South Haven Nursing and Rehabilitation Community

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow professional standards of nursing practice for physician notification of a change in condition and medication administration for 1 of 1 residents (Resident #2) reviewed for medication administration resulting in the withholding of a medication without a physician's order and the potential for affected resident not maintaining or achieving their highest practical physical well-being.Findings include: Review of Fundamentals of Nursing ([NAME] and [NAME]] revealed, Professional standards such as Nursing: Scope and Standards of Practice [ANA, 2010) .apply to the activity of medication administration. To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these six rights: 1.The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. 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 provide individualized activities based on resident preferences, needs, and abilities for 1 resident (Resident #59) of 16 residents for activities, resulting in potential for social isolation, decreased connectedness to the resident's environment, and decreased overall well-being.Findings include: Review of Participating in Activities You Enjoy as You Age, published by the National Institute on Aging, 3/28/22, revealed: Research has shown that older adults with an active lifestyle: Are less likely to develop certain diseases. Participating in hobbies and other social activities may lower risk for developing some health problems, including dementia, heart disease, stroke, and some types of cancer. Studies looking at people's outlooks and how long they live show that happiness, life satisfaction, and a sense of purpose are all linked to living longer. Doing things that you enjoy may help cultivate those positive feelings. Studies suggest that older…

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 services and assistive devices were provided to maintain adequate vision in 1 (Resident #24) of 1 resident reviewed for vision services resulting in inadequate glasses, outdated prescription, and the potential for vision strain. Findings include:Resident #24Review of a Resident Face Sheet revealed Resident #24 was a male who admitted to the facility on [DATE] and had pertinent diagnoses which included: Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (stroke). Review of a Minimum Data Set (MDS) assessment for Resident #24, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #24 was moderately cognitively impaired.In an observation and interview on [DATE] at 9:51 AM, Resident #24's glasses were noted to be missing the left lens. Resident #24 demonstrated where the frame of his glasses, near the nose piece…

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 proper treatment to maintain good foot health for 1 (Resident #5) of 1 resident reviewed for foot health, resulting in the potential for injury, unmet care needs and/or complications from chronic conditions that affect foot health.Findings include:Resident #5Review of a Resident Face Sheet revealed Resident #5 was a male who admitted to the facility on [DATE] and had pertinent diagnoses which included: Cerebral infarction (stroke) with left side weakness, type 2 diabetes (chronic condition resulting in high blood sugar levels due to ineffective insulin production or use), and hypertension (high blood pressure). Review of a Minimum Data Set (MDS) assessment for Resident #5, with a reference date of 10/02/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #5 was cognitively intact.In an interview on 12/15/25 at 12:26 pm, Resident #5 reported he was concerned with his fingernails and toenails…

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 hydration was readily available for 1 resident (Resident #25) of 1 resident, resulting in the potential for decline in function, fluid and electrolyte imbalance, dehydration, the development of skin breakdown, urinary tract infections, and altered mental status. Findings include: According to Bunn (2019), .Older people are more at risk of developing low-intake dehydration because, with age, kidney function decreases and muscle mass drops, reducing water stores in muscle. Older people may also develop difficulties remembering to drink, accessing drinks, and swallowing. If an older person is concerned about continence or needs help to get to the toilet, they often choose to drink less, thereby increasing their risk of low-intake dehydration. The risk of dehydration is increased in care homes residents because they are more likely to experience these problems, relying on staff to help with drinking.Residents rarely helped themselves to, or asked for, drinks, which puts the onus on nursing and care…

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 medications were administered at the correct dose per the physician's order for 1 (Resident #2) of 2 residents reviewed for significant medication errors, resulting in the potential for adverse effects. Findings include: Review of the Fundamentals of Nursing revealed, The National Coordinating Council for Medication Error Reporting and Prevention [2018] defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/ or failing to administer a medication. Preventing medication errors is essential.'' [NAME]. [NAME] A.: Perrv. [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p.605). Elsevier Health Science. Kindle Edition. Resident #2: Review of a Face Sheet revealed Resident…

