Evergreen Health and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00150187. Based on interview and record review the facility failed to ensure a consent for psychotropic medications were obtained from a legally authorized resident representative for one resident (R303) of three residents reviewed for rights of legally authorized representatives. Findings include: On [DATE], a concern submitted to the State Agency was reviewed with alleged R303 was provided psychotropic medications without the consent of their legally authorized representative (Durable Power of Attorney for healthcare-DPOA-H). On [DATE] the medical record for R303 was reviewed and revealed the following: R303 was initially admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, Fall from bed and Cerebral Infarction and had expired on [DATE]. A review of R303's MDS (minimum data set) with an ARD (assessment reference date) of [DATE] revealed R303 needed assistance from facility staff with their activities of daily living. R303's BIMS score (brief…

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 #MI00150047 Based on interview, and record review, the facility failed to follow pest control procedures for one resident (R305) of three residents reviewed for pest control. Findings include: On 2/19/25 a concern submitted to the State Agency was reviewed which alleged staff were not utilizing effective procedures to maintain pest control resulting in an infection of bed bugs. On 2/19/25 at 10:03 a.m., during a conservation with Maintenance Director A (MD A), MD A was queried regarding allegation of a bed bug infestation in the facility. MD A reported they did have multiple rooms in where bugs were found and that the facility pest control provider had been out multiple times to inspect and treat the rooms. MD A indicated that the rooms with alleged infestation were 414 and 409. A request for documentation of the bed bug procedures and treatments were requested. On 2/19/25 a review of the facility's investigation into the bed bug infestation revealed the following: Bed Bug…

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 MI00147674. Based on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for one (R803) of four residents reviewed for abuse, resulting in R804 pushing R803 out of their wheelchair. Findings include: A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) revealed an allegation that R804 pushed R803's wheelchair and R803 fell. On 12/10/24 at 12:40 PM, an interview was conducted with R803. R803 reported he used to be in another room and has had many roommates. R803 was difficult to understand, but said something about not trying to bother anyone. When queried about whether there had been any physical altercations with other residents, R803 reported there was, but did not give additional details and reported his memory was not good. On 12/10/24 at approximately 12:50 PM, R804 was observed seated at the table in the dining room for lunch. A review of R803's clinical 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 This citation pertains to Intake # MI000148791 Based on interview and record review the facility failed to report allegations of neglect to the Administrator/Abuse Coordinator and to the State Agency (SA) for one (R806) out of four residents reviewed for Abuse/Neglect. Findings include: A complaint was filed with the SA that alleged that on 12/5/24, R806 was observed covered in dry feces over an extended part of their body. The complainant noted that the allegation had been reported to Nurse F and the Director of Nursing (DON) on 12/5/24. The complainant noted that both the Nurse F and the DON indicated that incontinence care was not needed as the resident was dying and it was okay to leave them covered with hardened feces. The Complainant further reported that Unit Manager (UM) D, a family member of R806 was never informed on the incident until after the resident was discharged . A review of R806's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that…

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

Based on interview and record review, the facility failed to ensure unrestricted, 24-hour visitation for residents. This deficient practice had the ability to affect all 143 residents in the facility. Findings include: On 8/6/24 at 10:30 AM, during a resident council meeting with the State Agency, several anonymous residents reported that the facility's visitor hours ended each night at 8:00 PM with the front door being locked at that time, and were announced overhead. Twelve residents were present and each resident reported not knowing that they were allowed to have visitors outside of the hours of 8:00 AM and 8:00 PM. On 8/7/24 at 1:10 PM, an interview was conducted with the Administrator. When queried what the facility's visitor hours were, they responded 8:00 AM to 8:00 PM with the front door locking at 8:00 PM each day, which is announced overhead. When queried if the residents were aware that they had the right to have visitors outside of the 8:00 AM to 8:00 PM timeframe, the Administrator chose not to speak for what the residents were aware of. The Administrator mentioned…

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 maintain the ventilation hood filters in a sanitary manner, failed to ensure the dish machine was sanitizing, and failed to maintain the dish machine in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 8/5/24 at 9:30 AM, the cookline hood ventilation filters were observed with a buildup of grease. Certified Dietary Manager (CDM) O stated kitchen staff were responsible for cleaning the hood vent. According to the 2017 FDA (Food and Drug Administration) Food Code Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils.(C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 8/5/24 at 9:40 AM, a plate simulating dishwasher tester was sent through the dish machine to check the sanitizing properties of the facility's high temperature dish machine. The maximum temperature recorded on the plate simulator was noted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide an environment that promoted and enhanced residents' dignity for multiple residents, including three (R42, R73, and R85) of residents reviewed for dignity. Findings include: According to the facility's policy titled, Dignity dated 9/21/23: .Residents will be treated with dignity and respect at all times .Residents' private space and property are respected at all time .Staff are expected to knock and identify themselves before entering residents' rooms .Demeaning practices and standards of care that compromise dignity are prohibited .Staff are expected to treat cognitively impaired residents with dignity and sensitivity . On 8/5/24 from 9:00 AM to 11:30 AM, multiple observations included nursing staff entering the rooms of residents on Anna's Place (a secured unit) without knocking, announcing themselves prior to entering the room, or waiting of acknowledgment from the residents to enter. Additional dignity concerns were observed…

