Lakeside Manor Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to maintain the exterior trash refuse area in a sanitary manner. This deficient practice had the potential to affect all residents, staff and visitors. Findings include:On 08/04/2025 at 9:00 AM, the exterior trash refuse area was observed. There were 2 dumpsters, and both doors on each dumpster were observed to be in the open position. There was a greasy liquid observed leaking from the bottom corner of one of the dumpsters. A large area of a greasy liquid was pooled on the concrete near the dumpsters. There was a strong garbage odor present in the area. On 08/04/2025 at 10:30 AM, Dietary Manager R was queried about the dumpster area, and stated that Maintenance was responsible for cleaning that area. The policy for maintaining the exterior trash refuse area was requested from the Administrator on 08/04/25 at 11:00 AM, but was not provided by the end of the survey.According to the 2022 FDA Food Code section 5-501.115 Maintaining Refuse Areas and Enclosures, A storage area and enclosure for refuse, recyclables,…

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 quarterly Quality Assurance (QA) meetings (for identification of any deficiencies and for performance improvement) were held in 2024 for 59 residents in a census of 59. Findings include:On 08/06/2025 at 1:01 PM, a review of the facility QA program was conducted with the Administrator. The quarterly QA meeting sign in and evidence of an active QA committee for 2024 was requested. The Administrator reported they did not have and could not find evidence of the required quarterly meetings for 2024. No performance improvement plans or projects (PIPs) were identified for 2024. The Administrator reported they had taken the role in March of 2025 and no hand off of facility QA projects or quality improvement plans were provided by the previous Administrator. The Administrator was also asked about ongoing PIPs from 2025 and reported no action plans had been developed. Current survey concerns included infection control, falls, physician order implementation…