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

Based on observation and interview the facility failed to properly store controlled substance medications in a secure manner in 1 of 2 medication rooms.Findings include:On 12/17/25 at 8:29 am, the lock on the medication storage refrigerator in the medication room on the west unit of the facility was observed hanging in place on the latch and was not secured. The lock was not locked.On 12/17/25 at 8:29 am, Registered Nurse (RN) DD was observed handling the lock, flipping the lock to remove it from the latch on the refrigerator, and opening the refrigerator door. RN DD did not use a key to unlock the refrigerator.On 12/17/25 at 8:29 am, RN DD reported there was a controlled substance stored in the refrigerator.On 12/17/25 at 8:33 am, RN DD was observed replacing the lock on the latch of the refrigerator and not locking the lock. RN DD exited the medication room leaving the refrigerator unlocked.In an interview on 12/17/25 at 8:38 am, RN DD reported the refrigerator in the medication room should be always locked.In an interview on 12/17/25 at 9:09 am, Director of Nursing (DON) B…

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 resident food choices were obtained and honored for 1 (Resident #75) of 4 residents reviewed for meal services, resulting in resident dissatisfaction with their meal experience and the potential for inadequate food/fluid intake. Findings include:Resident #75: Review of Face sheet for Resident #75 revealed, Review of a Face Sheet revealed Resident #75 was a male with pertinent diagnoses which included diabetes, gout (a painful inflammatory arthritis from uric acid crystals in joints), and kidney disease. Review of Care Plan for Resident #75, revealed, the focus, .Resident is at Nutritional / Hydration risk r/t (related to) admitted with hx (history) of chronic lymphedema (swelling from lymph fluid buildup, caused by damaged lymph nodes, leading to heaviness, tightness, and limited movement) RLE (Right Lower Extremity), high blood pressure, deep vein thrombosis (a serious condition where a blood clot forms in a deep vein), diabetes, stage 4 kidney disease, rheumatoid arthritis (a chronic autoimmune…

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: MI00151221 Based on observation, interview, and record review the facility failed to develop and implement person centered care plans for 2 (Resident #1 and Resident #3) of 3 residents reviewed for care plan development and implementation resulting in Resident #1 exiting the facility unsupervised and the potential for Resident #3 to elope from the facility. Findings include: Resident #1 Review of an Facesheet revealed Resident #1 was a male who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: unspecified dementia, unspecified mood disorder, unsteadiness on feet, and a need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #1, with a reference date of 1/14/2025 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #1 was severely cognitively impaired. (BIMS score 0-7 indicates severe cognitive impairment). On 6/17/25 at 8:00 am, signage was observed posted…

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 employ either a full time Registered Dietitian or Certified Dietary Manager to provide oversight of kitchen and clinical nutritional services. This deficient practice has the increased potential to result in food service sanitation failures, food borne illness, or inadequate assessment of high-risk residents among all residents. Findings include: During a tour of the kitchen, at 8:35 AM on 9/26/24, an interview with Dietary Supervisor (DS) S, found that the facility does not have a full-time dietitian, but a dietitian comes in a couple times a week. When asked if she was a Certified Dietary Manager (CDM), DS S stated that she is not yet but is taking the classes. When asked how long she has been the Dietary Manager, DS S stated about two years. When asked how the CDM class was going, DS S stated it's been hard to fit it in sometimes, but she is getting an extension so she can complete it.

During a tour of the kitchen, starting at 8:35 AM on 9/26/24, an interview with Dietary Supervisor (DS) S found that potentially hazardous foods get dated for a three-day discard. Observation of the walk-in cooler found an open container of sliced ham with no discard date. During a tour of the bunny patch resident refrigeration unit, at 10:06 AM on 9/26/24, an interview with DS S found that dietary, nursing, and activities takes care of this refrigeration unit for residents. When asked how long food product gets in the refrigeration unit, DS S stated three days. Observation inside of the unit found the following: A carton of milk with a best by date of 9/20/24, a container of whole intact grapes with fuzzy mold looking substance on the grapes, a container of unlabeled soup with a best by date of 9/12/24, an unlabeled container of Chinese takeout with a foul odor and many areas of mold looking growth covering the food product, and a container of puree mac and cheese with no date. According to the 2017 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety…