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 choice of an attending physician was honored for one (R288) of three residents reviewed for choices. Findings include: On 8/5/24 at 10:30 AM, R288 was observed lying in bed. A sign announcing Contact Precautions was posted on the door and a isolation cart was observed in the hallway immediately outside R288's room which contained personal protection equipment (PPE) including isolation gowns and gloves. R288 was asked about care at the facility. R288 explained their doctor, Dr. F, had come in the day before, but was touching their PICC (peripherally inserted central catheter) line and the dressing over the wound on their foot without gloves . when they told Dr. F to put on gloves, Dr. F got an attitude about wearing gloves. R288 also explained they had told Dr. F they did not want them as their doctor anymore. Review of the clinical record revealed R288 was admitted into the facility on 7/29/24 with diagnoses that included: diabetes, cellulitis and acute kidney failure. According to a Brief Interview 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 observation, interview and record review, the facility failed to provide appropriate notice in a dignified manner of a room change for one (R289) of one resident reviewed for room changes. Findings include: On 8/5/24 at 11:11 AM, R289 was observed lying in a bed different than the room census provided by the facility. R289 was asked about being in that particular room. R289 explained their room had been changed that morning, it was the third room they had been in, and they had only been there four days. Review of the clinical record revealed R289 had been admitted into the facility on 8/1/24 with diagnoses that included: open wound of abdominal wall, prostate cancer and chronic kidney disease. According to a Brief Interview for Mental Status (BIMS) exam dated 8/2/24, R289 scored 13/15 indicating intact cognition. Review of R289's census revealed upon admission, R289 was in room [ROOM NUMBER]. On 8/3/24, R289 was moved to room [ROOM NUMBER], then on 8/5/24 R289 was moved to room [ROOM NUMBER], their…

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 execute a Do-Not-Resuscitate (DNR) Advance Directive order for one resident (R128) reviewed of two residents reviewed for Advance Directives. Findings include: Clinical record review revealed R128 was admitted from the hospital to the facility on 7/23/24. R128 required rehabilitation from right toe gangrene (death of body tissue due to lack of blood flow or infection). R128's medical history included diabetes, hypertension, end stage renal disease and required peritoneal dialysis (removal of waste products via the lining inside the belly as a natural filter for blood). A Brief Interview of Mental Status (BIMS) score totaled 14/15 indicating R128 was cognitively intact. On 7/29/24, a review of the health care conference summary held on 7/29/24 at 2:00 PM documented Advance Directives were reviewed and R128 expressed their choice of DNR code status. The facility documented the DNR form was completed by R128 and awaiting physician signature and order. On 8/6/24 at 12:49 PM, an interview with Corporate Social Services 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a safe and collaborated discharge for one (R29) of three residents reviewed for discharge. Findings include: On 8/5/24 at 9:40 AM, R29 was observed in the bathroom unassisted. R29's spouse was in the room waiting for them to return from the bathroom. R29 stated that they would like a surveyor to return once they were finished getting ready for the day. At 10:00 AM, this surveyor returned to the room, R29 was sitting in the wheel chair with their left leg elevated on the bed. Their spouse was sitting in a chair across the room. R29 was interviewed and asked how was their current stay at the facility, and stated, It has not been good and explained that they were getting discharged today (8/5/24). R29's spouse interjected and stated, Well, we don't know because social work came in and stated that we might not be getting discharged due to a fall (that R29 had that morning around 9:05 AM). R29's spouse explained that the facility called…

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 implement a baseline care plan for tube feeding was provided to one (R287) of one resident reviewed for tube feeding. Findings include: Review of a facility policy titled, Care Plan - Baseline dated 8/25/23 read in part, .It is the policy of the facility to develop a baseline plan of care to meet the resident's immediate health and safety needs for each resident within forty-eight (48) hours of admission . The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident . On 8/5/24 at 9:54 AM, R287 was observed sleeping in bed. Enteral nutrition (tube feeding) was being delivered via pump. Review of the clinical record revealed R287 was admitted into the facility on 8/3/24 with diagnoses that included: stroke, major depressive disorder and malnutrition. According to a Brief Interview for Mental Status (BIMS) exam dated…