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 resident rooms, and the north and south resident hallway carpets were clean and in good repair for four residents (R17, R47, R9, R1) in a census of 59. Findings include: On 08/04/2025 at 9:59 AM, a pillow was observed on the seat of an armchair in room [ROOM NUMBER]. The uncased pillow had multiple (greater than three linear cracks with multiple splintered cracks in the plastic covering of the pillow. On 08/06/25 the resident was observed seated on the uncased pillow in their wheelchair. On 08/04/25 at 8:30 AM, during the initial screening of residents and on 08/05/2025 at 9:14 AM, the south hall carpet was observed and revealed: An irregular pink/red stain/dried spill outside room [ROOM NUMBER], three areas of irregular red spots/dried spills between rooms [ROOM NUMBERS], the area from room [ROOM NUMBER] to room [ROOM NUMBER], appeared as the most soiled with solid blackened and gray area appearing carpet along the length 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 This citation pertains to intake 2589351.Based on observation, interview and record review, the facility failed to ensure the resident's incontinence brief preference was honored for one resident (R11) of three residents reviewed for choices. Findings include:On 08/04/2025 at 10:12 AM, R11 expressed concerns about needing something to have a bowel movement. R11 reported they felt the brief staff had put on was too small and too tight and felt like it was keeping them from having a bowel movement. R11 noted they required a larger brief. The brief was observed to not cover the thigh area nor wrap around the buttocks area. R11 noted they only had two brief changes in 12 hours and waits for a least an hour and reported the urine forgets to stop. The brief observed was white and the tabs to hold the front and back together at the sides was stretched thin (narrow) and R11 reported it was uncomfortable and dug into their sides. R11 further reported they had told the aide the brief was too small, but it was reported 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure timely delivery of the Medicare Notice of Non-Coverage (NOMNC-document that tells a resident and/or their representative that Medicare will no longer pay for their stay or services) for one resident (R55) of three residents reviewed for Medicare coverage and liability. Findings include: A review of the medical record revealed R55 was admitted to the facility on [DATE] with diagnoses included Heart Disease, Rheumatoid Arthritis, and High Blood Pressure. R55 was receiving Medicare Part A skilled services. The Notice of Medicare Non-Coverage (NOMNC) dated 05/30/2025 indicated services would end 06/04/2025, R55's guardian did not sign the notice until 06/09/2025. There was no documented evidence the guardian was notified at least two days prior to the end of skilled services. On 08/06/2025 at 2:00 PM, interview with Business Office Manager I reported the NOMNC was faxed to R55's guardian; however, they were unable to provide fax confirmation 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 Based on interview and record review, the facility failed to ensure a 14 day stop date for a PRN (as needed) anti-psychotic medication for one (R7) of five residents reviewed for unnecessary medications.On 08/04/25 at 9:28 AM, R7 was observed in bed. They did not respond to verbal greetings or open their eyes. During subsequent observations the resident was primarily non-responsive and non-communicative. Review of the facility record for R7 revealed they were originally admitted into the facility on [DATE] and had current diagnoses that included Cerebral Infarction with Left Hemiplegia, Vascular Dementia, and Anxiety Disorder. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5/15 indicating severe cognitive impairment. Review of R7's physician orders revealed they were receiving hospice services and they had an active order for PRN Haloperidol for agitation with a start date of 05/13/25 and an end date stating open-ended. Additional review of R7's record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure incontinence care was provided timely for one resident (R34) and bedding was changed timely for one resident (R46) of three reviewed for activities of daily living. Findings include: R34 On 08/04/2025 at 10:50 AM, R34 reported shortages of briefs, a concern with staff attitudes and being left wet and soiled for extended periods of time. R34 was asked if they were currently wet and reported they were. A yellow area was observed behind R34, and the sheet appeared yellow in spots. An odor of urine was also noted. The pillow R34 leaned on did not have a pillowcase. R34 reported they had been wet since the last shift and had overflowed the brief because the aide had left and had not come in to change them. R34 further noted they were served breakfast around 9:00 AM and was not changed at that time and denied they had refused any care. R34 then put their call light on. On 08/04/2025 at 5:08 PM, Certified Nursing Assistant (CNA) J, reported…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2580294.Based on interview, and record review, the facility failed to ensure Heparin (blood thinner) was administered per physician order, hospital discharge orders were accurately transcribed, and vital signs completed for three residents (R14, R17, and R55) out of five residents reviewed for following physician orders. Findings include: R17 On 08/04/2025 at 9:59 AM, an interview was conducted with R17, during which the resident expressed concerns that the facility runs out of Heparin doses at least two to three times per week. A review of Medication Administration Records (MAR) for June 1, 2025, through July 30, 2025, revealed 18 times Heparin was not administered as ordered on 18 occasions. The documented for each missed dose was (Not administered: Drug/item Unavailable). On 08/05/2025 at 11:32 AM, identified concerns were reviewed with Director of Nursing (DON) and the Unit Manager Registered Nurse (RN) A. The DON and RN A reviewed the MARs for June and July 2025 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 ensure resident inhalers were dated when opened in one of four medication carts. Findings include:On 08/05/2025 at 9:10 AM, an observation of the 200-back medication cart with Licensed Practical Nurse (LPN) M, revealed a Fluticasone Furoate/Vilanterol (generic name) inhaler not dated when opened (new admit not added to sample), a fluticasone/salmeterol 250/50 (name for generic) inhaler for R18 not dated when opened, and a Fluticasone/Salmeterol 250/50 inhaler for R56 dated opened 04/14. On 08/06/2025 at 1:51 PM, the Director of Nursing (DON) reported the reported inhalers should be dated as soon as they are opened. A review of the facility policy titled, Labeling of Medications and Biologicals implemented 11/01/2022, revealed, Policy: All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications . 9. Labels for medications designed for multiple administrations (such…

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 have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP) and failed to ensure nursing staff used appropriate Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Findings include:On 08/04/2025 at 10:00 AM, Corporate Life Safety Director F was queried about the Water Management Program (WMP) and stated that the building Maintenance Supervisor had resigned last week suddenly. Corporate Life Safety Director F stated he was trying to find any documents related to the facility's WMP. Corporate Life Safety Director F produced a binder with a policy dated 2022, and some blank monitoring forms. Further review of the binder noted there was no diagram of the building water system, and no text…

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 MI00150910 and MI00150259. Based on interview and record review, the facility failed to prevent staff to resident verbal abuse for one sampled resident (R906) from a total of four residents reviewed for abuse resulting in feelings of being disrespected. Findings include: A review of the Facility Reported Incident dated 02/23/25 documented, Resident (R906) and Aide (Certified Nurse Assistant (CNA) C) got into a verbal altercation. Both became threatening to each other. The Administrator was contacted immediately, and the aide was sent home with the instructions that (they) will be contacted. On 03/03/25 at 10:11 AM and 1:22 PM, Staff D was interviewed. Staff D reported they had witnessed the incident between CNA C and R906. Staff D reported the incident started with CNA C asking if R906 wanted a shower and subsequently a verbal exchange began. CNA C was telling R906 they would need to have the shower then (at that time) and was not going to help R906 later. There was profanity…

