Evangelical Home - Saline

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement interventions to prevent falls for one (R5) of two reviewed. Findings include:Review of the medical record reflected R5 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included vascular dementia, unspecified fracture of lower end of right femur (9/3/25), periprosthetic fracture around internal prosthetic right knee joint (9/3/25) and Alzheimer's. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/16/25, reflected R5 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 01/28/2026 at 11:39 AM, R5 was observed lying awake, in bed. The bed height was noted to be in a low position. An over-bed table was located at the left bedside. R5 was noted to be barefoot on the right foot. Their left foot was beneath the bed linens and unable to be observed. On 01/29/2026 at 11:28 AM, R5 was observed lying…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and 2 (#72, #132) of 22 sampled residents, the facility failed to provide palatable food products affecting 108 residents who consume food, resulting in the increased likelihood for resident decreased food acceptance and nutritional decline.Findings include:On 01/27/2026 at 11:53 A.M., An interview was conducted with Director of Dining Services S regarding the resident food tray delivery schedule. Director of Dining Services S stated: Main Dining Room, C-Wing, D-Wing, B-Wing, East Hall, South Hall, and North Hall. On 01/27/2026 at 11:55 A.M., Lunch meal food trays (19) were observed leaving the food production kitchen, within an insulated food transport cart. On 01/27/2026 at 11:58 A.M., Lunch meal food trays (19) were observed arriving to C-Wing, within an insulated food transport cart. On 01/27/2026 at 12:09 P.M., Lunch meal food trays (23) were observed leaving the food production kitchen, within an insulated food transport cart. On 01/27/2026 at 12:12 P.M.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer influenza and pneumococcal immunizations per consent for one (R6) of five reviewed.Findings include: Review of the medical record revealed R6 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, pleural effusion, atrial fibrillation, chronic obstructive pulmonary disease, dementia, and pneumonia.Review of the Consent to Administer Pneumonia Vaccination and the Consent to Administer Influenza Vaccination revealed R6 declined both vaccinations. R6 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of R6's Consent to Administer Pneumonia Vaccination and the Consent to Administer Influenza Vaccination revealed R6 consented and wished to receive both vaccinations upon readmission to the facility. Review of the medical record revealed R6 did not receive either vaccination.Review of the Health Status Note dated 1/10/26 revealed R6's chest x-ray results…

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

This citation pertains to intake number MI00150684. Based on observation, interview, and record the facility failed to document one out of three resident's (Resident #3) condition per professional standards of practice, resulting in the potential for a delay in treatment. Findings Included: On 3/11/2025 at 2:50 PM, Resident #3 (R3) was observed in her room lying in bed. R3 stated she that about three weeks ago she had a stroke. R3 said she felt weird, and was not able to speak. R3 was noted to have a slight speech impairment, but was understood. In an interview on 3/12/2025 at 11:11 AM, Certified Nurse Aid (CNA) C stated that on 2/11/2025 R3 seemed off around breakfast time, and stated R3's speech was slurred, was not swallowing food, was drooling food on her gown and face, eating messy, and her speech was slurred enough that is was noticed. CNA C said R3 was pocketing food (not chewing or swallowing the food but holding it in the cheek), was not able to be verbally understood, could not understand what the bed remote was for, and said the symptoms were all new. CNA C said Licensed…

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 includes intake number MI00144468. Based on observations, interviews, record reviews, and 3 (#12, #40, and #89) of 20 sampled residents the facility failed to effectively provide palatable food products effecting 95 residents, resulting in the increased likelihood for decreased resident food acceptance and nutritional decline. Findings include: Resident #40 (R40): In an interview on 11/19/24 at 11:16 AM, R40 stated she would not get a menu daily, and said sometimes when she would mark what she wanted on the menu she would not get what she marked. R40 said that the last week it happened everyday she did not get a menu and did not get what she wanted, and said when she did not get a menu the kitchen just serve me whatever. R40 said sometimes when she would order something for the next days meal and she did not receive that she would be upset because she was looking forward to that meal she ordered. Resident #12 (R12): In an interview on 11/19/2024 at 2:10 PM, R12 stated the food was terrible, the residents were supposed to get a menu every day at breakfast to fill out…

