Heartwood Lodge Trinity Health

Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled in 1 of 3 medication carts (Yellow Neighborhood Medication Cart) and 1 of 2 medication rooms (Yellow Neighborhood Medication Room) inspected, potentially affecting 25 of 74 facility residents. Findings Include: During an observation on 06/12/25 at 11:10 AM, the Yellow Neighborhood Medication Cart was inspected Licensed Practical Nurse (LPN) F. The following observation and interview were made: - A box of Ketotifen fumarate ophthalmic solution labeled [Resident # 52's last name] 2-10-25 [R52's room number] was observed in the medication cart. However, the solution bottle in the box was not labeled with any information that would identify the resident who the bottle belonged to should it become separated from the box. Other single user bottles/vials in other boxes in the medication cart were all labeled with resident names and/or room numbers. - LPN F stated she did not know if the vials and/or bottles in boxes that were for single resident user should be labeled 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.

Based on observation, interview, and record review, the facility failed to assess one resident (R66) for self-administration of medication and failed to track and record medication use. Findings: Review of the Electronic Medical Record (EMR) reflected R66 was admitted to the facility 5/1/25 with pertinent diagnoses that included Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease (COPD), and Emphysema. On 6/11/25 at 9:43 AM, R66 was observed in a recliner chair receiving supplemental oxygen through a nasal cannula. Also observed were a nebulizer machine, a device like a Continuous Positive Airway Pressure (CPAP) machine and an Albuterol multidose inhaler on the over-the-bed table next to the Resident. On 6/12/25 at 2:34 PM an observation and interview were conducted with R66 in his room. The Albuterol multi-use inhaler was again observed on the over the bed table next to R66. R66 reported he used the inhaler sometimes a couple of times a day. R66 reported staff had not asked him if he had used it or how often. R66 indicated staff never asked him anything about 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 respect the dignity of one (R224) of two residents reviewed for dignity. Findings include: Resident #224 (R224) Review of the Minimum Data Set (MDS) dated [DATE] for R224 revealed she was always continent of bowel and bladder. R224 required substantial/maximal assistance for toilet transfers. In an interview on 6/10/25 at 3:10 PM, R224 reported she has had to wait for long periods of time for the call lights to be answered so she can get assistance with toileting. The longest time she waited for the call light to be answered was about an hour and soiled her pants because she could not wait that long. A couple staff at night will tell her to just go in her brief if she cannot hold it and not to worry about it. If you have to go, just go they told her. R224 reported it makes her feel bad when she wets inside her brief even though the staff are very kind about it and will clean her up. In an interview on 6/13/25 at 10:41 AM, the Director of Nursing (DON)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately notify the physician/provider in a timely manner of a fall with injury for 1 of 2 residents (R15) reviewed for falls. Findings include: A review of R15's admission Record, dated 6/12/25, revealed they were a [AGE] year-old resident that was admitted to the facility on [DATE]. In addition, R15 had multiple diagnoses that included a traumatic subdural hemorrhage (brain bleed) with a loss of consciousness. A review of R15's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 2/21/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R15 was cognitively intact. During an interview on 06/10/25 at 12:30 PM, R15's spouse stated R15 had been in the hospital on and off five times since November 2024. Even though R15's MDS indicated he was cognitively intact, his spouse was interviewed because he had just returned to the facility after…

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 report an allegation of neglect to the state survey agency for 1 of 19 sampled residents (R1). Findings include: A review of the facility's Abuse, Neglect and/or Misappropriation of Resident Funds or Property and Exploitation Prohibition policy and procedure, revised February 2025, revealed, Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Serious Bodily Injury means an injury involving extreme physical pain . requiring medical intervention such as surgery, hospitalization, or physical rehabilitation . A review of the facility's Abuse, Neglect and/or Misappropriation of Resident Funds or Property and Exploitation Prohibition policy and procedure, revised February 2025, further revealed, The Administrator or his/her designee will notify the State Agency and any other agencies (i.e., law…