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 MI00150377. Based on interview and record review, the facility failed to monitor, timely initiate and complete treatment orders for a new wound, for one sampled resident (R902) of four reviewed for wounds, resulting in the potential for wound deterioration. Findings include: A review of an Intake noted the allegation, It was alleged the facility failed to monitor a blister for infection leading to toe amputation. A review of R902's medical record revealed, R902 was admitted to the facility on [DATE] and discharged to the hospital on 1/18/25. An admission Minimum Data Set (MDS) assessment dated [DATE] and quartely MDS dated [DATE] documented, R902 with an intact cognition, skin at risk for breakdown, one unhealed, present on admission, right heel pressure ulcer stage 3 (full thickness tissue loss) and moisture associated skin damaged. Nursing progress note dated 01/03/25 at 5:00 PM revealed, Resident received full bed bath today by assigned aide, no new skin issues . Further…

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 comfortable room temperatures, for two resident rooms (#118 and #206), resulting in resident complaints of cold rooms. Findings include: On 1/21/25 at 8:50 AM, the air temperature of room [ROOM NUMBER] was measured to be 66 degrees Fahrenheit. The resident in room [ROOM NUMBER] bed 1 was observed in bed with the blanket pulled up over his head. On 1/21/25 at 8:55 AM, the air temperature of room [ROOM NUMBER] was measured to be 65 degrees Fahrenheit. The resident in room [ROOM NUMBER] bed 1 was queried about the room temperature and stated, It's cold! The resident room directly next to room [ROOM NUMBER] (room [ROOM NUMBER]) was observed to be vacant. The room temperature of room [ROOM NUMBER] was measured to be 48 degrees Fahrenheit. During an interview on 1/21/25 at 11:30 AM, Maintenance Supervisor C was queried regarding a comfortable ambient air temperature in resident rooms, and what temperature would the facility consider…

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 MI00146809. Based on interview and record review, the facility failed to provide a bed hold policy notification for three residents (R902, R904, R905) out of three residents reviewed for hospitalizations. Findings include: A review of an Intake called into the State Agency noted the following, .does not provide bed old notice so they can refuse return. R902 A review of the medical record revealed R902 admitted into the facility on 9/21/2023 with the following diagnoses, Altered Mental Status and Metabolic Encephalopathy. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 99, indicating R902 was unable to complete the assessment. R902 also required assistance with bed mobility and transfers. Further review of the medical record revealed R902 was transferred to the hospital on 7/31/2024. On 9/19/2024 at 3:20PM, an interview was conducted with the Director of Nursing (DON). The DON stated they do not have anything to do with bed holds. The 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 This citation pertains to Intake MI00146837. Based on observation, interview and record review, the facility failed to notify the physician of vital signs and medication refusals for one resident (R904) of seven residents reviewed for care standards. Findings include: On 9/19/24 at 8:52 AM, R904 was observed to be in bed with blankets up around their neck. The resident was lying on his back, a knitted hat on his head with over in the ear headphones. R904 was pleasant and conversant. R904 did not appear to be distressed. A review of the record for R904 revealed R904 was admitted into the facility prior to 07/8/23 and readmitted on [DATE] after an admission for wound infection on 08/27/24. Diagnoses included Muscular dystrophy, Chronic Kidney Disease, Anemia, Vitamin D deficiency, Anxiety Disorder, High Blood Pressure, Heart Disease, Diabetes mellitus, contracture of muscle of right hand, and obesity. R904 had a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated intact cognition. R904 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain carpet throughout the facility in a clean, sanitary, and safe condition affecting all 58 residents residing at the facility. Findings include: 200 Unit Carpet On 7/14/24 at 9:01 AM, during an initial tour of the 200 unit at the facility, the carpet on the unit was observed to be stained, worn, with missing spots of carpet observed next to the walls on the unit. On 7/16/24 at 8:32 AM, a further inspection of the carpet on the 200 unit revealed many large stains on the carpet and the carpet to be buckled in some areas. On 7/16/24 at 8:32 AM, an interview regarding the condition of the carpet on the 200 unit was conducted with Housekeeper R. Housekeeper R stated, The carpet needs a deep clean. On 7/16/24 at 8:35 AM, an interview regarding the condition of the carpet was conducted with Housekeeping/Laundry supervisor (HLS) S. HLS S stated, We have shampoo' d it and the stains won't come out. I have no floor technician. It needs to be…

