Medilodge of Sault Ste. Marie

This citation pertains to intake 2702621. Based on observation, interview, and record review, the facility failed to provide a homelike dining environment for five of nine residents interviewed in a confidential group meeting. Findings include: During lunch observations on 2/8/2026 at 1:17 PM, the meal was delivered in food carts and served on trays. During observation on the A Hall and B Hall each tray included only disposable plastic utensils. Certified Nurse Aide (CNA) R serving the meal stated disposable plastic utensils often came on the trays. CNA R said sometimes meal trays sat near the kitchen door in the dining room and did not get washed in time for the next meal. During breakfast observations on 2/9/2026 at 8:31 AM, the meal was delivered to the halls in food carts and served on trays. During this observation on the A Hall, each tray included regular forks and spoons and plastic disposable knives. On 2/11/2026 at 10:27 AM, the Food Service Manager/Staff C stated, It goes down the hall, and it does not come back. Staff C said the trays did not come back in time to 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.

Based on observation, interview, and record review, the facility failed to secure medications, maintain the security for one medication cart of three medication carts and three of five treatment carts reviewed for medication storage. Findings include:On 2/8/26 at 12:37 PM, an observation was made of Resident #64 (R64) lying in his bed asleep with a full cup of medications sitting on his bedside table.On 2/8/26 at 12:38 PM, an observation was made of Resident #91 (R91) lying in her bed with a full cup of medications sitting on his bedside table. R91's medications were later identified as being morning medications. R91 also had a rescue inhaler on her bedside table identified as albuterol.An observation was made on 2/9/26 at 11:45 AM, of Resident #93 (R93) who had a topical ointment on her bedside table. R93 states it is her ointment mupirocin. During an observation on 2/8/26 at 12:53 PM, A Hall treatment cart was unlocked with a tube of diclofenac sodium topical gel 1% and an opened can of soda pop on top of treatment cart.During an interview on 2/8/26 at 1:26 PM, Registered Nurse…

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 2702621Based on observation, interview, and record review, the facility failed to ensure palatable meals were served at preferred and appetizing temperatures for six of nine residents interviewed in a confidential group meeting, and for one Resident (#93) of one resident who voiced concerns about food temperatures. Findings include:On 2/9/26 at 2:00 PM, a confidential group interview was conducted where six residents stated the food delivered at mealtimes is often cold. One Confidential Resident (CR) stated, Sometimes it's cold, other times it's lukewarm. Another CR indicated food trays either sit in the serving window or in food delivery carts for extended periods of time which contributes to the cold food temperatures. One CR revealed they had bought hairnets online in attempt to assist delivering meal trays due to ongoing staffing problems and were upset when the facility would not allow it. The CR indicated they frequently noticed meal trays stacking up in the serving window…

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 #2702621.Based on observation, interview, and record review the facility failed to honor resident food preferences or failed to offer substitutes or alternative menu items for 19 of 24 residents (#4, #6, #12, #13, #22, #23, #24, #30, #31, #37, #R41, #47, #48, #77, & #82) and four Residents in a confidential group meeting) reviewed for nutritional services.Findings include:During the lunch meal observation on 2/8/2026 at approximately 1:15 PM, the meal tray cards on each tray specified what each resident preferred or had been ordered by the Physician. Resident #30 (R30) R30 had a meal tray card which indicated, Standing Orders: 8 fl oz (fluid ounces) Assorted Fruit Juices. R30 received 4 oz orange juice. Resident #22 (R22) R22 had a meal tray card which indicated Standing Orders: 4 fl oz Assorted Fruit Juices (lemonade, cran[berry], or apple). R22 received 4 oz orange juice. Resident #48 (R48) R48 had a meal tray card which indicated, Standing Orders: 8 fl oz Assorted Fruit Juices…

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 dining adaptive equipment for four Residents (#6, #23, #30 & #48) of five residents reviewed for dining assistive devices. Findings include: During the lunch meal observation on 2/8/2026 at 1:15 PM, four meals did not receive the prescribed special adaptive equipment per the meal tray cards:Resident #6 (R6)R6 had a meal tray card which indicated Adap. Equip: (Adaptive Equipment) 2-handle Cup, Built-Up Utensil Handles, red plate. R6 received plastic silverware but did not receive silverware with built -up utensil handles and did not receive the specialty red plate.Resident #23 (R23)R23 had a meal tray card which indicated Adap. Equip including straws. No straws were observed on R23's tray.Resident #30 (R30)R30 had a meal tray card which indicated Adap. Equip including 2-handled cup, and straw. R30's tray did not include a straw or beverage in a 2-handled cup.Resident #48 (R48)During the breakfast meal observation on 2/9/2026 at 9:01 AM, R48 had a meal tray card which indicated Adap. Equip including…

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 promote and facilitate resident self-determination through support of resident choice for three Residents (#10, #12, & #30) of three Resident reviewed for resident choice.Findings include: Resident #10 (R10) According to the medical record, R10 was admitted on [DATE] with diagnoses including spastic quadriplegic cerebral palsy (the most severe form of cerebral palsy characterized by extreme muscle stiffness and poor motor control in all four limbs and trunk), need for assistance with personal care, major depressive disorder and chronic pain syndrome. R10's Minimum Data Set (MDS) dated [DATE] contained a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating R10 was cognitively intact. R10's functional status assessment revealed substantial assistance from staff to roll right or left, total dependence on staff to sit from lying down and total dependence on staff to transfer to and from a bed to a chair (or wheelchair). 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 ensure accurate advanced directive information was in place for one Resident (#11) of two residents reviewed for accuracy of advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time).Findings include:Resident #11 (R11)The Electronic Medical Record (EMR) for R11 revealed an admission on [DATE] with a primary diagnosis of autistic disorder (a lifelong neurological condition characterized by difficulties with social communication, restricted interests and repetitive behavior). The Minimum Data Set (MDS) assessment indicated the Brief Interview for Mental Status (BIMS) assessment could not be completed as the resident was rarely/never understood. The Physician Orders included Full Resuscitation, dated as 8/17/2022. R11's EMR was noted to have a chart banner on each page indicating Code Status: (Advanced Directives) Full Resuscitate.The documents filed in the EMR included a form titled…

