Medilodge of Southfield

Based on interview and record review facility failed to follow up timely about the grievances expressed by the resident and follow their grievance process for one (R177) of one resident reviewed for grievances. This deficient practice has the potential for dissatisfaction and frustration with the care/services received during their stay at the facility. Findings include: R177Record review revealed R177 was admitted to facility on 8/7/25 after hospitalization for skilled nursing care and rehabilitation services. R177's admitting diagnoses included exacerbation of Chronic Obstructive Pulmonary Disease (COPD), respiratory failure, Obstructive Sleep Apnea, morbid obesity, and hyperventilation syndrome. Based on Brief Interview for Status Assessment (BIMS) dated 8/11/25 R177 had score of 15/15, indicative of intact cognition.An initial observation was completed on 8/12/25 at approximately 10:15 AM. R177 was observed in their bed. R177 was so close to the edge of the bed on the left side of the bed and there was approximately 3-4 inches of space on the right side of the bed. An initial…

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 #2572077Based on interview and record review the facility failed to thoroughly complete a discharge summary for two residents (R172 and R173) of five residents reviewed for discharges. Findings include: R172 On 8/12/25 a concern submitted to the State Agency was reviewed which alleged R172 and R173 were inappropriately discharged from the facility. On 8/13/25 the medical record for R172 was reviewed and revealed the following: R172 was initially admitted to the facility on [DATE], had diagnoses including Edema and Cellulitis and was discharged on 9/7/24. A review of R172's MDS (minimum data set) with an ARD (assessment reference date) of 6/30/24 revealed R172 needed assistance from facility staff with most of their activities of daily living. R172's BIMS score (brief interview of mental status) was 15 indicating intact cognition. A review of R172's Discharge to Home/Community/AL(assisted living)/Equal Care Setting assessment (a documented provided to the resident upon discharge…

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 timely interventions were implemented to prevent the development of two facility acquired pressure ulcers for one (R21) out of three residents reviewed for pressure sores/wounds. Findings include: On 8/12/25 at approximately 10:37 AM, R21 was observed lying in bed. Next to their bed was a pair of heel boot protectors. When asked why their boots were on the wheelchair, R21 reported that they are used for their heels that had sores and was waiting for staff to put them on as they no longer were able to do it on their own. They noted that they had been at the facility for several years and never had a problem with their heels, but a few months ago they started. R21 further noted that they believe they got the pressure ulcer because their heels were rubbing on the bed sheet.A review of R21's clinical record was conducted and revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Type II…

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 catheter orders and monitoring were in place for one resident (R174) of one resident reviewed for catheter care resulting in the potential for infection and other complications. Findings include:On 8/12/25 at 9:43 AM, R174 was observed, lying in bed with foley Cather on ground and with no privacy bag. An attempt to interview R174 was made R174 was not verbal or able to understand questions.A review of the record revealed that R174 was readmitted to the facility on [DATE] with the medical diagnosis of Cognitive communication deficit, Alzheimer disease and dementia with a brief interview for mental status score (BIMs) that was skipped due to it not being conducted. A further review of the medical record indicated that there were no orders in place for a foley Cather nether was a care plan put into place. On 8/13/25 at 1:30 PM an interview was conducted with the Director of Nursing (DON), and asked what the protocol was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain physician orders for two residents (R176 & R95) of three residents reviewed for respiratory care resulting in the potential for respiratory difficulties related to no orders for R176's Bi-level Positive Airway Pressure (BiPAP - a breathing aid/machine that helps people with breathing difficulties) and no orders for R95's tracheostomy care/speaking valve (a surgical procedure that creates an opening in the trachea/windpipe to allow for breathing and/or to remove secretions). Findings include: On 8/12/25 at 9:51 AM, R95 was observed in their room with their eyes closed, lying in bed with a tracheostomy(trach) which had a purple speaking valve to assist the resident with communication and speech. R95 was on room air (breathing on their own without supplemental oxygen), with suction and trach supplies set up near the bed. A review of the record revealed R95 was admitted to the facility on [DATE] with the medical diagnosis of Trach…

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 #1194668.Based on observation, interview, and record review, the facility failed to provide medically related social services related to discharge planning for one (R138) of one resident reviewed for social services. Findings include:Review of a complaint filed with the State Agency included allegations that R138 has expressed their desire to move to a different facility, but staff won't assist them with completing the transfer.On 8/12/2025 at 10:36 AM, R138 was observed lying in bed with oxygen via nasal cannula. When asked to review their concerns, R138 reported they have been wanting to go to another nursing home and have been asking social work staff for months, but nothing is being done. They further reported they were supposed to transfer to another nursing home and wanted to be back in the Detroit area and had a facility set up in March 2025, but they ended up being hospitalized around the time of transfer and instead of going to the new nursing home, they returned to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure routine dental services were provided for one resident (R18) of one resident reviewed for ancillary services. Findings include:On 8/12/2025 at approximately 11:50 a.m., R18 was observed in their room, up in their wheelchair. R18 was observed to not have any teeth with their gum lines showing. R18 was queried if they have ever seen a dentist at the facility to examine their gums or to get dentures and they indicated they have not but would like dentures to be able to eat harder foods. On 8/13/25 at approximately 8:45 a.m., R18 was observed in their room, eating breakfast. R18 was queried regarding their ability to eat their soft breakfast, and they reported that they cannot eat anything hard because they have no teeth. On 8/13/25 the medical record for R18 was reviewed and revealed the following: R18 was initially admitted to the facility on [DATE] and had diagnoses including Dysphagia and Heart Failure. A review of R18's MDS…

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 for implementation of enhanced barrier precautions (EBP) and transmission-based precautions (TBP) for two (R5 and R10) of three residents reviewed for infection control. This deficient practice has the likelihood to result in cross-contamination and the spread of infection and disease. Findings include:R10 Record review revealed R10 was admitted to the facility on [DATE] for skilled nursing and rehabilitation services after hospitalization. R10’s admitting diagnoses included sepsis, Urinary Tract Infection (UTI) complicated, with Extended Spectrum Beta-Lactamase resistance (ESBL) (ESBLs are enzymes that specifically target and degrade certain antibiotics, rendering them ineffective), history of viral hepatitis, reduced mobility and weakness. An initial observation was completed on 8/12/25 at approximately 10:20 AM. R10 was observed in their bed. R10’s door had a signage that read…

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): MI00152656 Based on interview and record review, the facility failed to report an allegation of misappropriation of resident property and the facility's investigation into the allegation to the State Agency within the required time frame for one (R802) of three residents reviewed for misappropriation of property. Findings include: A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) on 4/11/25 at 11:48 AM revealed an allegation that the facility did not prevent misappropriation of R802's property (a pink wallet). On 5/28/25, on unannounced, onsite investigation was conducted. A review of R802's clinical record revealed R802 was admitted into the facility on [DATE], readmitted on [DATE], and discharged to the hospital on 4/9/25 with diagnoses that included: systemic lupus erythematosus. A review of R802's Minimum Data Set (MDS) assessment dated [DATE] revealed R802 had moderately impaired cognition and no behaviors. A review of a Nurse'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 Number(s): MI00152656 Based on interview and record review, the facility failed to thoroughly investigate an allegation of misappropriation of resident property for one (R802) of three residents reviewed for misappropriation of property. Findings include: A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) on 4/11/25 at 11:48 AM revealed an allegation that the facility did not prevent misappropriation of R802's property (a pink wallet). On 5/28/25, on unannounced, onsite investigation was conducted. A review of R802's clinical record revealed R802 was admitted into the facility on [DATE], readmitted on [DATE], and discharged to the hospital on 4/9/25 with diagnoses that included: systemic lupus erythematosus. A review of R802's Minimum Data Set (MDS) assessment dated [DATE] revealed R802 had moderately impaired cognition and no behaviors. A review of a Nurse's Note progress note dated 4/5/25 revealed, Resident alert and able to make own needs known.…