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

Based on interview and record review the facility failed to employ a full-time activities director this deficient practice has the potiential to affect all 58 residents that resident in the facility. Findings Include: On 7/15/2024 at 2:00 PM, an interview was conducted with a resident regarding activities in the facility. The resident stated the facility does not have an Activities Director and has not had one in months. The resident confirmed they do not have many activities, including none on the weekend. On 7/16/2024 at 10:00 AM, an interview was conducted with the Regional Nursing Home Administrator (RNHA). The RNHA stated they do not believe the facility has an Activities Director right now, but they have hired one and they should be starting soon. On 7/16/2024 at 11:29 AM, an interview was conducted with Activities Aide (AA) I. AA I stated the facility has been without an activities director for months and they have been by themselves. AA I stated they have been in the role as an activity's aide for the last year, both part time and full time. AA I stated prior to role 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.

This citation pertains to Intake MI00145043 Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, resulting in the potential for inadequate coordination of care and negative clinical outcomes, potentially affecting all residents residing in the facility. Findings include: On 7/15/2024 at 9:56 AM, a request was made for daily staff postings. Upon review of the postings RN coverage was not noted on the following dates: January -2 March-7,11,12,13,15,21,27 and 29 June-3,4,5,7,12,18,19,20,21,22,23,24, and 25 July-3 On 7/16/2024 at 1:00 PM, an interview was conducted with the scheduler, Staff J. Staff J stated sometimes they do have a hard time getting RN coverage. Staff J stated they have the weekend supervisor and a night RN and can sometimes use the Director of Nursing (DON) for coverage. On 7/16/2024 at 3:16 PM, an interview was conducted with the DON via phone. The DON stated initially when they joined in March, they did not have consistent RN coverage. However, they are working…

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 record and post necessary staffing information to ensure the facility had adequate staff per regulatory guidance to meet the care needs of the residents. This deficient practice had the potential to affect all 58 facility residents. Findings include: Review of the Centers for Medicare and Medicaid PBJ staffing data report showed the facility triggered for three areas of staffing concerns. During the quarter 1/01/24 to 3/31/24, the concerns were: low weekend staffing, one-star staffing rating, and no RN (Registered Nurse) consistent hours, per regulatory guidance. During an observation on 7/14/24 at approximately 9:35 a.m., a binder with nursing staff schedules was found at the central nurse's station on South Hall, which showed the names of the staff scheduled, and which hall and rooms they covered. There was no staff posting data, showing the number and hours of the staff working, for RN's or CNAs (Certified Nurse Aides). An interview was conducted 7/14/24 at approximately 9:40 a.m. with the Unit Manager, RN B who 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.

This citation pertains to intakes MI 143412 Based on observation, interview, and record review, the facility failed to ensure meal portion sizes met the nutritional needs of the residents, resulting in the potential for inadequate protein intake, weight loss, and decreased meal enjoyment. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 7/15/24 at 12:30 PM, Dietary Supervisor L was observed preparing meal trays for the lunch service. Dietary Supervisor L was observed placing a small 2 1/2 inch x 2 1/2 inch piece of baked chicken on each plate, along with a vegetable side, a pasta side and a dinner roll. A test tray of this lunch meal was requested. On 7/15/24 at 12:45 PM, the test tray was observed with Registered Dietitian (RD) M. RD M was queried about the size of the baked chicken that was being served for lunch to the residents. RD M stated that the piece of chicken served was probably around 2 ounces, and that it was not big enough. RD M stated that 2 pieces of the chicken would have been a more…

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 MI00145270. Based on observation, interview, and record review, the facility failed to serve food in a palatable manner and at the preferred temperature for one resident (R2) and seven confidential group residents, resulting in dissatisfaction during meals. Findings include: R2 On 7/14/24 at 2:38 PM, R2 was interviewed about food palatability at the facility and stated, The food is cold. I don't eat most of it. On 7/15/24 at 10:10 AM, a follow-up interview was conducted with R2 and they were asked about the palatability of their breakfast. R2 indicated they did not eat their breakfast and stated, It didn't look good. On 7/15/24 at 12:40 PM, an observation was made of staff serving lunch trays to residents' rooms with the food cart doors left open. On 7/15/24 at 12:43 PM, a random food tray off of the food cart was temperature checked by Registered Dietician (RD) M and the temperatures of the food was the following: Baked Chicken: 112 degrees Fahrenheit; Cooked Mixed Vegetables: 111 degrees Fahrenheit; Orzo (Pasta): 120 degrees Fahrenheit. RD M 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.

