Medilodge of Sterling Heights

Based on observation, interview, and record review, the facility failed to maintain the dish machine area in the kitchen in a clean manner, resulting in the presence of gnats. This deficient practice had the potential to affect all residents, staff and visitors. Findings include: On 03/10/25 at 9:15 AM, there were numerous gnats observed underneath the dish machine tank and drainboard. The flooring was wet with murky standing water, and the pipes underneath the drainboard were coated with a black slimy substance. When queried about the gnats, Dietary Manager S provided no explanation. Review of the pest control service reports noted: 8/20/24 Upon inspection of the kitchen it was found there was heavy gnat activity. The cause of the gnat activity is the cleanliness in the kitchen. Areas all around and underneath dish tank were so soiled with debris that they were creating harboring spaces for gnats. 9/20/24 Upon inspecting the kitchen, many gnats were present. Kitchen staff must do a better job of cleaning. 1/15/25 Upon inspection of the kitchen there was heavy gnat activity. This is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure call lights were in reach for five residents (R34, R86, R147, R612, and R613) of six residents reviewed for call light accessibility. Findings include: R612 On 3/10/25 at 1:10 PM, R612's call light was observed out of reach of R612 and on the floor. On 3/12/25 at 10:55 AM, [NAME] Clerk (WC) P was observed in R612's room and was interviewed regarding the preferred location of the call light for R612. WC P stated, It should be within hand reach. A review of R612's electronic medical record (EMR) revealed that R612 was admitted to the facility on [DATE] with diagnoses that included End stage renal disease (Damaged kidney) and Type 2 diabetes. R612's most recent minimum data set assessment (MDS) dated [DATE] revealed R612 had an intact cognition and required moderate assistance to supervision for all activities of daily living (ADLs). R613 On 3/10/25 at 2:32 PM, R613's call light was observed on the floor by the end of their bed. 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 This citation pertains to Intake MI00150763. Based on interview and record review, the facility failed to timely complete an investigation for an allegation of abuse for one (R2) of two resident reviewed for abuse. Findings include: A review of the Intake reported to the State Agency noted an allegation that staff in the facility failed to treat the resident with dignity and respect (on 2/27/25). On 3/11/25, R2 was observed sitting in their room looking at their computer tablet. R2 did not recall the alleged incident or staff who cared for him on 2/27/25. A review of R2's electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, dysphagia, delusional disorders, and mild intellectual disabilities. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Brief Interview of Mental status score of 1 which indicated severely impaired cognition. On 3/12/25 at 9:00 AM, an interview was conducted with Maintenance Director (MD) I .…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete an annual PASARR (Preadmission Screen and Resident Review) for two residents (R70 and R139) of 6 residents reviewed for PASARR screening. Findings include: R70 A review of R70's medical record revealed they were admitted into the facility on [DATE] with diagnoses including dysphagial, intellectual disabilities, functional quadriplegia. A Minimum Data Set (MDS) assessment dated [DATE] and a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Further review of R70 electronic medical record revealed a PASARR dated 11/27/24 and marked Preadmission screening and revealed no level II PASAAR request. R139 On 03/10/25 at 10:00 AM, R139 was observed lying in bed and watching television. R139 was finishing his breakfast meal. R139 verbalized concerns about wanting to meet with the social worker to discuss change in guardianship. A review of R139's medical record revealed they were 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.

Based on observation, interview and record review, the facility failed to develop a care plan addressing Post-Traumatic Stress Disorder (PTSD) for one resident(R62) out of three reviewed for mood/behavior care plans. Findings include: A review of the medial record revealed R62 was admitted into the facility on 6/13/2022 with the following medical diagnoses, Major Depressive Disorder and Post-Traumatic Stress Disorder (PTSD). A review of the most recent Minimum Data Assessment (MDS) set revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. On 3/10/2025 at 10:00 AM, an interview was conducted with R62. R62 stated they do have PTSD due to things in their past. R62 stated they have triggers, but the medicine helps manage it. Further review of the medical record revealed a mood/behavior care plan. The mood/behavior care plan did not include the PTSD diagnosis or known triggers. On 3/12/2025 at 10:13 AM, an interview was conducted with Social Worker (SW) F. SW F stated when they assess the resident when they admit into the facility it should be added…

