The Lakeland Center

This citation pertains to Intake #'s 2615522 and 2610188. Based on observation, interview, and record review, the facility failed to ensure a medication error rate less than five percent when five errors were made from 25 opportunities for two residents (R#'s 57 and 92) of three residents reviewed during the medication administration task, resulting in a medication error rate of 19%. Findings include: R57On 2/11/26 at 8:30 AM, Nurse 'EE' was observed preparing medications for R57. Among the medications prepared, Nurse EE prepared a magnesium oxide (supplement) 400 mg (milligram) tablet, a folic acid (supplement) 400 mcg (microgram) tablet, and a gabapentin (neuropathy medication) 100 mg capsule. Nurse 'EE' then crushed all the medications including the gabapentin capsule, mixed them with applesauce, entered R57's room and administered them. Upon the completion of the administration, Nurse 'EE' confirmed all medications due at that time were administered to R57. Nurse 'EE' was asked about crushing the gabapentin capsule as opposed to emptying the capsules content and discarding 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 decision making was exercised by residents' court-appointed representatives for three (R3, R6, and R88) of three residents reviewed for arbitration. Findings include:R3 On 2/9/26 at 10:48 AM, R3 was observed lying in bed sleeping. R3 had a tracheostomy (a tube surgically inserted into the windpipe to assist with breathing) and a feeding tube delivering nutrition into a surgically inserted tube into the stomach. When addressed, R3 did not open her eyes. R3 was unable to participate in an interview. A review of R3's clinical record revealed R3 was admitted into the facility on 9/15/25 and most recently readmitted on [DATE] with diagnoses that included: epilepsy, respiratory failure, aphasia (difficulty speaking), and dysphagia (difficulty swallowing). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R3 had severely impaired cognition and was dependent on staff for all activities of daily living. 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.

This citation pertains to intake #2615522. Based on observation, interview, and record review, the facility failed to promote resident self-determination through support of resident choice for two residents (R72 and R96) of two residents reviewed for self-determination and resident choice resulting in frustration, verbalized complaints, and the withholding of occupational therapy rehab services. Findings include:R72 On 2/10/26 at 10:09 AM, R72 was observed in their room. At that time, an interview was conducted regarding an allegation lodged with the State Agency regarding the facility's refusal to apply a seat belt to R72's wheelchair. They explained that when they used to go to their outpatient day program, they were allowed to have a seatbelt in their wheelchair, which gave them a sense of security and safety. They continued to explain that since they stopped attending the outpatient day program (in the summer of 2025) they had been given a different wheelchair and the facility repeatedly refused to equip it with a seatbelt upon their request. They continued to say they were…

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 #2671721. Based on observation, interview and record review, the facility failed to ensure freedom from neglect for one resident (R96), of four residents reviewed for neglect resulting in R96's frustration and complaints that staff do not tend to their needs/requests when they activate their call light. Findings include: On 2/10/26 at 1:30 PM, a review of facility provided, Concern Form dated 8/4/25 reported from R96 was interviewed and read, Describe concern using factual terms: Resident alleges when call light is pressed staff turn of {sic} call light from desk without completing the task .[NAME] taken regarding concern: Verbal statement from nurse during Admin (Administrator) investigation: Nurse admitted to turning off call light without addressing issues. Staff educated on call light response .Nurse provided one-on-one . On 2/11/26 at 12:15 PM, an interview was conducted with the facility's Administrator regarding R96's concern form. They were asked if they recalled 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 Numbers: 2671563, 2671721. Based on observation, interview and record review, the facility failed to report an injury of unknown origin and an allegation of neglect to the Abuse Coordinator and State Agency, and failed to report resident to resident physical abuse to the State Agency without misleading information that minimized the seriousness of the incident for three (R22, R76, and R96) of five residents reviewed for abuse and neglect. Findings include: R22 and R76 A review of a Facility Reported Incident (FRI) revealed on 11/3/25, the facility reported the following to the State Agency: physical contact made by resident (R22) to resident (R76) .Resident (R22) placed on one-on-one supervision .Investigation initiated . The report did not document the type of physical contact that was made. A review of R76's progress notes revealed a Nursing-Progress Note dated 11/3/25 that documented, Writer called to the unit for an incident involving res (resident) and another resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to thoroughly investigate an allegation of mistreatment for one (R28) of five residents reviewed for abuse/neglect. Findings include:On 2/9/26 at 9:32 AM, R28 was observed in their motorized wheelchair entering their room. When interviewed, R28 said an aide entered their room in May of 2025 and stated they were going to get R28 up. R28 stated they were telling the aide how to properly transfer them and the aide said they were getting R28 up however they (the staff member) wanted to get them up. R28 stated the aide then proceeded to transfer them into the sit to stand machine and left them strapped to the machine hanging while the aide changed the resident's brief while they were in the standing position. R28 explained the position they were left in for that extended period of time have caused them pain they still endure from the incident. R28 stated they had called the police over the incident, however, they were denied the opportunity to file…