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# MI00151103. Based on interview and record review, the facility failed to ensure incontinence care was provided in a timely manner for one resident (R905) of two residents reviewed for Bowel and Bladder. Findings include: On 4/24/25 a complaint submitted to the State Agency was reviewed which alleged R905 was left soiled when a Certified Nursing Assistant (CNA) had refused to provide incontinence care on 2/25/25. On 4/24/25 the medical record for R905 was reviewed and revealed the following: : R905 was initially admitted to the facility on [DATE] and had diagnoses including Brain damage and Muscle weakness. A review of R905's MDS (minimum data set) with an ARD (assessment reference date) of 3/5/25 revealed R905 was dependent on staff for all of their activities of daily living. R905's cognition was documented as severely impaired. A review of R905's comprehensive careplan revealed the following: Focus-[R905]/Resident incontinence related to Quadriplegia. Date Initiated:…

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): MI00150901, MI00151135, MI00151140, MI00151161. Based on interview and record review, the facility failed to report multiple allegations of sexual abuse by a staff member to the Abuse Coordinator and/or State Survey Agency in a timely manner for one (R801) of four residents reviewed for abuse, and one unidentified resident, resulting in a delay in investigation and R801 exhibiting signs of fear and distress when a male Certified Nursing Assistant (CNA) regularly assigned to the unit continued working after the allegations were made. Findings include: A review of a complaint submitted to the State Agency on 3/5/25 revealed allegations that a male staff (Certified Nursing Assistant - CNA 'E's first name only) touched R801's breast on two separate occasions. No additional details were given at that time. On 3/11/25 at 5:30 PM, the complainant was interviewed. The complainant reported R801 told them on two separate occasions that CNA 'E' touched her breasts. 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: MI00147960 & MI00147915. Based on observation, interview and record reviews the facility failed to notify the family of R707 of a fall and notify both legal guardians for R706 of an accident that resulted in an injury, for two of three residents reviewed for an injury of unknown origin. Findings include: R706 Review of a complaint submitted to the SA documented an allegation of the facility to have failed to have notified both legal guardians of an accident that resulted in an injury for R706. On 1/21/25 at 12:09 PM, R706 was observed laying back in a geri chair next to their bed. A blue sling for the hoyer was observed under the resident. A brief interview was attempted with the resident at that time. Review of a Letters of Guardianship form dated 2/6/24, documented Full guardianship appointed to two individuals for R706. The facility's medical record documented both of the appointed individuals as guardians. A review of a Nursing note dated 10/31/24 at 1:56 AM, documented in…

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: MI00147960. Based on interview and record reviews the facility failed to coordinate effective discharge planning that met the needs and provided care giver support for one (R707) of two residents reviewed for discharges. Findings include: On 1/21/25 at 11:49 AM, during a telephone interview with the complainant, the complainant stated in part, . she was discharged on the 14th of December. She was supposed to received home health care and she still has not. Allegedly the doctor was supposed to complete paperwork and they didn't. She has a PEG (percutaneous endoscopic gastrostomy tube) tube and dialysis . open wounds . The complainant stated how they reached out to the facility Social Worker multiple times regarding their concerns with their loved one's discharge. Review of the medical record revealed R707 was admitted to the facility on [DATE] with diagnoses that included: sepsis, end stage renal disease, sacral pressure ulcer, dysphagia, dependence on renal dialysis, cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00147759. Based on observation, interview and record reviews the facility failed to ensure staff consistently provided assistance with brief changes/toileting needs for one (R705) of three residents reviewed for Assistance of Daily Living. Findings include: Review of a complaint submitted to the State Agency (SA) documented the following in part . On Sunday October 20, 2024 . I found my sister laying in her urine and massive amounts of feces. I took pictures of how it looked. My sister had been laying there for quite some time that the feces dried up and stained her gown. It went through her brief, through the blue pad and on the fitted sheet. The feces had gone between her legs and upward. She had been laying there at least a few hours if not the whole day without being changed . I wrote up a complaint . dropped it off . (Nurse Unit Manager - NUM C name) called me to tell me that she will issue a write up for the aide and remove her (alleged aide that failed to provide 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 This citation has two deficient practices. Deficient Practice #1 This citation pertains to intake #MI00147354. Based on observation, interview, and record review, the facility failed to ensure resident's rights related to the appropriateness of placement on a locked, secured unit for one resident (R702) of three residents reviewed for resident's rights, resulting in feelings of frustration after being moved to a locked, secured unit. Findings include: A complaint was received by the State Agency that alleged resident's who were not appropriate for placement on a locked, secured unit were placed there. On 10/28/24 at 10:02 AM, a review of R702's clinical record revealed they admitted to the facility on [DATE] and most recently re-admitted on [DATE] with diagnoses that included: bipolar schizoaffective disorder, dementia, falls, and major depressive disorder. R702's most recent Brief Interview for Mental Status score was 9, indicating moderately impaired cognition. A review of the resident's census tab in 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 has two deficient practices. Deficient practice #1 This citation pertains to Intake #MI00147275 Based on interview and record review the facility failed to ensure adequate staffing and proper bed mobility were provided to prevent a fall for one (R701) of four residents reviewed for falls. Findings include: A complaint was made to the State Agency (SA) that alleged R701 slipped out of bed and noted that the resident was a two person assist for bed mobility and transfers and a Certified Nursing Assistant (CNA) attempted to change the resident on their own. A review of R701's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: end stage renal failure, type II diabetes and a pressure ulcer of sacral region. A review of the resident Minimum Data Set (MDS) dated [DATE] noted the resident had a Brief Interview for Mental Status (BIMS) score of 00/15 (severely cognitively impaired). The resident's Care Plan documented, in part, Focus:…

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): MI00146327 and MI00146090. Based on interview and record review, the facility failed to report an allegation of neglect and multiple resident to resident abuse incidents to the Administrator and the State Agency for two (R507 and R501) of five residents reviewed for abuse and three unknown residents, resulting in the allegations not being investigated and the potential for unidentified and continued abuse and neglect. Findings include: R507 A review of a complaint submitted to the State Agency alleged R507 had a change in condition that was not addressed in a timely manner, did not receive adequate tracheostomy (trach - a tube surgically placed into the windpipe to assist with breathing) care, and needed to be changed. The complainant alleged a nurse was yelling in the hallway. On [DATE] at approximately 10:00 AM, an interview was conducted with an individual who wished to remain anonymous (Person 'N'). Person 'N' expressed concern about a situation they witnessed 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 interact with a resident in a dignified and respectful manner for one (R505) of two residents reviewed for dignity and respect. Findings include: On 9/30/24 at 11:05 AM, during an interview with R505, Nurse Aide (NA) 'I' knocked on R505's door, entered, asked R505 if their call light was in reach. R505 said that was the first time anyone asked her that and asked why it was only asked when the State Agency was in the building. NA 'I' breathed out as if irritated, did not say anything further to R505, turned around, walked quickly out of the room, and aggressively pulled the door closed, which made a loud noise. At that time, R505 reported NA 'I' was a non-certified Nurse Aide who did tasks such as changing linens and passing water. R505 reported they frequently acted unprofessionally toward the resident. On 9/30/24 at approximately 11:30 AM, an interview was conducted with NA 'I'. When asked her name, NA 'I' stated, What did I do? NA 'I'…

