Optalis Health and Rehabilitation of Sterling Heig

Based on observation, interview, and record review the facility failed to prevent a fall for one resident (R143) of four residents reviewed for falls resulting in pain. Findings include: On 6/23/25 at 9:28 AM, R143 was observed in bed, unable to move their right arm. R143 was asked about their care in the facility and explained they've had concerns regarding transfers and bed mobility as they recently sustained a fall. A review of R143's medical record revealed they were admitted into the facility on 4/18/25 with diagnoses which included, nontraumatic intracerebral hemorrhage in brain stem, Diabetes, and Heart Failure. Further review revealed the resident was cognitively intact and required 1-2 person assist with transfers, bed mobility, and grooming. Further review of the medical record revealed the following progress notes: 6/11/2025 21:21 (9:21pm) . Note Text: Resident is A&Ox3-4. (alert and oriented to person, place, and time) Assist x1-2 (persons) with adl's (activities of daily living), bed mobility, and transfers. Incont (incontinent) of bowel and bladder with incontinence…

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 label, date, and provide tube feeding (nutrition infused directly into the stomach via a tube) as ordered for one resident (R152) of three residents reviewed for tube feeding. Findings include: A review of the record for R152 revealed R152 was admitted into the facility on [DATE]. Diagnoses which included Non traumatic Brain Dysfunction, Stroke and High Blood Pressure. The Minimum Data Set (MDS) assessment dated [DATE], indicated severely inmpaired cognition, impaired range of motion of the extremities, and R152 was dependent on staff for all activities of daily living including eating, bed mobility, bathing and personal hygiene. On 06/23/25 at 8:53 AM, 3:45 PM and on 06/24/25 at 8:33 AM, R152's was observed to be in bed with the tube feeding actively running at 40 milliliters(ml) per hour (ml/hr), with the formula bag dated 6/22 5:30 PM. A review of the active Physician's order R152's tube feeding rate revealed the feeding should have…

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 medications were not left at the bedside for one resident (R74) of one resident reviewed for medication storage. Findings include: On 6/23/25 at 3:32 PM, R74 was observed lying in their bed. A medication cup with 2 pills were observed sitting on the resident's overbed table. The resident was asked about the medications and explained they didn't realize they were there, and didn't know how long they had been sitting there. On 6/23/25 at 3:34 PM, during an interview with Licensed Practical Nurse (LPN) G, assigned nurse to R74, who explained they had gone into the room to provide services to R74's roommate and in doing so provided the medications to the R74. LPN G confirmed they didn't know why the resident hadn't taken them. LPN G then entered R74's room and watched the resident take the medication. LPN G indicated the medications in the medication cup were, Robaxin (muscle relaxer) and (R74's) blood pressure medication because their blood pressure runs high.' A review of R74's medical record…

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

Based on interview and record review, the facility failed to ensure the completion of 12-hours of annual in-service trainings of two Certified Nursing Assistants (CNA O and CNA P), of five reviewed for the completion of 12-hours of annual in-service training. Findings include: On 6/25/25 at 8:43 AM, 12-hours of annual in-service training was requested from the facility for CNA O and CNA P. On 6/25/25 at 11:44 AM, the facility provided documentation the 12-hours of annual training was requested from the vendor the facility uses for CNAs that work on an as needed basis and are not hired directly through the facility. A review of a document titled, CNA skills competency checklist was provided for CNA P however, it did not reveal the number of training hours, nor did it reveal that dementia management training and resident abuse prevention was provided. Training documentation for CNA O was not received by the end of the survey. On 6/25/25 at 4:18 PM, In-service Director Q was interviewed regarding training for agency CNAs, and explained the facility has a contract with a vendor that is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00151526 Based on interview and record review, the facility failed ensure timely assess a pressure ulcer for one resident (R703) out of two reviewed for pressure ulcers. Findings include: A review of the medical record revealed that R703 admitted into the facility on 2/26/2025 with the following medical diagnoses, Severe Protein-Calorie Malnutrition and Urinary Tract Infection. A review of the Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status assessment score of 3/15 indicating an impaired cognition. The MDS also did not note any unhealed pressure ulcers/injuries at the time of assessment. R702 also required staff assistance with bed mobility and transfers. Further review of the progress notes revealed the following, 2/27/2025 at (4:20 PM) .Wound Rounds Note: WCC (Wound Care Consultant) and WCNP (Wound Care Nurse Practitioner) to room for admission skin assessment during IDT (Interdisciplinary Team) rounds .Skin intact, sacrum 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.