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 2603176 and 2610478.Based on observation, interview and record review, the facility failed to implement interventions per plan of care following a resident to resident incident (between R51 and R16) for one (R51) of six residents reviewed for accidents. Findings include:Review of a complaint reported to the State Agency on 9/9/25 documented R51 reported an incident from 9/8/25 in which another resident (R16) came into their room with just a brief on and scared her.Review of the clinical record revealed R51 was initially admitted into the facility on 5/19/21, readmitted on [DATE] with diagnoses that included: generalized anxiety disorder, major depressive disorder recurrent moderate, adjustment disorder, other osteochondrodysplasia with defects of growth of tubular bones and spine, short stature due to endocrine disorder unspecified, and neuralgia and neuritis.According to the Minimum Data Set (MDS) assessment dated [DATE], R51 had intact cognition.Review of the care plans…

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

This citation pertains to intakes 2615522, 2645363, and 2671721. Based on interview and record review, the facility failed to ensure that one of five Certified Nursing Assistants (CNA 'AA') whose in-service training files were reviewed, had the required 12 hours of in-service training within the required time period. Findings include:On 2/11/26 at 8:06 AM, the facility was requested via email to provide the CNA (Certified Nursing Assistant) inservice/education training hours for five CNAs (Y, Z, AA, BB, and CC).Review of the documentation provided by the facility revealed CNA 'AA' only had 7.75 hours of education from 2024.On 2/11/26 at 12:45 PM, an interview was conducted with the Infection Preventionist / Staff Development (Nurse 'C'). They reported they had been in their role as Staff Development since mid-October (2025). When asked about the facility's process for ensuring annual education in-services were completed, Nurse 'C' reported they did reconcile of the hours and was not sure if the electronic system was glitching or not, but the documentation provided was what they were…

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 adequately assess one (R22) of one resident reviewed for social services to ensure they received appropriate medically related social services. Findings include: A review of R22's clinical record revealed R22 was admitted into the facility on 5/6/22 with diagnoses that included: hemiplegia right dominant side, motor vehicle accident injury, hypothyroidism, aphasia (difficulty speaking), dysphagia (difficulty swallowing), epilepsy, brain injury, depression, and anxiety. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R22 had severely impaired cognition. A review of R22's annual and quarterly Social Services Assessments revealed the last assessment was completed on 5/6/22. A review of R22's quarterly assessment progress notes revealed the last note was documented in 2023. On 2/11/26 at 9:04 AM, an interview was conducted with the Social Services Director (Social Worker - SW 'B'). When queried about when residents were assessed 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.

Based on interview and record reviews the facility failed to ensure documentation of the resident/resident representative to have been offered the Influenza vaccine annually (R72) and ensure documentation of education to have been provided to the resident and/or resident representative for the Influenza immunization for two (R's 72 & 23 ) of five residents reviewed for Immunizations. Findings include:R72A review of R72's medical record and immunization profile noted the family to have refused the Influenza vaccine on 10/01/2021. This was the only documentation of the Influenza vaccine on the profile.Further review of the medical record documented the resident as their own responsible party.There was no documentation of the resident/resident representative to have been educated and offered the Influenza vaccine since 2021.R23A review of R23's medical record and immunization profile noted on 12/23/25 the resident refused the Influenza vaccine.Further review of the resident's medical record noted the granddaughter to be the resident's responsible party and power of attorney for 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.