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 assistance for two residents (R24, R154) out of six reviewed for Activities of Daily Living (ADLs). Findings include: R24 On 3/10/25 at 10:27 AM, R24 reported over the past weekend Saturday (3/8/25) into Sunday (3/9/25) they requested ADL care around 6:15 AM, no one on the midnight shift came in to provide care. They explained they received care on the day shift at 9:45 AM. R24 explained on another (unknown) day they put the light on around 7:00 PM on a Friday, and did not receive care until 9:30 PM. A review of R24's medical record revealed, R24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Myocardial Infarction. A review of R24's annual Minimium Data Set (MDS), dated [DATE] noted, R24 with an intact cognition and required assistance from staff to complete activities of daily living (ADLs). Further review of R24's concern forms provided by the facility noted, multiple days of staff not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure timely podiatry care was provided for one resident (R201) of one resident reviewed for foot care. Findings include: On 03/10/25 at 9:00 AM, R201 was observed sitting on the side of the bed. When asked about any concerns, R201 stated they are concerned about their toenails because they are too long and starting to hurt. R201 toenails were observed to be long extending past the tip of the toes. R201 could not recall the last podiatry visit. A review of R201's medical record revealed they were admitted to the facility on [DATE] with a diagnosis of Down's syndrome, Schizophrenia, and Chronic kidney disease. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Brief Interview of Mental status (BIMS) score of 14 which indicated intact cognition. Further review of R201's elcetronic medical record did not reveal a current podiatry consultation. On 3/11/25 at 2:00 PM, an interview occured with the Social Service Director…

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 label and date a tube feeding bottle for one resident (R75) out of two reviewed for tube feedings. Findings include: On 3/11/2025 at 10:24 AM, R75 was observed laying in bed. R75 was observed to have a tube feeding running. The bottle was noted to be unlabeled and undated. On 3/11/2025 at 10:24 AM, Licensed Practical Nurse (LPN) A was brought into the room and shown the tube feeding bottle. LPN A stated the tube feeding goes up on the evening shift, and that it should be labeled. A review of the medical record revealed that R75 was admitted into the facility on 6/10/2024 with the following diagnoses, Quadriplegia and Gastrostomy. A review of the recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 99 indicating they were unable to complete the assessment. R75 also required staff assistance with bed mobility and transfers. On 3/12/2025 at 1:24 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the tube feeding goes up at night and that the tube…

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

Based on observation and interview, the facility failed to ensure medications were discarded when expired from one medication cart (U100 low numbers) of three medication carts reviewed. Findings include: On 3/12/2025 at 02:07 PM, along with Licensed Practical Nurse (LPN) G, two expired stock medications were located in the top drawer of Unit 100's lower numbered medication cart. The medications were Glucosamine Chrondroitin with an open date of 10/1/24 and a stamped expiration date of 01/25 and Oyster Shell Calcium 500mg (milligrams) with an open date of 9/25/24 and a stamped expiration date of 08/24. On 3/12/2025 at 04:15 PM, the Director of Nursing (DON) indicated expired medications should be removed from use. A policy for Medication Storage was requested but not received by the end of the survey.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident equipment (two beside dressers, one overbed table) was in good, clean, and safe condition for three residents (R20, R143, R167) of residents reviewed for homelike environment. Findings include: On 03/10/25 at 09:55 AM an observation of the bedside dresser for R20 revealed a two-inch gap between the first and second drawer. R20 was queried regarding the gap and responded, oh without further verbalization. On 03/12/25 a review of the record revealed R20 was admitted on [DATE] with a diagnosis of dementia. R26 has a Brief Interview of Mental Status (BIMS) score of 00 indicating severe cognitive impairment. On 03/10/25 at 10:10 AM, an observation revealed the overbed table for R143 had many dark circular stains. R143 was asked if they found the condition of the overbed table bothersome. R143 provided a blank stare and did not respond at all. On 03/12/25 a review of the record revealed R143 was admitted [DATE] with a diagnosis…