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 protect the privacy of medical records for one Resident (#99) of one resident reviewed for privacy of medical records.Findings include:During an observation on 2/11/26 at 8:22 a.m., A medication cart at the beginning of C Hall had a facility laptop computer open with R99's personal health information present on the screen with no facility staff present near the medication cart.During an interview on 2/11/26 at 8:23 a.m., Licensed Practical Nurse (LPN) U reported, I know I am not supposed to leave the screen opened with resident information available for anyone to have access to.During an interview on 2/11/26 at 9:38 a.m., the Nursing Home Administrator (NHA) acknowledged medical record information was not secured when the LPN walked away from the medication cart.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This deficient practice pertains to intake #2702621 Based on interview and record review, the facility failed to protect one Resident (#93) of one resident reviewed for misappropriation of property.Findings include:Resident #93 (R93)The facesheet for R93 had an original admission to the facility on 1/29/26 with diagnoses including fracture of the left tibia/fibula (both lower leg bones were broken).According to R93's Minimum Data Set (MDS) dated [DATE], a Brief Interview for Mental Status (BIMS) was completed and a score of 15/15 indicated R93 was cognitively intact.During an interview on 2/8/26 at 2:15 PM, R93 stated a night shift nurse took her pain pills (four hydrocodone 10 milligram (mg)/325 mg acetaminophen a narcotic pain medication) and she was having increased pain and wanted to take one. R93 stated that she brought them into the facility with her when she was admitted from the hospital.R93's inventory sheet, dated 1/28/26, was reviewed and did not list any medications.Review of R93's progress note,…

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 deficient practice pertains to intake #2702621 Based on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one resident (Resident #93) out of one resident reviewed for reporting abuse. Findings include:Resident #93 (R93)Face sheet for R93 had an original admission to the facility on 1/29/26 with medical diagnoses including fracture of the left tibia/fibula (both lower leg bones were broken).According to R93's Minimum Data Set (MDS) dated [DATE], a Brief Interview for Mental Status (BIMS) score of 15/15 indicated R93 was cognitively intact.During an interview on 2/8/26 at 2:15 PM, R93 stated a night shift nurse took her pain pills (four hydrocodone 10 milligram (mg) / 325 mg acetaminophen a narcotic pain medication) and she was having increased pain and wanted to take one. R93 stated that she brought them into the facility with her when she was admitted from 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 interviews and record review, the facility failed to implement policies and procedures for ensuring investigating of an alleged resident misappropriation of medication for one Resident (#93) out of one resident reviewed for investigation of abuse.Findings include:Resident #93 (R93)The facesheet for R93 had an original admission to the facility on 1/29/26 with medical diagnoses including fracture of the left tibia/fibula (both lower leg bones were broken).According to R93's Minimum Data Set (MDS) dated [DATE], a Brief Interview for Mental Status (BIMS) score of 15/15 indicated R93 was cognitively intact.During an interview on 2/8/26 at 2:15 PM, R93 stated a night shift nurse took her pain pills (four hydrocodone 10 milligram (mg)/325 mg acetaminophen a narcotic pain medication) and she was having increased pain and wanted to take one. R93 stated that she brought them into the facility with her when she was admitted from the hospital.The Director of Nursing (DON) was asked on 2/9/26 at 9:00 AM and 2:30…

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 obtain physician dietary orders for the resident's immediate care for two Residents (#91 & #94) of two records reviewed for admission orders.Findings include: Resident #94 (R94) During an interview on 2/8/2026 at 3:05 PM, R94 was observed in his bed and said, I am mad. I got here Friday and today I did not get breakfast or lunch. I am going to call the administrator. He said he had only had a coffee and donut holes brought in by his visitor and he pointed to the empty disposable coffee cup and empty donut box. R94's roommate stated, I just went down and told the kitchen that he did not get any food today. During an interview on 2/08/2026 at 3:07 PM, Dietary Manager (DM/Staff) C said, I guess he got here yesterday. I will deliver it. A review of the Electronic Medical Record (EMR) revealed R94 was admitted to the facility on [DATE] at 5:31 PM. The Physician Orders contained a diet order for R94 dated 2/8/2026 at 3:27 PM. The diet…

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 deficient practice pertains to intake 2702621Based on observation, interview, and record review, the facility failed to ensure residents were provided individualized care to promote dignity and enhance their quality of life for three Residents #4 (R4), #47 (R47) and #93 (R93) of five residents reviewed for ADL's.Findings include: Resident #4 (R4) Review of Minimum Data Set (MDS) assessment dated [DATE] revealed admission to the facility on 7/25/23, with active diagnoses that included: depression, anxiety disorder, malnutrition, and osteoporosis. Further review of MDS Section GG, required staff to provide R4 supervision/touching assistance for turning or repositioning in bed. Further review of the MDS Section M revealed R4 was at risk of developing pressure ulcers. During an observation on 2/10/26 at 8:30 a.m. until 10:30a.m., R4 was laying on her back in her bed with the head of the bed slightly elevated. None of the staff went into the room to assist R4 to turning/repositioning in bed or encourage R4 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2702621.Based on observation, interview and record review, the facility failed to initiate bowel protocol in a timely manner for two Residents (#25 and #69) and failed to complete an assessment upon admission for one Resident (#91) of three residents reviewed for quality of care. Findings include:Resident #91 (R91) The facesheet for R91 had an original admission to the facility on 2/6/26. According to R91's minimum data set (MDS) dated [DATE], a brief interview for mental status (BIMS) score of 15/15 indicated R91 was cognitively intact. On 2/8/26 at 2:33 PM, R91 provided a notebook where she had been writing about her experience at the facility since her admission on [DATE] at approximately 6:20 PM. R91 had written she was told dinner was on the way and at 7:15 PM still did not get dinner on 2/7/26. During her arrival staff scurried in, did a few things and flew back out of her room. R91 stated, I had no idea what was happening with the staff and there I was just lying in bed.…