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 observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 95 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 11/19/24 at 09:35 A.M., An initial tour of the food service was conducted with General Manager Dining Services C. The following items were noted: The True two-door reach-in cooler interior 48-inch-long fluorescent light bulbs were observed missing. General Manager Dining Services C indicated she would contact maintenance for necessary repairs as soon as possible. The 2017 FDA Model Food Code section 6-303.11 states: The light intensity shall be: (A) At least 108 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry FOOD storage areas and in other areas and rooms during periods of cleaning; (B) At least 215 lux (20 foot candles): (1) At a surface where FOOD is provided for CONSUMER self-service such as buffets and salad bars or where fresh…

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 securely store medication, resulting in the potential for misuse, and medication administration errors. Findings include: During an observation on 11/20/24 at 12:15 PM, hall D treatment cart, located in the hall, was noted un-locked with no staff in area and residents self propelling in the area. Continued to observe treatment cart un-locked at 12:46 p.m. During an observation and interview on 11/21/24 at 2:15 PM, observed overflowing open bin of medications located on the floor in the charge nurse office between Redies East hall and D hall. LPN Q reported was the nurse manager and exited the charge nurse office, leaving room unoccupied and door open, and entered the Redies North/East medication room. Residents were noted in common area outside nurse manager office. During an observation on 11/22/24 at 12:32 PM Redies East medication cart observed unlocked in hall with no nurse observed in the area. Residents were observed in hall. During an interview on 11/22/24 at 2:10 PM, Licensed Practical Nurse (LPN) T…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a comprehensive care plan was in place for prevention of skin breakdown for one (Resident 94) of 20 residents. Findings Included: Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed R94 was at risk for pressure ulcers (PU). The MDS also revealed R94 did not have any pressure ulcers, or other skin concerns. The MDS revealed R94 was admitted to the facility on [DATE]. Review of a quarterly MDS dated [DATE], revealed R94 was at risk for PU, and had one unstagable pressure injury (not stageable due to the wound bed not being visible) that presented as a deep tissue injury (DTI) (an area over a bone that appears dark/purple, soft, and the color does not return when pressed on which can indicate a deep wound underneath). Review of R94's electronic medical record (EMR) revealed R94 was admitted to Hospice upon the same date of admission the facility, 5/25/2024. Diagnoses listed were protein-calorie malnutrition…

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 develop and implement new interventions after a fall with injury for one resident (#28) of 20 reviewed for care plans. Findings include: Review of the clinical record, including the Minimum Data Set reflected Resident # 28 (R28) was [AGE] years old and resided on the facility's dementia unit. R28 scored 3 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status. Further review of R28's clinical record revealed R28 fell on [DATE] at approximately 8:00 am. R28's fall was not witnessed, and resulted in bruising to bilateral hands. The incident report reflected R28 was taking herself to the bathroom to get cleaned up ready for breakfast. R#28's fall care plan dated 9/21/21 with the most recent revision date of 12/14/23 which added range of motion to be done during care. On 11/20/24 at 01:38 PM, during an interview with Certified Nursing Assistant (CNA) H reported the dementia hall was her permanent assignment, CNA H stated she 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 provide services that met the acceptable standards of clinical practice for PICC (peripherally inserted central catheter) line dressings in 1 of 1 sampled resident (Resident #319) reviewed for PICC lines, resulting in the increased likelihood for infection. Findings include: Resident # 319(R319) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R319 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included infection right knee post joint removal, anemia, heart failure, hypertension (high blood pressure), kidney disease, and chronic obstructive pulmonary disease . The MDS reflected R319 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact. During an observation and interview on 11/20/24 at 4:05pm R319 was laying in bed and appeared calm, pleasant and able to answer questions without difficulty. R319 reported received…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent a skin tear from developing into a stage 3 pressure ulcer for one of one resident (Resident 94). Findings Included: Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed R94 was at risk for pressure ulcers (PU). The MDS also revealed R94 did not have any pressure ulcers, or other skin concerns. The MDS revealed R94 was admitted to the facility on [DATE]. Review of a quarterly MDS dated [DATE], revealed R94 was at risk for PU, and had one unstagable pressure injury (not stagable due to the wound bed not being visible) that presented as a deep tissue injury (DTI) (an area over a bone that appears dark/purple, soft, and the color does not return when pressed on which can indicate a deep wound underneath). Review of R94's electronic medical record (EMR) revealed R94 was admitted to Hospice upon the same date of admission the facility, 5/25/2024. Diagnoses listed were protein-calorie malnutrion, encounter for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the attending physician documented in the medical record that identified medication irregularities were reviewed, the action taken, and/or the rationale for no changes to the medications for three (Resident #12, #28, and #63) of five reviewed. Findings include: Resident #12 (R12) Review of the medical record revealed R12 was admitted to the facility on [DATE] with diagnoses that included dry eye syndrome and allergic rhinitis. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/15/24 revealed R12 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R12's Physician's Orders revealed current orders for Cetirizine HCl 5 milligrams (mg) in the morning for allergies, Systane eye gel, and Refresh eye drops. Review of the Medication Regimen Review dated 8/27/24 revealed This resident has received Cetirizine 5mg daily for allergies since 11/2023. She also has 2…