This citation pertains to intake MI 143412 Based on observation, interview, and record review, the facility failed to ensure meals were served in a timely manner and in accordance with the scheduled mealtimes for the resident, resulting in late meals and resident dissatisfaction. Findings include: A review of an undated facility document titled, Meal Times, revealed the following: Breakfast 7:30 am-8:30 am, Lunch 11:30 am-12:30 pm. On 7/14/24 at 9:15 am, kitchen staff was observed getting ready to start the breakfast meal trayline service. When queried as to why the breakfast meal was late, Dietary Aide K stated that they do not have enough staff in the kitchen, and that if's difficult to get meals out on time when they are trying to do everything with just 1 or 2 staff members. On 7/14/24 at 10:30 am, breakfast trays were still being delivered to residents throughout the building. On 7/14/24 at 3:07 pm, lunch trays were observed being passed to residents on the South Hall. Resident #6 and Resident #34 complained about the late lunch meal and stated they were hungry. On 7/15/24 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.

Based on observation, interview, and record review, the facility failed to store, prepare and serve food under sanitary conditions. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 7/14/24 at 8:40 AM, the trash can located at the handwashing sink near the main entrance of the kitchen, was observed with no liner, and was heavily soiled on the inside and outside with a black mold-like substance. In addition, the handwashing sink located near the ice machine was observed with food debris in the sink basin, and there were no paper towels in the towel dispenser. According to the 2017 FDA Food Code section 5-501.116 Cleaning Receptacles, .(B) Soiled receptacles and waste handling units for REFUSE, recyclables, and returnables shall be cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents. According to the 2017 FDA Food Code section 5-205.11 Using a Handwashing Sink, .2. (B) A HANDWASHING SINK may not be used for purposes other than…

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 effectively administer its daily operational processes to provide for the needs of residents for all 58 residents residing in the facility by not correcting unsafe carpet throughout the hallways of the facility, and maintaining or timely replacing resident care equipment. Findings include: On 7/16/24 at 8:35 AM, an interview regarding the condition of the carpet was conducted with Housekeeping/Laundry supervisor (HLS) S. HLS S stated, We have shampooed it and the stains won't come out. I have no floor technician. It needs to be replaced, I have talked to the owner about it. On 7/15/24 at 9:45 AM, Maintenance Supervisor (MS) D was interviewed and asked about the status of the facility's mechanical lift and indicated the lift went out for repairs on/around 7/4/24, and the lift company provided the facility with a temporary mechanical lift which is currently in use at the facility. MS D was further interviewed about the lift being out of the building…

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 has multiple deficient practice statements. Deficient practice #1. Based on interview and record review, the facility failed to implement an active water management plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all of the 58 residents in the facility. Findings include: On 7/14/24 at 1:30 PM, the facility's Water Management binder was reviewed, with a form entitled Steps To Creating a Water Management Program that noted: Establish a Designated Team, Develop Water Flow Diagrams, Identify Areas, Equipment & Systems at Risk, Identify Strategies to Mitigate Risk, Establish Program to Monitor Strategies, Review Program Periodically to Confirm Effectiveness. There was no list of water management team members and no water flow diagram for the building in the Water Management binder. In addition, in the Water Management…

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: MI00143142. Based on observation, interview, and record review, the facility failed to answer call lights timely for four residents (R50, R49, R24, and R9) out of five reviewed for call lights. Findings Include: R50 On 7/15/2024 at 9:03 AM, R50's call light was observed activated. A computer screen behind the nurse's station showed that R50's light had been activated for 13:00 minutes. At 9:06 AM, R50's light was observed activated. Two certified nurses' assistants were noted to walk past R50's room and a nurse was noted at their cart down the hallway. At 9:10 AM, R50's light was observed still activated. At 9:12 AM, a nurse was observed going into R50's room and deactivating the call light. R50 was heard stating they wanted a pain pill. On 7/15/2024 at 2:33 PM, R50 was interviewed regarding call light waits. R50 stated sometimes it takes a while to get their call light answered. R50 stated they can wait anywhere from 30 minutes to an hour for help after pushing their light…