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): MI00146090. Based on interview and record review, the facility failed to protect the residents' right to be free from verbal abuse by staff and verbal abuse (as witnessed by R514) by a resident for two (R501 and R502) of five residents reviewed for abuse. Findings include: A review of a Facility Reported Incident (FRI) submitted to the State Agency on [DATE] revealed an allegation of verbal and physical abuse by Certified Nursing Assistant (CNA) 'J' toward R501. A review of an incident report for R501 dated [DATE] at 2:14 PM revealed R501 reported to Licensed Practical Nurse (LPN) 'M' that on [DATE] during the evening shift, the assigned Certified Nursing Assistant (CNA) shuffle him to the wheel chair while he was adjusting the temperature and also shuffle him to the bed. It was documented R501 informed the charge nurse on the night shift and called the police. It was further noted that R501 was alert and oriented to person, place, time, and situation. A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate multiple incidents of resident to resident abuse perpetrated by one (R501) of five residents reviewed for abuse, resulting in the potential for continued and unidentified abuse and the lack of identifying three victims to ensure their safety and well being. Findings include: On 9/30/24 at 8:45 AM, an interview was conducted with R501. R501 did not answer questions directly and engaged in tangential conversation. A review of R501's clinical record revealed R501 was admitted into the facility on 1/30/24 and readmitted on [DATE] with diagnoses that included: bipolar disorder. A review of R501's Minimum Data Set (MDS) assessment dated [DATE] revealed R501 had intact cognition and verbal and other behaviors, including rejection of care. A review of R501's progress notes revealed multiple documented incidents of resident to resident abuse perpetrated by R501, as follows: 1. On 5/3/24 it was documented R501 was yelling, pointing finger in peer…

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 sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 7/29/24 between 8:45 AM-9:15 AM, during an initial observation of the kitchen with District Manager E, the following items were observed: The handwashing sink located near the dish machine room was blocked by 3 carts and not accessible. The trash can near the handwashing sink had no liner inside, and when the lid was opened, numerous gnats flew out from inside the trash can. According to the 2017 FDA Food Code section 5-205.11 Using a Handwashing Sink, 1. (A) A HANDWASHING SINK shall be maintained so that it is accessible at all times for EMPLOYEE use. Pf In addition to the hand sink, there were gnats observed near the steam table, and there was a heavy concentration observed near the 3 compartment sink. Underneath the 3 compartment sink, there was standing water, and a swarm of gnats was observed on the floor tiles. When queried, District…

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 an effective pest control program, resulting in the presence of gnats and flies (R26 and R102) throughout the facility and resident complaints. This deficient practice had the potential to affect all residents in the facility. Findings include: On 7/29/24 between 8:45 AM-9:15 AM, during an initial observation of the kitchen with District Manager E, numerous gnats were observed in the following kitchen locations: The trash can near the handwashing sink had no liner inside, and when the lid was opened, numerous gnats flew out from inside the trash can. In addition, there were gnats observed near the steam table, and there was a heavy concentration observed near the 3 compartment sink. Underneath the 3 compartment sink, there was standing water, and a swarm of gnats was observed on the floor tiles. In the chemical/mop room, there was a mop bucket with wet sludge on the inside bottom surface, and standing water on the floor. There…

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 #MI00145602. Based on observation, interview and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment, affecting multiple residents throughout the facility. Findings include: Review of a complaint submitted to the State Agency included allegations that the facility was not clean. On 7/29/24 at 10:10 AM, room [ROOM NUMBER] which had three residents in the room, was observed to have a warm air temperature. There were three residents in the room that were observed laying in bed, with blankets on. The residents all reported concerns with being too warm. One resident reported the facility staff took their fan to clean it a couple of weeks ago and never brought them back and they were very uncomfortable and hot. During this interview, there were several flying insects observed throughout the room. The resident in 220-3 did not have a privacy curtain. When asked about the lack of curtain, the resident reported it had been removed a while ago…

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 three deficient practices (DPS). DPS#1 Based on observation, interview and record review the facility failed to ensure a resident transfer was completed per the plan of care for one resident (R93) of six residents reviewed for accidents/hazards/supervision. Findings include: On 7/30/24 at approximately 11:14 a.m., Certified Nursing Assistant P (CNA P) was observed in R93's room doing a transfer with a mechanical lift (hoyer) with R93 up in the sling. R93 was observed suspended in the air for multiple minutes swinging in the sling while CNA P directed the lift and lowered R93 down into their chair by themselves. On 7/30/24 at approximately 11:20 a.m., CNA P was queried regarding the transfer for R93 and if the safety protocol was for two people to complete a mechanical lift transfer and they indicated that it was but that they could not find anyone to help them. CNA P indicated they knew a hoyer lift transfer required to people to be safe. On 7/30/24 a review of R93's medical record was reviewed…

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 that residents were free of any significant medication errors for one (R70) of one resident reviewed for medication errors. Findings include: On 7/30/24 at 10:12 AM R70 was interviewed and reported that they had not received their monthly migraine medication (Emgality) for several months. R70 reported the medication really helps with their migraines that they stated were linked to their Multiple Sclerosis diagnosis. Review of the clinical record revealed R70 was admitted into the facility on 7/7/2023 with diagnoses that included: Multiple Sclerosis and headache syndrome. According to the Minimum Data Set (MDS) assessment dated [DATE], R70 had scored 15/15 on the Brief Interview for Mental Status exam, which indicated intact cognition. Review of R70's clinical record revealed an order for Emgality (galcanezumab) 120mg/ml (milligram/milliliter) Solution, inject 2ml subcutaneously one time every 28 days for migraine dated 2/1/2024. Further 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 observation, interview, and record review the facility failed to ensure that one (R395) of one resident reviewed for abuse, was free from misappropriation of their social security money when the money was rerouted to the facility without consent of the resident. Findings include: On 7/29/24 at 9:40AM, R395 was observed in their room lying in bed reading a book. R395 was asked how their experience at the facility was. R365 stated that the overall experience had been pleasant however a few weeks ago the facility started to take their money because their payor source had changed and the money from social security income (SSI) was no longer coming to her, but to the facility. R395 stated, When it happened, I didn't know when it was going to occur because I didn't authorize them to do so, I wasn't able to pay my phone bill and my other monthly things that I've had to pay. So, it has been really frustrating. A record review revealed that R395 was admitted to the facility on [DATE] with a diagnosis of chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop resident-specific comprehensive care plans for two (R137 and R246) of 29 residents reviewed for care plans, resulting in lack of identified mood, behavior, targeted symptoms and use of psychotropic medication for R137, and lack of hospice needs for (R246). Findings include: R137 On 7/29/24 at 1:10 PM, a phone interview was conducted with R137's legal guardian (LG). When asked about the resident's use of psychotropic medication and recent behaviors, the LG reported the resident had been recently diagnoses with Alzheimer's and seizures. The LG further reported the resident had a memory problem for a couple of years, but recently had gotten worse. The LG reported an incident at the hospital at night in which the resident tried to push past the guards and had been given medication to sedate. Review of the resident's current physician orders included: Risperdal oral tablet 1 MG (Milligrams) (Risperidone) give 1 mg by mouth in the evening 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 ensure care plan reviews were completed with the required interdisciplinary (IDT) team for two (R246 and R137) residents, and ensure the care plan was revised to reflect the current status of the resident's post-fall interventions for one (R26) of 29 residents reviewed for care plan revisions, resulting in the lack of opportunity for the Residents, their legal representatives, and/or family members to participate in the discussion of treatment options and decisions which pertained to their care, and direct care staff being unaware of changes in the resident's care needs following a fall. Findings include: According to the facility's policy titled, Comprehensive Care Plans dated 6/30/2022: .The comprehensive care plan will describe, at a minimum, the following .The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .The comprehensive care plan will 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 activity of daily living care including timely brief change, associated peri-care and linen change for one (R29) resident of two residents reviewed for Activities of Daily Living (ADLs). Findings include: On 7/29/24 at 11:12 AM, R29 was observed sitting in a wheelchair, a strong urine smell was present, and the resident's bed had been striped of linens and remained unmade. R29 reported they were soiled and needed assistance getting changed as they had a big mess. R29 reported that the staff member that striped their bed was aware he needed to be changed but had not come back to assist him. On 7/29/24 at 1:13 PM R29 was observed once again sitting in their wheelchair in their room, they reported that they remained in a soiled brief and the bed was observed to remain unmade, strong urine odor still was present. R29 reported that they had went down to the dining room for lunch in their soiled brief. On 7/31/24 at approximately 10:00…