This citation pertains to intakes 2615522, 2645363, and 2671721. Based on interview and record review, the facility failed to ensure that two of five Certified Nursing Assistants (CNAs 'AA' and 'CC') reviewed for required annual in-service education, had the required 12 hours of in-service training within the required time period which included abuse prevention and dementia care. Findings include:On 2/11/26 at 8:06 AM, the facility was requested via email to provide the CNA (Certified Nursing Assistant) inservice/education training hours for five CNAs (Y, Z, AA, BB, and CC).Review of the documentation provided by the facility revealed:CNA 'AA' last had abuse and dementia care education on 2/20/24.CNA 'CC' had no dementia care education.On 2/11/26 at 12:45 PM, an interview was conducted with the Infection Preventionist / Staff Development (Nurse 'C'). They reported they had been in their role as Staff Development since mid October (2025). When asked about the facility's process for ensuring annual education in-services were completed and included all the required components including…

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

This citation pertains to complaint: 2570541. Based on observations, interviews and record reviews the facility failed to ensure the resident call light system was fully operable and functioning for two of three residents observed. This deficient practice had the ability to affect multiple residents residing in the facility. Findings include: A review of a complaint submitted to the State Agency (SA) documented allegations of the facility's call light system to be broken. On 8/19/25 an onsite investigation into the reported allegation was conducted. On 8/19/25 at approximately 9:55 AM, an observation of R204's call bell function was conducted with Licensed Practical Nurse (LPN) A. LPN A pressed R204's call light several times and the call light indicator outside of the resident's door failed to light up. LPN A confirmed the call bell/light was not working. At approximately 10:00 AM, an observation was made of R205 sitting on the side of their bed. R205 was asked to press their call bell light to see if it was working properly. R205 was observed to have pressed the call bell several…

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 relates to Intake MI00153706. Based on interview and record review, the facility failed to follow a physician order to ensure proper catheter care per standards of practice for one Resident (R702) of one resident reviewed for catheter care. Findings include: Review of a complaint intake received by the State Agency on 6/16/25 revealed R702 had quadriplegia (a form of paralysis affecting all four limbs) and needed a 20 (size diameter) French catheter, the facility ran out of supplies, and R702 was provided an 18 French catheter instead, which was leaking urine. The complaint further alleged R702 was not kept updated when a new catheter was available. On 7/01/25 at 11:33 a.m., Licensed Practical Nurse (LPN) “E” was asked about R702’s stay. LPN “E” confirmed an incident occurred in the past month on a Sunday (6/15/25), when R702’s suprapubic catheter (an abdominal urinary catheter to drain urine) became clogged. LPN “E” said the facility did not have a 20 sized French catheter (a type of catheter 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 relates to Intake #MI00151265. Based on observation, interview, and record review, the facility failed to provide adequate staffing to adequately meet the care needs of three Residents (R101, R102, and R105) of five residents reviewed for staffing, with the potential to affect all facility residents. Findings include: Review of a complaint received by the State Agency on 3/17/25 revealed resident-centered concerns related to not enough nursing aides with an increasing census. This reportedly resulted in residents not being gotten out of bed timely, with additional concerns about resident safety and comfort. The complaint described limited management oversight and problem solving given recent management staff turnover. On 4/03/25 at 9:31 a.m., Certified Nurse Aide (CNA) B reported they felt there should be two aides on Unit 4, which they described as primarily rehabilitation (skilled) residents when there was higher acuity on their unit, as many residents coming in required full care and full body…

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 #MI00147045. Based on observation, interviews, and record review, the facility failed to consistently ensure sufficient nursing staff was provided for residents who resided in the facility, resulting in verbalized complaints of delayed care and services and the likelihood for further delayed care and unmet care needs. This deficient practice had the ability to affect all 66 residents in the facility. Findings include: The survey team entered the facility on Sunday 11/17/24 at 8:30 AM. Rounding was completed on the facility units. Licensed Practical Nurse (LPN) A who was assigned to Unit 1 was interviewed. When asked, LPN A said their unit had two nurses and two certified nursing assistants (CNA) assigned to Unit 1. LPN E who was assigned to Unit 2, reported they were the only nurse assigned to Unit two with 2 CNAs. CNA H who was assigned to Unit 3 was interviewed and said the unit was currently assigned with one nurse, two CNAs, and one CNA in orientation. The facility's census was confirmed to be 66 on entrance. On 11/17/24 at 12:29 PM, an interview…