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

DPS A Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). Findings include: During an interview with Maintenance Director M regarding the facilities Water Management Plan, at 3:40 PM on 9/26/24, it was found that the facility does routine flushing of domestic fixtures to help remove stagnant water from their system. When asked what other control measures are put in place to reduce the risk of OPPP from growing and spreading, MD M was unsure. When asked if the facility does any testing of the water, MD M stated that he has been waiting on a tester to do that. When asked if the water line in the family room, behind where the old refrigeration unit was, is being flushed, MD M stated it was not one that he would flush. A review of the Water Management Plan binder found an annual review from August 2023. When asked if he has gone over the WMP with the administrator, MD M stated not yet. During a review of the facilities Water Pathogen…

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 1.) Implement and operationalize an antibiotic stewardship program and 2.) failed to monitor to ensure appropriate use of an antibiotic for 1 (Resident # 368) of 5 residents reviewed for antibiotic use, resulting in the potential for inappropriate antibiotic utilization and antibiotic resistance. Findings include: Resident #368 Review of an admission Record revealed Resident #368 was originally admitted to the facility on [DATE] with pertinent diagnoses which included cellulitis. During an interview on 10/01/24 at 11:53 AM, Infection Preventionist (IP) C reported that the facility utilized Mcgeer's criteria when residents were prescribed an antibiotic. IP C reported that any time a resident was prescribed an antibiotic, she was responsible for reviewing the resident's record to ensure that Mcgeer's criteria was used. IP C confirmed that Resident #368 had been on an antibiotic in September 2024. IP C reviewed Resident #368's electronic health record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain general cleanliness and repair of resident rooms, equipment, and aspects of the physical facilities for 5 of 38 residents (Resident #9, #50, #1, #8, and #10). Findings Include: During a tour of the facility, at 10:26 AM on 9/26/24, observation of resident room [ROOM NUMBER] found dust and debris under the bed and an accumulation of dirt debris around the perimeter and corners of the rooms vinyl coving. During a tour of the facility, at 1:54 PM on 9/26/24, it was observed that resident room [ROOM NUMBER] was found with increase staining and debris on the perimeter and corners of the room. Observation of shared resident bathroom found accumulations of dirt in the corners of the floor. Observation of the 200 hall Soiled Utility room, at 2:03 PM on 9/26/24, found numerous brown and stained ceiling tiles showing that possible roof leaks have been happening in this area. During a tour of resident room [ROOM NUMBER], at 2:08 PM 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 call lights were in reach for 1 (Resident #8) of 20 residents reviewed for accommodation of needs, resulting in the inability to call for staff assistance and the potential for unmet care needs. Findings include: Review of an admission Record revealed Resident #8 was originally admitted to the facility on [DATE] with pertinent diagnoses which included unsteadiness on feet. Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 8/7/24 revealed a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated Resident #8 was moderately cognitively impaired. Review of Resident #8's Care Plan revealed, Category: ADLs (Activities of daily living) Functional Status/Rehabilitation Potential. Alteration in ADLs - self care deficit r/t (related to) H/O (history of) CVA (cerebrovascular accident-a stroke) with L sided weakness .Problem start date:3/27/17 .Approach: .Call light to be within reach .…

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 develop and implement a comprehensive, person-centered care plan for 1 (Resident #42) of 5 residents reviewed for medications, resulting in an incomplete reflection of the resident's care and monitoring needs for anticoagulant therapy. Findings include: Resident #42 Review of an admission Record revealed Resident #42 was a female, with pertinent diagnoses which included: congestive heart failure and hypertension (high blood pressure). Review of a Physician's Order revealed Resident #42 was prescribed an anticoagulant, Eliquis (apixaban) tablet; 2.5 mg (milligrams); amt (amount): 2.5 mg; oral Special Instructions: DX (diagnosis): HX (history) DVT (deep vein thrombosis - a blood clot) Twice A Day . with a start date of 7/9/24. Review of Resident #42's current Care Plan revealed no care planned problem, goal, or approach related to Resident #42's anticoagulant therapy. In an interview and record review on 9/26/24 at 2:27 PM, MDS Coordinator (MDSC) EE reported that he was responsible for creating care plans for high-risk…