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 restorative therapy services for two Residents (#15 & #83) of two Residents reviewed for restorative therapy needs.Findings include:Resident #83 (R83) On 2/8/2026 at 2:50 PM, an observation of R83 revealed she was sitting in a reclined position in bed with her meal tray in front of her. R83 said she had just finished lunch and was fed by staff. When asked about her left contracted hand, R83 stated staff do not work with her on it, and she is supposed to have a brace on but it is the weekend, so nothing is happening. On 2/10/2026 at 12:37 PM, during a follow-up interview, R83 stated she was not getting restorative therapy and had not had it for a long time. R83 stated she was supposed to have a splint for her hand, and she needed assistance putting it on. R83 said, They do not put it on enough. During an interview on 2/10/2026 at 12:34 PM, Certified Nurse Aide (CNA) TT stated, the Restorative Aide put on the splints and did 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 #2702621.Based on observation, interview, and record review, the facility failed to implement fall interventions for one Resident #6 of six residents reviewed for falls and ensure the safety of one Resident #12 for smoking of three residents reviewed for smoking.Findings include:Resident #6 (R6) Review of Minimum Data Set (MDS) assessment dated [DATE] revealed admission to the facility on 4/25/25, with diagnoses including seizure disorder or epilepsy, fracture, and anxiety disorder. R6 scored 9 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of moderate cognitive impairment. During an observation on 2/9/26 at approximately 9:28 a.m., R6 was in bed with his bed in a high position and two floor mats [a specialized shock-absorbing safety device placed on the floor beside a resident's bed to reduce the impact and risk of injury from falls] were folded behind the chair in R4's room. Review of R4's Care plan revealed Focus area resident is at risk 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 attempt the use of non-pharmacological interventions prior to administration of PRN (as needed) opioid pain medications for two Residents (#8 & #15) of five residents reviewed for unnecessary medications.Findings include:Resident #8 (R8)Review of the Minimum Data Set (MDS) assessment, dated 12/24/2025, revealed R8 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, adjustment disorder with mixed anxiety and depressed mood, spinal stenosis, muscle weakness, and a history of falling.Review of R8's physician orders revealed the following: Oxycodone-acetaminophen [opioid pain medication] Oral Tablet 5-325 MG [milligram]. Give 1 tablet by mouth every six hours as needed for pain. Start Date: 1/21/2026 [1:45 p.m.].Review of R8's February 2026 Medication Administration Record (MAR), located in the electronic medical record (EMR), revealed R8 was administered doses of the ordered oxycodone-acetaminophen 5-325 mg 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 interview and record review the facility failed to ensure implementation of physician orders for hospice services for one Resident (#8) and communication with hospice providers and receipt of hospice documentation for one Resident (#4) of two residents reviewed for hospice services.Findings include: Resident #8 (R8) A review of the Electronic Medical Record (EMR) for R8 on 2/9/2026, revealed a physician's order for Hospice consultation dated 1/21/26. The EMR also included a Social Services Progress Note dated 1/28/2026 3:34 PM which read, Note Text: This writer reached out to the guardian in order to provide hospice services through (name of Hospice Organization). Guardian consented to hospice consultation. Referral issued. No hospice consultation follow-up was found in the EMR. On 2/9/2026 at 5:06 PM, the hospice consultation results were requested from the Nursing Home Administrator (NHA). On 2/10/2026 at 8:00 AM, the hospice consultation results were requested from the Director of Nursing (DON).…

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 2645585.Based on interview and record review, the facility failed to accurately reconcile medications on admission and failed to monitor blood glucose levels according to facility policy and professional standards of practice for one Resident (#10) of three residents reviewed for quality of care.Findings include:This citation pertains to intake 2645585.Based on interview and record review, the facility failed to accurately reconcile medications on admission and failed to monitor blood glucose levels according to facility policy and professional standards of practice for one Resident (#10) of three residents reviewed for quality of care.Findings include:Resident #10 (R10)Review of the Minimum Data Set (MDS) assessment, dated 10/7/2025, revealed R10 was admitted to the facility on [DATE] and had severe cognitive impairment. Review of R10's diagnoses list from the electronic medical record (EMR), revealed active diagnoses including dementia, diabetes with long-term use of insulin…

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 2630912 and 2666718.Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for five Residents (#10, #11, #12, #13, and #16) of five residents reviewed, resulting in the potential for unrecognized and continued abuse.Findings include:Resident #12 (R12) and Resident #13 (R13)Review of a facility incident report submitted to the State Agency on 9/20/2025 at 3:11 p.m. revealed the following: Resident [R12] struck out with closed fist and made contact with upper arm of another resident [R13]. Residents were immediately separated. Skin and pain assessments completed with no injuries noted. Police notified. Guardians and physician notified. Medication regiment review to be completed on [R12] and to be supervised during meals. 5-day investigation to follow.Review of the facility investigation summary received by the SA 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 intake MI00153461. Based on observation, interview, and record review the facility failed to maintain a safe, sanitary community shower room area for the facility population. Findings include: On 6/17/25 at 7:24 PM, an interview was conducted with Complainant I regarding their concerns about a recent short stay at the facility. The complainant stated the D-Hall shower had mold growing around the shower drain and at the base of the shower, and it, looked disgusting and was gross. The complainant felt the facility was doing a very poor job cleaning and was mortified to take a shower in the shower room. Complainant I stated they were glad they were in a shower chair during their shower to avoid making direct contact with the shower floor. On 6/18/25 at 8:00 AM, an observation of the D-hall shower room found mold in the double shower along the base of the shower on the right and back side and around the shower drain. On 6/18/25 at 8:05 AM, an interview was conducted with Certified Nurse Aide (CNA) F who was responsible for assisting with showers. CNA F 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.