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 provide activities to meet the resident needs for four residents (R9, R19, R20, and R32) out of five reviewed for activitites. Findings include: R9 On 7/15/2024 at 12:29 PM, R9 was interviewed regarding the activities provided in the facility. R9 stated they do not offer activities for everyone. R9 stated when they get up in their wheelchair, there is nothing to do except ride in circles in my chair. On 7/15/2024 at 2:03 PM, activity notes were requested for R9. None were received by end of survey. R19 On 7/15/2024 at 11:00 AM, R19 was observed walking around the facility. R19 stated they were bored and wondered where the best place in the facility was to bird watch. R19 was observed walking around the facility, sitting in the lobby, and then going back to their room. On 7/15/2024 at 2:03 PM, activity notes were requested for R19. None were received by end of survey. R20 On 7/15/2024 at 2:43 PM, an interview was conducted with R20 regarding activities in the facility. R20 stated they don't get out their 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a 14 day stop date to an antianxiety or provide adequate documentation to justify use beyond 14 days for PRN (as needed) medication for two residents (R21 and R44) out of four reviewed for unnecessary medications. Findings Include: R21 A review of the medical record revealed that R21 admitted into the facility on 6/26/2024 with the following diagnoses, Anxiety and Rheumatoid Arthritis. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 15/15 indicating an intact cognition. R21 also required assistance with bed mobility and transfers. Further review of the physician orders revealed the following orders, Alprazolam-Schedule IV tablet;0.25 mg: amt: 1 tablet; oral. Special Instructions: take 1 tablet 2 times a day as needed. Alprazolam-Schedule IV tablet;0.5 mg: amt: 1 tablet; oral. Special Instructions: take 1 tablet 2 twice a day as needed. No stop date was noted for either order. On 7/15/2024 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.

This citation pertains to Intake MI00145142. Based on observation, interview, and record review, the facility failed to ensure patient equipment was in safe operating condition for the prevention of hazards and accidents for four residents (R49, R2, R34 and R6) from a sample of five residents. Findings include: R49 During on observation on 7/14/24 at approximately 9:55 a.m., R49 was observed in the South Hall aisleway. She was seated in a manual wheelchair, with her arms wrapped in gauze, with some bruising noted, and a small amount of blood was seeping from her right arm bandage. Upon further observation, it was noted there was blood on the right armrest of R49's wheelchair. It was further observed the padded wheelchair armrests had cracks in the fabric, and were worn down, so the plastic edge appeared to be a contact point to R49's arms, especially the right armrest. During an interview on 7/14/24 at approximatley 10:00 a.m., R49 was asked about the blood, and their wheelchair. R49 reported they cut their arms on the plastic edge of the wheelchair arms and said they made 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 This citation pertains to Intake MI00145142. Based on interview and record review, the facility failed to ensure that a (name of) total assistance mechanical lift was available for two residents (R2 and R9 ) of two residents reviewed for accommodation of needs/choices, resulting in residents not being able to get in and out of bed safely and as desired. Findings include: R2 A review of a complaint submitted to the state agency (SA) revealed the following, On 6/14/24, staff had to call the Fire Department to come and put [R2] in bed because the lift wasn't working properly and had been out for repairs. A review of R2's electronic medical record (EMR) revealed the following progress note dated 6/22/24 5:03 AM, Resident called the fire department [four] times. The fire department some how was in the building and stating that the resident was on the floor. Writer followed the fire department passed the resident room the resident was in the room sitting in the chair. Resident was asked on several occasions by the…