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 the kitchen was maintained in a sanitary manner and potentially hazardous food items were properly labeled and stored. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 11/17/24 at approximately 8:54 a.m., during the tour of the kitchen the following was observed: The reach in freezer contained packages of unsealed/undated sausage patties with ice crystals accumulated on them, unsealed and undated chicken breasts with ice crystal formation, and unsealed and undated hot dogs with ice crystals. At the time of the observation, Dietary Manager Q was queried regarding the observed meats and said they would have to be thrown away. Continued observation of the kitchen revealed the dry racks for pans had pans stored on them with water puddled inside of the pans. Dietary Manager Q was queried regarding the wet pans and indicated they should be not stacked until they were dry. A review of a facility provided policy titled, Kitchen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure appropriate infection control practices related to transmission based precautions (TBP) for five residents (R#'s 39, 48, 2, 51, and 66 ) of five residents reviewed for transmission based precautions, resulting in the potential for the spread of infection. Findings include: On 11/17/24 at 12:45 PM, a review of rooms marked with signs for enhanced barrier precautions (EBP, a type of transmission based precautions for the use of gown and gloves during high-contact resident care activities for residents at high risk of colonization of multi-drug resistant organisms) was conducted on Unit 3. The following was observed: R39 and R48's rooms had signs that indicated they were on EBP. A review of R39's clinical record revealed an order dated 9/24/24 that indicated they were on EBP related to having an indwelling urinary catheter, however; a progress note dated 11/12/24 revealed R39's catheter had been removed. On 11/18/24 at 8:53 AM, R39 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the comprehensive care plan was revised to reflect non-pharmacological interventions for one resident (R42) of one resident reviewed for psychotropic medications. Findings include: On 11/17/24 the medical record for R42 was reviewed and revealed the following: R42 was initially admitted to the facility on [DATE] and had diagnoses including: major depressive disorder-recurrent. A review of R42's Minimum Data Set (MDS) with an assessment reference date of of 6/11/24 revealed R42 needed assistance from facility staff with most activities of daily living. A Psychiatric provider evaluation dated 10/25/24 revealed the following: ASSESSMENT & PLAN Adjustment insomnia .Plan: Continue with trazodone (medication used for off label purpose of sleep) Pt (patient) reports sleep to be stable on his current dose of trazodone Monitor for sleep impairment and document. Counseled patient on sleep hygiene, relaxation therapy, and stimulus-control therapy Mood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure services met professional standards for two residents (R#'s 13 and 45) of four residents reviewed for professional standards during medication pass. Findings include: On 11/17/24 at 9:38 AM, Nurse 'I' was observed preparing medications for administration to R13. Nurse 'I' prepared multiple medications including Miralax (laxative powder mixed with water). Nurse 'I' proceeded to R13's room to administer the medications. R13 informed Nurse 'I' they did not want the Miralax medication. Nurse 'I' did not administer the medication and disposed of it. On 11/18/24 at 8:49 AM, a reconciliation of medications observed administered to R13 was compared to the medication administration record (MAR). During the reconciliation it was discovered Nurse 'I' signed the Miralax medication off as given, despite R13 having refused the medication. On 11/18/24 at approximately 2:20 PM, an interview was conducted with the Director of Nursing and they said…

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 consistently follow physician's orders for notification of abnormal blood glucose levels and obtain additional orders for treatment for one resident, (R46) of one resident reviewed for insulin medication, resulting in the potential for adverse outcomes related to elevated blood glucose levels. Findings include: On 11/17/24 at 11:00 AM, R46 was observed in their bed. At that time, an interview was conducted and they said the facility was not giving them enough insulin to keep their blood glucose levels down. They were asked how high their levels had been running and said as high as 400 and 500. It is noted the recommended blood glucose levels for people with diabetes is 80-130 before meals and less than 180 one-to-two hours after meals. On 11/18/24 at 12:11 PM, a review of R46's physician's orders for insulin coverage was reviewed and indicated that if a blood glucose level over 400 was obtained, the nurse was to contact the physician. A review of R46's blood glucose levels were reviewed and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure physician's notes were entered into the record at each visit and accurately addressed the resident's total program of care for one resident (R69), of one resident reviewed for physician visits. Findings include: On [DATE] at 11:14 AM, a review of R69's closed clinical record revealed they admitted to the facility on [DATE] and expired in the facility on [DATE]. R69's facility physician, Dr. 'J's progress notes were reviewed and revealed the following: A progress note effective [DATE] entered into the record on [DATE] at 8:20 PM. A progress note effective [DATE] entered into the record on [DATE] at 8:21 PM. A progress note effective [DATE] entered into the record on [DATE] at 8:17 PM. A discharge note effective [DATE] entered into the record on [DATE] at 9:56 PM. Continued review of R69's clinical record revealed a nursing progress note dated [DATE] at 12:05 AM that read, .resident on the floor .Pt (patient) does have a lump on the left neck 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 Based on interview and record review, the facility failed to ensure individualized/person centered non-pharmacological interventions were in place for the use of psychotropic medications for one resident (R42) of five residents reviewed for unnecessary psychotropic medications. Findings include: On 11/17/24 the medical record for R42 was reviewed and revealed the following: R42 was initially admitted to the facility on [DATE] with diagnoses that included: major depressive disorder-recurrent. A review of R42's Minimum Data Set assessment with an assessment reference date of 6/11/24 revealed R42 needed assistance from facility staff with most their activities of daily living. A review of R42's Psychotropic medications revealed the following: Start date: 6/6/24 (Wellbutrin)-buPROPion HBr ER Oral Tablet Extended Release 24 Hour (Bupropion Hydrobromide) Give 300 mg by mouth one time a day for ANTIDEPRESSANTS Start date: 6/6/24-TraZODone HCl Tablet 100 MG Give 1 tablet by mouth at bedtime for insomnia A 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.