This citation pertains to intakes MI00150502 and MI00150541. Based on interview and record review, the facility failed to protect residents' rights to be free from abuse for four Residents (#21, #22, #23, #26) of four residents reviewed for sexual abuse. Findings include: Resident #20 (R20), Resident #21 (R21), Resident #22 (R22) On 2/11/25, the State Agency (SA) received an initial facility reported incident summary which stated, Resident (R20) kissed (R22) on the cheek. (R20) also touched resident (R21) on the thigh. An Investigation Summary was received by the SA on 2/20/25 and read in part, R20 had multiple diagnoses including dementia with agitation, dementia with psychotic disturbance, and adjustment disorder with mixed anxiety and depressed mood. R20 had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. R22 had multiple diagnoses including Parkinson's disease with mood disturbance and a BIMS score of 14 indicating intact cognition. R21 had multiple diagnoses including dementia, anxiety disorder, depression, cognitive…

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 intakes MI00150502 and MI00150541. Based on interview and record review, the facility failed to thoroughly investigate allegations of sexual abuse for one Resident (#20) of one resident reviewed for sexual abuse. This deficient practice resulted in the potential for additional exposure to sexual abuse for cognitively impaired resident, including Residents (#21, #22, #23, #26). Findings include: On 2/11/25, the State Agency (SA) received an initial facility reported incident summary which stated, Resident (R20) kissed (R22) on the cheek. (R20) also touched resident (R21) on the thigh. An Investigation Summary was received by the SA on 2/20/25. The investigation summary stated, The incident was reported to (the SA) as abuse. The one witness listed in the report was documented as Certified Nurse Aide (CNA) A. On 2/14/25, the SA received an additional initial facility reported incident summary which stated, Resident (R20) touched (R22) on the thigh near the genital area. Before we had the opportunity to get him (R20) on a 1:1 (a system to closely monitor R20)…

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 maintain sufficient nursing staff as evidenced by confidential resident and family interviews and payroll data analysis. This deficient practice resulted in embarrassment and worry on the part of residents whose needs were not met with potential to impact all 74 residents living in the facility. Findings include: A review of the Payroll-Based Journal (PBJ) report indicated excessively low staffing levels and a one star staffing rating in the fourth quarter (July1-September 30). A review of the facility's Facility Assessment Tool for Medilodge of [NAME] Ste. [NAME] 08/2023 through 07/2024 indicated Each hall is staffed based on resident acuity. Resident acuity is discussed each morning at the IDT (Interdisciplinary Team) morning meeting. IDT discusses current resident acuity on each unit, admission planned for the next 48 hours and discharges planned for the next 48 hours. Staffing levels are adjusted based on the evaluation of acuity. The charge nurse…

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 a safe and sanitary environment for 6 of 6 residents of a total census of 74, who had personal refrigerators in their rooms. This deficient practice has the potential to result in personal food spoilage and contribute to an overall unsanitary condition in the rooms. Findings include: On 1/7/25 between 3:00 PM and 4:30 PM, resident rooms were observed for the presence of personal refrigerators. Six residents were identified having personal refrigerators which stored both perishable (lunch meats, dairy products, etc.) and non-perishable foods (canned beverages). Rooms identified with personal refrigerators were: A2; B7, B5, D9, D8, and D15. None of the six observed refrigerators were provided with a thermometer. Internal temperature measurements were made with an infrared thermometer which detected temperatures varying between 37°F and 54°F. No evidence of temperature logs were observed in proximity to the refrigerator units. On 1/8/25 at approximately 8:00 AM, a list of all residents having personal…

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 care plans were updated promptly and revised appropriately for four Residents (R15, R24, R25, and R36) out of 18 Resident care plans reviewed. This deficient practice resulted in care plans which did not reflect resident needs. Findings include: Resident #15 (R15) On 11/5/24 a Facility Reported Incident (FRI) was submitted to the State Agency (SA) which read in part, Incident Summary: Resident #23 (R23) was witnessed yelling (obscenities) at resident (R15) staff immediately intervened and separated the 2 residents. The care plan for R15 included a Focus: Resident has impaired cognitive function related to disorganized thinking, Traumatic Brain Injury. Date Initiated: 08/03/2023. This care plan was updated 1/8/25 with an intervention to prevent further altercations which read, Make sure (initials of R23) is not seated close to resident (R15). Redirect resident by offering coffee or going for a walk when frustrated. During an interview on 1/9/25 at 10:44 AM, Certified Nurse Aide (CNA) V stated she worked throughout…

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 appropriately store and label respiratory equipment, provide supplemental oxygen, and provide Continuous Positive Airway Pressure (CPAP) therapy according to physicians' orders for four Residents (#31, #46, #7, and #57) of four residents reviewed for respiratory care services. Findings include: Resident #31 (R31) On 1/7/25 at 11:50 a.m., R31 was observed wearing a nasal cannula (a tube used to deliver supplemental oxygen). The cannula tubing was observed dated 12/25/24. The oxygen concentrator was observed set to deliver 2.5 liters per minute (lpm) of supplemental oxygen. Physician's orders for R31 included an order for oxygen tubing/filter change every week to be changed by [name of oxygen supplier] weekly during rounds on Thursdays. Another physician's order for R31 read Oxygen: RUN @ [2]L (liters)/MIN (minute) VIA [X]N/C (nasal Cannula) . [X] CONTINUOUS. On 1/8/25 at 2:45 p.m., R31's O2 (oxygen) concentrator was set to deliver 3 lpm of supplemental O2. R31 said she did not know who changed the flow rate of…