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 appropriately transfer and/or discharge two residents (R69, R70) of two residents reviewed for discharges. Findings include: Resident #69 (R69) Review of the MDS dated [DATE] for R69 revealed in section A2105, R69's discharge status was 04. Short-Term General Hospital (acute hospitals, IPPS), indicating R69 was discharged to the hospital. Review of a Nursing Progress note dated [DATE] for R69 revealed he was discharged with his son to an Assisted Living Facility. Review of a document titled Discharge Instructions dated [DATE] for R69 revealed: admission (sic) In Progress, with no locked date. The document was not complete with the reason for the discharge and where the resident was discharged to, and no document signed by the resident indicating he or his representative acknowledged or received discharge information/instructions. No Home Care Agency information was documented. No other discharge form was in the electronic medical record (EMR). Review…

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 accurately code the Minimum Data Set (MDS) for two Residents (R70 and R69) of three residents reviewed for closed records. Findings include: Resident #70 (R70) Review of the MDS dated [DATE] for R70 revealed in section A2105, R70's discharge status was 13. deceased and indicated as a death in the facility. Review of the Electronic Medical Records (EMR) for R70 revealed the resident had a change of condition and the Emergency Medical Services (EMS) was called. There was no documentation to show the resident left the facility and no documentation to show he died in the facility. In an interview on [DATE] at 8:35 AM, MDS Coordinator/Registered Nurse (RN) Q reported R70 did go to the hospital and died there. R70 should not have been documented as a death in the facility. R70 acknowledged there were no transfer forms in the EMR indicating R70 left the facility accompanied by EMS. Resident #69 (R69) Review of the MDS dated [DATE] for R69 revealed in section…

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 complete an annual Preadmission Screening/Annual Resident Review (PASARR) Level I Screening and Level II Evaluation timely for 1 of 1 resident (R9) reviewed. Findings include: A review of R9's admission Record, dated 6/12/24, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R9 had multiple diagnoses that included dementia, depression, and narcissistic personality disorder. A review of R9's medical record, dated 5/1/24 to 6/11/25, revealed R9 last had a PASARR Level II Evaluation completed on 5/15/24. However, there was not any documentation in R9's medical record that a PASARR Level I Screening and/or Level II Evaluation had been completed since then (they should have been completed prior to 5/15/25). During an interview on 06/11/25 at 02:10 PM, Social Worker (SW) A stated per her tracking tool R9's PASARR Level I Screening was due on 5/1/25. She stated she knew it was late, but had not completed it yet. 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 observation, interview and record review, the facility failed to develop and implement a person-centered Care Plan for one (R224) of two residents reviewed for Care Plans. Findings include: Resident #224 (R224) Review of a Face Sheet revealed R224 admitted to the facility on [DATE] with pertinent diagnoses of fusion lumbar spine, urinary tract infection (UTI), and fractured lumbosacral spine and pelvis. Review of the Minimum Data Set (MDS) dated [DATE] for R224 revealed she was always continent of bowel and bladder. R224 required substantial/maximal assistance for toilet transfers. Review of the Care Plan for R224 revealed: Focus: I have indwelling catheter, initiated on 5/30/25 and revised on 6/2/25 by the MDS Coordinator. The MDS reflects R224 is continent. Focus: At risk for infection related to indwelling catheter, initiated on 6/2/25. Focus: ADL (activities of Daily Living) Self Care Performance . Interventions/Tasks: TOILET USE: I require 1 staff participation to use toilet, initiated 5/30/25 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 revise the Care Plan for two facility residents (R66 and R26) who had documented changes in care following admission to the facility. R66 Review of the Electronic Medical Record (EMR) reflected R66 was admitted to the facility 5/1/25 with pertinent diagnoses that included Acute Respiratory Failure and Chronic Obstructive Pulmonary Disease (COPD) On 6/11/25 at 9:43 AM and again on 6/12/25 at 2:34 PM, R66 was observed in a recliner chair with an Albuterol multidose inhaler on the over-the-bed table next to the Resident. R66 reported he used the inhaler sometimes a couple of times a day. R66 reported staff had not asked him if he had used it or how often. R66 indicated staff never asked him anything about the inhaler. Review of the EMR Doctor's Orders reflected an order for Ventolin HFA Inhalation Aerosol Solution 90 micrograms (mcg) (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for COPD/wheezing. May leave at bedside with a start date of 5/5/25. Review of the Care Plan for R66 did not reflect…