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

This citation pertains to Intake MI00145446. Based on interview and record review, the facility failed to ensure abuse allegations were reported timely to the State Agency (SA) for one resident (R4) of three residents reviewed for abuse. Findings include: A review of an Intake MI00145446 revealed the following, Incident Summary: R45 was observed reaching out trying to touch R4 inappropriately. R45 was observed by staff trying to touch R4's chest. The incident occured on 6/11/24. The facility incident report was received via online submission on: 6/25/24 at 10:47 AM (14 days after incident occured). On 07/16/24 at 10:00 AM, a phone interview occurred with the Director of Nursing (DON). DON was asked their expectation for reporting abuse and stated, All abuse investigations shoud be reported to the Abuse Coordinator and State Agency in a timely manner. In this case when the incident occurred the administator was on vacation and I did not know how to report, so the incident was reported when the administator returned. A review of the facility's Abuse, Neglect and Exploitation Policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written transfer notification to the resident and Ombudsman notification for one Resident (R29) of two residents reviewed for required acute care hospital transfer notifications. Findings include: During an interview on 7/14/24 at 1:58 p.m., R29 confirmed they were recently hospitalized when they had a bruise which worsened and caused a wound. Review of R29's census revealed R29 was hospitalized on [DATE] and returned to the facility in the same room and bed on 3/21/24. Review of R29's Electronic Medical Record (EMR) revealed no written notification of transfer to the acute hospital. The survey team requested documentation of R29's written transfer notification, and the Ombudsman monthly notification list from corporate administrative staff on 7/16/24, per regulatory guidance. The administrative staff confirmed neither were found by survey exit.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement a plan of care for one resident (R15) out of three residents reviewed for respiratory care. Findings include: On 07/14/24 at 10:00 AM, R15 was observed lying in bed with oxygen concentrator running and the nasal cannula lying on floor next to the bed. At 02:26 PM, R15 was observed lying bed. R15 was asked if they were having trouble breathing and the reply was yes. The nasal cannula remained laying on the floor next to the bed. On 07/15/24 at 08:59 AM, R15 was observed sitting up in the bed eating breakfast. The nasal cannula was observed on the floor with oxygen concentrator running. At 010:15 AM, Nurse U was asked to assess R15's oxygen reading and it revealed 92%. The nurse was asked to show the physician's order for R15 oxygen. There was no active order. A review of R15's medical record revealed they were admitted into the facility on 4/06/24 with diagnoses of Acute Respiratory Failure, Pneumonia, Adjustment disorder 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 interview and record review, the facility failed to update the fall care plan interventions following resident falls for one resident (R39) of two reviewed for care planning. Findings include: On 7/14/24 at 9:22 AM, during a tour of the facility R39 was observed to have bruising on their upper forehead. When interviewed, R39 indicated they had a recent fall at the facility. A review of R39's incidents and accidents (I/As) from April 2024 to the present revealed that R39 had falls at the facility on 4/28/24, 5/1/24, 5/5/24, 5/12/24, 5/15/24, 5/29/24, 6/11/24, and 7/8/24. A review of R39's fall care plan revealed no new interventions were placed on the care plan following any of the above listed falls. The most recent fall intervention listed on R39's care plan was dated with a start date of 4/23/24. A review of R39's electronic medical record (EMR) revealed that R39 was admitted to the facility on [DATE] with diagnoses that included Encephalopathy (Damage or disease that affects the brain) and Type 2…

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 MI00145293. Based on interview and record review, the facility failed to provide consistent, scheduled showers for one resident (R29) of three residents reviewed for Activities of Daily Living (ADL) bathing care needs. Findings include: During an interview on 7/14/24 at 1:55 p.m., R29 reported they wanted to receive showers regularly. R29 stated, I want a shower and I am not getting them, as they are at night, and they [nursing staff] will not do them. I talked to a nursing manager about it [unnamed], and they are supposed to be twice a week. R29 reported this made them feel upset and frustrated, as being clean was important to them, and they wanted full showers. Review of the Electronic Medical Record (EMR) revealed no shower logs. Review of R29's, ADL bath logs showed R29 had received four baths in a one-month period, with six entries showing, activity did not occur, without explanation. There was no documentation of any showers for R29 during the 30-day look back, only baths.…

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 Practice Statements (DPS). DPS #1 Based on observation, interview, and record review, the facility failed to set up follow up appointments for one resident (R55) out of two residents reviewed for follow up appointments, resulting in delay of care. Findings include: On 7/15/2024 at 9:55 AM, R55 was observed laying in bed. R55 stated they were waiting for a pain pill. R55 stated they had a fracture in their left knee, upon observation the left knee was visibly swollen. R55 stated they had a left hip replacement due to a fall at home. A surgical dressing was observed on the left hip. R55 stated the dressing had been there since 6/12/2024 and they had not had a follow up with Orthopedics (bone specialist) yet. R55 also stated they had cancer and should be receiving chemotherapy. R55 stated they should be going every Friday, and they have missed four treatments since being admitted into the facility. A review of the medical record revealed that R55 admitted into 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide restorative services to one resident (R29) of one resident reviewed for limited range of motion and restorative services. Findings include: During an observation on 7/14/24 at 1:00 p.m., R29 was observed in their room, seated in a power wheelchair. R29's right arm was bent up at the elbow, and their right hand was closed tightly, with increased muscle tone, and they had an amputated right leg, below the knee. R29 reported they had a right-hand splint, which they wore during the day on and off, and showed surveyor a right hand and forearm padded handroll splint on their dresser. R29's power wheelchair had a joystick on the left side, and R29 reported they used thier left hand to maneuver their joystick and operate the power wheelchair. During an interview on 7/14/24 at 1:53 p.m., R29 reported they wanted exercise and range of motion to their right arm and remaining leg to maintain and improve their mobility, and stated, No one 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.