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 justify continued use of psychotropic medications for one residents (#28) of five residents reviewed. Findings include: Resident #28 (R28) Review of the clinical record, including the Minimum Data Set reflected Resident # 28 (R28) was [AGE] years old and had diagnoses that included dementia, depression, iron deficiency and osteoporosis. R28 scored 3 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status. R28 was observed throughout the survey dates of 11/19-11/22 to be pleasant , up daily for meals and socially engaging with staff, other residents and visitors. Review of R28's Physician's Orders revealed current orders for the antidepressant Celexa 20 milligrams daily. Pharmacy review dated 3/4/24 revealed Celexa 20 mg daily since 9/22/21 with no gradual dose reduction. The Physician/Prescriber disagreed with the recommendation based on a Physician note dated 1/30/24 that revealed R28s son wanted the Celexa 20 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 to ensure a medication error rate was less than five percent when 2 medication errors were observed from a total of 25 opportunities for one resident (R319) of eight residents observed during medication administration, resulting in a medication error rate of 8%. Findings include: Resident # 319(R319) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R319 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included infection right knee post joint removal, anemia, heart failure, hypertension (high blood pressure), kidney disease, and chronic obstructive pulmonary disease . The MDS reflected R319 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact. During an observation on 11/21/24 at 9:14 AM, Licensed Practical Nurse(LPN) R disconnected R319 intraveounous (IV) antibiotic after the infusion and flushed first with 5ml 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 observations, interviews, and record reviews, the facility failed to effective clean and maintain the physical plant effecting 97 residents, resulting in the increased potential for cross-contamination, bacterial harborage, and decreased air quality. Findings include: On 11/20/24 at 10:05 A.M., A common area environmental tour was conducted with Director of Environmental Services G. The following items were noted: Bridgeway Boulevard Two ceiling mounted return-air-exhaust ventilation grills were observed heavily soiled with accumulated and encrusted dust/dirt deposits, adjacent to resident rooms B7 and B8. Director of Environmental Services G indicated he would have maintenance staff thoroughly clean and sanitize the soiled return-air-exhaust ventilation grills as soon as possible. [NAME] Court The ceiling return-air-exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits, adjacent to resident rooms C9 and C10. Dovecote Drive The ceiling return-air-exhaust…

