takes a long time, and when the girls come in, they talk over the top of me, and they complain about their job, and I have to tell them that they are here to work on me and not to get so rough. Resident #82: Record review of Resident #82's electronic medical record revealed that the resident was care planned for on 10/21/2020 for behavioral symptoms of: (Resident name) has periods of refusing care due to (resident name) believing she is able to do it on her own which is a safety concern. Interventions included: Convey an attitude of acceptance toward the resident and explain the need for assistance from staff for her safety.…

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 administer oxygen per orders, and store respiratory equipment in a sanitary and proper manner for six residents (#9, #65, #82, #88, #101, #130), resulting in the likelihood for cross contamination, increased risk for respiratory infections and prolonged illness. Findings include: Record review of facility 'Oxygen Delivery Systems' policy dated 6/2022 revealed all oxygen delivery systems shall be set up in a uniform manner with proper procedure to provide an adequate delivery of oxygen to the patient/resident. The purpose was to allow patient/resident to receive the maximum benefits of oxygen therapy. Resident #82: Record review of Resident #82's care plan of Alteration in breathing related to chronic obstructive pulmonary disease (COPD) revealed on 4/26/2023 intervention: Suction as needed. Observation on 08/22/23 at 10:42 AM of Resident #82's room revealed a Suction machine on the floor. Oral [NAME] for oral suction noted to be laying on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for use, assessment, and ongoing evaluation of bed rails for 164 of 165 Residents reviewed resulting in lack of consent for use, identification and implementation of alterative interventions, lack of entrapment assessment, maintenance and monitoring of side rails, extremely loose and moveable rails, and the likelihood for injury. Findings include: An initial tour of the Wheels unit of the facility was completed on 8/22/23 beginning at 10:14 AM. During the tour, all 33 Residents residing on the unit were noted to have various types of bed/side rails in place on their beds. Rails were also observed on unoccupied, made beds in resident rooms. Resident #20: On 8/22/23 at 11:37 AM, Resident #20 was observed sitting a wheelchair in their room. A dark purple colored bruise was observed over the Resident's right eye. An interview was completed at this time. When asked what happened to their eye,…

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 issue a beneficiary notice (ABN/Nomnic) for Resident #4 and notify an eligible resident in writing of the items and services which are or are not covered under Medicaid or by the facility's per diem rate, including the cost of those items and services: resulting in the likelihood for financial hardship. Findings include: Record review of the facility 'Administrative Manual- Utilization Management Beneficiary Notification Procedure P-006' dated 1/2014 revealed that the Utilization Management and/or the Neighborhood Registered Nurse Manager shall be responsible for the notifying beneficiary and/or responsible party and attending physician in writing of benefit status. To ensure beneficiary and/or responsible party of notification of status as required by insurance carriers. Procedure: Written notification on non-covered care shall be issued to competent resident or responsible party: (a.) Prior to termination of coverage. (b.) Following notification by intermediary or insurance carrier. (c.) If inpatient stay…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure appropriate medical justification and ongoing evaluation and assessment of physical restraint use for one resident (Resident #313) of one resident reviewed, resulting in a lack of comprehensive reevaluation of necessity following readmission, physical restraint use per family request for fall prevention and positioning, lack of attempts of alternative interventions, lack of reevaluation and implementation of less restrictive devices, and the likelihood for injury and psychosocial distress using the reasonable person concept. Findings include: On 8/23/23 at 8:40 AM, Resident #313 was observed in the central activity room area of the unit alone sitting in their wheelchair. The Resident's wheelchair was positioned against the table. The Resident was holding a cardboard container of chocolate milk. An unopened container of apple juice and an open applesauce with no spoon was sitting in the table in front of them. Bilateral (left and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a discharge summary was created and provided for one resident (Resident #159) of one resident reviewed for discharge, resulting in the admitting hospital not having an updated plan of care and unmet care needs. Findings include: Resident #159: On 8/23/23, at 12:33 PM, a record of Resident #159's electronic medical record revealed an admission on [DATE] and discharged to the hospital on 7/27/23. A review of the discharge summary screen revealed no discharge summary. On 8/23/23, at 1:27 PM, a record review along with unit manager G was conducted of Resident #159's electronic medical record. UM G was asked where the discharge summary would be located and UM G stated, under the discharge summary tab. A review of the discharge summary tab revealed no discharge summary. A further review of the miscellaneous documents tab revealed no discharge summary. On 8/23/23, at 3:15 PM, Nurse M was asked if there was any other document the facility could…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the PASAAR and Level II OBRA evaluation was completed timely for one resident (Resident #313) of one resident reviewed for PASAAR, resulting in the likelihood of unmet needs and no communication with the local community OBRA coordinator. Findings include: Resident #313: On 8/24/23, at 12:05 PM, a record review of Resident #313's electronic medical record revealed an admission on [DATE] with a readmission on [DATE] with diagnoses that included stroke, attention and concentration deficit and mental illness. A review of the most recent PAS/AAR From Date 01/15/2021 revealed SECTION II - Screening criteria . 1. The person has a current diagnosis of . the YES box was check and MENTAL ILLNESS was circled. 2. The person has received treatment for . the YES box was checked and MENTAL ILLNESS was circled.Explain and YES . Note: The person screened shall be determined to require a comprehensive Level II OBRA evaluation if any of the above items are…