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 narcotic medication for discharged resident (R445) was disposed of in a timely manner. Findings include: On 7/30/24 at approximately 4:30 PM during a review of the medication cart, R445's narcotic log for Hydrocodone-APAP 5-325mg revealed that R445 had discharged (indicated by DC on the narcotic log) however 38 tablets remained in the narcotic drawer. LPN X reported that R445 had been discharged several weeks prior and that it was the responsibility of the director of nursing (DON) to dispose of medications for discharged residents. Unit Manager Y and LPN X reported that the DON was aware that R445 had discharged , and the medications needed to be disposed of. The DON was notified with this surveyor present and the medications were disposed of. The DON reported they would provide a copy of the facility policy that stated the appropriate timeline for when medications should be disposed of. On 7/31/24 at 9:56 AM, the DON was queried again about the facility's policy related to when/how discharged narcotics…

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 Physician ordered diagnostic (duplex scan) was obtained per the physician's order for one resident (R46) of one residents reviewed for radiology diagnostics. Findings include: On 7/29/24 the medical record for R46 was reviewed and revealed the following: R46 was initially admitted to the facility on [DATE] and had diagnoses including Congestive heart failure and Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity. A review of R46's MDS (minimum data set) with an ARD (assessment reference date) of 6/30/24 revealed R46 needed assistance from facility staff with their activities of daily living. R46's BIMS score (brief interview for mental status) was 13 indicating intact cognition. A Physician progress note dated 7/2/24 revealed the following: chief complaints/History of present illness Complaining of swelling rt (right) arm/ hand. No Current Venous catheters in place Denies any pain - no swelling of face etc…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow core infection control procedures for enhanced barrier precautions (EBP) for two residents (R93 and R297) of three residents reviewed for transmission based precautions. Findings include: Resident #93 On 7/30/24 at approximately 11:14 a.m., Certified Nursing Assistant P (CNA P) was observed in R93's room doing a transfer with a mechanical lift (hoyer) with R93 up in the sling. CNA P was observed to not be wearing any gloves or protective gown during the transfer. At that time, R93's door was observed to contain signage that indicated staff were be donning gloves and a gown when performing transfers. On 7/30/24 at approximately 11:20 a.m., CNA P was queried regarding the transfer for R93 and if the safety protocol was for them to have on gloves and a gown and they indicated that they should have been but had forgotten. On 7/30/24 a review of R93's medical record was reviewed and revealed the following: R93 was initially admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain an effective immunization program (for influenza and pneumonia) for two (R77 and R82) of five residents reviewed for vaccinations resulting in the potential for influenza and pneumonia infections. Findings include: R77 A record review revealed that R77 was a long-term resident of the facility and originally admitted to the facility on [DATE]. R77's diagnoses included respiratory failure, brain damage, diabetes, quadriplegia (paralysis of all four limbs) and seizures. R77 was breathing through a tracheostomy tube (an opening surgically created through the neck into the trachea/windpipe to allow air to fill the lungs) with supplemental oxygen. R77 received their nutrition via a PEG (Percutaneous Endoscopic Gastrostomy (PEG) is a tube surgically placed on the stomach to receive nutrition and hydration). R77 had a legal guardian. Review of R77's clinical record revealed an influenza consent dated 9/22/23 and they had received influenza vaccine.…

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 functional furniture (bed with working remote) was provided for one (R16) of 14 residents reviewed for the environment task, resulting in the potential loss of independence, dignity, and well-being due to poor positioning during meals. Findings include: On 7/29/24 at 10:10 AM, R16 was observed laying flat in bed. When asked about whether they had any concerns, R16 reported their bed didn't go up and down due to a broken bed remote control and This is my 24 hour position now. R16 further reported because they weren't able to put the head of the bed up and down, they had to try to eat while laying down. On 7/29/24 at 1:45 PM, 7/30/24 at 8:25 AM, and 7/31/24 at 8:20 AM, R16 was observed attempting to eating breakfast while laying flat in bed. R16 was asked if anyone had followed up with them and they reported they were told a new bed controller had to be ordered. When asked if they were offered the use of another bed until that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number(s): MI00145377. Based on interview and record review, the facility failed to ensure two (R806 and R812) of three residents reviewed for abuse, were free from misappropriation of their money and property, resulting in a staff member electronically transferring $13.00 of R806's money to himself and $142.00 to an unknown person using a mobile payment service application, and the same staff member stealing R812's cellular phone. Findings include: A review of a Facility Reported Incident (FRI) that was submitted to the State Agency revealed R806 alleged on 4/15/24 that while trying to order lunch with Certified Nursing Assistant (CNA) 'A', she tried to send money through a mobile payment service application on her cell phone. At that time, CNA 'A' asked R806 to give him her phone and said he had a faster way of doing it. The next day, R806 noticed all of her money was gone and was sent to a person (Person 'G') she did not know. R806 reported she did not send money to Person…

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 maintain general repair and cleanliness of resident rooms, bathrooms, and common areas for all residents residing on 1st floor South unit, and 2nd floor North and South units, resulting in the potential for avoidable contamination and decrease in satisfaction of living. Findings include: An initial facility observation was completed on 6/12/24 at approximately 11:00 AM. During this observation on the 2nd floor (North unit) locked unit that housed residents with cognitive impairments, multiple residents were observed ambulating with/without assistive devices and in their wheelchairs on the unit. The faucet in the sink on the hallway to the dining room area was dripping water. There were six residents sitting in the dining room area. There were food crumbs and other debris on the floor. The dining room had a strong offensive odor. The hallway floors were sticky with multiple areas of dried fluid stains. There was a puddle of water on the floor next to a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure physician notification and follow-up for a resident with a change of condition for one (R701) of four residents reviewed for quality of care. Findings include: Review of a complaint submitted to the State Agency (SA) documented concerns of the facility's failure to provide timely medical care which resulted in the death of R701. Review of the medical record revealed R701 was admitted to the facility on [DATE], with diagnoses that included multiple sclerosis, asthma, and chronic kidney disease with heart failure. Review of a Nursing note dated 5/18/24 at 1:52 PM, documented in part . Resident informed nurse she feels as though she has food poisoning writer contacted DR (doctor), no answer or reply. Writer awaiting call back for further orders. Review of a Nursing note dated 5/18/24 at 10:14 PM, documented in part . upon making rounds at beginning of shift, resident daughter at her bedside stated her mother had not been feeling well today and she…

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 #MI00144187. Based on observation, interview, and record review, the facility failed to ensure treatment in a dignified manner for two residents (R#'s 506 and 510) of three residents reviewed for dignity, resulting in verbalized feelings of anger, embarrassment and disgust. Findings include: On 5/14/24 at 8:30 AM, upon entry to the facility a schedule of events for Nursing Home Week was observed taped to the reception desk. It was noted an activity scheduled for 5/13/24 was Wheelchair Races. On 5/14/24 at 10:40 AM, an interview was conducted with R506 in their room. They related an incident that occurred on 5/13/24. They went on to say the staff had a facility sponsored Wheelchair Race in the hallway where they pretended to be disabled to celebrate Nursing Home Week. R506 said they overheard, yelling, hooting, hollering, cheering and a general ruckus in the hallway. R506 stated, They picked disabilities and had to race in the wheelchair as if they had that disability. R506 further went on to say they overheard staff saying, I want to change my…