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

Based on observation, interview, and record review, the facility failed to: 1. Secure one topical medication, 2. Securely lock a treatment cart and, 3. Store medications properly for one of two medication carts reviewed for medication storage. This deficient practice had the potential for medication errors, drug diversion, and ingestion of medications inappropriate for consumption for cognitively impaired residents. Findings include: On 1/7/25 at 11:58 AM, an observation was made of an unlocked and unattended treatment cart on the A-hall. This Surveyor opened the treatment cart which contained eight topical medication creams and various wound care supplies. One of the wound care supplies normal saline 500 ml (milliliters) was opened with approximately 300 ml of liquid and had no date to show when it was opened. On 1/7/25 at 12:07 PM, an observation was made of R21 in her room. R21 was sitting in her wheelchair. During an observation of R21's bathroom a topical medication cream identified as Nystat (Nystatin [topical antifungal agent] was observed sitting on a ledge. Review of R21's…

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

Based on interview and record review, the facility failed to protect a resident from verbal abuse for one Resident (#37) of four residents reviewed for abuse. This deficient practice resulted in mental distress and anguish after a staff member used inappropriate language towards a resident. Findings include: This citation is linked to Facility Reported Incident (FRI) MI00148016. Resident #37 (R37) Review of R37's electronic medical record (EMR) revealed initial admission to the facility on 2/16/22 with diagnoses including cerebral infarction (a stroke referring to damage to tissues in the brain due to loss of oxygen), dementia, muscle weakness (generalized), difficulty walking, and need for assistance with personal care. Record review of R37's most recent Minimum Data Set (MDS) assessment, dated 11/1/24, revealed a Brief Interview for Mental Status (BIMS) score of 10, indicative of moderate cognitive impairment. Review of the FRI submitted to the State Agency (SA) included an incident summary which read, in part: .received report from [Certified Nursing Assistant (CNA) M] that two…

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 appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one Resident (#25) of one resident reviewed for limited range of motion. This deficient practice had the potential for development and/or worsening of contractures, pain, and skin breakdown. Findings include: Resident #25 (R25) Review of R25's Electronic Medical Record (EMR) revealed admission to the facility on 2/23/22 with diagnoses including cerebral palsy, contractures, lack of coordination, and dementia. The most recent Minimum Data Set (MDS) assessment, dated 11/25/24, revealed a Brief Interview for Mental Status (BIMS) score of 0, indicative of severe cognitive impairment. During a room visit on 1/7/25 at 12:47 PM, R25 was alert but non-verbal in bed grasping his TV remote with his clenched fists. He did not have any protective device such as a rolled cloth in his contracted closed fists to prevent skin breakdown. When asked if he could open his fists, he did not make 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 interview and record review, the facility failed to provide adequate medically related social services for one Resident (R36) of four residents reviewed for social services care. Findings include: Resident 36 (R36) Review of R36's electronic medical record (EMR) revealed initial admission to the facility on 5/31/24 with diagnoses including dementia, hypertension, and cognitive communication deficit. Record review of R36's most recent Minimum Data Set (MDS) assessment, dated 9/4/24, revealed a Brief Interview for Mental Status (BIMS) score of 1, indicative of severe cognitive impairment. Review of the Facility Reported Incident (FRI) submitted to the State Agency (SA) dated 12/28/24 included an incident summary which read, in part: .[R36] was behind resident [Resident #50 (R50)] in the hall and reached up to grab resident [R50] on the shoulder, grabbing at his t-shirt and causing scratches to his right upper back and shoulder . Review of R36's Plan of Care revealed the following focus, initiated on 6/1/24: Resident has impaired communication . maintain eye contact, approach…

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 their medication error rate was below 5% when three medication errors were observed from a total of 26 opportunities for one Resident (#7) of two residents reviewed for medication administration. This deficient practice resulted in a medication error rate of 11.54%. Findings include: Resident 7 (R7) Review of the medical record revealed R7 admitted to the facility on [DATE] with diagnoses including diabetes mellitus, heart disease, sleep apnea, and hypertension. Record review of R7's most recent Minimum Data Set (MDS) assessment, dated 12/7/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. On 1/9/25 at 8:20 AM, Registered Nurse (RN) C was observed preparing and administering medications to R7. RN C prepared two insulin glargine pens, one with 9 units and the other with 16 units to total a total of 25 units. RN C also prepared an insulin needle for R7 with 4 units of insulin lispro…

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 effective infection control practices and the appropriate use of personal protective equipment (PPE) for two Residents (#9 and #38) of seven residents reviewed for infection prevention and control. This deficient practice resulted in the potential transmission of communicable disease and infectious organisms to all 74 residents residing in the facility. Findings include: Resident #38 (R38) On 1/7/25 at approximately 11:35 a.m., R38's room was observed with three signs posted on the door indicating isolation for contact precautions, airborne precautions, and droplet precautions. The door to the room was open, and two residents were observed in the room (R38 and R38's room mate). The sign for airborne precautions read, in part: .Door to room must remain closed . There was no indication on the signage indicating which isolation precaution pertained to which resident. Resident #9 (R9) At approximately 11: 38 a.m. on 1/7/25, R9's room was noted to have four signs posted on the door indicating isolation 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.