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 pertians to Intakes MI00149291, MI00149568, and MI00149398. Based on observation, interview, and record review, the facility failed to ensure incontinence care, repositioning or water was provided for three dependent residents (R703, R706, and R707) of three reviewed for Activites of Daily Living (ADL) care. Findings include: R703 and R707 On 01/22/25 at 8:52 AM, R707 reported they did not have any water and had been left an extended amount of time waiting to be assisted with incontinence care. R707 had finished their breakfast. On 01/22/25 at 8:55 AM, R703 was observed to be in bed. A wedge was visible at the right side of the torso. The resident verbalized concerns about being changed (providing care) timely in the after dinner hours. R703 reported they had not been turned since earlier in the morning and was supposed to be turned every two hours. The resident was able to read the clock in the room. The time stated by R703 was correct. R703 reported the breakfast tray had been removed and noted…

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 MI00147415 and MI00147559. Based on observation, interview, and record review, the facility failed to ensure resident rooms, common areas, and shower rooms were homelike on two nursing units (units 100 and 200) of four units reviewed. Findings include: A review of the intake dated 10/18/24 revealed, .bathroom had no working lights, and the piping underneath the sink was not attached to the sink . It was also noted there was a burnt outlet in the room. A further comment noted, staff were asked to switch bed to a pressure release bed, but staff did not switch it until the last day . and .there are sharp metal objects sticking out the floor in the hallway . On 10/22/24 at 9:21 AM, the main hall to the 100 and 200 units was noted to have a round metal disc in the center of the hallway outside the main dining room. The disc was held down with a screw in the center. The edges of the disc were bent upwards above the level of the floor and the disc was loose when stepped on. A piece of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00145616. Based on interview and record review, the facility failed to develop and implement actions to prevent repeated falls for one (R703) of one resident resulting in nine falls without goals and interventions to prevent further falls. Findings include: On 7/30/2024 st 10:57 AM, phone contact with the complainant was attempted. A voicemail was left when the call was unanswered. A return call was not received. On 4/18/2024, R703 was admitted to the facility on [DATE] after falling and sustaining a fractured left wrist and left femur prior to admission. Other pertinent diagnoses include, dementia, heart disease, difficulty walking, cognitive communication deficit, and muscle weakness. R703's BIMS (Brief Interview for Mental Status) documented a 9 out of 15, indicating moderate cognitive impairment. On 7/30/2024 a facility record review revealed R703 experienced falls on the following dates, 4/19/2024, 4/20/24, 5/1/2024, 5/2/2024, 5/1/2024. 5/24/2024, 5/29/2024, 6/12/2024, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains in part to intake #145421. Based on observation, interview, and record review, the facility failed to serve food in a palatable manner and at the preferred temperature for three residents (R704, R705, R706 ) of three reviewed for food palatability, resulting in dissatisfaction during meals. Findings include: A review of a complaint submitted to the state agency (SA) revealed the following, Complainant states the food is terrible .The complainant(s) state they have to spend their own money on food and they can't afford it. On 7/30/24 at 12:40 PM, the surveyor taste tested a random lunch meal and the results revealed that the cheeseburger and fries were [NAME] warm, the [NAME] slaw lacked flavor, and the pickle spear was soggy. All of these issues had a negative impact upon the palatability of the meal. On 7/30/24 at 2:25 PM, Dietary Manager (DM) B was interviewed regarding preferred food temperatures for meals to the residents and stated, Hot food should be hot and cold food should be cold.…

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 pertains to Intake MI00145962. Based on observation, interview, and record review, the facility failed to maintain adequate lighting in one (East Dining Room) of two dining rooms reviewed for homelike environment. Findings Include: On 7/30/2024 at 10:30 AM, during an interview with R701 they said the East Dining Room lights had been out for some time. They further revealed staff had been made aware and were very frustrated with the maintenance in the facility. On 7/30/2024 observation was made regarding lighting in the East Dining Room. It was observed that 5 lights were not illuminated. With the assistance of the Activities Director, the surveyors tried all switches controlling the lights without success. On 7/30/2024 at 1:20 pm, the Nursing Home Administrator (NHA) indicated staff have the ability to enter into their maintenance system and was unaware of the lights being out until the Activities Director notified them. The NHA indicated maintenance requests need to go through the electronic maintenance request system. The policy, Preventative Maintenance Program, revised…