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 medications were accurately documented and orders written according to professional standards of practice for two (R27 and R287) residents. Findings include: R27 On 8/6/24 at 8:25 AM, as part of the Medication Administration task, Licensed Practical Nurse (LPN) E was observed to prepare seven medications for R27. LPN E crushed the medications and mixed them with applesauce. LPN E was observed to enter R27's room to give the seven crushed medications to R27. R27 refused to take the medications. LPN E was then observed to leave R27's room with the medications R27 had refused. On 8/6/24 at 9:05 AM, the medications LPN E had prepared were reconciled with R27's physician orders. All seven medications were marked as given by LPN E. On 8/6/24 at 9:15 AM, LPN E was asked if she had gone back and given R27 their medications. LPN E explained she had not. When informed all the medications had been marked as given, LPN E explained she had marked them as done before R27 had refused them. LPN E was asked when should…

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 has 2 Deficient Practice Statements. Deficient Practice Statement #1 Based on observation, interview and record review, the facility failed to provide wound care for two (R337 and R120) of two residents reviewed for nonpressure related wound care. Findings include: R337 On 8/5/24 at 9:15 AM, R337 was observed lying in bed resting. R337 was asked how their stay at the facility had been. R337 stated that they were in pain and that someone needed to change their wound dressings but they (the facility) had not done so. R337 stated, There is an area on my butt that they have not changed yet. R337 stated that the abdominal wound had started to stink and proceeded to show this surveyor the abdominal wound. There was blood and drainage from the wound that had a mild odor. A record review revealed that R337 was admitted to the facility on [DATE] with the diagnosis of hyperlipidemia, type two diabetes and mild protein deficit. R337 had a brief interview for mental status score of 15, indicating an intact…

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 there were wound care orders placed for one resident (R337) of two residents reviewed for pressure ulcers. Findings include: On 8/5/24 at 9:15 AM, R337 was observed lying in bed rest. R337 was asked how their stay at the facility had been. R337 stated that they were in pain and that someone needed to change their wound dressings but they had not done so yet. R337 stated, There is an area on my butt that they have not changed yet. R337 explained that the abdominal wound had started to stink. R337 proceeded to show the abdominal wound area to this surveyor. There was blood and drainage on the bancage with a mild odor that came from the site. On 8/5/24 at 9:20 AM, the certified nurse aid performed incontinence care for R337. At that time R337's coccyx area was observed. The wound presented with a reddened border and a greenish yellow slough base. There were two dime sized stage two pressure sores on the left gluteal cheek. A 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 observations, interview and record review the facility failed assess promptly after a fall for one (R29) resident of reviewed for accidents. Findings include: On 8/5/24 at 9:40 AM, R29 was observed in the bathroom unassisted. R29's spouse was in the room waiting for them to return from the bathroom. R29 stated that they would like this surveyor to return once they were finished getting ready for the day. At 10:00 AM, this surveyor returned to the room, R29 was sitting in the wheel chair with their left leg elevated on the bed and the spouse sitting in a chair across the room. R29 was asked about their stay at the facility and explained that they had fallen that morning (8/5/24). R29 stated that they hurt their leg and they hit their head a little bit because when they fell, they landed on their left side. A record review revealed that R29 was admitted to the facility on [DATE] with diagnoses of type two diabetes, repeated falls, and generalized anxiety disorder. R29 had a brief interview for mental…

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 infection control protocols and practices including hand hygiene during meals, transmission-based precautions (TBP) regarding use of personal protective equipment (PPE) and room placement for four (R42, R73, R288, and R289) of four residents reviewed for infection control. Findings include: Dining Observation: On 8/5/24 at 1:00 PM, the family member of R42 was observed standing at the end of the table and feeding the R42 by the spoonful. This family member was then observed to state to R73, You look like you haven't had a crumb of food in years, right?. During this time, the family member was observed to touch their clothing, hair, and table multiple times. This family member was then observed to assist R73 and R42 at the same time. There was no use of hand sanitizer or washing of hands by this family member in between assisting the two residents with their lunch meal. Additionally, although nursing staff were present, no one…