Based on observation, interview and record review, the facility failed to ensure a medication error rate less than five percent when two medication errors of 26 opportunities for error were observed for two residents (R#'s 13 and 2) of four residents reviewed during the medication administration observation, resulting in a 7.69% medication error rate. Findings include: A review of a facility provided policy titled, Medication Administration issued 8/2023 was conducted and read, POLICY OVERVIEW: To safely and accurately prepare and administer medication according to physician order, professional standards of practice, and resident needs . R13 On 11/17/24 at 9:38 AM, Nurse 'I' was observed preparing medications for administration to R13. Among the medications prepared was Miralax (laxative) granulated powder. Nurse 'I' was observed to use a medication cup for use with liquid medications to measure the powder. An observation of the cup revealed granules measured up to the 15 milliliter line in the cup. At that time, Nurse 'I' was asked how they measured the granule powder and said they…

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

Based on observation, interview and record review, the facility failed to ensure medications were not stored at the bedside for R67, expired medications were disposed, and insulin pens were properly dated of in one of three medication carts reviewed. Findings include: On 11/17/24 at 9:16 AM, R67 was observed lying in bed on their back. A tube of hemorrhoid cream in a clear pharmacy bag was observed on their night stand. At that time, R67 was asked about the cream and said sometimes staff applied it and sometimes they did not. R67 further indicated they were not able to reach their backside to apply the medication. A review of R67's medical record revealed no assessments for self-administration of the cream. Review of a facility policy titled Medication and Treatment Storage dated 8/7/23, documented in part .All medications and biologicals will be stored in locked compartments .treatments will be stored in medication rooms and in treatment carts . On 11/18/24 at 9:02 AM, an observation of the Unit 3 medication cart was completed with Registered Nurse (RN) C. A round loose 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00145151 Based on observation, interview, and record review, the facility failed to ensure an allegation of abuse was immediately reported to the abuse coordinator and reported to the State Agency for three residents, (R901, R902 and R903) of four residents reviewed for abuse/neglect/mistreatment. Findings include: On 7/1/24 a concern submitted to the State Agency was reviewed and alleged R902 hit R903. On 7/1/24 at approximately 10:30 a.m., during an observation and conversation with R901, R901 indicated they had had issues with R902 being aggressive and further said they witnessed R902 hit R903 in the dining room. R901 was queried if they informed any of the facility staff of what they witnessed, and said they had. They further said R902 now had someone, always watching them. R903 On 7/1/24 at approximately 10:46 a.m., R903 was observed dressed and up in their wheelchair. R903 was queried if they had any altercations with any other residents and they said R902 had previously…