This citation pertains to Intake: MI00147942. Based on interview and record review, the facility failed to provide timely incontinence care for one resident (R702) of two residents reviewed for Activities of Daily Living (ADL) care. Findings include: A review of a complaint submitted to the State Agency (SA) documented concerns of the facility's failure to timely change the soiled brief of R702. On 11/13/24 at 1:10 PM, R702 was interviewed in bed and was asked about concerns related to not being changed timely. R702 opened a notepad of written notes that contained dates, and assigned staff for the day, in addition to wait times for care. They explained on 11/10/24, day shift, they had a soiled brief, and was told by their assigned certified nursing assistant (CNA C) they would return to change them however, the resident waited for approximately one hour before they were eventually changed by the CNA. R702 further explained they have experienced issues like this before, and has tried to plan when to have a bowel movement based on the shift, as they have struggled with getting changed…

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: MI00147856. Based on interview and record review the facility failed to timely implement preventative and effective interventions to prevent the development of a pressure ulcer (wound caused by pressure) for one resident (R701) of two residents reviewed for pressure ulcers. Findings include: A review of a complaint submitted to the State Agency (SA) documented concerns of the facility's failure to prevent the development of a pressure ulcer for R701. A review of R701's medical record revealed the resident was initially admitted into the facility on 3/14/24 without skin integrity issues, and had diagnoses that included Vascular Dementia, Cerebral Infarction, Dysphagia, and Acute Kidney Disorder. Further review revealed the resident was severely cognitively impaired, and required extensive assistance of two persons for bed mobility, transfers, and toileting. Further review of the medical record revealed R701 was transferred to the hospital on 3/22/24, returning to the facility on 4/4/24 with a Stage II pressure ulcer (partial thickness tissue loss…

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 intakes: MI00146160, MI00146194, MI00146496. Based on observation, interview and record review the facility failed to document and provide Activities of Daily Living for two dependent residents (R902 and R903) of five residents reviewed. Findings include: R902 On 8/22/24 at 10:48 AM, R902 was observed lying in bed and asked about their stay in the facility. R902 explained that they have not been obtaining showers, and when they are provided with bathing, it is only a bed bath. A review of shower documentation for the last 30 days for R902 were reviewed and revealed that the resident received a bed bath on 8/8/24, and a shower on 8/22/24. There was one shower documented as resident refusal however, the remaining dates were marked as Not Applicable. A review of R902's medical record revealed that they were admitted into the facility on 4/12/24 with diagnoses that included Dementia, Diabetes, ad Heart Failure. Further review revealed that the resident is significantly cognitively…

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 food was safely stored and failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 5/14/24 between 8:35 AM-9:25 AM, during an initial tour of the kitchen with Certified Dietary Manager (CDM) H, the following observations were made: In the walk-in cooler, there were 2 foil covered pans with cooked whole pork roasts dated 5/13. When queried about the pork roasts, CDM H stated they had been cooked sometime last evening and were to be served for dinner on 5/14. The internal temperature of the pork roasts was measured to be between 56-58 degrees Fahrenheit. When queried if staff utilized cooling logs, CDM H stated they do use cooling logs, but was unsure of where the cook had put the log. When asked to see a blank copy of the cooling log utilized by kitchen staff, CDM H looked in the office and on the computer, but stated she couldn't find one. According to the 2017 FDA Food Code section…

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

Based on observation, interview, and record review, the facility failed to label/date and remove a peripheral intravenous line (PIV) for one resident (R95) out of one reviewed for PIV's. Findings include: On 5/14/2024 at 9:00 AM, R95 was observed laying in bed and eating breakfast. R95 was noted to have an PIV inserted in their left wrist, the dressing was not dated or labeled. An IV pump was also noted to be in the room. R95 stated they were not receiving anything through the PIV and did not know why they still had it in. R95 stated they would like it removed because it was uncomfortable. A review of the medical record revealed that R95 admitted into the facility on 4/26/2024 with the following diagnoses, Parkinson's Disease and Dementia. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 14/15 indicating an intact cognition. R95 also required assistance with bed mobility and transfers. Further review of the medical record revealed the following progress notes, 5/7/2024 17:24 (5:24 PM) General Progress Note. Note Text: IV to left hand…