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 #MI00144802. Based on interview and record review, the facility failed to ensure safe transfer per plan of care (use of a mechanical hoyer lift) and facility policy for one (R901) of three residents reviewed for accidents. Findings include: Review of a complaint filed with the State Agency included allegations that the resident was not transferred with the correct assistance required. On 7/8/24 at 1:28 PM, the facility was requested to provide any incident reports and investigations since R901's admission. Review of the clinical record revealed R901 was admitted into the facility on 5/2/24, discharged on 5/27/24 and had not returned to the facility. Diagnoses included: other specified fracture of right pubis (5/2/24) and morbid obesity due to excess calories (severe). According to R901's care plans and [NAME] since admission, the resident's transfer status was TRANSFER: Resident requires Mechanical Lift with 2 PA (Person Assist). Review of the progress notes included: An entry…

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 #s MI00143487 and MI00143823. Based on observation, interview and record review, the facility failed to maintain a clean, comfortable, safe, and homelike environment, as evidenced by soiled floors, walls, trash/debris throughout the facility, broken chair and tile, unsecured sharps and chemicals, and visible harborage of pests. This deficient practice has the potential to affect multiple residents throughout the facility. Findings include: Review of multiple complaints reported to the State Agency included allegations that the facility was not clean. During the abbreviated survey conducted on 5/28/24, the following concerns with the facility's environment were identified: At 9:50 AM, the hallway outside room [ROOM NUMBER] and 114 was littered with debris. The chair outside room [ROOM NUMBER] had linens and used gloves stored directly on the floor behind the chair. The flooring throughout hallway near room [ROOM NUMBER]/202 observed with scattered debris. At 9:57 AM, the Anna'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a medication cart was locked and secured, resulting in the potential for unauthorized access and diversion of narcotic medications. Findings include: On 5/28/24 at 3:23 PM, a medication cart located on the Oakridge Unit, in front of room [ROOM NUMBER], was observed unlocked and unattended by authorized staff. The medications were accessible in all drawers, including the narcotic storage drawer. Registered Nurse (RN) A returned to the cart on the Oakridge Unit indicating a medication count was being performed with another nurse, away from the assigned medication cart. RN A confirmed the cart was left unlocked, unattended, and medications, including scheduled narcotics were accessible to unauthorized personnel. On 5/28/24 at 3:38 PM, the Director of Nursing (DON) was interviewed and acknowledged medication carts are to be locked and secured by authorized personnel. Review of the facilities policy title; Medication and Treatment Cart Storage dated…

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: MI00142846 Based on interviews and record reviews the facility failed to ensure professional standards of nursing practice was provided by the nursing staff to administer pain medications as directed by the physician for one (R801) of three residents reviewed for pain. Findings include: Review of a complaint submitted to the State Agency (SA) documented concerns of the facility staff to have failed to administer R801's pain medication as directed by the physician. Review of the medical record revealed R801 was admitted to the facility on [DATE] with diagnoses that included: malignant neoplasm of cervix, abscess of vulva and acute kidney failure. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition and required staff assistance for Activities of Daily Living (ADLs). Review of a Physician Team - H&P (history & physical) dated 10/29/23 at 8:08 AM, documented in part . diagnosed with…

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: MI00142846. Based on interviews and record reviews the facility staff failed to ensure labs were completed as ordered by the medical clinicians for one (R801) of three residents reviewed for a change of condition. Findings include: Review of a complaint submitted to the State Agency (SA) documented concerns of the facility to have failed to assess a change of condition with R801 in a timely manner. Review of the medical record revealed the following: A Complete Blood Count (CBC) report dated 11/1/23, documented a [NAME] Blood Cell (WBC) Count of 12.3, High, (normal range 3.3-10.7). A Physician Team - Progress Note dated 11/6/23 at 1:50 PM, documented in part . WBC 12.3, repeat labs . consider UA (urinalysis) if leukocytosis (elevated WBC) persists . Review of the physician orders revealed multiple orders to repeat the CBC labs on the following dates: 11/5/23, 11/12/23, 11/15/23 & 11/17/23. Review of the medical record revealed no documentation of the CBC to have been repeated as directed by the medical clinician for the above dates. A Stat…

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: MI00143149 & MI00142861. Based on interviews and record reviews the facility failed to ensure supervision for an appointment (appt) was provided for a resident who lacked capacity, one R802 of three residents reviewed for accidents. Findings include: Review of a complaint submitted to the State Agency (SA) documented concerns of the facility staff to have failed to accompany R802 to their medical appt and once found, R802's head helmet that's worn for medical purposes was found on the floor. Review of the medical record revealed R802 was admitted to the facility on [DATE], with diagnoses that included: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, functional quadriplegia, gastrostomy, and anoxic brain damage. Review of a Physician Statement of Capacity for Medical Treatment and Decisions documented the resident lacked the capacity to make reasoned medical decisions and provide informed consent for their medical affairs, signed by 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: MI00142846. Based on interview and record reviews the facility failed to obtain weights per the facility's policy for one (R801) of one resident reviewed for weight loss. Findings include: Review of a complaint submitted to the State Agency (SA) documented a concern of R801 to have had a significant weight loss while inpatient at the facility. Review of the medical record revealed R801 was admitted to the facility on [DATE] with diagnoses that included: malignant neoplasm of cervix, abscess of vulva and acute kidney failure. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition and required staff assistance for Activities of Daily Living (ADLs). Review of the only documented weight obtained by the facility staff on 10/27/23 at 8:12 PM, documented 143.3 lbs (pounds). Review of the medical record revealed the resident was transferred to the hospital on [DATE] for a change of condition.…