This deficiency pertains to Complaint Intake MI00145457. Based on interview and record review, the facility failed to report an employee's criminal conviction to the Stage Agency (SA). This deficient practice resulted in the potential to jeopardize the safety and welfare of all 69 residents of the facility. Findings include: On 7/25/24 at 9:24 AM, a phone interview was conducted with a confidential staff member who expressed concern that a different confidential employee [Confidential Staff R] had a criminal conviction involving brandishing a firearm in public that was unknown to facility administration. The confidential staff member verbalized concern regarding the safety of the facility residents. On 7/30/24 at 11:40 AM, an interview was conducted with the Nursing Home Administrator (NHA), Regional Director of Clinical Services G, and Regional Director of Clinical Services F who stated they were unaware of Confidential Staff R's criminal conviction. The NHA stated, We [administration] were under the impression the charges were dropped. On 7/30/24 at approximately 11:55 AM, 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.

This deficiency pertains to Complaint Intakes MI00145340 and MI00145457. Based on observation, interview and record review, the facility failed to provide sufficient staffing to address the care, needs, and safety of the entire facility population. This deficient practice resulted in unmet care needs and the potential for serious safety issues for all 69 residents of the facility. Findings include: Review of Complaint Intake MI00145457 submitted to the State Agency (SA) read, in part: .I am an RN [Registered Nurse N] . are we are currently understaffed. We have been understaffed for some time, but it has gotten to the point where it is unsafe for our residents . Last Friday [6/28/24] on night shift there was only 1 LPN [Licensed Practical Nurse] and 3 CNAs [Certified Nursing Assistants] in the building caring for 80 residents. Our DON [Director of Nursing] was aware of this and said she was coming in to help but then she stopped answering her phone and never showed up. Review of timecards from 6/28/24 - 6/29/24 revealed LPN P was the sole nurse on duty for 4.5 hours (2:00 AM - 6:30…

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 deficiency pertains to Complaint Intake MI00145750. This Deficient Practice Statement (DPS) has two parts: A and B. DPS A: Based on interview and record review, the facility failed to report an allegation of potential sexual abuse for one Resident (#5) of nine residents reviewed for abuse. This deficient practice resulted in no investigation into the allegation of abuse by the State Agency (SA) and the potential for continued abuse. Findings include: Resident #4 (R4): Review of R4's electronic medical record (EMR) revealed admission to the facility on 5/16/24 with diagnoses including Alzheimer's Disease and diabetes. Record review of R4's most recent MDS assessment, dated 5/20/24, revealed a BIMS score of 7, indicative of severe cognitive impairment. Resident #5 (R5): Review of R5's EMR revealed admission to the facility on 5/16/24 with diagnoses including vascular dementia, congestive heart failure, and adjustment disorder with anxiety. Record review of R5's most recent MDS assessment, dated 5/20/24, revealed a BIMS score of 13, indicative of intact cognition. On 7/30/24 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.

Based on interview and record review, the facility failed to investigate an allegation of potential sexual abuse between two Residents (Residents #4 and #5) of nine residents reviewed for abuse. Findings include: Resident #4 (R4): Review of R4's electronic medical record (EMR) revealed admission to the facility on 5/16/24 with diagnoses including Alzheimer's Disease and diabetes. Record review of R4's most recent MDS assessment, dated 5/20/24, revealed a BIMS score of 7, indicative of severe cognitive impairment. Resident #5 (R5): Review of R5's EMR revealed admission to the facility on 5/16/24 with diagnoses including vascular dementia, congestive heart failure, and adjustment disorder with anxiety. Record review of R5's most recent MDS assessment, dated 5/20/24, revealed a BIMS score of 13, indicative of intact cognition. On 7/30/24 at 10:30 AM, a telephone interview was conducted with Certified Nursing Assistant (CNA) O regarding the protocol for reporting allegations of abuse. CNA O stated during a shift on 7/30/24 she walked into R5's room and observed him lying in bed with his…

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 MI00145233. Based on observation, interview, and record review, the facility failed to provide meals at regular times in accordance with resident preferences and expectations for five residents (R2, R4, R6, R12 and R13) of 8 residents reviewed for timely meal delivery. This deficient practice resulted in frustrated hungry residents. Findings include: On 6/25/24 a complaint was filed with the State Agency (SA) which alleged the meals were not served in a timely manner with the evening meal arriving as late as 7:00 PM. On 6/26/24 at 12:15 PM, an observation of the noon meal revealed the main dining room trays were being served. Several residents on the A Hall had chosen to eat in their rooms and were waiting for their meals. On 6/26/24 at 12:22 PM, Resident #2 (R2) was visiting with his wife in his room. His wife stated she was here daily and said the facility serves the dining room first and then the hall trays are served. Sometimes R2 goes to the dining room, but often prefers to eat in his room. R2's wife stated, there is often a long wait. R2's wife…

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 MI000145229: Based on interview, and record review, the facility failed to implement its policy and assure the timely administration and physician notification of unavailable ordered medications for two residents (R1 and R11) from a total sample of 3 residents reviewed for medication administration. This deficient practice resulted in delayed administration of ordered antibiotics without physician notification to combat known infections. Findings include: On 6/21/24, the State Agency (SA) received a complaint regarding the administration of antibiotics for urinary tract infections for Resident #1 (R1). The Electronic Medical Record (EMR) of R1 revealed an admission date of 5/23/24 with diagnoses which included a personal history of urinary tract infections (UTI). The physician orders for R1 included Nitrofurantoin Macrocrystal Capsules (an antibiotic) to be given twice a day for seven days with a start date of 6/18/24 at 20:00 (8:00 PM). The Medication Administration Record (MAR) indicated the medication was not available and was not given on 6/18/24 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.

