Optalis Health and Rehabilitation at St. Francis

Based on interview and record review, the facility failed to implement policies and procedures for antidepressant medication use for one resident (Resident #8) of 4 residents reviewed resulting in a lack of Gradual Dose Reduction (GDR), and the potential for ineffective and inappropriate treatment. Findings include: Record review of the facility 'Psychotropic Medication Use' policy dated 2/3/2026 revealed that it is the policy of the facility to only prescribe psychotropic medications when it is necessary to treat a specific diagnosed condition and the medication is deemed as beneficial to the resident . Residents who use psychotropic medications will receive gradual dose reductions, unless clinically contraindicated . The following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications; Antipsychotics, anti-depressants, anti-anxiety and hypnotics . Gradual Dose Reduction: Psychotropic medications should be reviewed for gradual dose reduction in an effort to find an optimal dose or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake Numbers 2708679 & 2708703.Based on observation, interview, and record review, the facility failed to implement appropriate enhanced barrier precautions (EBP) for one resident (Resident #103), identified with an indwelling percutaneous endoscopic gastrostomy (PEG) tube, of three residents reviewed for infection prevention. Findings include:Resident #103 (R103): According to a review of R103's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to cerebral edema (fluid collection in the brain), oropharyngeal dysphagia (difficulty swallowing), severe protein-calorie malnutrition, Metastatic malignant neoplasm of right lung (cancer), secondary malignant neoplasm of bone (cancer), antineoplastic chemotherapy, weakness with difficulty walking, on 11/21/2025 PEG tube placement. R103's Minimum Data Set (MDS) record revealed Brief Interview of Mental Status (BIMS) score of 11/15 indicated the resident had moderately impaired cognition.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.

This citation pertains to Complaint Number 2644043.Based on interview and record review, the facility failed to reimburse trust funds for one resident (Resident #1) of three residents reviewed for trust funds, resulting in trust funds not being reimbursed upon death. Findings include. On 11/21/2025, at 11:30 AM, the Interim Director of Nursing was asked to provide all grievances and/or complaints regarding trust funds reimbursement for Resident #1. On 11/21/2025, at 1:00 PM, a record review of Resident #1's electronic medical record reveled a death in the facility on 11/13/2024 at 5:35 AM. A review of the miscellaneous tab revealed no scanned documentation regarding trust fund agreement, balances or reimbursements. On 11/21/2025, at 2:00 PM, the Interim Director of Nursing (DON) was interviewed regarding Resident #1. Per the Interim DON, Resident #1 passed away in November 2024. The Interim DON was asked to provide the ending balance of Resident #1's trust fund account. On 11/25/2025, at 10:00 AM, the Administrator provided a copy of a reimbursement invoice for Resident #1's trust…

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 MI00150995. Based on observation, interview and record review, the facility failed to ensure supervision for 1 resident (Resident #101) with a known history of falls prior to admission and after admission (who fell on 3/4/25, with a facial injury) of 3 resident's reviewed for falls, resulting in a contusion above the left eye, skin tear on bridge of nose, pain and hospitalization. Findings Include: Resident #101: Review of the Face Sheet, Minimum Data Set, dated 3/25, nursing and physician notes dated 2/24/25 through 3/4/25, and facility fall assessments dated 2/26/25 and 3/4/25 (total of 8 day's), revealed Resident #101 was [AGE] years old, admitted to the facility on [DATE] and discharged after a fall on 3/4/25, confused with a BIMS (cognitive assessment, 1 to 15) of 0, had memory loss, was unsteady, repeatedly attempted to self-transfer, had poor safety awareness, required total Activities of Daily Living assistance and had a history of falls prior to admission and at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number MI00150622. Based on observation, interview and record review, the facility failed to ensure that medications were administered to 4 residents (#702, #703, #704, #705) of 5 sampled residents, and 10 unsampled residents, resulting in multiple residents not receiving their 5:00 PM medications on 02/25/2025. Findings include: Observation on 2/27/2025 at 8:10 AM of the [NAME] nursing unit revealed Licensed Practical Nurse (LPN) H was observed to be passing medications to residents on the 101-113 hallway. Record review of Resident #702's Medication Administration Record (MAR) for the month of February 2025 revealed that on 2/25/2025 at 5:00 PM that Xarelto (anticoagulant) 20 mg tablet by mouth for DVT/PE (Deep [NAME] Thrombosis/Pulmonary embolism) was not signed out as being completed. The medication Questran 4-gram packet was not signed out as being completed. Record review of Resident #703's Medication Administration Record (MAR) for the month of February 2025 revealed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number MI00149640. Based on interview and record review the facility failed to address the disparities in one resident's (Resident #701) significant weight fluctuations over a short time period of one resident reviewed for weight loss. Findings include: Resident #701: On 2/27/2025 at approximately 9:00 AM, a review was conducted of Resident #701's clinical record and it revealed that he initially admitted to the facility on [DATE] with diagnoses that included, Lymphedema, Cellulitis, Congestive Heart Failure, Anxiety and Ulcer of left lower leg. Resident #701 was his own responsible party and able to make his needs known to staff. Further review of Resident #701's records yielded the following: Care Plan: The resident is at potential for nutrition risk rt (related to) venous insufficiency, chronic le (lower extremity) wounds, lymphedema morbid obesity. anticipated significant weight changes r/t edema/diuretic .weight per facility protocol as resident allows . Weights: Resident…