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: MI00143213. Based on interview and record review the facility failed to provide therapy services as ordered by the physician for one (R803) of two residents reviewed for rehabilitation services. Findings include: Review of a complaint submitted to the State Agency (SA) documented the facility failed to provide appropriate and adequate rehabilitation services. The complaint documented in part . Multiple times (R803) went 3 & 4 day stretches without PT (physical therapy) or OT (occupational therapy). When we brought this up, we were told they were short staffed & another time we were told that a stomach bug had hit their PT staff . Review of the medical record revealed R803 was admitted to the facility on [DATE] with diagnoses that included: acute kidney failure and diastolic congestive heart failure. Review of the documents provided to that facility by the transferring facility noted the resident was transferred for extensive rehabilitation. Review of the physician orders…

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(s): MI00141529. Based on interview and record review, the facility failed to assess and treat a resident who expressed pain for one (R804) of two residents reviewed for changes in condition, resulting in unrelieved pain. Findings include: Review of a complaint submitted to the State Agency revealed the following allegations: .(R804) discharged from the hospital and was transferred to (facility) around 1:30 PM on 12/7(2023). After being transported to her room, (R804) did not see another staff member until about 9:30 PM, and only after family intervened. (R804) la <sic> in her bed bleeding and in pain. She tried many times to use her call light, however, no staff came to assist her. She eventually called her daughter by phone, who then called the facility directly and also 911 to have (R804) transported back to the hospital . Review of R804's clinical record revealed R804 was admitted into the facility on [DATE] and was discharged to the hospital on the same day with…

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

This citation pertains to Intake Number(s): MI00142295 and MI00142293. Based on observation, interview, and record review, the facility failed to ensure safe positioning in a wheelchair with access to a call light for one (R801) of two residents reviewed for falls, resulting in a fall from the wheelchair and sustaining a bump to the head. Findings include: Review of a complaint submitted to the State Agency revealed the following allegations: .facility staff put the resident in her wheelchair with a pillow on the seat and it was slippery .staff didn't lock the wheelchair and they didn't put the residents call light within reach before leaving the room .the resident used her cellphone to call her daughter and tell her she was falling out of her wheelchair and needed help .staff didn't get to the residents room until after she fell out her wheelchair and onto the floor .the resident hit her head and right shoulder and .blacked out .resident does have a knot on her head where it hit the floor . On 1/29/24 at 3:05 PM, R801 was observed lying on her side in bed. Bed was not in the lowest…

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 MI00139462 Based on interview and record review the facility failed to ensure narcotic medications were documented as administered per professional standards for one (R802) of one resident reviewed for professional standards resulting in the inaccurate representation of the amount given and the effectiveness of pain medications. Findings include: A complaint was filed with the State Agency (SA) that alleged in part that R802's record was inaccurate/false. Review of the closed record revealed R802 was admitted into the facility on 8/25/23 with diagnoses that included: fracture of left tibia, fracture of left fibula and multiple fractures of pelvis. According to the Minimum Data Set (MDS) assessment dated [DATE], R802 was cognitively intact and required the assistance of staff for activities of daily living (ADL's). Review of R802's pain care plan initiated 8/26/23 revealed an intervention that read, Administer pain medication as ordered. Monitor for effectiveness. Review of R802'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes: MI00140611 and MI00140683. Based on observation, interview, and record review, the facility failed to timely obtain, acknowledge and ensure a resident's choice for health care decision making prior to petitioning for a third party guardian for one (R807) of one resident reviewed for resident rights, resulting in expressions of extreme frustration, distress, fear of loss of autonomy and the increased potential for further denial of the resident's right for self-determination under a reasonable person concept for a resident who had appointed a family member as their legal representative prior to the deterioration of their health condition. Findings include: Review of a complaint filed to the State Agency read in part, I should file a petition for guardianship of my (age omitted) year old (relationship omitted) (blind with dementia). In Aug. 2023, I called the court and made plans to file the petition. Prior to going to court, I called (facility name omitted). The social worker…