This deficient practice has two different DPS statements labeled part A and B. DPS A Based on observation, interview, and record review the facility failed to properly don personal protective equipment (PPE) for three Residents (R3, R9, and R10) who were placed in Enhanced Barrier Precaution (EBP) rooms of three reviewed for infection control. This citation is linked to intakes MI00142467 AND MI00142753. On 4/16/24 at 12:35 PM, an interview was conducted with Complainant M and was asked about the nature of the allegations. Complainant M replied, There was an isolation room near my room in the same hallway and staff was not putting on protective gowns or shields and I am not sure what the person had. I think maybe Covid-19, but then they would come and assist me. I don't feel like that was right. The staff should have been wearing protection. On 4/17/24 at 10:50 AM, a facility tour was taken, and the following observations were made locating residents for sample who were in EBP rooms down three different hallways. On 4/17/24 at 11:00 AM, an observation was made of R3 in his 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 Based on observation, interview, and record review the facility failed to obtain physician order for indwelling catheter device for one Resident (R3) of three reviewed for bowel and bladder care. On 4/17/24 at 11:00 AM, an observation was made of R3 in his room lying in his bed with an indwelling catheter bag hanging off the left side of his bed. On 4/17/24 at 12:20 PM, an interview was conducted with Certified Nurse Aide (CNA) H and was asked why R3 had an indwelling urinary catheter and replied, I would have to ask the nurse, but he has had it ever since he came back from the hospital. Review of R3's progress notes, dated 3/18/24 through 4/17/24, revealed, an original admission on [DATE] to the facility, a transfer out to a local hospital on 3/26/24, and a return to the facility on 3/28/24. Review of R3's progress note, dated 3/28/24 at 4:33 PM, read in part, Resident arrived .transferred to bed .has indwelling catheter . Review of R3's progress note, dated 3/28/24 at 5:46 PM, read in part, Called [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.

Based on observation and interview, the facility failed to ensure exhaust ventilation was functioning in resident bathrooms, on two halls, serving 48 of a total 64 residents. This deficient practice has the potential to result in noxious odors permeating the resident environment rendering the living conditions unpleasant and uncomfortable. Findings include: On 1/22/24 at 11:45 AM, noxious odors were noted throughout the A and D halls. On 1/22/24 at 4:30 PM, in response to the presence of continued noxious odors on the A wing, an investigation was initiated into determining the functioning of the exhaust ventilation system for resident bathrooms. The bathrooms serving the following rooms were inspected for functioning exhaust by placing a paper towel over the ceiling mounted duct cover and determining if there was adequate negative pressure to hold the paper in place. The failure to hold the towel in place was deemed a failure for that bathroom's exhaust system. This failure was noted in the bathrooms serving the following resident rooms: A Hall 3/5; 10/12; 11/13; 14/16; 15/17 D…

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

Based on interview and record review the facility failed to ensure the exercise of resident rights for one Resident (R170) of 17 residents reviewed for resident rights. This deficient practice prevented R170 from exercising her resident right and desire to have family members present during a telehealth visit. Findings include: Review of R170s Minimum Data Set (MDS) assessment, dated 1/16/24, revealed admission to the facility on 1/12/24 with active diagnoses that included osteoporosis, pubis fracture, anxiety, and depression. The Brief Interview for Mental Status (BIMS) score was 6 of 15 on the admission MDS, reflective of severe cognitive impairment. A BIMS score completed on the day of discharge, 1/25/24, was 12 of 15, indicative of moderate cognitive impairment. Review of R170's admission Record revealed R170 was their own responsible party and did not have an activated Durable Power of Attorney or Guardian making their decisions. During an interview on 1/25/24 at 9:18 a.m., Family Member (FM) I reported they were related to R170. FM I said they were discharging R170 from 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 accuracy of a Minimum Data Set (MDS) assessment, quarterly nursing assessments (including elopement and fall risk assessments), and nutritional assessments for two residents (Resident #49 and #31) of 16 sampled residents reviewed for comprehensive assessments. This deficient practice resulted in the potential for unmet care needs including inadequate supervision to prevent elopement and inadequate nutritional interventions to prevent unnecessary weight loss. Findings include: This deficiency pertains to Facility Reported Incident (FRI) MI00142212. Resident #49 (R49): Review of R49's electronic medical record (EMR) revealed a most recent admission to the facility on 9/29/23 with diagnoses including Parkinson's Disease with dyskinesia (uncontrolled, involuntary movements), cognitive communication deficit, dementia, difficulty in walking, and history of falling. Record review of R49's most recent Minimum Data Set (MDS) 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 ensure appropriate Quality of Care per professional standards of practice for one Resident (R9) of two residents reviewed for quality of care for adequate seating and positioning for pressure relief and completion of activities of daily living (adls). This deficient practice resulted in pain and feelings of frustration and helplessness. Findings include: Review of R9's Minimum Data Set (MDS) assessment revealed R9 was admitted to the facility on [DATE], with diagnoses including quadriplegia (paralysis that affects all a person's limbs and body from the neck down), anoxic brain damage (brain injury caused by a complete lack of oxygen to the brain), neurogenic bladder (lack of bladder control from neurological compromise), adjustment disorder with anxiety, depression, muscle weakness, muscle spasm, and aphasia (a communication disorder from brain damage). The assessment revealed R9 required moderate assistance with eating, maximal…

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 hygienic catheter care and services to prevent urinary tract infections (UTIs) for one Resident (R29) of two residents reviewed for catheter care. This deficient practice resulted in the potential for cross-contamination of infectious organisms and the increased likelihood of UTIs. Findings include: Resident R29 Review of R29's Minimum Date Set (MDS) assessment, dated 12/23/23, revealed R29 was admitted to the facility on [DATE], with active diagnoses that included obstructive uropathy and UTI. R29 scored 5 of 15 on the Brief Interview for Mental Status (BIMS) reflective of severe cognitive impairment. R29 was able to be understood and understand others. Suprapubic catheter and peri care was observed on 1/24/24 at 9:45 a.m., performed by Certified Nurse Aides (CNA) N and M. CNA N performed the care, with the physical assistance of CNA M. Both CNAs washed their hands and donned clean gloves. CNA N placed a wet washcloth in a plastic…