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 observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 104 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and plumbing water leaks. Findings include: On 09/11/23 at 10:10 A.M., An initial tour of the food service was conducted with Dining Services Hospitality Manager X and General Manager Dining Services Y. The following items were noted: Walk-In Cooler: The refrigeration unit condenser coils were observed soiled with accumulated dust and dirt deposits. The refrigeration unit fan blade guard covers were also observed soiled with accumulated dust and dirt deposits. The 2017 FDA Model Code section 4-602.13 states: Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Food Preparation Double Sink: The faucet assembly was observed leaking water from the spout. Three-Compartment Sink: 1 of 2 faucet assemblies were observed leaking water from the spout. Dining Services Hospitality…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 104 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 09/11/23 at 02:00 P.M., An environmental tour of the facility Laundry Service was conducted with Environmental Services Director Z. The following item was noted: Clean Laundry Room: The two-drawer metal cabinet was observed severely (etched, scored, corroded). The interior shelves and lower cabinet surface were also observed severely corroded and particulate. Environmental Services Director Z stated: The cabinet is very old and should be replaced. On 09/11/23 at 02:15 P.M., An interview was conducted with Environmental Services Director Z regarding the facility maintenance work order system. Environmental Services Director Z stated: We have the WorxHub software system. On 09/12/23 at 09:15 A.M., A common area environmental tour 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 one resident (Resident 75) of 1 resident reviewed was assessed for self-administration of medications resulting in unsupervised administration of medications and the potential for mismanagement of medication and potential for adverse side effects. Findings Include: Resident 75 (R75) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R75 admitted to the facility on [DATE] with diagnoses of end stage renal disease, dementia, depression, type 2 diabetes. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicates R75 was cognitively intact. During an interview on 09/12/23 at 08:12 AM, R75 was lying in bed. It was noted he had 8 pills in a pill cup on his bedside table. R75 stated that he didn't have a chance to take them all yet and he was behind in taking them. R75 said that the nurse normally drops it off and he takes it himself. During a follow-up visit on 09/12/23 at 12:07 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.

Based on observation, interview, and record review the facility failed to report an allegation of physical abuse for one resident (#20) of one resident sampled for abuse resulting in allegation of abuse not being reported to the State Agency and the potential for further allegations of abuse to go unreported and not thoroughly investigated. Findings Included: Resident #20 (R20) Review of the medical record revealed R20 was admitted to the facility 05/30/2019 with diagnoses that included dementia, type 2 diabetes, hypertensive heart disease with heart failure, congestive heart failure (CHF), atrial fibrillation, pulmonary hypertension, anemia (low red blood cells), psychotic disorder with delusions, chronic pain, osteoporosis (weak and brittle bones) , cognitive impairment, depression, hyperlipidemia (high fat in blood), osteoarthritis, hearing loss, macular degeneration (eye disease causing vision loss), gout (high uric acid in bone joints), constipation, and gastro-esophageal reflux. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/17/2023,…

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 investigate, implement preventive measures, and take correction action for an allegation of physical abuse with one resident (#20) of one resident review for abuse resulting in the potential of further abuse to residents. Findings Included: Resident #20 (R20) Review of the medical record revealed R20 was admitted to the facility 05/30/2019with diagnoses that included dementia, type 2 diabetes, hypertensive heart disease with heart failure, congestive heart failure (CHF), atrial fibrillation, pulmonary hypertension, anemia (low red blood cells), psychotic disorder with delusions, chronic pain, osteoporosis (weak and brittle bones) , cognitive impairment, depression, hyperlipidemia (high fat in blood), osteoarthritis, hearing loss, macular degeneration (eye disease causing vision loss), gout (high uric acid in bone joints), constipation, and gastro-esophageal reflux. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/17/2023, revealed R20 had a Brief Interview of Mental Status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement interventions to maintain or increase range of motion for two (Resident #3, #69) of two reviewed, resulting in the potential for a reduction in range of motion and worsening contractures. Findings include: Resident #3 (R3) Review of the medical record revealed R3 admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, contracture of the left knee, and contracture of the right knee. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/27/23 revealed R3 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had a functional limitation in range of motion impairment on both sides of upper and lower extremities. On 09/11/23 at 11:50 AM, R3 was observed lying in bed with the head of the bed raised. R3 reported she was not receiving physical or occupational therapy services any longer. R3 reported she would like exercises for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one out of one resident (Residents #21) received the necessary behavioral health care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being, resulting in the potential for unmet emotional and/or mental well-being care needs. Findings include: Resident #21 Review of an admission Record revealed Resident #21 (R21) admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included alcohol abuse, insomnia, muscle weakness, anxiety disorder, and major depressive disorder. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/13/23 reflected R21 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R 21 did not walk and required extensive assistance of two or more people for toileting and personal care. In an observation and interview on 09/11/23 at 10:48 AM, R21…