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 care plan interventions to prevent worsening of contractures for 1 (Resident #1) of 2 residents reviewed for range of motion resulting in the potential for worsening of contractures (a condition of shortening and hardening of muscles, tendons, or other tissue often leading to deformity and rigidity of joints). Findings include: Review of an admission Record revealed Resident #1 was originally admitted to the facility on [DATE] with pertinent diagnoses which included contracture of muscles. Review of Resident #1's Occupational Therapy Discharge Summary dated 5/3/24 revealed, .Discharge Recommendations: . Right hand T bar splint (a device used to treat contractures) on with am care and off at lunch or as tolerated, LUE (left upper extremity)hand roll/carrot or gauzed during as tolerated and LUE elbow position device on with AM care and off at lunch or as tolerated . Review of Resident #1's Care Plan revealed, Category: ADLs…

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 MI00145027 and MI00145248. Based on observation, interview, and record review, the facility failed to ensure a safe environment and implement safety interventions for 1 (R15) of 2 residents reviewed for accidents and hazards, resulting in a fall with facial bruising and laceration that required sutures, and the increased potential for further falls with injuries. Findings include: According to the Minimum Data Set (MDS) dated 6/1124, R15 scored 5/15 (cognitively impaired) on her BIMS (Brief Interview Mental Status) with no impairments to either her arms or legs, the resident was able to independently wheel 150 feet in a corridor or similar space once seated in a wheelchair. Her diagnoses included dementia. Review of R15's Safety Event-Fall Event, event date 6/5/24, indicated at 6:10 PM the resident was discovered after wheeling down by the chapel (sic) and fell out of wheelchair. The resident had been self-ambulating in her wheelchair near the chapel prior to the fall. There were no witnesses to the fall. After the fall the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to attempt a required Gradual Dose Reduction (GDR) of antidepressant and antipsychotic medications for 1 (Resident #22) of 5 residents reviewed for unnecessary medications, resulting in the potential that the resident was receiving the medication at an unnecessary dose or for an unnecessary length of time. Findings include: Resident #22 Review of an admission Record revealed Resident #22 was originally admitted to the facility on [DATE] with pertinent diagnoses which included unspecified mood affective disorder. Review of Resident #22's Physician's Orders revealed, Olanzapine (Antipsychotic medication). 2.5 mg (milligrams) twice a day. Start date 7/16/24 . Olanzapine. 5 mg at bedtime. Start date: 7/16/24 Sertaline (Antidepressant medication). 25 mg daily. Start date: 7/16/24 . Review of Resident #22's Care Plan revealed, (Resident #22) has a DX (diagnosis) of psychosis, delusional disorder, dementia with behaviors and experiences resistance with care,…

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 residents remained free from significant medication errors, when professional standards of medication administration were not followed for 1 (Resident #16) of 1 resident reviewed for insulin (works to lower blood sugar levels in your body) administration, resulting in the potential for serious adverse effects from an excessive dose of insulin. Findings include: Resident #16 Review of an admission Record revealed Resident #16 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: diabetes (when the body cannot properly control blood sugar levels). Review of a Minimum Data Set (MDS) assessment for Resident #16, with a reference date of 8/9/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #16 was cognitively intact. In an interview on 09/26/24 at 09:18 AM, Resident #16 reported that she had received the incorrect dose 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 Based on interview and record review, the facility failed to ensure residents were screened for eligibility to receive pneumococcal vaccinations and receive vaccination if eligible for 1 (Resident #22 ) of 5 residents reviewed for vaccinations, resulting in the potential of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia. Findings include: Resident #22 Review of an admission Record revealed Resident #22 was originally admitted to the facility on [DATE] with pertinent diagnoses which included chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe). Review of Resident #22's Consent for vaccines form dated 10/22/23 indicated that Resident #22's guardian had received and read the Pneumococcal vaccine information, risks, and benefits, and would like to receive the Pneumococcal vaccine as recommended. Resident #22's guardian wrote on the consent As long as it is outside if three years since last . This form was signed by Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Covid-19 immunizations were offered to 1 (Resident #51) out of 5 residents, reviewed for Covid-19 immunizations, resulting in the increased likelihood of infection and complications from Covid-19. Findings include: Resident #51 Review of an admission Record revealed Resident #51 was originally admitted to the facility on [DATE] with pertinent diagnoses which included chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe). Review of Resident #51's Electronic Health Record (EHR) did not indicate that Resident #51 had received any Covid-19 vaccinations. Review of Resident #51's Vaccine Consent Form dated 6/4/24 indicated that that Resident #51 had previously received Covid-19 vaccination, but did not indicate if he wanted additional doses. During an interview on 9/26/24 at 12:53 PM, Infection Preventionist (IP) C reported that she she was not able to locate any evidence that Resident #51 had been…