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 urinary catheter tubing was off the floor and not dragging underneath a wheelchair, and 2) use an appropriate technique with the emptying of a urinary catheter bag, 3) ensure Activities of Daily Living (ADL) were done daily, and 4) maintain privacy by placing a urinary catheter bag in a privacy bag for 1 resident (Resident's #143), of 3 residents reviewed for urinary catheter, resulting in the high likelihood for cross contamination and urinary tract infection, embarrassment with possible dislodging of a urinary catheter. Findings Include: Resident #143: Review of the facility face sheet, minimum data set (resident assessment tool dated 2/23/23), and care plans dated 8/23, revealed Resident #149 was 78 years-old, admitted to the facility on [DATE], very confused, non-ambulatory, and dependent on staff for all ADL's. The resident had recently had a suprapubic catheter put in (directly into the bladder on the abdomen). The…

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

Based on observation, interview and record review, the facility failed to ensure proper medication storage for one of four medication carts reviewed, resulting in the storage of a pre-drawn medication syringes with cloudy insulin with the likelihood of missed insulin. Findings include: On 8/22/23, at 9:46 AM, medication storage task was conducted with Nurse EE of the Garden unit Med Cart 2. Nurse EE opened up drawer 3 of the cart which revealed a syringe of fluid in an insulin syringe placed loosely on the bottom of a drawer. There was an alcohol prep pad located near the syringe. The syringe had 10 units of liquid and appeared cloudy and grey. There was no name on the syringe. Nurse EE picked up the syringe for observation and stated, I did not do that and that is not mine. Nurse EE was asked what they thought the liquid was and Nurse EE stated, it looks like regular insulin but its cloudy. Nurse EE discarded the insulin syringe with the 10 units of liquid into the sharps container on their medication cart. On 8/23/23, at 5:20 PM, the Director of Nursing (DON) was asked if the…

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

Based on interview and record review, the facility failed to ensure that the Medical Director was present at least quarterly at the Quality Assurance and Performance Improvement meetings, resulting in the likelihood of the Medical Director not being made aware of quality concerns throughout the facility. Findings include: On 8/24/23, at 8:51 AM, QAPI task was conducted with Nurse M A record review of the QAPI sign in sheets from 5/2022 to 9/2023 revealed no Medical Director (MD) signature for the months of 5/2022, 6/2022, 7/2022 . and the . QUALITY MANAGEMENT COMMITTEE sign in sheet for August 2022 listed names under Present: . The MD's name was not listed on the August 2022 sign in sheet. The record review of the QAPI sign in sheets continued with Nurse which revealed no QAPI sign in sheet for December, 2022 and no MD signature for the months of 1/2023, 2/2023. Nurse M was asked why the Medical Director was not signed in for the months of May through August, 2022 and Nurse MM stated, I don't know and that the MD is usually there.

Based on interview and record review, the facility failed to provide Certified Nursing Assistant (CNA) education hours for two of two CNA's reviewed during staffing task, resulting in the lack of the required 12 hour education hours. Findings include: On 8/23/23, at 09:38 AM, A record review of CNA GG Relias Transcript for education hours along with Organizational Executive (OE) JJ revealed that CNA GGhad only 6.05 hours of education since 1/1/2022 through 8/24/2023. OE JJ stated, well you really can't' go by that and offered that the CNA's do other education. OE JJ was asked to provide all education the CNA's were offered. A review of CNA HH Relias education hours from 1/1/2022 through 8/4/2023 revealed 6.72 hours of education. OE HH offered that the CNA's also do mandatory training comp stomp which was listed in the Relias training. A further review of CNA's HH revealed cna comp stomp 2022 10/24/2022 was listed. Under the column for Hours revealed Met. The Mandatory Packet-Nursing revealed Hours 2.00. OE HH was asked to provide the detailed education offered for the comp stomp 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 Number MI00138575. Based on interview and record review the facility failed to implement policies and procedures for ensuring the reporting of the elopement of one resident (Resident #101) to the State Agency (SA) in accordance with Section 1150B of the Act, resulting in the potential for other residents to elope and risk being stuck by a vehicle, falling into a large ditch, and the potential for serious harm, injury, and/or death. Findings Include: On 8/9/23 at approximately 1:30 PM, Nurse Managers G and H, were queried if there were any other resident elopements at their facility since April 2023. They shared that Resident #101 eloped from the facility a few weeks ago and that the DON (Director of Nursing) completed an investigation. The DON provided the facility internal investigation from Resident #101 eloping from the facility. The DON stated at 7:00 PM on 7/25/2023, Resident #101 walked out his room and past the front receptionist out the South entrance of the facility. 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 This Citation pertains to Intake Number MI00137221. Based on interview and record review the facility failed to schedule a CT Scan in a timely manner for one resident (Resident #103), resulting in Resident #103 being transferred to another facility on 07/27/2023 without a scheduled CT Scan appointment as his Neurosurgeon requested. Findings Include: On 8/10/2023 at 9:50 PM, an interview was conducted with Nurse Manager F regarding Resident #103's CT Scan. Manager F explained they encountered issues scheduling his CT scan as they were informed it required an insurance preauthorization. When they called the insurance company, they had issues reaching a representative and they required certain identification number that Manager F did not have. Once they gathered all the necessary information, they were informed by the representative that Resident #103 did not require a preauthorization for the CT scan. This was discovered some days before his discharge to another facility and Manager F informed their HUC (Health…

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.