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 is based on intake MI00143989. Based on interview and record review, the facility failed to (1) obtain authorization to manage personal funds, (2) properly manage a trust account, and (3) follow the policy provided by facility on personal funds and trust accounts for one resident(R500) reviewed for misappropriation of funds resulting in resident alleging stolen money. Findings include: On 4/16/24 the State agency received a Facility reported incident (FRI) for R500 alleging that 50 dollars was stolen from their wallet during the nighttime hours. The facility conducted an onsite investigation and concluded that there was no evidence to substantiate the missing money. On 5/14/24 the facility was asked to provide their FRI report and investigation. The investigation revealed that R500 was missing 50 dollars that the facility stated, couldn't confirm R500 had (the money); a police report was made. The resident's guardian was notified and it was considered not substantiated. On 5/14/24 at around 1:00…

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 #MI00144015. Based on observation, interview, and record review, the facility failed to properly care for percutaneous endoscopic gastrostomy (PEG) tubes (feeding tubes) for one resident (R#505), of two residents reviewed for PEG tubes. Findings include: On 5/14/24 at 10:18 AM, Certified Nurse Aide (CNA) 'B' was observed in R505's room preparing to provide care. At that time, they were asked to reveal R505's PEG tube site. An observation of the site revealed a dressing, but no abdominal binder in place. On 5/14/24 at 1:15 PM, a review of R505's clinical record was conducted and revealed following census information: 3/10/24-discharged from facility and admitted to the hospital for a PEG tube replacement. R505 re-admitted to the facility on [DATE]. 4/1/24-discharged from facility and admitted to the hospital for respiratory distress. Records indicated R505's PEG tube was dislodged upon admission to the hospital. R505 re-admitted to the facility on [DATE]. 4/16/24-discharged from…

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 #MI00144187. Based on observation, interview, and record review, the facility failed to appropriately implement enhanced barrier precautions (EBP, infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) and wear the required personal protective equipment (PPE) for resident's on EBP for two residents, (R#'s 505 and 509) of three residents reviewed for enhanced barrier precautions, resulting in the potential for the transmission of multidrug-resistant organisms. Findings include: R505 On 5/14/24 at 10:10 AM, R505's room door was noted to have a sign that indicated they were on EBP. The directions on the sign indicated any providers or staff performing high-contact resident care activities (dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toilet use) were to be wearing a gown and gloves. At that time, R505 was observed in their bed asleep. A tube feeding pump 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 # MI00143211. Based on interview and record review, the facility failed to notify and discuss a room change with a resident and their responsible party for one resident (R901) of one residents reviewed for room changes, resulting in R901 being moved to a new room without approval of the responsible party and the increased potential for transfer trauma. Findings include: On 4/1/24 a complainant submitted to the State Agency was reviewed and indicated R901 (a cognitively impaired resident) had their room changed without the responsible party's involvement. On 4/1/24 the medical record for R901 was reviewed and revealed the following: R901 was initially admitted on [DATE] and was discharged to hospital on 2/2/24. They were re-admitted on [DATE] and discharged on 3/8/24. R901 had diagnoses including Alzheimer's disease and Chronic kidney disease. A review of R901's MDS (minimum data set) with an ARD (assessment reference date) of 2/27/24 revealed R901 had a 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 # MI00143211. Based on interview and record review, the facility failed to provide a written copy of the bed-hold notification upon transfer to the hospital for one resident (R901) of one residents reviewed for transfers, resulting in R901 being discharged to the hospital without written notification of the bed-hold instructions and the potential for them to save their bed for return to the facility. Findings include: On 4/1/24 a complainant submitted to the State Agency was reviewed and indicated R901 was provided a different room upon return to the facility after having been transferred to the hospital. On 4/1/24 the medical record for R901 was reviewed and revealed the following: R901 was initially admitted on [DATE] and was transferred to the hospital on 2/2/24. They were re-admitted on [DATE] and discharged on 3/8/24. R901 had diagnoses including Alzheimer's disease and Chronic kidney disease. A review of R901's MDS (minimum data set) with an ARD (assessment reference 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.

This citation pertains to Intake MI00143384. Based on interview, and record review, the facility failed to ensure physician ordered diagnostic laboratory testing was completed for one resident (R902) of one resident reviewed for change of condition, resulting potential for unidentified infection. Findings include: On 4/1/24 at 9:36 AM, a complaint sent to the State Agency (SA) was reviewed that alleged R902 had significant mental status changes and required an emergent transfer to the hospital. On 4/1/24, a clinical record review revealed R902 was admitted the facility on 05/17/23 with hemiparesis and hemiplegia (weakness or inability to move one side of the body) related to a stroke, diabetes, epilepsy, dementia, and psychotic disorder. A Brief Interview for Mental Status (BIMS) score totaled eight, indicating moderate cognitive impairment. A clinical record review of the Nursing progress notes dated 2/8/24 at 1:45 PM, indicated R902 .returned from therapy lethargic and slow to respond, leaning forward, Physician A was called . A Physician order dated 2/8/24, revealed 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.

This citation pertains to intake #MI00141573. Based on observation, interview and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: Review of a complaint filed with the State Agency on 12/13/23 included allegations that the kitchen was not maintained in a sanitary manner, including staff not wearing hairnets, staff not using sanitizer buckets properly, and cross-contamination was occurring. On 2/12/24 between 9:34 AM - 9:55 AM, during a tour of the kitchen with Dietary Manager (DM 'K'), the following items were observed: 1) The juice station was observed to have one of the tubing units connected to a bag which usually holds the juice concentrate stored directly on the floor with the entire bag touching the tiled flooring. The surrounding tile was observed to be soiled with build-up of debris. When asked about the storage of the juice bag, DM 'K' reported that should not have been stored like that and needed to be replaced. 2) 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 #MI00140589. Based on observation and interview, the facility failed to provide a clean, comfortable, safe, and home-like environment for four residents (R601, R603, R607 and R618), in addition to multiple residents throughout the facility, resulting in unsanitary/unsafe conditions and lingering urine odors. Findings include: Review of complaints filed with the State Agency on 10/15/23 included allegations that there is a strong urine smell that is so strong there are concerns about the facility being properly sanitized and when management is told that the state will be called, they say to go ahead because the state will not do anything. On 2/13/24 at 10:25 AM, observation of the room occupied by R603 and R618 revealed a very strong urine odor that was present from the hallway and throughout the room. R603 was currently out of the room in a group activity. R618 was laying in bed and was only able to respond to simple questions asked. On 2/13/24 at 10:32 AM, observation of R601'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 MI00139360 and MI00140459. Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one (R601) of 11 residents reviewed for abuse, resulting in multiple instances of misappropriation not being reported to the local police. Findings include: A complaint was filed with the State Agency on 9/13/23 that alleged in part, .(R601) left her debit card out while visiting another resident. When she returned the card was gone and was later notified that her [Bank Name] account had received a $74.00 charge. There is suspicion that a staff member used (R601's) card. A complaint was filed with the State Agency on 10/11/23 that alleged in part, .There was fraud on (R601's) bank account for $189.29 via her debit card. (R601) is concerned that someone at the nursing home, either a care provider or someone visiting another resident, is…