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 pertains to Intake MI00145962. Based on based on observation, interview, and record review, the facility failed to maintain steam tables in a sanitary condition in one of three steam tables in the East Dining Room. Findings Include: On 7/30/2024 at 11:20 am, an observation was made of the steam tables in the East Dining Room. While observing the condition and cleanliness of the steam tables, loose crusted material and mold was noted on the third steam table with a small hood. When the material was touched, it fell onto the area where food would be sitting when in use. On 7/30/2024 at 12:35 pm, The Nursing Home Administrator (NHA) was shown the area of concern and indicated their expectation is the steam table hoods should be clean and free of mold and materials that could drop into food. The cleaning policy for cleaning steam table hoods was requested and received, Cleaning and Sanitizing Training by (name of cleaning company). The training document revealed Cleaning and sanitizing properly is one of the most important things we continually do in our kitchens to keep our…

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 MI00144848. Based on observation, interview, and record review, the facility failed to provide a clean and comfortable environment for two residents (R701 and R705 ) of three reviewed for environment, resulting in feelings of anger and frustration. Findings include: A review of a complaint submitted to the state agency (SA) revealed the following, There is bugs in room, there is black mold or oil leaking from the air conditioner on the floor both the roommate and [complainant] are not getting any help to get it fixed . On 6/12/24 at 11:55 AM, R705 was met in their room (room [ROOM NUMBER]) and interviewed about the room environment. R705 stated, Look at the carpet by the air conditioner, black stuff comes out of the air conditioner and there are black stains on the rug. R705 further indicated there were Pincher bugs that Pinch seen. R705 proceed to show the surveyor pictures on their phone of bugs which they indicated had been identified in their room. R705 indicated this…

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 MI00143948. Based on interview and record review, the facility failed to notify guardian of transferring out to the hospital for one (909) of two residents reviewed for notification of changes resulting in the guardian not being informed of resident's condition. Findings include A record review of R909's medical record revealed, R909 was admited on 9/04/15 with diagnoses of Vascular Dementia, Acute Kidney Failure, and Hypertension. A review of the most recent Minimum Data Set (MDS) dated [DATE] noted, R909's Brief Interview for Mental Status (BIMS) score of 0, which indicates severe cognitive impairment. On 5/07/24, a record review of R909's medical record revealed on 11/28/2023 at 12:00 a note stated,Writer was rounding on unit and approached resident's bedside, resident was found to be tachypneic on room air. Initiated oxygen immediately via nasal cannula at 8liters per minute . (Medical Doctor)MD was called, orders to have (Nurse Practitioner)NP at bedside and administer…

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

Based on observation, interview, and record review, the facility failed to maintain the ventilation covers in a clean manner, failed to maintain the ice machine rooms in a sanitary manner, and failed to ensure resident food items were labeled, dated and discarded when expired. This deficient practice had the potential to affect all residents that consume food. Findings include: On 1/30/24 at 8:55 AM, the ceiling/wall ventilation covers located by the dish machine, by the steam table, and near the ice machine, were observed with a buildup of dust. When queried, Dietary Manager D stated that Maintenance was responsible for cleaning the vents. On 1/30/24 at 9:15 AM, in the 200 unit refrigerator utilized for the storage of resident food items brought in from the outside, there were 2 undated food containers. When queried, Dietary Manager D confirmed the food items should have been dated, and further stated that the resident refrigerators were monitored by nursing staff. On 1/30/24 at 9:25 AM, in the 500/600 unit resident refrigerator, there was a container with moldy noodles dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to MI00141058. Based on observation, Interview, and record review, the facility failed to ensure that food was served in a palatable manner and at the preferred temperature for three residents (R167, R230, and R279) of six residents reviewed for food palatability and twelve anonymous group members, resulting in dissatisfaction during meals. Findings include: R167 On 1/30/24 at 11:32 AM, during an initial tour of the facility R167 was interviewed regarding food palatability at the facility and stated, The food is cold and doesn't taste good. On 1/30/24 at 2:00 PM, a review of R167's electronic medical record (EMR) revealed that R167 was admitted to the facility on [DATE] with diagnoses that included Fracture of ribs and Quadriplegia (Paralysis of all four limbs). R167's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R167 had an intact cognition. R279 On 1/30/24 at 11:56 AM, during an initial tour of the facility R279 was interviewed regarding food…