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

Based on interview, and record review, the facility failed to complete a performance review every 12 months for five Certified Nurse Aides (CNA's S, T, U, V, & X) of 5 reviewed for an annual performance review. This deficient practice resulted in the potential for inadequate and unmet resident care needs. Findings include: On 1/23/2025 at 9:40 AM, review of human resource files in the presence of Human Resources Director R was completed. It was found five of the five CNA's reviewed for annual competencies were not completed in 2024. The following staff members did have annual skills checks completed. CNA S - last completed 10/2023 CNA T - last completed 10/2023 CNA U last completed 10/2023 CNA V - last completed 10/2023 CNA X - last completed 10/2023 Director R explained they hold annual competencies classes yearly for staff instead of basing it on their hire date and she shared Educator B is actively holding classes this week. It can be noted when reviewing the files the 2023 competencies were filed but the date completed for each specific competency were checked off at different…

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 medication and medical supply labeling, storage, and disposal in one of one medication rooms and two of two medication carts reviewed, resulting in a medication cart being left unlocked and unattended, a lack of dating of medications with specified time frames for use after opening, expired medications, open and undated medications, and the potential for residents to receive medications with altered efficiency. Findings include: On 1/22/25 at 2:04 PM, Licensed Practical Nurse (LPN) Z was observed walking away from a medication cart in the hallway near room [ROOM NUMBER] towards the nursing station and medication room at the other end of the hallway. The medication cart was left unlocked. While the medication cart was left unlocked and unattended, a different staff member walked down the hall to the cart but did not lock the cart. At 2:09 PM on 1/22/25, LPN Z was observed walking down…

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 MI00149278. Based on observation, interview and record review, the facility failed to ensure the provision of bathing and hygiene care for two residents (#7 and #59) of four residents reviewed, resulting in a lack of bathing/showers, nail care, and personal hygiene. Findings include: Resident #7: On 1/21/25 at 11:31 AM, Resident #7 was observed in their room. The Resident was lying in bed on their back. The Resident was unshaven and their hair had a greasy with an unkept appearance. When queried regarding bathing and ADL care, Resident #7 indicated they do not get out of bed. When asked why they do not get out of bed, the Resident did not provide a response. Resident #7 was asked when they last had a shower and stated, Not had a shower in a long time. When asked why they had not had a shower, the Resident revealed they prefer bed baths because it is too difficult to sit up in the chair. When asked the last time they had a bed bath, Resident #7 stated they have diarrhea…

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 record review the facility failed to ensure nursing assessments were completed for two residents (#71 and #231) of three residents reviewed for assessment and monitoring, resulting in a delay in assessment and treatment for bowel management and skin/back rash of Residents #71 and #231. Findings Include: Resident #231: During initial tour on 1/21/2025, Resident #231 shared she developed a rash on her coccyx that extends to her back from the briefs used daily for incontinence care. She continued the rash is the shape of the brief and rom what staff from told her the rash is reddened with small bumps. She continued the rash was causing her great discomfort, but nursing staff mixed a cream to assist. On 1/2/2025 at 11:50 AM, Nurse P stated Resident #231's mid to lower back was reddened and it is in the same area where the brief would sit. The reddened area spanned the width of her back and wrapped slightly onto her sides. She was made aware of the area yesterday but does not know when it…

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, record review, the facility failed to implement and operationalize policies and procedures to ensure safe care and maintenance of PowerMidline (intravenous (IV) catheter inserted in the arm with the tip of the catheter positioned near the axillary for long term IV treatment) use and care per professional standards of practice and manufacturer's recommendations for one resident (Resident #61) of one resident reviewed, resulting in improper IV medication reconstitution, inappropriate PowerMidline flushing technique, lack of infection control standards, and the potential for infection, phlebitis (inflammation in vein), embolism (blockage in blood vessel), infiltration (medication administration into surrounding tissue), unnecessary pain and decline in overall health. Findings include: Resident #61: On 1/22/25 at 9:21 AM, Resident #61 was observed sitting in a recliner in their room. An interview was completed at this time. An IV pole and pump with a bag of Cefepime (antibiotic) 1…