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 complete and accurate medical records for 1 of 19 sampled residents (R1). Findings include: R1 A review of R1's admission Record, dated 6/12/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R1's admission Record revealed they had multiple diagnoses that included cerebral palsy, epilepsy, abnormal posture, torticollis (a rare condition in which the neck muscles contract causing the head to twist to one side), and scoliosis. During an interview on 06/12/25 at 09:50 AM, R1 stated through short statements and yes/no answers that in February 2025 she rolled out of bed while staff were doing a bed bath. She stated staff rolled her to the side and she kept going until she was on the floor. R1 stated one staff member was present and giving her the bed bath. She stated usually only one staff member provides care to her, including bed baths. R1 denied the facility uses two staff members for her care. R1…

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 related to MI00152071. Based on interview and record review, the facility failed to maintain appropriate infection control practices for 1 of 11 residents reviewed (R7) and for 1 of 3 facility units (Blue Neighborhood), potentially affecting 18 of 70 residents. Findings include: R7 A review of R7's admission Record, dated 4/18/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included an infection of the left knee prosthesis. A review of R7's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 1/11/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R7 was cognitively intact. During an interview on 4/17/25 at 10:45 a.m., R7 stated they were sent to the hospital via ambulance the morning of 1/11/25 because the night nurse had left their PICC line uncapped (i.e., no cap on the end of the line to prevent bacteria 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 is related to MI00152071. Based on interview and record review, the facility failed to maintain complete and accurate medical records for 1 of 11 residents reviewed (R7). Findings include: A review of R7's admission Record, dated 4/18/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included an infection of the left knee prosthesis. A review of R7's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 1/11/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R7 was cognitively intact. During an interview on 4/17/25 at 10:45 a.m., R7 stated they were sent to the hospital via ambulance the morning of 1/11/25 because the night nurse had left their PICC line (peripherally inserted central catheter- a line inserted into a peripheral site (usually the upper arm) and extends into a large vein that leads into the heart) uncapped…

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 review, the facility failed to accurately assess, monitor and treat wounds for 3 Residents (R1, R2 and R3) of 3 residents reviewed for wound care. Findings included: Review of R1's face sheet dated 2/12/25 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: encounter for other orthopedic aftercare, infection of amputation stump, osteomyelitis, muscle weakness, need of assistance with personal care and obesity. R1 was his own responsible party. Review of R1's Skin assessment dated [DATE] revealed that he and a left knee surgical incision. (no description). Review of R1's orders revealed, 1/4/25, reinforce dressing if staining, if saturation noted please contact ortho (orthopedic) PA (physician assistant). Do not remove dress for any reason unless discussed with ortho PA. Review of R1's surgical note dated 1/8/25 Revealed, He states that he is doing okay, patient says they are using a sit to stand at his nursing…

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 #MI00147647. Based on interview and record review, the facility failed to report an allegation of abuse timely for 1 resident (Resident #101), of 3 residents reviewed for abuse. Findings include: Review of an admission Record revealed Resident #101 (R101) admitted to the facility on [DATE] with pertinent diagnoses which included dementia and anxiety. Review of R101's Facility Reported Incident (FRI) Investigation Report, MI-FRI #00057977, revealed R101's allegation of abuse was discovered on 10/10/2024 at 12:30 PM, the Nursing Home Administrator (NHA) was notified of the allegation on 10/10/2024 at 3:41 PM, and the incident was reported to the State of Michigan on 10/10/2024 at 9:54 PM. In an interview on 10/28/2024 at 1:28 PM, Regional Nurse Consultant C reported she was assisting at the facility on 10/10/2024. Regional Nurse Consultant C reported R101 told the facility Nurse Practitioner at approximately 11:30 AM on 10/10/2024 that he had been assaulted by staff the previous…

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, resulting in the potential to spread food borne illnesses to all residents that consume food from the kitchen. Findings include: During an initial tour of the walk-in cooler, at 9:44 AM on 6/24/24, it was observed that half empty box of nutritional shakes was found on the bottom storage rack. When asked if there was a date on the box of shakes, Certified Dietary Manager (CDM) J was unable to find one and stated that typically the box is dated for 14 days. A review of the items stated it was good for 14 days after thaw. When asked if the shakes are placed directly into the cooler upon receiving, CDM J stated they are first put in the freezer. During a tour of the Blue Pantry, starting at 10:23 AM on 6/24/24, it was observed that a container holding a dozen nutritional drinks were found in the refrigeration unit with no date to indicate discard. A review of the manufacturer's directions state the item is good 14 days from thaw. Further review found an open container…