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 MI00139360 and MI00140459. Based on interview and record review, the facility failed to ensure the protection of residents and thoroughly investigate allegations of misappropriation for one (R601) of 11 residents reviewed for abuse, resulting in the potential for further misappropriation to occur and allegations not being thoroughly investigated. Findings include: A complaint was filed with the State Agency on 9/13/23 that alleged in part, .(R601) left her debit card out while visiting another resident. When she returned the card was gone and was later notified that her [Bank Name] account had received a $74.00 charge. There is suspicion that a staff member used (R601's) card. A complaint was filed with the State Agency on 10/11/23 that alleged in part, .There was fraud on (R601's) bank account for $189.29 via her debit card. (R601) is concerned that someone at the nursing home, either a care provider or someone visiting another resident, is responsible for the fraud on her account. It…

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

Based on interview and record review, the facility failed to implement an effective Quality Assurance & performance improvement (QAPI) program that identified, developed and implemented appropriate plans of action or correct quality deficiencies, resulting in reoccurrence of deficient practices related to the facility's abuse reporting and investigation. This deficient practice has the potential to affect all 142 Residents that reside within the facility. Findings include: On 8/29/23 at 9:14 AM, an interview was conducted with the facility's Administrator/Abuse Coordinator regarding the QAPI program. The facility was provided with an Immediate Jeopardy (IJ) regarding the facility's failure to thoroughly investigate allegations of sexual contact. The Administrator was queried as to how allegations of abuse, including allegations of inappropriate touching are reported to them, the State Agency and how the allegations were investigated. The Administrator stated that they now know that there had been other concerns regarding CNA A that should have been investigated. The Administrator…

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 administer medications according to professional standards of practice for one (R707) of two residents reviewed for medication administration. Findings include: On 8/29/23 at approximately 8:40 AM, R707 was observed lying in bed. The resident's floor was covered with garbage and four pills were observed on the floor. An empty medication cup was at the resident's bedside table. R707 was asked if they were aware of the pills that were on their floor, and they reported that they did not know anything about the pills and was not sure if they even belonged to him. On 8/29/23 at approximately 8:45 AM, Nurse F was observed by the medication cart. Nurse F was asked if they were aware that four pills were on R707's floor and an empty medication cup was on their bedside table. Nurse F reported that they were not aware that the pills were on the floor and noted that they recently started their shift and had yet to provide the residents with any…

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 sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 8/8/23 between 8:45 AM-9:30 AM, during an initial tour of the kitchen with Dietary Manager ZZ, the following items were observed: In the dish machine room, there was water leaking onto the floor from the water line behind the garbage grinder. There was stagnant, standing water on the floor, and a bowl located on the floor under the leak was filled with water. In addition, there was an old biscuit, orange, cups and silverware on the floor underneath the soiled drainboard of the dish machine. There were numerous gnats observed flying around underneath the soiled side of the dish machine, and there was a heavy, musty odor. When queried, DM ZZ stated she would get that cleaned up right away. According to the 2017 FDA Food Code section 5-205.15 System Maintained in Good Repair, A plumbing system shall be: (A) Repaired according to law; P and (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 maintain the exterior dumpster area in a sanitary manner. This deficient practice had the potential to affect all residents, staff and visitors. Findings include: On 8/8/23 at 9:20 AM, the 3 exterior dumpsters were observed with a buildup of trash (cans, bottles, paper, disposable gloves, debris) on the ground behind the dumpsters. When queried as to who is responsible for maintaining the exterior dumpster area, Dietary Manager ZZ stated that Maintenance was responsible and said they must not look behind there. Review of the facility's policy Disposal of Garbage and Refuse revised 1/1/22 noted: 7. Refuse containers and dumpsters kept outside the facility .Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. 8.Garbage should not accumulate or be left outside the dumpster.

Based on observation, interview and record review, the facility failed to implement an effective Quality Assurance & Performance Improvement (QAPI) program that identified systemic quality issues and implemented appropriate plans of action to correct quality deficiencies (R294) and maintain sustained compliance resulting in the potential to affect all residents that resided in the facility. Findings include: A recertification survey was conducted from 8/8/23 through 8/11/23. On 8/9/23 at 3:02PM, the facility was provided with an Immediate Jeopardy (IJ) concern regarding the facility's failure to prevent an elopement. This deficient practice resulted in an IJ to the health and safety of R294 when R#294 had left the facility without staff knowledge on 7/24/23. R#294 was located and assisted back to the facility by the local Police Department. R#294 was previously identified as elopement risk. Resident exited the facility and left the facility premises without staff supervision. The immediate jeopardy began on 7/24/23 and facility remained out of compliance at a scope of isolated 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 eliminate harborage conditions to maintain an environment free from pests. This deficient practice had the potential to affect all residents, staff and visitors. Findings include: On 8/8/23 at 8:45 AM, in the kitchen dish machine room, there was water leaking onto the floor from the water line behind the garbage grinder. There was stagnant, standing water on the floor, and a bowl located on the floor under the leak was filled with water. In addition, there was an old biscuit, orange, cups and silverware on the floor underneath the soiled drainboard of the dish machine. There were numerous gnats observed flying around underneath the soiled side of the dish machine, and there was a heavy, musty odor. When queried, Dietary Manager ZZ stated she would get the area cleaned up right away. Review of the pest control service reports dated 2/28/23, 3/29/23, 4/26/23, 5/24/23, 6/30/23, and 7/26/23 all noted: Kitchen: Condition- Standing or ponding water found on floor, in kitchen increasing the survivability of the area…

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: MI00138275, MI00136994 and MI00138484. Based on observation, interview and record review, the facility failed to ensure multiple residents were treated in a dignified manner including two (R57 and R131) of four residents reviewed for dignity and failed to provide dignified dining (R9, R10, R58, R16, R72, R37, R51, R137 R60, R44, R84), resulting in the expressions of frustration, and the potential for decreased feelings of self-worth. Findings include: Review of complaints reported to the State Agency included allegations that staff were not treating the residents in a dignified manner. On 8/9/23 at 7:55 AM, upon walking up to the medication cart on back end of 2 south, Nurse 'F' was observed at the medication cart, scrolling through their cell phone. After a short while, Nurse 'F' put away their phone and acknowledged the surveyor. When asked about their use of cell phone, Nurse 'F' proceeded to ask other questions without answering about the cell phone use. On 8/10/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intakes: MI00135989, MI00136742, and MI00138275. Based on observation, interview and record review, the facility failed to provide a clean, comfortable, safe and home-like environment to ensure that hallways, resident rooms, floors and other facility areas and equipment were clean and in good repair affecting multiple residents (Rs: 2,8, 27, 32, 34, 38, 48, 61, 64, 66, 80, 86, 101, 116, 121, and 341) throughout the facility, resulting in an unclean physical environment, resident dissatisfaction and complaints regarding the lack of cleanliness and upkeep. This deficient practice had the potential to affect all residents that reside within the facility. Findings include: Complaints were filed with the State Agency (SA) that alleged issues pertaining to the cleanliness of the facility, including but not limited to foul odors, damaged walls, soiled floors, and resident care equipment. According to the facility's policy titled, Safe and Homelike Environment dated 1/1/2022: .the facility will…