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 MI00139532, MI00139080 Based on observation, interview and record review, the facility failed to provide food in the prescribed texture/consistency for one (R803) of four residents reviewed for therapeutic diets, resulting in the increased potential for episodes of choking and aspiration to occur. Findings include: A complaint was filed with the State Agency (SA) that alleged in part, the facility did not provide the correct diet to R803. On 11/14/23 at 12:28 PM, R803 was observed sitting in a wheelchair eating lunch. The food on the tray appeared to be pureed. R803 was asked if they had difficulty swallowing. R803 said yes. When asked how was the food at the facility, R803 made a noncommittal sound. Review of the clinical record revealed R803 was admitted into the facility on 3/31/20 and readmitted [DATE] with diagnoses that included: dementia, diabetes and macular degeneration. According to the Minimum Data Set assessment dated [DATE], R803 had severely impaired cognition 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.

Based on observation, interview, and record review, the facility failed to maintain a sanitary kitchen; ensure food items were properly labeled, dated, and stored; monitor and maintain refrigerator and freezer temperature logs; and ensure proper functioning of the dish machine, resulting in the increased potential for cross-contamination and foodborne illness. These deficient practices had the potential to affect all residents that consume food from the kitchen. On 6/27/23, during an initial tour of the kitchen with Interim Dietary Manager (Staff 'S') between 8:56 AM - 9:45 AM, the following items were observed: In the dry storage room, there was an opened plastic bag of pecans that were stored on a top shelf. The package was not properly sealed and was open to air, and there was no date of when it had been opened. The temperature log on the outside of the walk-in freezer was documented as last completed on 6/26/23 for evening shift. In the walk-in freezer, the entire left side of the freezer ceiling, wall and storage shelving underneath had thick build-up of ice. Staff 'S' reported…

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 a homelike dining experience based on the reasonable person standard for one resident (R94) and multiple other residents with cognitive impairments who ate their meals in the Anna's Place dining room. Findings include: On 6/28/23 at approximately 9:33 a.m., An observation of the breakfast meal was made on the Anna's Place dining room in which four residents were observed sitting at the tables eating the breakfast meal. All of the residents were observed to be served their food on cafeteria style meal trays without the plates being taken off and put on the table for consumption. On 6/28/23 at approximately 1:35 p.m., During the lunch meal, facility staff were observed serving the lunch meal to the residents in the Anna's Place dining room. The staff were observed to serve the meal on cafeteria style meal trays and leaving the plates and silverware on them while the residents were served the food. On 6/28/23 at approximately 1:40 p.m., R94 was observed eating their lunch meal off of the cafeteria meal…

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 R153 A complaint was filed with the SA that alleged R153 was not receiving weekly showers two times per week. A review of R153's clinical record documented the resident was admitted to the facility on [DATE] with diagnoses that included: cellulitis, gangrene and type II diabetes. A review of the resident's MDS indicated the resident had a Brief Interview for Mental Status (BIMS)score of 15/15 (cognitively intact) and required extensive one to two person assist for most ADLs. On 6/28/23 at approximately 10:11 AM, the facility was asked to provide any documentation pertaining to R153's showers during their stay at the facility. The following paper shower documents were provided: 1/24/23: R (refused) 2/1/23: Shower not provided 2/10/23: Shower not provided * There were not further documentation as to resident receiving showers during their stay at the facility from 1/24/23 to discharge on [DATE]. Resident #124 On 6/27/23 at approximately 11:04 a.m., R124 was observed in their room, up in their wheelchair. R124 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake # MI00134296 Based on observation, interview, and record review the facility failed to ensure over an extended period that residents with limited mobility were assessed timely for appropriate assistive devices to maintain or improve functional mobility for one (R118) of one Residents reviewed for mobility and assistive devices resulting in the potential for a decline their bed mobility/self-care, dissatisfaction, and frustration with care. Findings include: A record review revealed R118 was a long-term resident of the facility and was originally admitted to the facility on [DATE]. R118's admitting diagnoses included left hemiplegia and hemiparesis, osteoarthritis, congestive heart failure, and had history of heart valve replacement surgery. R118 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicative of intact cognition. Based on the most recent Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 5/18/23, R118 needed one-person (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 appropriate storage and/or labeling of medications and treatments/biologicals in three of five medication carts and one treatment carts reviewed, resulting in the potential for unauthorized entry, misuse, contamination, and diversion of narcotics and controlled substances. This deficient practice has the potential to affect multiple residents in the facility. Findings include: According to the facility's policy titled, Medication & Treatment Cart Storage dated 5/4/2022: .It is the policy of this facility to ensure all supplies for treatments and medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication…