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 MI00142836. Based on observation, interview, and record review, the facility failed to ensure timely care and services to promote dignity in 3 of 4 residents (Resident #200, #201, & #202) reviewed for dignity/respect, resulting in long call light wait times, cluttered rooms, and the potential for feelings of diminished self-worth, sadness, and frustration. Findings include: Resident #200 Review of a Face Sheet revealed Resident #200 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: cellulitis (bacterial infection of the skin), weakness and pressure ulcers. Review of a Minimum Data Set (MDS) assessment for Resident #200, with a reference date of 1/9/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #200 was cognitively intact. In an interview on 4/11/24 at 2:13 PM, Resident #200 reported that call lights take a long time to get answered. Resident #200…

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 #MI00143198. Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse by staff for 1 of 3 residents (Resident #201) reviewed for abuse, resulting in the potential for a decline in physical, mental, and psychosocial well-being. Findings include: Review of a Face Sheet revealed Resident #201 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: stroke (with paralysis of left side of body), weakness, depression, anxiety, and dementia without behavioral disturbance. Review of a Minimum Data Set (MDS) assessment for Resident #201, with a reference date of 2/9/24 revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #201 was moderately cognitively impaired. Review of a Facility Reported Incident (FRI) dated 2/20/24 revealed, .Hospice Worker reported (Resident #201) was allegedly punched by a Certified…

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 #MI00142836. Based on interview and record review, the facility failed to provide care and services in accordance with professional standards of practice to 1.) ensure physician orders were in place for scheduled pain medications and 2.) accurately document the administration of controlled medications in 1 or 3 residents (Resident #202), reviewed for quality of care, resulting in the potential for ineffective management of pain, and the potential for drug diversion of controlled substances. Findings include: Review of a Face Sheet revealed Resident #202 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: cancer. In an interview on 4/11/24 at 4:01 PM, Registered Nurse (RN) H reported that Resident #202 was not in the facility for very long and was always in a lot of pain. In an interview on 4/10/24 at 1:55 PM, Family Member (FM) I reported that Resident #202 lived in the facility for a short time before going to the hospital, and that he was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain safe infection control practices in regard to hand hygiene (glove use), and implement enhanced barrier precautions (EBP) in 1 resident (Resident #200) reviewed for infection control, resulting in the potential for cross-contamination and the development and spread of multi-drug resistant bacteria. Findings include: Review of a Face Sheet revealed Resident #200 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: cellulitis, weakness and pressure ulcers. Review of a Minimum Data Set (MDS) assessment for Resident #200, with a reference date of 1/9/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #200 was cognitively intact. During an observation and interview on 4/10/24 at 11:04 AM Resident #200 was lying in his bed and there was signage outside of his door indicating Enhanced Barrier Precautions .Wear gloves…