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: MI00138275 This citation has two deficient practices. Deficient Practice #1: Based on observation, interview and record review the facility failed to ensure Physician orders for oxygen therapy were followed for one residents (R56) of three residents reviewed for respiratory care. Findings include: On 8/8/23 at approximately 10:27 a.m., R56 was observed in their room room, up in their bed. R56 was observed not to have any oxygen infusing via nasal cannula. No oxygen concentrator was observed in their room. R56 was queried if they have had any oxygen and they indicated they have never been provided oxygen. On 8/10/23 at approximately 1:44 p.m., R56 was observed in their room, up in their bed. R56 was queried again if they have ever been on oxygen in the facility and they indicated they have not. R56 reported they have do not have an oxygen machine or any any oxygen tanks and again indicated they have never been on oxygen in the facility. On 8/08/23 The medical record for R56 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 interview and record review, the facility failed to ensure that a resident diagnosed with Post Traumatic Stress Disorder (PTSD) received care and services that accounted for experiences and identified and implemented interventions to mitigate triggers for one (R73) of one resident reviewed for trauma informed care, resulting in the potential for exposure to trauma triggers and re-traumatization. Findings include: Review of the clinical record revealed R73 was admitted into the facility on 1/21/17, readmitted on [DATE] with diagnoses that included: Post-Traumatic Stress Disorder (PTSD). According to the Minimum Data Set (MDS) assessment dated [DATE], R73 had diagnoses which included PTSD. Review of the social service documentation included three social service assessments dated 1/6/23, 4/6/23 and 7/12/23. The assessments completed on 4/6/23 and 7/12/23 by the Social Services Director (SSD 'M') included a question that asked, Does resident have a diagnosis of Post-Traumatic Stress Disorder (PTSD)?. Each…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the provider documented a rationale in the medication record for continuing a medication dosage identified as an irregularity by the consultant pharmacist and failed to address pharmacy recommendations for two (R78 and R166) of five residents reviewed for medication regimen reviews, resulting in the potential for adverse reactions and ineffective medications. Findings include: Review of a facility policy titled, Addressing Medication Regimen Review Irregularities revised on 1/1/22, revealed, in part, the following: .Any irregularities noted by the pharmacist during this review must be documented on a separate written report which may be in paper or electronic form .The report will be sent to the attending physician, the facility's medical director and director of nursing and lists, at minimum, the resident's name, the relevant drug, and the irregularity pharmacist identified .The attending physician must document in the resident's medical 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 #MI00138215. Based on interview and record review, the facility failed to ensure antipsychotic medication orders were implemented as intended for one (R58) of five residents reviewed for unnecessary medications, resulting in the resident receiving an additional 1 Milligram (MG) of antipsychotic medication for over three months and the increased likelihood for serious adverse side-effects. Findings include: Review of a complaint reported to the State Agency alleged concerns regarding R58's medication regimen. Review of R58's Physician orders included the following antipsychotic medication: An active order started on 4/13/23 for Risperidone 1 mg give 1 tablet by mouth two times a day for delirium. The administration times for this order were 9:00 AM and 5:00 PM. The total dosage for this order was 2 MG. An active order started on 5/4/23 for Risperidone Tablet 0.5 MG (milligrams) give 1 tablet by mouth at bedtime for delirium give with 1 mg tab for total of 1.5 MG q HS (every…

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 # MI00138275 Based on observation interview and record review, the facility failed to ensure a medication room was maintained in a safe/sanitary manner in one of two medication rooms reviewed. Findings include: On 8/11/23 at 12:00 PM, an observation of the 2 North medication room with Licensed Practical Nurse (LPN) Y revealed a purse, lunch bag and a small bag of potato chips were lying on the counter. LPN Y was asked to open the cupboard directly under the sink. Observed in the cupboard under the sink, were three sharps containers and boxes of gloves. When asked if items could be stored under the sink, LPN Y explained it was allowed if it was not wet. Upon leaving the medication room, LPN Y gathered the purse, lunch bag and chips and removed them from the medication room and asked the other nurse on the unit if the items were hers. The other nurse explained they were hers and she would take them to her car. On 8/11/23 at 1:30 PM, the Director of Nursing (DON) was interviewed and asked about personal items in the medication room. The DON explained…

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 reviews the facility failed to consistently provide therapy services for one (R102) of three residents reviewed for rehab services. Findings include: On 8/8/23 at 10:24 AM, R102 was observed lying on their back in bed. When asked, R102 stated they were admitted to the facility in January and the staff will not get them out of bed into their wheelchair. When asked if they had a wheelchair, the resident pointed to a wheelchair next to the window. When asked why staff won't get them out of the bed, R102 stated they did not know the reason. Review of the medical record revealed R102 was admitted to the facility on [DATE], with a readmission date of 7/25/23 with diagnoses that included: type 1 diabetes mellitus, chronic kidney disease stage 3, neuromuscular dysfunction of bladder, paraplegia, and hypertension. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition and required…

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 all evaluations/consultations were available for review in the medical record for one resident (R56) of one residents reviewed for medical records. Findings include: On 8/08/23 The medical record for R56 was reviewed and revealed the following: R56 was initially admitted to the facility on [DATE] and had diagnoses including Chronic obstructive pulmonary disease, Malignant neoplasm of oropharynx. A review of R56's MDS (minimum data set) with an ARD (assessment reference date) of 6/8/23 revealed R56 needed extensive assistance from facility staff with most of their activities of daily living. R56's BIMS score (brief interview for mental status) was 15 indicating intact cognition. Section O indicated that R56 was on oxygen. Further review of the medical record revealed no Medical Provider notes/evaluations from R56's primary care team were available for review. The only noted medical provider consultations available in R56's record were from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #s: MI00135989 and MI00136742. Based on observation, interview and record review, the facility failed to maintain ventilation exhaust systems on the first floor and second floor south units (including the rooms of R27,34,48,73,64,101 and141), resulting in strong, unpleasant fecal and urine odors affecting all residents and/or visitors that reside within those units, extending to the facility's front hallway and lobby area. Findings include: Complaints were filed with the State Agency (SA) that alleged issues pertaining to pervasive, foul odors. According to the facility's policy titled, Safe and Homelike Environment dated 1/1/2022: .Have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two . Observations throughout the survey conducted 8/8/23 to 8/11/23 revealed multiple concerns with pervasive, lingering foul odors upon entering and throughout the facility. On 8/10/23 at 9:00 AM, an environmental tour was conducted with 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 #: MI00136638 Based on observation, interview, and record review, the facility failed to ensure a bed of appropriate length was provided for one resident (R56) of one residents reviewed for accommodation of needs. Findings include: Resident #56 On 8/08/23 at approximately 10:27 a.m., R56 was observed in room, laying in bed. R56 was queried if they had any concerns regarding their care in the facility. R56 reported the bed that he had was too small. At that time, R56 was observed in their bed with their knees bunched bunched up with no bed extender noted on their bed. R56 was queried if they had let any staff members know about the small bed and they indicated they have told everyone and that no one is doing anything about it. On 8/08/23 The medical record for R56 was reviewed and revealed the following: R56 was initially admitted to the facility on [DATE] and had diagnoses including Chronic obstructive pulmonary disease, Malignant neoplasm of oropharynx. A review of R56's MDS…

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: MI00136994. Based on observation, interview, and record review the facility failed to document care concerns and follow the facility's policy for concerns for one (R131) of one resident reviewed for grievances. Findings include: Review of a complaint submitted to the State Agency (SA) documented an allegation of the facility staff to have failed to administer R131's night medication to the resident in June of 2023. Review of the medical record revealed R131 was admitted to the facility on [DATE] with diagnoses that included: hypertension, hyperlipidemia, and rheumatoid arthritis. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15 (which indicated intact cognition) and required staff assistance for all ADLs. Review of the June 2023 Medication Administration Record (MAR) revealed on 6/25/23, R131 had not received their hour of sleep Atorvastatin Calcium 20 MG (milligram) medication for hyperlipidemia. On 8/8/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00136994 and MI00138275. Based on observation, interview, and record review the facility failed to prevent verbal aggression and mistreatment for one (R131) of five residents reviewed for abuse. Findings include: On 8/8/23 at approximately 11:15 AM, R131 was observed sitting on their bed. When asked about any concerns they had R131 stated a few nights ago the Receptionist who sits at the front desk in the lobby (later identified as Receptionist NN) had called them from the front lobby phone and told R131 that they did not like R131 and asked when R131 was leaving the facility. R131 went on to say that Receptionist NN then stated that R131 was a liar, manipulator and was always trying to use the facility staff. R131 stated this made them angry and played on their thoughts. R131 stated Nah, I'm not going out like this R131 explained they called Receptionist NN back to defend their selves. R131 stated in part . she called me back on her work phone saying my name out loud 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 This citation pertains to Intake(s) MI00136561 and MI00136742 Based on observation, interview and record review the facility failed to timely report to the State Agency (SA) allegations of staff to resident physical abuse for one (R91) of nine residents reviewed for abuse. Findings include: Two complaints were filed with the SA that alleged R91 was physically abused by a nursing staff member. A review of the facility policy titled, Abuse, Neglect and Exploitation (revised 10/24/22) documented, in part: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights by developing and implementing written policies and procedures that prohibit and prevent abuse .Abuse means the willful infliction of injury .Identification of Abuse .The facility will have written procedures to assist staff in identifying the different types of abuse-mental/verbal abuse .Possible indicators of abuse include, but are not limited to: 1. Resident, staff, or family report of abuse .Reporting…