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 toilet was maintained in working condition for one resident (R136) of three reviewed for clean, comfortable, homelike conditions, resulting in resident dissatisfaction with living conditions. Findings include: On 1/30/24 at 9:01 AM, during an initial tour of the facility R136 was interviewed about their satisfaction with the care and services that they were receiving at the facility. R136 stated, My toilet doesn't flush. It hasn't flushed in three weeks. It has overflown. R136 expressed dissatisfaction with the functioning of the toilet in their room and further indicated that maintenance has unplugged their toilet, but it gets plugged up again frequently and on a consistent basis. On 1/30/24 at 9:02 AM, urine was observed in R136's toilet and when the toilet was flushed it did not completely drain. On 1/31/24 at 2:13 PM, a follow up visit was conducted with R136 in their room and R136 was asked if their toilet was flushing…

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 prevent resident to resident abuse for one (R38) of seven residents reviewed for abuse. Findings include: On 01/30/24 at 10:13 AM, R38 reported that R60 stuck their hand down the front of their (R38's) blouse twice. R38 stated They (staff) came and talked to me about it. It just happened two or three days ago. Review of the facility record for R38 revealed an admission date of 04/19/23 with diagnoses that included Left Hip Osteoarthritis with Left Hip Replacement, Diabetes Mellitus, Anxiety Disorder and Depression. The 10/24/23 Brief Interview for Mental Status (BIMS) assessment score of 15/15 indicated intact cognition. Further review of R38's record revealed a progress note dated 01/25/24 authored by Licensed Practical Nurse (LPN) A stating Resident stated resident of room [ROOM NUMBER]-2 put [their] finger down [their] shirt into [their] breast area. Resident did not sustain any injuries during event. Writer contact Admin (NHA), DON (Director 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 interview and record review, the facility failed to thoroughly investigate and report a sexual abuse allegation for one (R38) of seven residents reviewed. Findings include: On 01/30/24 at 10:13 AM, R38 reported that R60 stuck their hand down the front of their (R38's) blouse twice. R38 stated They (staff) came and talked to me about it. It just happened two or three days ago. Review of the facility record for R38 revealed an admission date of 04/19/23 with diagnoses that included Left Hip Osteoarthritis with Left Hip Replacement, Diabetes Mellitus, Anxiety Disorder and Depression. The 10/24/23 Brief Interview for Mental Status (BIMS) assessment score of 15/15 indicated intact cognition. Further review of R38's record revealed a progress note dated 01/25/24 authored by LPN A stating Resident stated resident of 517-2 put [their] finger down [their] shirt into [their] breast area. Resident did not sustain any injuries during event. Writer contact Admin (NHA), DON (Director of Nursing), and MD (physician) to report occurrence. Pain and Skin assessment performed. No change 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.

Based on interview and record review, the facility failed to ensure a Level I Preadmission Screening (PAS)/Annual Resident Review (ARR) Mental Illness/Intellectual Disability/Related Conditions Identification was completed timely and sent to the local community mental health (CMH) for a level II OBRA (Omnibus Budget Reconciliation Act of 1993) evaluation for one resident (R135) of one resident reviewed for PASARRs. Findings include: A review of R135's medical record revealed that they were admitted into the facility on 7/13/23 with diagnoses of Hemiplegia and Hemipresis, Dysphagia, Depression, Anxiety, and Diabetes. Further review revealed that the resident was cognitively intact and required 1-2 person assistance for Activites of Daily Living. Further review of R135's medical record revealed that a PASARR was completed on 4/28/23 by the acute care setting that referred the resident to the facility. On 2/1/24 at 9:48 AM, all of R135's PASARRs were requested from the facility, however the only documentation received was the 4/28/23 PASAAR, and an exemption form completed by the acute…

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 implement care planned interventions to prevent falls, and skin breakdown, for two sampled residents (R118 and R135) of seven residents reviewed for person centered comprehensive care plans. Findings include: R118 On 1/31/24 at 10:12 AM, R118 was observed in bed feet lying flat on the mattress, bed not in its lowest position. Attempts to interview R118 were unsuccessful as the resident was pleasantly confused. A review of R118's medical record revealed that they were admitted into the facility on 5/21/21 with diagnoses that included Dementia, Chronic Obstructive Pulmonary Disease (COPD), and Dysphagia. Further review of R118's medical record revealed that they required 1-2-person assistance for Activities of Daily Living. Further review of R118's medical record revealed the following care plans: Resident is at risk for impaired skin integrity related to confined to a bed all or most of the time r/t (related to) decreased mobility. Date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake: MI00141406 and MI00141058. Based on observation, interview and record review, the facility failed to provide the preferred bathing method and frequency for one (R78) of seven residents reviewed for bathing. Findings include: Review of the facility record for R78 revealed an admission date of 08/21/23 with diagnoses that included Liver Contusion/Laceration, Chronic Obstructive Pulmonary Disease and Bipolar Disorder. The Minimum Data Set (MDS) assessment dated [DATE] indicated R78 required maximum assistance for bathing. The Brief Interview for Mental Status (BIMS) score of 15/15 indicated intact cognition. On 01/30/24 at 10:43 AM, R78 reported they had not received a shower in about three weeks. R78 stated When I ask for a shower they say they can only do a bed bath or they say they can't because they don't have towels. I've had about four showers and four bed baths since I came here at the end of August. R78 indicated that they were scheduled for a shower for that afternoon. On…