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. Properly store, label, date mark, and discard potentially hazardous foods; 2. Ensure proper working order of dish machine prior to use; 3. Ensure proper thawing and cooling of potentially hazardous foods; 4. Clean food and non-food contact surfaces; 5. Monitor the sanitizer concentration of the three-compartment sink; and 6. Ensure proper air drying of sheet pans. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 61 residents who consume food from the kitchen. Findings include: In an observation and interview on 10/16/23 beginning at 10:45 AM and ending at 11:55 AM, reviewed the main facility kitchen, accompanied by Dietary Supervisor X. Dietary Supervisor X reported she worked at another facility, and was here today to assist Dietary Supervisor U. Observed a microwave on a stainless steel table. Noted the interior surface of the microwave was soiled with splattered food debris. Visible crumbs/food debris noted on the table…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain the dignity for 4 residents (Resident #10, Resident #56,Resident #42 and Resident #49) of 5 residents reviewed for dignity, from a total sample of 17 residents, resulting in residents feeling anger, fear, frustration,anxiety, and embarrassment. Findings include: Resident #10 Review of a Resident Face Sheet dated 8/22/23 revealed Resident #10 was admitted to the facility with the following pertinent diagnosis: weakness, schizophrenia (a mental disorder characterized by disruptions in thought, processes, perceptions, emotional responsiveness, and social interactions), and major depressive disorder (persistently depressed mood and long-term loss of pleasure or interest in life). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was able to understand and make self-understood with verbal and non-verbal expression and scored 15/15 on a Brief Interview for Mental Status (BIMS) assessment which indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide comfortable environmental temperatures for 1 of 1 resident (Resident #46) reviewed for comfortable temperatures, resulting in decreased satisfaction with living environment and affecting the feeling of a homelike environment. Findings include: During an observation on 10/16/23 at 09:48 AM, this writer was near the middle of the 300 hallway when there was an extreme shift in the hallway temperature with noticeable cold air felt on this writer's leg and arms. This writer went to the junction of the 200 hallway and the 300 hallway and read the temperature on the thermostat located there which read the temperature was approximately 64 degrees, the needle was just below the mid mark between 60 and 70 degrees on the thermostat. In an interview on 10/16/23 at 09:48 AM, Certified Nursing Assistant (CNA) G reported the heating and cooling guy had been to the facility a few times in the last few months. Resident #46: Review of an admission Record revealed…

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 In an observation on 10/16/23 at 9:07 AM, noted a sign on the exterior portion of the facility, near the front entrance, which stated to not lean on the white metal railing as it is weak. Observed tall, white metal railing surrounding the wheelchair ramp/stairs near front entrance. In an observation on 10/16/23 at 9:32 AM, observed room [ROOM NUMBER] had solid-colored dark blue carpet. Visible/extensive amount of debris/food particles and pieces of trash littered the floor. Observed a smeared, light brown substance on the floor in front of the armchair on the right side of the room. In an observation on 10/16/23 at 9:33 AM, observed room [ROOM NUMBER] had a tile floor with visible pieces of trash/food/debris scattered throughout. Noted a visible darkening along the perimeter of the room from dust buildup. In an observation on 10/16/23 at 9:34 AM, observed the door to the soiled utility room on the low-numbered section of the 300 hall was propped open with a three-binned hamper. Noted all the lids to the hamper…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain the call light within reach of the resident in 2 of 7 residents (Resident #14 & #55) reviewed for accommodation of needs, resulting in the inability to call staff for assistance and the potential for unmet care needs. Findings include: Resident #14 Review of a Face Sheet revealed Resident #14 was a female, with pertinent diagnoses which included back pain, muscle spasm, kidney disease, high blood pressure, dementia, anxiety, depression, weakness, difficulty walking, and a history of falls. Review of a Minimum Data Set (MDS) assessment for Resident #14, with a reference date of 9/15/23, revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated moderate cognitive impairment. Review of a current Care Plan for Resident #14 revealed the problem .Alteration in ADLs (Activities of Daily Living) - self care deficit .Patient currently receives HTN (high blood pressure), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written notification of the bed hold policy upon transfer to the hospital for 3 (Resident #24, #32, #37) of 3 residents reviewed for transfer and discharge requirements, resulting in the potential for residents and/or their representatives to be unaware of their rights in regard to facility bed holds. Findings include: Resident 24: Review of an admission Record revealed Resident #24 was a male with pertinent diagnoses which included dementia, parkinson's disease, delusional disorders, unsteadiness on feet, weakness, need for assistance with personal care, GERD, and iron deficiency anemia. Review of Progress Notes dated 09/17/2023 at 07:02 AM, .CNA was assessing resident with care when CNA notice a extreme amount of dark red blood with clots in residents brief. CNA yelled for nursing assistant Writer and another nurse came to assess resident he was bleeding from rectal area. Resident is alert and oriented able to hold a conversation with staff.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that professional standards of nursing practice were followed during medication administration and for the implementation of physician orders for 3 residents (Resident #15, Resident #22, and Resident #37) of 16 sampled residents reviewed for professional standards of nursing care resulting in a nutritional supplement not being administered, medication errors, and no monitoring of high risk medications. Findings include: Resident # 15 Review of a Face sheet revealed Resident #15 had pertinent diagnoses which included malignant neoplasm of the spinal cord s/p (status post) resection, weakness, history of traumatic brain injury, and hemiplegia and hemiparesis of dominant side (paralysis of one side of the body). Review of a Minimum Data Set (MDS) assessment for Resident #15, with a reference date of 9/26/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #15 was cognitively intact. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to obtain radiology services in a timely manner in 1 of 1 resident (Resident #37) reviewed for radiology services, resulting in delayed assessment and treatment for right quadrant pain. Findings include: Review of an admission Record revealed Resident #37 was a female with pertinent diagnoses which included acquired absence of left leg above knee, history of falling, weakness, need for assistance with personal care, dementia, iron deficiency anemia, high blood pressure, and stroke. Review of Progress Notes dated 06/22/2023 at 10:19 PM, .Resident stated she was having pain on right side on lower part of rib cage. Assess resident she had swelling on the right side called the on call doctor .he order a stat X ray of right of right rib cage and order to place her on 2 Liters of O2 resident vitals BP 173/87, HR 104, RR 19, O2 89% . Review of Progress Notes dated 06/23/2023 at 06:10 AM, .Up till 12 am visiting then back to room and to bed.Up this am.RT upper…