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

On 6/29/23 at 8:23 AM, R55's Family Member was interviewed by phone. When asked about concerns at the facility, R55's Family Member explained the meals are frequently served late, as an example, on 6/28/23, lunch was not served until 1:40 PM and dinner will sometime be served at 6:30 PM, an hour after it is supposed to be served .it is ridiculous because the residents are just sitting in the dining room with nothing to do, they just sit there for hours. Based on observation, interview, and record review, the facility failed to ensure meals were served in a timely manner and per facility scheduled times for residents that resided within the Anna's House (secured unit), resulting in delayed meal service and dissatisfaction with the dining experience. Findings include: According to the documentation of facility scheduled mealtimes, the meals were to be provided for Breakfast from 7:30 AM - 8:30 AM; Lunch from 11:30 AM - 12:30 PM; and Dinner from 4:30 PM - 5:30 PM. On 6/28/23 at 12:15 PM, observations of the facility's lunch meal setup revealed an adequate number of dietary 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.

Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were followed for one (R148) of three residents reviewed for transmission-based precautions (TBP). Findings include: On 6/27/23 at 10:34 AM, signage was observed on R148's door that indicated they were on Contact Precautions (Contact precautions prevent transmission of infectious agents that are spread by direct or indirect contact with the resident or their environment). The signage also indicated a gown, gloves, and separate and/or sanitized equipment was required when entering that room. At that time, Nurse 'PP' was observed entering R148's room without a gown. R148 was observed passing medication to R148 without gloves. Nurse 'PP' was holding a plastic basket that contained a glucometer and was full of unused lancets. Nurse 'PP' exited R148's room and wiped the outside of the basket that contained the lancets with a sanitizing wipe and placed it into the medication cart immediately without waiting for the sanitizer to dry. When queried about why a gown and 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 ensure medication administration was performed according to professional nursing standards of practice for two (R90 and R253) residents. Findings include: On 6/28/23 at 8:24 AM, Nurse 'JJ' was observed passing medications to R90's roommate. After passing medications to R90's roommate, Nurse 'JJ' entered R90's side of the room carrying a cup of medications to administer to R90. At that time, Nurse 'JJ' took R90's vital signs and discovered their heart rate was low. Nurse 'JJ' took the medication cup to the medication cart and removed a tablet from the cup and discarded it and then administered the remaining medication to R90. When queried about when medications should be prepared, Nurse 'JJ' reported medications were prepared at the time of administration. When queried about when vital signs were taken to determine whether a medication with parameters was required or needed to be held, Nurse 'JJ' reported vital signs were taken before preparing the medication. When queried about why Nurse 'JJ' had R90'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake #MI00136649 Based on interview and record review, the facility failed to ensure a resident was adequately prepared for discharge home for one (R156) of three sampled residents reviewed for discharge planning from a total of three, Findings include: A complaint was filed with the State Agency (SA) that alleged R156 was discharged from the facility without their necessary pain medication, insulin and medical equipment. The complainant reported that R156 suffered from a spinal injury that caused severe pain. They further reported that R156 did not receive a shower chair, grab bars and an extended toilet seat prior to their discharge resulting in the resident not being able to take a shower at home. A review of R156's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: end stage renal disease, spinal injury. Continued review of R156's record revealed, in part: Discharge Summary & Instructions: .discharge date : [DATE]…

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 has two deficient practices. Deficient practice #1. This citation pertains to Intake #MI00137787 and MI00137804. Based on interview and record review the facility failed to ensure neuro checks were completed following a resident's fall causing injury to the head for one (R162) of seven residents reviewed for falls/accidents. Findings include: A Complaint was filed with the State Agency (SA) that alleged on 2/23/23 they observed R162 with a bruise on the left side of their head. The Complainant noted that staff did not know what happened, but told them they put R162 back to bed at about 7:00 PM on 2/22/23 and did not provide medical attention. On 2/23/23 the resident was transferred to the hospital and diagnosed with a subdural hematoma and a concussion. A facility policy titled, Neurochecks on those Residents who Hit their Head (10/1/2017) was reviewed and documented, in part: .Policy: Any resident who sustains a fall with head involvement shall have neurochecks times 48 hours .Any resident who…