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

Based on observation, interview, and record review, the facility failed to provide restorative services per therapy recommendation for one of one resident (R132) reviewed for range of motion. Findings include: On 1/30/24 at 12:55 PM, was observed eating lunch with their left hand as their right hand was contracted. There were no observations of any interventions in place for R132's contracture. Attempts to interview R132 were unsucessful as they smiled and ate their lunch. A review of R132's medical record revealed that they were admitted into the facility on 8/5/21 with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction, Dysphagia, and Vascular Dementia. Further review of R132's medical record revealed that the resident had a moderately impaired cognition, and required one person assistance for Activities of Daily Living. A review of R132's Occupational Therapy discharge recommendations dated 12/27/23 revealed the following, .Discharge Recommendations: Recommend RNP (restorative nursing program) for Contracture management. Restorative Program…

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 oxygen and tracheostomy (a surgical opening into the neck to allow for breathing) care, for one resident (R429) of one resident reviewed for tracheostomy care. Findings include: On 1/30/24 at 10:03 AM, R429 was observed lying in bed with a tracheostomy collar on with oxygen attached. The oxygen concentrator read 7 Liters. On 1/31/24, at 3:50 PM, R429 was observed lying in bed without being hooked up to their oxygen. Nurse E was asked about R429. Nurse E entered the room and reconnected the oxygen concentrator. Nurse E checked the resident's oxygen and reported that the pulse oximeter was at 86% (normal range between 95-100%). R429 was asked how long they had been without their oxygen, and stated, I returned from dialysis at around 2:15 PM and was put in the bed. On 2/1/24 at 8:28 AM, R429 was observed lying in bed with their tracheostomy collar on with the oxygen concentrator on at 7 liters. The resident was asked about their use…

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 medications were available and provided timely for one resident (R230) of one whose medications were reviewed resulting in expression of poorly controlled pain. Findings include: On 01/30/24 at 12:28 PM, R230 reported that they had entered the facility on a Friday afternoon and and through a series of room changes due to uncooperative roommates ended up in the cold lobby until they received a room late in the morning the next day. R230 reported that during their first four days they did not receive any pain medication and reported rib and leg pain. It was also reported they were to have oxygen at night and it had not been set up. R230 further noted the bed in the room was in need of repair. R230 reported a nurse noted they had to cover two nursing units which were not close together and was not seen by a member of the medical staff until that following Monday. R230 noted they were also on heart medication. A review of the medical record for R230 revealed, R230 was admitted into the facility on Friday 01/19/24.…

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 implement a 14-day stop date on an anti-anxiety medication for two (R26, and R135) of seven residents reviewed. Findings include: R26 Review of the facility record for R26 revealed an admission date of 05/14/23 with diagnoses that included Chronic Osteomyelitis, Chronic Obstructive Pulmonary Disease and Generalized Anxiety Disorder. The Minimum Data Set (MDS) dated [DATE] indicated R26 required total to maximum assistance with activities of daily living and the presence of moderate cognitive impairment. On 2/1/24 review of R26's active physician orders revealed an order dated 12/27/23 for Ativan Oral Tablet 0.5 milligram (MG): Give one tablet by mouth every six hours as needed for anxiety. Additional review of R26's record revealed no documentation of justification for continuing the Ativan order. R135 A review of R135's medical record revealed that they were admitted into the facility on 7/13/23 with diagnoses of Hemiplegia and Hemiparesis, Dysphagia,…