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 1.) Administer controlled medications following a physician's order and professional standards of practice and 2.) Ensure that medications were administered following the physician-ordered parameters for 4 residents (Resident #1, Resident #14, Resident #32, and Resident #57), reviewed for medication administration, resulting in medication errors and the withholding of medications without a physician's order. Findings include: Resident #1 (R1): Review of an admission Record revealed R1 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: spastic quadriplegic cerebral palsy. Review of R1's Order Summary revealed, Norco Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth three times a day for pain -Start Date-11/28/2023. To be administered at 5:00 AM, 12:00 PM, and 8:00 PM. Review of R1's Controlled Substance Record revealed on 6/20/24 R1 received a dose of Norco 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 Based on observation, interview, and record review, the facility failed to follow its established protocol to provide residents with clean oxygen delivery equipment and to monitor oxygen levels for one resident (Resident #11) of 3 residents reviewed. Findings include: Resident #11 (R11): Review of an admission Record reflected R11 was a [AGE] year-old female, last admitted to the facility on [DATE]. During an observation on 06/24/24 at 11:10 AM, R11 sat up in bed awake and alert. R11 reported using oxygen at night while sleeping. The oxygen tubing and bottle of water to humidify the oxygen were dated 06/05/24. During an observation on 06/25/24 at 7:09 AM R11 laid resting in bed with eyes closed and received oxygen via a nasal cannula. The oxygen tubing and bottle of water to humidify the oxygen were dated 06/05/24 and the bottle of water was empty. During an interview on 06/25/24 at 9:30 AM the Director of Nursing (DON) stated the all oxygen tubing and equipment are changed out weekly by third shift staff.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to operationalize policies and procedures and have a functional system in place for controlled substances to ensure that they were accounted for, dispensed, and disposed of in a sensical manner, resulting in the potential for drug diversion and the misappropriation of property. Findings include: Resident #65 (R65): During an observation and interview on [DATE] at 7:52 AM, the 200 Hall Registered Nurse (RN) A (night shift nurse) and Licensed Practical Nurse (LPN) D (oncoming nurse) were exchanging report and destroying a Schedule II narcotic (Norco (Hydrocodone/acetaminophen)). A blister pack of Norco 5/325 mg tablets had 23 tablets left from a 30-count blister pack for Resident #65 (R65). Both nurses entered the medication storage room and RN A popped the 23 tablets into his hand and discarded them into the drug buster bottle (a medication disposal system that quickly turns most non-hazardous medications into a non-toxic slurry that can be…

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

Based on interview and record review, the facility failed to 1) Implement Enhanced Barrier Precautions for residents with chronic wounds or indwelling medical devices to prevent, recognize, and control the onset and spread of infection among residents and 2) Investigate, document surveillance of, and implement preventative measures to address an outbreak of a respiratory illness among residents. Findings include: OUTBREAK INVESTIGATION Review of the Infection Prevention and Control Program revealed that in March 2024 there were 9 positive cases of Influenza A. On 06/24/2024 at 10:26 AM a request for a copy of any Line Lists and Outbreak Investigations was requested via email. There was no Line Lists or Outbreak Investigations received prior to the Infection Prevention and Control Program Review. During an interview on 06/27/2024 at 10:00 AM, the Infection Control Program was reviewed with Director of Nursing (DON) and Registered Nurse/Consultant (RNC) L. RNC L and DON were unable to locate/provide any additional outbreak investigation documentation related to the March 2024…