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 #'s MI00136943 and MI00136471. Based on observation, interview, and record review, the facility failed to perform a wheelchair transport in a safe manner and thoroughly investigate the root cause of an injury; and failed to follow the plan of care for two (R4 and R110) of eight Residents reviewed for accidents hazards, resulting in an injury (bruising, redness, swelling, and pain) to R4's ankle and potential for further falls. Findings include: R4 On 6/27/23 at 10:48 AM, R4 was observed in their bed. An interview was conducted at that time. When queried about their care in the facility, R4 reported they had pain in their leg due to an incident that occurred with the physical therapist the week prior. R4 explained that the therapist had them in a wheelchair and it did not have foot rests. R4 reported the therapist instructed them to place their right foot on top of their left foot and began rolling the wheelchair. R4 explained their right food fell off of their left foot and went…

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 assessment and monitoring of hydration for one (R51) of one resident reviewed for hydration. Findings include: On 6/27/23 at 9:51 AM, R51 was observed lying in bed. An intravenous (IV) catheter was observed in R51's right wrist connected to an IV bag of 0.9% Sodium Chloride Injection USP (United States Pharmacopoeia) hanging on a pole. Review of the clinical record revealed R51 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: kidney disease, dementia and stroke. According to the Minimum Data Set (MDS) assessment dated [DATE], R51 had moderately impaired cognition and required the extensive assistance of staff for activities of daily living (ADL's). Review of R51's nutritional care plan initiated 6/14/23 revealed an intervention that read, Offer food and beverage selections. Review of R51's June 2023 Medication Administration Record (MAR) revealed an order dated 6/26/23 that read, Sodium…

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 #MI134568 Based on observation, interview and record review, the facility failed to ensure consistent communication between the hemodialysis center and the facility for one (R152) of three residents reviewed for dialysis. Findings include: A complaint was filed with the State Agency (SA) that alleged R152 had missed dialysis appointments and often left for dialysis without a coat. A review of R152's clinical record revealed R152 was initially admitted on [DATE] and had diagnoses that included: CVA (stroke), type II diabetes and end stage renal disease. A review of R152's MDS (minimum data set) noted the resident had a BIMS score (brief interview of mental status) of 12/15 (moderately impaired cognition) and required extensive two-person assistance for transfers and bed mobility. Continued review of R152's clinical record noted, in part, the following: Order (1/19/23): Dialysis Treatment Center (name redacted) .Tues, Thurs, Sat . *It should be noted that on 1/20/23 the Order was…

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

Based on observation, interview, and record review, the facility failed to ensure two (Nurse 'PP' and Nurse Aide 'N') of 11 nursing staff reviewedf had the skills and competencies necessary to care for residents' needs. Findings include: Review of a complaint submitted to the State Agency revealed an allegation that a newly licensed nurse was assigned to a unit with residents who had high acuity medical issues and they did not feel comfortable working on that unit. On 6/23/23 at 4:12 PM, a phone interview was conducted with the complainant who reported they ended up leaving the facility after they were assigned to a high acuity unit that they were not comfortable with as a newly licensed nurse. The complainant explained that the rehabilitation unit had residents who had tracheotomies and were unstable. The complainant reported they received orientation when they started working at the facility, but they were paired with another new nurse for training on the floor who did not know how to do everything. On 6/27/23 at 10:34 AM, Nurse 'PP' was observed entering a resident's room and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00137804. Based on observation, interview and record review the facility failed to ensure a Physician ordered laboratory diagnostic were completed in a timely manner for one resident (R67) of one residents reviewed for laboratory diagnostics. Findings include: On 6/29/23 the medical record for R67 was reviewed and revealed the following: R67 was initially admitted to the facility on [DATE] and had diagnoses including Dementia, Chronic obstructive pulmonary disease and Severe Protein Calorie Malnutrition. A review of R67's MDS (minimum data set) with an ARD (assessment reference date) of 6/9/23 revealed R67 needed extensive assistance from facility staff with with most of their activities of daily living. R67's BIMS score (brief interview of mental status) was 11 indicating moderately impaired cognition. A Physician progress note dated 6/22/23 revealed the following: following up on pelvic pain Notified by staff that pt (patient) has been complaining of lower pelvic pain and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a legally authorized representative signed a binding arbitration agreement (a legal contract that dictates an out-of-court alternate form of dispute resolution) for one resident (R152) of four residents reviewed for binding arbitration agreements. Findings include: On 6/27/23 the medical record for R152 was reviewed and revealed the following: R152 was initially admitted on [DATE] and had diagnoses that included: CVA (stroke), type II diabetes and end stage renal disease. A review of R152's MDS (minimum data set) noted the resident had a BIMS score (brief interview of mental status) of 12/15 (moderately impaired cognition) and required extensive two-person assistance for transfers and bed mobility. An Arbitration Agreement located in the resident's electronic record was reviewed. The Agreement documented, in part, the following: .This voluntary Arbitration Agreement .is entered into by .facility and between R152 and if applicable (no name 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.