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/label/discard expired medications for (a) one (500/600 unit) of three medication storage rooms, (b) two (200 unit and 700 unit) of four medication carts reviewed and (c) two of two refrigerators reviewed for medication storage. Findings include: On 1/30/24 at 11:13 AM, the 500/600 medication storage room was inspected with Unit Manager, Registered Nurse (RN) H and the results were the following: -A vial of Lantus (Diabetes insulin) 100 ml (milliliter)/unit with no name on it was observed in the medication cupboard in the medication storage room; -A bottle of Guaifensin (Expectorant medication) 400 mg (milligrams) with an expiration date of 11/23 was also observed. RN H was interviewed about the expired vial of insulin in the cupboard and stated, It should be refrigerated. RN H was further interviewed about the expired medication and did not directly answer the question. On 1/31/24 at 1:25 PM, the 200 unit medication cart was inspected with RN I present and the results were the following: -Two inhalers…

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 ciation pertains to Intake: MI00141406 and MI00141058. Based on observation, interview, and record review the Facilty failed to ensure that resident call lights were functioning properly for one resident (R79 ) of five residents reviewed for call lights, resulting in feelings of frustration. Findings include: On [DATE] at 9:20 AM, during an initial tour of the facility R79 was interviewed regarding their level of satisfaction with the care and services they were receiving at the facility. R79 expressed frustration related to long call light wait times. R79 indicated that they currently needed their pillows adjusted and R79 activated their call light while the Surveyor was present in their room. A small red light went on next to R79's bed when the call light was activated. On [DATE] at 9:21 AM until 9:40 AM, multiple staff members were observed to walk back and forth in the hallway passing R79's room without answering the resident's call light. On [DATE] at 9:41 AM, the Surveyor exited R79's room and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to MI00141632, MI00138084, and MI00137973. Based on interview the facility failed to ensure the responsible party was informed of a change in condition for one of two residents (R918) reviewed for a change in condition, resulting in lack of knowledge about a decline and or change in the resident's condition and the potential for a delay in advanced treatment. Findings include: A review of the record for R918 revealed the resident was admitted into the facility on [DATE] and discharged on 12/13/23. Diagnoses included Sepsis, Bacteremia (systemic infection), Gastroenteritis (Stomach/Bowel inflammation/infection), Ascites (build up of fluid in the abdomen) and Dependence on Dialysis. A skilled nursing note dated 12/13/23 indicated R918 was alert to name and place but not to time and date. A review of a progress note by Licensed Practical Nurse (LPN) J dated 12/13/2023 at 7:12 AM revealed, .resident had a large projectile emesis at approx 0400. vitals are stable. resident has had no 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 This citation pertains to MI00138087. Based on observation, interview, and record review the facility failed to ensure appropriate interventions were implemented and documented to prevent falls for one of three residents (R903) whose falls were reviewed. Findings include: On 12/18/23 at 9:53 AM and on 12/19/23 at 7:48 AM R903 was observed to be standing in the doorway of the bathroom. On 12/19/23 at 10:58 AM, the therapy treatment notes for R903 were reviewed with the Therapy Director. It was reported that the root cause for many of R903's falls a lack of safety awareness, not calling for help and not able to follow safety instructions given even with in context reminders such as remembering to lock the wheelchair before standing. The Therapy Director reported R903 could stand by themselves, but should not. A review of the record for R903 revealed that R903 was admitted into the facility on [DATE]. Diagnoses include Syncope (fainting) and Collapse, Hemiplegia (weakness on one side), Mild Cognitive Impairment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00138118, MI00138025 and MI00137992. Based on interview and record review the facility failed to provide activities of daily living care (ADLS) for dependent residents for one of seven residents (R905) reviewed for ADL care. Findings include: On 12/18/23 at 9:00 AM, documentation was reviewed from a complaint received by the State Agency from [Hospital Representative] which indicated, [R905] had a strong foul odor to them .[R905] had to be cleaned up once they arrived to the [Emergency Room]. On 12/19/23 at 10:30 AM, a review of R905's electronic medical record (EMR)/shower documentation during their last stay at the facility from 10/26/23 through 11/28/23 revealed that R905 had no shower documentation observed in their record and no record of shower/bath refusals. Review of R905's EMR revealed that R905 was scheduled to receive their showers on, Thursday and Sunday day shift. Prefers showers. Further review of R905's EMR revealed that R905 was most recently admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00141644. Based on interview and record review, the facility failed to accurately assess and document vital signs for one of one sampled resident (R919) reviewed for professional standards, resulting in inaccurate vital sign recording. Findings include: A review of the Intake noted, On 12/15/2023 at 7:55pm [R919] was not breathing and without a pulse when the [Local] Fire Department arrived at the facility. [R919] had blood pooling on [their] back, lividity (bluish-purple discoloration of skin after death). [R919] was in rigor mortis and was cool to the touch and [R919] pupils were affixed . A review of the Patient Care Report by the local ambulance service that arrived to pick R919 for their scheduled discharge noted, Call Demographics. Incident Location: (Nursing Home) . Reason for leaving Nursing Home: Discharge to home . Misc (miscellaneous) Call Info . Reason for Ambulance? Dead on Scene . Response Information. Complaint Reported by Dispatch: Sick Person. Response Mode to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to MI00141632 and MI00138087. Based on observation, interview, and record review the facility failed to ensure an air mattress was in place, and or reposition a resident timely and or document wound care as completed for three residents (R922, R904, R918) of three reviewed for pressure ulcer care, resulting in the potential for decreased wound healing. Findings include: R922 On 12/18/231:15 R922 was observed to be in bed. R922 appeared to be on their back in bed despite a foam wedge on the left side. A visitor in the room reported they had been with the resident since around 11:30 AM and the staff had not repositioned R922. The visitor reported that the staff were attending to R922's wounds but the facility had yet to place the air mattress on R922's bed and the resident had been at the facility for two weeks since returning from the hospital. The visitor further noted R922 to be a long-term resident and that R922 had the mattress in their other room prior to discharge to the hospital. 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 MI00140698. Based on observation, interview, and record review, the facility failed to ensure four (R903, R911, R921, and R923) of four residents reviewed for dietary services, received meals according to their preferences. Findings include: A review of R921's medical record revealed, R921 was admitted to the facility on [DATE] with diagnosis of Acute Respiratory failure. A review of R921's [NAME] Data Set (MDS) assessment noted, R921 with an intact cognition. On 12/18/23 at 10:17 AM, R921 was asked about the food at the facility and stated, I get a lot of pasta and I'm diabetic. I don't eat it because I know I can't have that many carbs. A lot of rice and ravioli. The broccoli is mushy and cold. R921 was asked if they are able to preview the menu and then select. R921 stated, No. R921 also stated, I'm allergic to nuts and tuna but I get them both on my tray. I had a care conference and said no bread, I keep getting it. R921 was observed to pointed out that the HS snack for last…