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 timely care for two residents (Resident #1 and Resident #53) of three residents reviewed, who are dependent on staff to meet their needs. Findings include: Resident #1(R1): Review of an admission Record revealed R1 was a [AGE] year old female, last admitted to the facility on [DATE], with pertinent diagnoses of quadriplegic cerebral palsy and difficulty speaking. Review of a Brief Interview for Mental Status (BIMS) reflected a score of 13 out of 15 indicating R1 was cognitively intact despite not always being able to communicate her needs. R1 was completely dependent on staff for Activities of Daily Living (ADL) such as bathing, going to the bathroom, getting dressed, and eating. During an observation on 06/25/24 at 7:24 AM, the call light monitoring system showed that the call light in R1's room had been activated at 6:57 AM and remained on. During an interview on 06/25/24 at 7:28 AM, R1's call light remained on and she laid 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 Based on observation, interview and record review, the facility failed to 1.) Provide care following professional standards of practice and facility policy to prevent the development of an avoidable pressure injury and 2.) Promptly notify the family/emergency contact and provider of a newly-identified pressure injury for one resident (Resident #10) out of 6 residents reviewed for alterations in skin integrity/pressure injuries, resulting in the development of a pressure injury and a delay in treatment. Findings include: Resident #10 (R10): Review of an admission Record revealed R10 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Review of a Minimum Data Set (MDS) assessment for R10, with a reference date of 3/14/24 revealed in Section C-Cognitive Patterns that R10 was severely cognitively impaired. Review of Section M-Skin Conditions revealed R10 did not have a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. R10 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident with limited mobility received appropriate/recommended equipment for one resident (Resident #10) out of 6 residents reviewed for range of motion, positioning, and mobility. Findings include: Resident #10 (R10): Review of an admission Record revealed R10 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Review of a Minimum Data Set (MDS) assessment for R10, with a reference date of 3/14/24 revealed in Section C-Cognitive Patterns that R10 was severely cognitively impaired. Review of R10's Functional Abilities and Goals dated 6/15/24 revealed that R10 was dependent on staff for bathing, dressing, toileting, and mobility. Review of R10's Screen Request for Potential Risk or Intervention and Therapy Orders dated 10/6/22 revealed the therapy department provided dumped (seat slope/recline), high back w/c (wheelchair)-10/7/22. The wall in R10's room held a picture 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 discard expired medications for 1 of 3 medication carts reviewed, from a total 6 medication carts, resulting in the residents receiving medications that are expired and/or have reduced efficacy. Findings include: During an observation and interview on 6/26/24 at 8:00 AM, the 200 hall Medication cart had a bottle of eye drops with an opened date of 5/12/24, a bottle of nasal spray with a date opened of 5/2/24, a Lantus multi dose vial with an opened date of 5/10/24 and another Lantus multi dose vial with an open date of 5/8/24. Licensed Practical Nurse (LPN) D reported she was not sure of the expiration dates of the medications once they were opened but believed it was around 28 days. Review of an Insulin Storage Parameters document provided by the facility revealed Lantus is to be discarded 28 days after opening. Ophthalmic Solutions Storage Parameters: Eye medication bottles/tubes with accelerated expiration dates must be dated/initialed upon opening. Follow manufacturers instructions, or facility policy.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to 1.) ensure residents received consistent and comprehensive physician ordered care, 2.) notify the physician a change in condition, and 3.) ensure residents received care in accordance with professional standards for medication administration, in 3 residents (Resident #51, #55, and #6,) reviewed for quality of care, resulting in a delay in treatment and the potential for the worsening of a medical condition and residents not attaining or maintaining his or her highest practicable level of wellbeing. Findings: Resident #51 (R51) Review of an admission Record revealed R51 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: atrial fibrillation (abnormal beathing of the heart). Review of R51's Nurses Notes dated 5/2/2023 at 9:00 AM revealed, Resident came to nurse this morning and c/o (complained of) not feeling good. Resident pale and diaphoretic (excessive sweating due to an underlying…

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 storage of medication in 1 of 2 medication carts on the [NAME] Unit for 2 residents (Resident #28 and #36), resulting in the potential for diversion and/or misappropriation of medication. Findings: Resident #28 (R28) Review of an admission Record revealed R28 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: lung disease, heart disease, kidney disease, diabetes, and opioid dependence. Review of R28's Medication Administration Record (MAR) revealed R28 was to receive the following medications the morning of 6/27/23: *Norco Tablet 10-325 MG (milligram) (HYDROcodone-Acetaminophen) Give 1 tablet by mouth every morning and at bedtime for pain (controlled drug/narcotic medication) *AmLODIPine Besylate Tablet Give 10 mg by mouth in the morning for high blood pressure. *Celecoxib Capsule 200 MG Give 200 mg by mouth in the morning for arthritis pain *Ferrous Sulfate…

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.