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

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate coordination of emergency or routine care and unmet care needs that could cause negative outcomes, affecting all residents who resided in the facility. Findings include: On 1/29/24 the facility payroll based journal (PBJ) report was reviewed and revealed no RN hours were recorded for the following dates during quarter four (July 1, 2023-September 30, 2023): 7/2, 7/23, 8/13, 8/20 and 9/10. On 1/30/24 the staffing assignment sheets were reviewed for 7/2/23, 7/23/23, 8/13/23, 8/20/23 and 9/10/23. No RN's were indicated to have worked on the staffing sheets for the reviewed dates. On 1/30/24 Staffing Coordinator D (SC D) was queried regarding the documented lack of RN coverage on the triggered dates on the PBJ report and they reported that they thought they may have been in between RN's at that time and were lacking coverage on the dates in question but would have to check to see if 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to effectively maintain the physical plant for two residents (R15 and R24) and ensure a safe/homelike environment (rooms 201, 238 and 276), potentially effecting all residents who use the handrails for locomotion assistance. Findings include: On 1/29/24 at approximately 9:30 a.m., R24 was observed in room, laying in bed. R24's floor base plastic molding was observed to be peeling away from the drywall. On 1/29/24 at 9:25 a.m., R15 was observed in their room, laying in their bed. R15 was observed to have the heating register on the ground with the heating elements exposed. On 1/30/24 at approximately 11:23 a.m., R24's room was observed to still have the floor base molding peeling away from the drywall. On 1/30/24 at approximately 11:25 a.m. the handrail across from the shower room (room [ROOM NUMBER]) was observed to be broken and have large jagged hole exposed in the middle of it. On 1/30/24 at approximately 1130 a.m., a blue communications…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one resident (R8) of one reviewed for medication, was assessed for the safe self-administration of medication and to have medication kept at bedside. Findings include: On 1/29/24 at 10:06 AM, R8 was observed in bed with the television on and sitting upright with latanoprost ophthalmic solution eye drops in the bed beside the resident. R8 was interviewed about their stay at the facility and R8 stated there were no complaints that the facility has been good in handling care for the past few years. R8 was also asked about the eye drops left on the bed and stated that the eye drops were needed and that they had to be administered on time so R8 preferred to do them by their self. A record review revealed that R 8 was re-admitted to the facility on [DATE] with a diagnosis of essential hypertension, presence if intraocular lens and other malaise and had a Brief interview for Mental status (BIMs) score of 15 (indicating an intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #s MI00138743 and MI00139119. Based on interview and record review the facility failed to ensure an environment free from physical abuse for one resident (R18) of six residents reviewed for abuse/neglect/mistreatment, when R42 was physically aggressive with R18. Findings include: On 1/29/24 a facility reported incident submitted to the Stage Agency was reviewed which indicated R42 was physically aggressive towards R18 on 6/29/23. Resident #42 On 1/31/24 at approximately 12:52 p.m. R42 was observed in their chair in the dining room, alone at the table. R42 was queried regarding the incident between them and R18 and they reported that they were on the patio playing cards and R18 was talking s* during the game. R42 reported they told R18 to quit talking and they didn't stop so they picked up their can of pop and threw it at them and hit them in the face. On 1/30/24 the medical record for R42 was reviewed and revealed the following: R42 was initially admitted to the facility 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.

Based on observation, interview, and record review, the facility failed to document as needed (PRN) doses of medication for one resident (R1), of one resident reviewed for PRN medication administration, resulting in feelings of frustration. Findings include: On 1/29/24 at 9:31 AM, R1 was observed in their bed. At that time, they were asked about their stay in the facility and said they had been suffering a sore throat. They further continued to say they asked their physician for chloraseptic sore throat spray a week or so ago, but said they thought the physician forgot to order it because they don't remember receiving any doses of the spray. On 1/29/24 at 12:32 PM, a review R1's physician orders for January 2024 was conducted and revealed chloraseptic throat spray had been ordered for administration three times daily, as needed for ten days. A review of R1's medication administration record for January 2024 was reviewed and did not document any administrations of the medication. On 1/29/24 at 12:45 PM, a review of R1's chloraseptic spray stored in the medication cart 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Deficient Practice Statement (DPS) #1 Based on observation, interview, and record review the facility failed to appropriately position a resident (R32) in a specialized wheelchair, of one resident reviewed for positioning, resulting in the potential for aspiration of gastric (stomach) contents, increased intra-cranial (head) pressure/pain, decreased output from the heart, and decreased blood pressure. Findings include: A record review revealed that R32 was a long-term resident of the facility. R32 was originally admitted to the facility on [DATE]. R32 was most recently hospitalized on [DATE]. R32's admitting diagnoses and medical history included quadriplegia (is a form of paralysis that affects all four limbs and the torso/trunk) from brain injury, seizures, GERD (Gastro-Esophageal Reflux Disease), Pneumonia, contractures, and anxiety disorder. Based on the Minimum Data Set (MDS) assessment dated [DATE], R32 had severe cognitive deficits. R32 received their nutrition and hydration via their PEG tube…

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.