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 pharmacy policy and acceptable practice for maintaining controlled medication for three out of 9 medications carts resulting in the potential for controlled medication diversion. Findings Included During observation of Redie hall medication cart on 09/12/2023 at 07:46 a.m. it was observed that facility Controlled Substance Inventory document was signed by the out-going nurse for the date of 09/13/2023 (11 p.m. to 7 a.m.) but was not signed by the on-coming nurse. In an interview on 09/13/2023 at 08:38 a.m. Registered Nurse (RN) L explained that a physical count was to be completed for all controlled medication at the beginning of each shift when there is a change of nurses. RN L explained that the on-coming and off-going nurse would do a manual count of the controlled medication. RN L explained that each nurse would then place their signature, in the appropriate place, on the Controlled Substance Inventory document. RN L confirmed…

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 medication regimen irregularities were reviewed, acted upon, and documented in the medical record for one (Resident #3) of five reviewed, resulting in the potential for unnecessary medications and adverse reactions. Findings include: Review of the medical record revealed R3 admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, and insomnia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/27/23 revealed R3 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R3's Progress Notes revealed monthly medication regimen reviews contained comments/recommendations on 1/21/23, 3/18/23, and 7/29/23. The medical record did not include documentation as to what the recommendations were, or physician follow up to the recommendations. In an interview on 09/12/23 at 3:25 PM, Director of Nursing (DON) B reported she had only been 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 on interview and record review, the facility failed to justify the continued PRN (as needed) use and/or provide a duration of use of a psychotropic medication for one (Resident #3) of five reviewed, resulting in the potential for unnecessary medications and adverse reactions. Findings include: Review of the medical record revealed R3 admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, and insomnia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/27/23 revealed R3 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Physician's Order dated 8/9/22 revealed and order for trazodone daily at bedtime as needed for sleep. Review of R3's Progress Notes revealed monthly medication regimen reviews contained comments/recommendations on 1/21/23, 3/18/23, and 7/29/23. The medical record did not include documentation as to what the recommendations were, or physician follow up to 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 label medication in accordance with accepted professional principles, dating of open medication for one out of nine medication carts resulting in the potential for residents to receive expired medication that is not providing its effective efficiency. Findings Included: During observation of the D wing medication cart on [DATE] at 10:19 a.m. it was observed that the following medications did not have a date when the medication was opened placed on the container of the medications: Timolo Maleate Opthalmic 0.5 precent eye drops, Azelastin HCL (hydrochloride) 0.05 percent eye drops, and Latanoprost Ophthalmic .005 percent eye drops. In an interview on [DATE] at 10:19 a.m. Licensed Practical Nurse (LPN) P explained that all multiple use medication containers, for specific residents, should be dated at the time that the medication container is opened. LPN P explained that the medications found undated above would be destroyed and new…

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 clean/disinfect the glucometer (machine used to determine blood sugar levels) used for two residents (#113, #322) of two residents sampled during observation of blood level glucose testing and failed to ensure hand hygiene was performed by a care giver during the collection of bodily fluids resulting in the potential to development and of infection and spread of infection to other residents. Findings Included: Resident #113 (R113) Review of the medical record revealed R113 was admitted to the facility 08/22/2023 with diagnoses that included osteoporosis (weak and brittle bones), pathological fracture of the right femur (leg), cellulitis (bacterial skin infection) of right lower limb, elevated white blood cells, pathological fracture of the right humerus (arm), anemia (low red blood cells in blood), Sjogren syndrome (Immune disorder), type 2 diabetes, rheumatoid arthritis, thrombocytopenia (low platelets in blood), and hypertension. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD)…

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.