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 behavioral health care and services for one resident (Resident #332) of one resident reviewed, resulting in a lack of timely and ongoing assessment of distress related to adjustment, timely evaluation for consent to receive behavioral health services, and expressions of emotional and psychosocial distress. Findings include: Resident #332: On 1/22/25 at 9:19 AM, an observation occurred of Resident # 332 in their room. The Resident was sitting in bed with a meal tray on the overbed table in front of them. When spoke to, Resident #332 made eye contact but did not engage when asked questions. On 1/22/25 at 10:32 AM, Resident #332 was observed sitting in a Broda chair (reclining, high back wheeled chair with solid, padded leg and footrests). Resident #332 was visibly upset and crying. When asked what was wrong, Resident #332 stated, Wanna go home. Resident #332 only repeated they wanted to go home when asked additional questions 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 MI00148817. Based on observation, interview and record review the facility failed to maintain sanitary conditions in the kitchen and nourishment rooms, resulting in improper kitchen sanitization of all kitchenware utilized to prepare and plate residents' meals, and soiled floors and ice machine for all residents who consume meals from the kitchen. Findings Include: On 12/23/2024 at 3:00 PM, the kitchen was toured in the presence of Dietary Manager N and the following was observed: -Used gloves on the ground behind the handwashing sink and stove. -Container of oats lid was not secured. -Floor by stove had multiple brown/orange dried substances stains scattered throughout the area. -Floors by three compartment sink was visibly soiled with dirt, debris and food particles. -Vents are soiled with thick dust particles on juice machine controller. -Metal plate affixed to the wall behind the juice machine has multiple residue streaks. -Was unable to test the three-compartment sink…

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 MI00148129 and MI00148412. Based on observation, interview and record review, the facility failed to ensure a clean environment for all residents who use the main dining room, the main activity room and eleven residents' rooms, resulting in dust-filled heater covers and ceiling vents, cobwebs and spiders, dirty floors/base boards and ceiling/roof leakage. Findings include: On 12/26/24, at 11:06 AM, an observation along with Housekeeping Supervisor (E of rooms 118, 121, 122 and 127 revealed dirty floors, dirty bathroom floors with baseboards having dirty dusty buildup. Behind the room doors revealed dusty cobweb build up. Housekeeping Supervisor E was asked why the floors appeared unkept and Housekeeper Supervisor E offered, that when the new company took over they did a walk through and found the old white floors to be the worse. The common walkways throughout the rooms appeared to have less dirty buildup than the buildup around the base boards. On 12/26/24, at 11:11 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 intakes MI00147160 and MI00148129. Based on observation, interview, and record review, the facility failed to ensure dignity and a clean urinal for one resident (Resident #9) out of twelve residents reviewed for dignity, resulting in the use of an old discolored and dirty urinal. Findings include: Resident #9: On 12/23/24, at 2:30 PM, Resident #9 was heard asking a staff member for a new urinal. The staff member walked to the clean utility room and brought back a graduate container not a urinal and offered to Resident #9 there aren't any urinals. On 12/23/24, at 2:38 PM, Resident #9 was asked if the facility runs out of urinals often and Resident #9 stated, always. Resident #9 offered they had to throw theirs away because it was turning black and that it was about a month old. On 12/23/24, at 2:40 PM, an observation along with Unit Manager (UM) B of Resident #9's disposed urinal in the bathroom trash revealed a urinal that appeared old with dark brown residue to the handle and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number MI00147389. Based on interview and record review, the facility failed to treat pain timely for one resident (Resident #4) of three residents reviewed for pain control, resulting in unwanted pain, crying and no pain medication offered for nearly 10 hours. Findings include: Resident #4: On 12/26/24, at 1:42 PM, during a phone conversation, Resident #4 complained they didn't get enough pain medication for their broken hip surgery the first night they were in the facility. Resident #4 offered they arrived at the facility about 5:00 O'clock on October 5th. Resident #4 was asked if they got any pain medication the day of arrival and Resident #4 offered, yes, about 10 that night. Resident #4 further complained they were crying in pain throughout the night, and it wasn't until a manager came to visit the next morning that they received their pain medication. Resident #4 complained that the Aides knew they were crying in pain and tried to get the nurse. Their pain level was at an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number MI00148129. Based on observation, interview and record review, the facility failed to ensure medication administration for one resident (Resident #14) out of three residents reviewed for medication administration, resulting in pills spilled onto the floor and a medication cup with pills at the bedside and not consumed. Findings include: Resident #14: On 12/23/24, at 12:50 PM, Resident #14 was in their bed awake. There were 3 medication cups on the floor with loose pills also on the floor. Resident #14 stated, I spilled them sometime in the night or this morning. Resident #14 was unsure what time and what the pills were for. On 12/23/24, at 1:00 PM, Unit Manager (UM) H entered Resident # 14's room and was asked why there was pills on the floor and UM H stated, there shouldn't be. UM H picked up 1 medium white round shiny pill, 2 tan oblong pills, 1 medium round tan pill, a large chalky white pill from the floor along with the medication cups. There was another medication…