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 level I Preadmission Screening (PAS)/Annual Resident Review (ARR) Mental Illness/Intellectual Disability/Related Conditions Identification was completed accurately and sent to local community mental health for a level II OBRA (Omnibus Budget Reconciliation Act of 1993) evaluation for one (R75) of three residents reviewed for PASARR assessments, resulting in the potential for unmet mental health treatment and services, and a decline in psychosocial well-being. Findings Include: R75 R75 was admitted to the facility on [DATE] after hospitalization. R75 was living in the community with their family prior to hospitalization. R75's admitting diagnoses included Chronic Obstructive Pulmonary Disease (COPD), diabetes, seizures, Dementia, and depression. R75 had a Brief Interview for Mental Status (BIMS) 09/15, indicative of moderate cognitive impairment. Review of R75's Electronic Medical Record (EMR) revealed a Minimum Data Set (MDS) assessment with an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive care plan which addressed behaviors for one (R444) of 38 residents reviewed for care planning. Findings include: Review of the closed record revealed R444 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: chronic obstructive pulmonary disease (COPD), tracheostomy status, dependence on supplemental oxygen and Down Syndrome. According to the Minimum Data Set (MDS) assessment, R444 had severely impaired cognition and required the supervision to extensive assist for activities of daily living (ADL's). Review of R444's progress notes revealed: A Nurse Note dated [DATE] at 5:54 PM read in part, .Upon skin assessment trach size 5 shiley cuffed with trach care compete upon admit . A Nurse Note dated [DATE] at 5:10 PM read in part, .was observed in fowlers position (semi-setting position in bed) with head back with trach inner cannula out and eye closed non-responsive to verbal/tactile stimuli .…

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 Based on observation, interview and record review, the facility failed to ensure medications were available for administration and medications were prepared appropriately for three residents (R56, R6 and R107) of three residents reviewed for Nursing standards of practice. Findings include: Resident #56 On 8/08/23 The medical record for R56 was reviewed and revealed the following: R56 was initially admitted to the facility on [DATE] and had diagnoses including Chronic obstructive pulmonary disease, Malignant neoplasm of oropharynx. A review of R56's MDS (minimum data set) with an ARD (assessment reference date) of 6/8/23 revealed R56 needed extensive assistance from facility staff with most of their activities of daily living. R56's BIMS score (brief interview for mental status) was 15 indicating intact cognition. A Physician's order dated 6/26/23 revealed the following: Gabapentin Capsule 300 MG (Gabapentin) *Controlled Drug* Give 1 capsule by mouth…

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 MI00135989, MI00138215, MI00138275, and MI00136638. Based on observation, interview and record review, the facility failed to ensure dependent residents were consistently provided with nail care for one (R42) of seven residents reviewed for Activities of Daily Living (ADL's). Findings Include: On 8/8/23 at 9:51 AM, R42 was observed lying in bed, her fingernails were noted to be approximately 3/4-1 inch in length. When asked if she wanted her nails that long, R42 explained she would like them shorter, but no one cut them for her. Review of the clinical record revealed R42 was admitted into the facility on 1/19/23 with diagnoses that included: dementia, rheumatoid arthritis and osteoarthritis. According to the Minimum Data Set (MDS) assessment dated [DATE], R42 had moderately impaired cognition and required the total dependence of staff for activities of daily living (ADL's). Review of R42's 30 Day Look Back for ADL - Bathing, grooming, nail care twice a week on Wednesday 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 observation, interview and record review the facility failed to ensure treatments for pressure ulcers were completed per Physicians orders for one resident (R93) of six residents reviewed for pressure ulcers. Findings include: On 8/8/23 at approximately 9:58 a.m. R93 was observed in their room, laying in their bed. R93 was observed to be thin/frail in their bed. On 8/08/23 The medical record for R93 was reviewed and revealed the following: R93 was initially admitted to the facility on [DATE] and had diagnoses including Dementia and Traumatic brain injury. A review of R93's MDS (minimum data set) with an ARD (assessment reference date) of 7/24/23 revealed R93 was at risk of developing pressure ulcers. A review of R93's care plan revealed the following: Focus-he resident has pressure ulcer development to the right heel, right lateral malleolus, right buttock, right foot 1st hallux. She is at risk for forward breakdown to all bony prominence r/t (related to) Immobility, B&B (bowel and bladder)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to develop person-centered dementia care for one (R37) of four residents reviewed for dementia care, resulting in the potential for increased behaviors and unmet care needs. Findings include: R37 was a long-term resident of the facility. R37 was originally admitted to the facility on [DATE]. R37 was recently hospitalized on [DATE] for physical aggression and agitation towards another resident and resident returned to the facility on 7/17/23. R37 was residing in the secured unit on the second floor of the facility. R37's admitting diagnoses included dementia, stroke, and cognitive communication deficit. R37 had a Brief Interview for Mental Status (BIMS) score of 3/15, indicative of severe cognitive impairment. An initial observation was on 8/8/23 at approximately10:55 AM. R37 was observed walking independently in the hallways. R37 did not use any assistive devices for walking. Later that day, at approximately 12:03 PM, R37 walked into room…

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

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent when medication errors were observed from a total of 30 opportunities for two (R's 6 & 107) of five resident's observed for the medication administration task, resulting in a medication error rate of 50%. Findings include: On 8/10/23 at 8:17 AM, Licensed Practical Nurse (LPN) T was informed that they would be observed by the surveyor for the morning administration of medications. Observed already prepared was one cup with a pink pill in it and on the bottom of the cup was the last name of R107 and three additional medication cups all containing pills in each cup stacked on top of each other, with no name observed on the cups. LPN T closed and locked the medication cart and proceeded to the room of R's 6 & 107. Once in the room LPN T washed their hands and donned on gloves. LPN T obtained the blood pressure from R6's right upper arm. The blood pressure reading was 132/57, LPN T stated they would hold the blood pressure pill for R6, however no pill 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 prevent significant medication errors for two (R's 6 and 107) of five residents reviewed for the medication administration task. Findings include: On 8/10/23 at 8:17 AM, Licensed Practical Nurse (LPN) T was informed that they would be observed by the surveyor for the morning administration of medications. Observed already prepared was one cup with a pink pill in it and on the bottom of the cup was the last name of R107 and three additional medication cups all containing pills in each cup stacked on top of each other, with no name observed on the cups. LPN T closed and locked the medication cart and proceeded to the room of R's 6 & 107. LPN T obtained the blood pressure from R6's right upper arm. The blood pressure reading was 132/57, LPN T stated they would hold the blood pressure pill for R6, however no pill was removed from the medication cup administered to R6, multiple pills were observed in the medication cup. After the administration of R6's medications, LPN T removed their gloves and washed their hands…

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.