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 MI00138084. Based on observation, interview and record review the facility failed to ensure rooms were cleaned appropriately and beds were in good condition for two room [ROOM NUMBER]-1 and 716-1 resulting in the potential for resident disatisfaction with their rooms and lingering debris on the floor. Findings include: On 12/18/23 at 10:24 AM, 1:03 PM and 3:36 PM, room [ROOM NUMBER] was observed to have a metal fork under the center area of the bed. On 12/19/23 at 7:55 AM and 10:36 AM, the fork remained under the bed. On 12/18/23 at 12:57 PM, in room [ROOM NUMBER] piles of different sized pieces of sheet rock and sheet rock dust were observed on the floor below vertical gouges in the sheetrock behind the head of the first bed. A visitor commented that it had been that way for months and had not been cleaned up. On 12/19/23 at 10:32 AM, it was noted that the sheet rock dust remained and two of the four wheels at the foot of the first bed were broken and the wheel trucks rested on 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 MI00137875. Based on interview and record review, the facility failed to obtain a stool (bowel movement) sample, initiate a new wound treatment timely, adequately document nursing assessment and monitor edema/swelling, affecting one resident (R003) of three reviewed for quality of care, resulting in decreased coordination of care and the potential for unmet care needs. Findings include: A review of R003's record revealed the resident was admitted into the facility on 5/5/23 and discharged on 7/1/23. R003's medical diagnoses included Myocardial Infarction (Heart Attack), Diabetes, Lung Disease, Muscle Weakness, Dysphagia (difficulty swallowing), and Malignant Neoplasm Of Uterus and Colon (Cancer). A review of R003's record revealed that the resident began having loose stools on 5/27/23 that persisted through 5/30/23. A Physician Progress note dated 5/30/23 indicated that a stool sample was to be collected to test for C. Diff (Clostridioides difficile - an infection of the large…

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.