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 consistent incontinence care for two dependent residents (Resident #1, Resident #4), resulting in verbal complaints of incontinence care not received, frustration, embarrassment and the likelihood for skin breakdown. Findings include: Record review of the facility 'Incontinence Care- Urinary and Fecal' policy, dated 04/22/2024, provided guidelines for leaning the perineum and buttocks after an incontinence episode or with daily care. Residents who are incontinent of bowel and/or bladder will be provided incontinent care assistance as needed based on resident request and/or check and change, or as per resident preference or need . Report any skin alterations to the licensed nurse. Resident #1: Observation on 9/17/202 at 11:10 AM of Resident #1, who resided in room [ROOM NUMBER]-2, revealed no there was no roommate residing in the room. Resident #1 was asleep with the head of bed elevated, and the resident slumped to the bottom of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility 1) Failed to provide hand hygiene with meals for residents, 2) Failed to label open food items, clean dirty/unsanitary food surface, proper drying of dishware and no back flow protect on steam table, cover sliced cheese/clean mop bucket, and 3) Failed to ensure proper food storage of dairy products for cold food service and did not routinely check temperatures of cold food items for 79 of 83 residents who consume oral food items. Findings include: Record review of the facility provided 'Handwashing Guidelines for Dietary Employees' copyright 2022 The Compliance Store, LLC, revealed handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses. Dietary employees shall clean hands in handwashing sink or approved automatic handwashing facility and may not clean hands in a sink used for food preparation, ware washing, or in a sink used for the disposal of mop water or similar waste. (6.) Frequency of handwashing: Dietary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility 1) Failed to provide hand hygiene with meals for 79 of 83 residents who consume oral foods, and staff cross contamination with resident meals and 2) A Certified Nurses Aide failed to ensure appropriate PPE use, resulting in cross contamination of organisms. Findings include: Record review of the facility provided infection control 'Standard Precautions Infection Control' copyright 2022 The Compliance Store, LLC, revealed all staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere to Standard Precautions to prevent the spread of infection to residents, staff, and visitors. (1.) Hand Hygiene: During the delivery of resident care services, avoid unnecessary touching of surfaces in close proximity to the resident to prevent both contamination of clean hands from environmental surfaces and transmission…

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 accuracy of a Minimum Data Set (MDS) assessment for one resident (Resident #5) reviewed for MDS assessments, resulting in Resident #5 being coded under Section I (Active Diagnoses) as being diagnosed with Schizophrenia when that was not one of his DSM diagnosis. Findings Include: Resident #5: During initial tour on 1/29/2024, Resident #5 was observed watching television in his room. As this writer spoke to him, he appeared to be somewhat guarded but communicated no concerns regarding his stay at the facility. On 1/29/2024 at approximately 2:20 PM, a review was completed of Resident #5's medical records and it indicated he was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Major Depressive Disorder, Bipolar II Disorder, Suicidal Ideation's, Anxiety and Vascular Dementia. Further review of Resident #5's medical record yielded the following: MDS (Minimum Data Set) Assessment: -…