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 nutritional interventions for one (Resident #31) of sixteen residents reviewed for nutrition and hydration. This deficient practice resulted in the potential for unnecessary weight loss. Findings include: Resident #31 (R31): Review of R31's electronic medical record (EMR) revealed initial admission the facility on 12/4/23 with diagnoses including fracture of the right femur, congestive heart failure, and osteoporosis (a condition in which bones become weak and brittle). Review of R31's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, indicative of moderate cognitive impairment. Review of R31's weight history revealed she weighed 123.0 lbs. (pounds) on 12/5/23 and weighed 106.2 lbs. on 1/2/24 for a total weight loss of 16.8 lbs. This resulted in a 13.7% weight loss within an approximate 30-day period. On 1/23/24, R31 weighed 95.2 lbs., which represented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the physician was notified and involved in implementing nutritional interventions for significant weight loss in one (Resident #31) of 16 sampled residents. This deficient practice resulted in the lack of physician coordination related to nutritional decline. Findings Include: Resident #31 (R31): Review of R31's electronic medical record (EMR) revealed initial admission the facility on 12/4/23 with diagnoses including fracture of the right femur, congestive heart failure, and osteoporosis (a condition in which bones become weak and brittle). Review of R31's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, indicative of moderate cognitive impairment. On 1/22/24 at 1:28 PM, R31 was observed sitting in a wheelchair in her room with a meal tray sitting in front of her on an overbed table. A hamburger on a bun, a serving of French fries, a full bowl of cottage…

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 acquire and administer medications to meet the need of two Residents (R26 & R58) of five residents reviewed during medication administration observation. This deficient practice resulted in the potential for infection and adverse medication side effects. Findings include: Review of R26's Minimum Data Set (MDS) assessment, dated 11/26/23, revealed R26 was admitted to the facility on [DATE] with active diagnoses that included non-Alzheimer's dementia, anxiety disorder and depression. A Brief Interview for Mental Status (BIMS) was not completed, however R26 was documented with severely impaired cognition, usually understood and able to understand others. During an observation on 1/25/24 at 10:29 a.m., Registered Nurse (RN) F prepared R26's medications. RN F removed a blister pack of Citalopram (antidepressant medication), 40 milligram (mg) tablets out of the medication drawer and popped one pill into a plastic 30 cubic centimeter (cc) cup.…

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 less than five percent with three observed medication errors out of 26 opportunities. This deficient practice resulted in a medication error rate of 11.5 percent and an increased likelihood for medications to be improperly prepared, administered, and/or omitted from residents' medication regimens. Findings include: R26 Review of R26's Minimum Data Set (MDS) assessment, dated 11/26/23, revealed R26 was admitted to the facility on [DATE] with active diagnoses that included non-Alzheimer's dementia, anxiety disorder and depression. A Brief Interview for Mental Status (BIMS) was not completed, however R26 was documented with severely impaired cognition, usually understood and able to understand others. During an observation on 1/25/24 at 10:29 a.m., Registered Nurse (RN) F prepared R26's medications. RN F removed a blister pack of Citalopram (antidepressant medication), 40 milligram (mg) tablets out of 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 staff donned appropriate personal protective equipment (PPE) for one (Resident #16) of one residents reviewed for Enhanced Barrier Precautions (EBP). This deficient practice resulted in the potential for the spread of infectious organisms to a vulnerable resident. Findings include: Resident #16 (R16): Review of R16's electronic medical record (EMR) revealed initial admission to the facility on 8/24/21 with diagnoses including diabetes mellitus, acute osteomyelitis (an infection in the bone) of the left ankle and foot and acquired absence of the right leg below the knee (amputation). Review of R16's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. On 1/22/24 at 11:10 AM, a sign was observed on the door of R16's room titled, Enhanced Barrier Precautions. The signage indicated: Everyone Must: Clean their hands, before entering…

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 deficiency pertains to Facility Reported Incident (FRI) MI00142212. Based on interview and record review, the facility failed to maintain a compliance and ethics program for one (Resident #49) of one residents reviewed for a Facility Reported Incident. This deficient practice resulted in an inaccurate depiction of a facility reported elopement incident to the State Agency (SA). Findings include: Resident #49 (R49): Review of R49's electronic medical record (EMR) revealed a most recent admission to the facility on 9/29/23 with diagnoses including Parkinson's Disease with dyskinesia (uncontrolled, involuntary movements), cognitive communication deficit, dementia, difficulty in walking, and history of falling. Record review of R49's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicative of moderate cognitive impairment. Review of the FRI submitted to the SA included an incident summary which read, in part: .On the morning 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 This Citation Pertains to Intake Number: MI00138909 Based on interview and record review the facility failed to properly assess, stage, and implement treatment for newly developed pressure ulcers for two Residents (R1 and R2) of two residents reviewed for pressure ulcers. This deficient practice resulted in delay in treatment and the potential for worsening pressure ulcers. Findings include: R1 (Resident #1) On 10/9/23 at 1:38 p.m. an interview was conducted with Complainant E who stated that R1 developed a pressure ulcer while staying at the facility. Complainant E stated R1 had discharged from the facility in August 2023. Review of R1's Electronic Medical Record (EMR) revealed admission to the facility on 8/8/23 with diagnoses including metabolic encephalopathy, right femur fracture, and type 2 diabetes. R1's 8/12/23 Minimum Data Set (MDS) assessment revealed he scored an 8/15 on the Brief Interview for Mental Status (BIMS) score indicating he had moderate cognitive impairment. R1 required one 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.