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 perform proper hand hygiene during medication administration for 3 residents (Resident #22, Resident #28, and Resident #8) of 8 residents reviewed for medication administration, resulting in the potential for the spread of infection, cross contamination, and disease transmission. Findings include: Resident #22 During an observation on 10/17/23 at 7:54 AM, Licensed Practical Nurse (LPN) AA walked from the medication cart parked at the nurses' station on the 400 hall, to the locked door of the storage room on the 400 hall. LPN AA then retrieved storage room key, unlocked and opened door, and retrieved ice from the cooler in the storage room to fill water pitcher for the medication cart. LPN AA returned the water pitcher to the top of the medication cart. LPN AA moved the medication cart to the middle of the 400 hall and prepared Resident #22's medications. LPN AA did not perform hand hygiene at any time during this observation. During an observation on 10/17/23 at 8:10 AM, LPN AA entered Resident #22's room and obtained her…

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 professional standards of care for medication administration for 1 resident (Residents #108) of 4 residents reviewed for medication administration, resulting in the potential for mis-administration of medication and the diversion of narcotics. Findings include: Review of an admission Record revealed Resident #108, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: weakness. Review of a Minimum Data Set (MDS) assessment for Resident #108, with a reference date of 9/7/23 revealed a Brief Interview for Mental Status (BIMS) score of 07/15 which indicated Resident #108 was cognitively impaired. Review of Resident #108's Physicians Orders revealed: hydrocodone- acetaminophen - Schedule II tablet; 5-325 mg (milligram) amount: 1 tab; oral Special Instructions: For pain Twice A Day 9/30/2023 . Review of Resident #108's Incident Report dated 10/05/2023 06:59 PM revealed: Description: Resident was given an extra…

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 MI00139876 and MI00138198 Based on observation, interview, and record review the facility failed to maintain an environment free of accident hazards and provide adequate supervision for 2 residents (Resident #113 and #104) of 5 residents reviewed for accidents/hazards, resulting in Resident #113 falling while being transported in a facility van, and Resident #104 eloping from the building. Findings include: Resident #113 Review of a Resident Face Sheet dated 10/3/23 revealed the resident was admitted to the facility with the following pertinent diagnoses: coronary artery bypass graft (medical procedure to improve blood flow to the heart requiring sternal precautions (limited motion, lifting restrictions), dependence on renal dialysis (clinical intervention to provide artificial replacement for lost kidney function). Review of a Minimum Data Set (MDS) assessment for Resident #113 dated 10/6/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated 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.