Based on interview and record review, the facility failed to ensure that a physician responded to Pharmacist Medication Regimen Reviews (MRR) recommendations timely for one resident (R29) out of two reviewed for MRR's. Findings include: A review of the medical record revealed pharmacy progress notes that stated, See report for any irregularities on the following days: 1/3/2024, 3/6/2024, and 6/5/2024. On 7/16/2024 at 2:35 PM, an email was sent requesting the complete MRR and pharmacy recommendations for R29. On 7/16/2024 at 3:43 PM, an email was received stating they did not have the full MRR and/or the pharmacy recommendations with the physician follow up. On 7/16/2024 at 4:47 PM, an interview was conducted with the Director of Nursing (DON) via phone. The DON stated the staff in the facility probably could not find the MRR's because they are in a binder in the office. The DON stated they were not sure why they were not provided. No additional information was provided prior to the end of survey. A policy for MRR's was requested, but not received prior to the end of survey.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number MI00141707. Based on observation, interview and record review, the facility failed to provide wound care treatment and prevention interventions as ordered for one resident (R706) of three residents reviewed. Findings include: Resident 706 (R706): Review of the facility record for R706 revealed an admission date of 01/09/19 with diagnoses that included Cerebral Infarction, Sepsis and Pneumonia. The Minimum Data Set (MDS) assessment dated [DATE] indicated R706 required total assistance for all mobility and activities of daily living. On 02/29/24 at 9:50 AM, R706 was observed laying in bed. Bilateral heel float boots were observed laying on the floor next to the dresser. Additional review of R706's facility record revealed an active physician order dated 01/22/24 to Cleanse right heel with normal saline, apply collagen & Sanyl then cover, then apply foam boots to heels. On 02/29/24 at 10:40 AM, R706 was observed laying in bed. Float boots were not on the resident and 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 M100141492, M100142045 and M100142910. Based on interview and record review, the facility failed to provide pain medication as ordered for one resident (R703) of three residents reviewed. Findings include: Resident #703 (R703): Review of the facility record for R703 revealed an admission date of 09/18/20 with diagnoses that included Muscular Dystrophy, Anxiety Disorder and Right Hand Contracture. The Minimum Data Set (MDS) assessment dated [DATE] indicated that R703 required total assistance for most activities of daily living and that their cognition was intact. On 02/28/24 at 10:12 AM, R703 was interviewed in their room and they reiterated their complaint report that they did not receive their pain medication between 01/05/24 and 01/08/24 because the facility had run out of the medication. Further review of R703's facility record revealed an active physician order for Norco one 325 mg tablet every four hours dated 06/08/21. Review of R703's Medication Administration…

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 observation, the facility failed to assess for self-medication administration prior to leaving inhalers in room, for one resident (R708) out of two reviewed for self-medication administration, resulting in medications left in the resident's room and the potential for error in administration. Findings Include: On 10/9/2023 at 9:11 AM, R708 was observed in their room and laying in bed. R708 was observed with three inhalers at their bedside. R708 stated that they always keep their inhalers at the bedside and use them when they feel like they need them. R708 stated that they don't use them on a schedule, just when they feel like they need to use them. A review of the medical record revealed that R708 admitted into the facility on 5/13/2023 with the following diagnoses, Displaced Fracture and Bipolar Disorder. A review of the Minimum Data Set assessment revealed a Brief Interview for mental Status score of 15/15 indicating an intact cognition. R708 also required extensive two-person assistance with bed mobility and transfers. On 10/9/2023 at 9:52 AM,…

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 provide 1:1 feeding assistance to two residents (R703 and R704) out of four reviewed for dining, resulting in the potential for inadequate meal intake and potential for aspiration. Findings include: R703 On 10/9/2023 at 9:20 AM, R703 was observed sitting in a geriatric chair, with their breakfast tray sitting on their lap. R703 was observed holding a bowl of grits and eating them. The meal ticket on the tray stated the following, 1:1 food assistance. There was also a sign posted on the wall by R703's closet that stated that R703 required 1:1 food assistance. No one was observed in the room with R703 during the breakfast meal. A review of the medical record revealed that R703 admitted into the facility on 9/27/2023 with the following diagnoses, Dysphagia, Maxillary Fracture, and Muscle Weakness. A review of the Minimum Data Set assessment revealed Brief Interview for Mental Status score of 99, indicating that R703 was unable to complete the assessment. R703 also required extensive two person assistance 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.