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 shave one resident (Resident #328) out of 21 residents reviewed for Activities of Daily Living (ADL) care, resulting in unwanted facial whiskers. Findings include: Resident #328: On 1/29/24, at 11:39 AM, Resident #328 was sitting in her wheelchair at the nurses station common area. Resident #328 had numerous facial whiskers on their chin. On 1/29/24, at 1:12 PM, a record review of Resident #328's electronic medical record revealed an admission on [DATE] with diagnoses that included Hypertension, weakness and unspecified intellectual disabilities. Resident #328 had severely impaired cognition and required assistance with all ADL's. A review of the Kardex revealed . ADLs . I am assist of 1 with Grooming/hygiene . A review of the care plan I have a self care deficit R/T: weakness . revealed . I am assist of 1 with Grooming/hygiene Date Initiated: 11/09/2023 . A review of the Task: MONITOR - BEHAVIOR SYMPTOMS Look Back: 30 (days) revealed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number MI00137559 Based on interview and record review the facility failed to provide a comprehensive discharge for one resident (Resident #278) of five residents reviewed for discharge planning, resulting in, Resident #278 being discharged from the facility without prescribed pain medications as indicated in his discharge summary and appropriate referral to DME (Durable Medical Equipment) company for recommended therapy equipment. Findings Include: Resident #278: On 1/30/2024 at 8:15 AM, an interview was conducted with the complainant regarding Resident #278's discharge from the facility in May 2023. It was shared the resident admitted to the facility after a knee surgery for therapy and was discharged back to his Adult [NAME] Care (AFC) home, but the facility failed to send his prescriptions for pain medications. Resident #278 discharged from the facility on 5/21/23 (Sunday) with prescriptions for Oxycodone and Gabapentin (per the discharge packet) but the pharmacy the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow care plan interventions and document self-ambulation for one resident (Resident #24), resulting in a near fall, unassisted ambulation and Activities of Daily Living (ADL.). Findings include: Resident #24: On 1/29/24, at 12:01 PM, Resident #24's room call light was activated. Upon entering the room, the resident was standing at their closet removing clothes from the hangers. Resident #24 had a shirt, regular white cotton socks on and was in their incontinent brief. Their wheelchair was approximately 4 feet away and the wheels were not locked. On 1/29/24, at 12:07 PM, Resident #24's call light remained activated. Nurse K walked into Resident #24's room and asked the resident if they needed help. Nurse K was asked if Resident #24 was safe and Nurse K stated, yes. On 1/30/24, at 2:05 PM, Resident #24 was resting on their bed. They had white cotton socks on with no grippers on the bottom. There was 3 pairs of shoes on the floor 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 timely notify and obtain physician's consent prior to administration of a medication with the potential for a drug allergy for one resident (Resident #25) of three residents reviewed for antibiotic usage, resulting in Keflex being pulled from the facility's back up box and administered to Resident #25 prior to the physician's verification for contraindicated antibiotic therapy. Findings Include: Resident #25: During initial tour on 1/29/2024, Resident #25 was observed sleeping peacefully in bed. On 1/29/2024 at approximately 11:58 AM, a review was conducted of Resident #25's medical records and it revealed she admitted to the facility on [DATE] with diagnoses that included Heart Failure, Atrial Fibrillation, Cerebral Infarction and Peripheral Vascular Disease. Resident #25 is allergic to Aspirin, Nitroglycerin, Naprosyn, Penicillin's and Sulfa Antibiotics. Further review yielded the following: Physician Order: Keflex Oral Capsule 500 MG…

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 properly administer medications to two residents (Resident #21, Resident #64), resulting in the wrong medications being administered. Findings include: Resident #21: On 1/30/24, at 3:35 PM, During medication administration task with Nurse K, Nurse K was observed to prepare Resident #21's Primidone medications of 4 tablets. Nurse K walked to the residents room and the resident was unavailable. Nurse K walked back to the medication cart, wrote the residents room number on a paper souffle cup, placed it inside the medication cup. Nurse K then opened up the top drawer of the medication cart and placed the medication cup inside the drawer along with other medications. Nurse K was asked if they normally place opened medications in the drawer with other items and Nurse K stated, I label it first. After medication pass observation was completed, Nurse K was asked if they planned to administer Resident #21's medication that they previously prepared…

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 provide palatable timely meals, for Resident #16 and Resident Council members, resulting in breakfast meals served cold and not fully cooked and late cold dinners. Findings include: On 1/30/24, at 8:33 AM, Resident #16 was sitting in their room on their bed. Nurse K assisted resident with set up for her breakfast meal. Resident #16 looked at her breakfast meal which consisted of a fried egg that was approximately 50% translucent. The egg white was runny. Resident #16 looked at their runny fried egg and complained they couldn't eat it because it ain't done. On 1/30/24, at 8:41 AM, Dietary Manager (DM) U entered Resident #16's room. The resident complained their fried egg wasn't done. DM U touched the translucent egg white and stated, no, it doesn't look quite done. On 1/31/24, at 8:30 AM, breakfast trays were passed from a 3-compartment rolling cart and the last tray was taken to the conference room for meal palatability and temperature testing. On 1/31/24, at 8:31 AM, an observation of the breakfast meal revealed 1 fried…

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.