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 identify and document targeted behaviors, non-pharmacological interventions for behaviors, and monitor side effects of a prescribed psychotropic for one resident (R9) of six residents reviewed for unnecessary medications. Findings include: On 05/14/24 at 8:45 AM, R9 was observed lying on their back in bed asleep. A review of R9's medical record revealed they were admitted into the facility on 4/27/24 with diagnoses that included Cerebral Infarction, Adjustment Disorder with mixed disturbance of emotions and conduct, Diabetes Type II, and Hypertension. Further review revealed the resident was severely cognitively impaired and required one person assistance for bed mobility and transfers. On 5/15/24 at 9:05 AM, R9 was observed in bed asleep. On 5/15/24 at 10:06 AM, R9 was observed in bed asleep. Their breakfast food tray was observed on their overhead table untouched. On 5/15/24 at 12:15 PM, R9 was observed still in bed asleep. Their lunch tray at the bedside. On 5/15/24 at 1:55 PM, R9 was observed still in bed…

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.

Deficient Practice Statement #2 Based on observation, interview, and record review, the facility failed to monitor the temperatures of one of one medication refrigerator that stored drugs and biologicals. Findings include: On 5/16/24 at 8:12 AM, the One [NAME] Unit medication refrigerator located in the medication storage unit was viewed with Licensed Practical Nurse (LPN B), and was asked about the process for checking and documenting refrigerator temperatures. LPN B explained that the day shift nurse is responsible for completing the temperature log on the day shift, and the afternoon nurse is responsible for its completion on the afternoon shift. A review of the Medication/Vaccine Refrigerator Temperature Log revealed the following, .Store medications in accordance with manufacturer's specifications, state requirements and standards of practice . A review of the February 2024 temperature log revealed incomplete documentation for the following dates on both shifts: 2/7/24, 2/11/24 , 2/12/24, 2/13/24, 2/14/24, 2/15/24, and 2/24/24. A review of the March 2024 temperature log…

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 MI00142524. Based on interview and record review, the facility failed to involve the guardian in the plan of care for one resident (R807) out of one reviewed for resident/representative rights. Findings Include: A review of an Intake called inot the State Agency revealed the following, [Guardians] have given [facility] their guardianship court papers twice but they have not returned any calls. [Facility] also made a doctor appointment and transported [R807] to the appointment without the guardian's permission. [R807] is supposed to be discharged on 2/2/2023 and will be taken home but [guardian] has yet to hear from [facility] about this upcoming discharge. A review of the medical record revealed that R807 admitted into the facility on [DATE] with the following diagnoses, Acute Osteomyelitis, Right Ankle and Foot, and Dysphagia. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 14/15 indicating an intact cognition. R807 also required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00142524. Based on interview and record review, the facility failed to properly provide a Notice of Medicare Non-Coverage (NOMNC) to the guardian of one resident (R807) out of one reviewed for NOMNC's. Findings Include: A review of an intake called inot the State Agency revealed the following, [R807] is supposed to be discharged on 2/2/2023 and will be taken home but [guardian] has yet to hear from [facility] about this upcoming discharge. A review of the medical record revealed that R807 admitted into the facility on [DATE] with the following diagnoses, Acute Osteomyelitis, Right Ankle and Foot, and Dysphagia. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status (BIMS) score of 14/15 indicating an intact cognition. R807 also required assistance with bed mobility and transfers. The face sheet also noted that R807 had two guardians. Further review of the progress notes revealed the following, Effective Date:2/2/2024 at 5:00 PM .Writer called…

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 MI00141267, MI00142762, and MI00143006. Based on interview and record review, the facility failed to complete wound care treatments for one resident (R801) out of three reviewed for wound care. Findings include: A review of an Intake called into the State Agency noted the following, Continual inadequate care. Wound to be cleaned two times per day per doctors' orders-only happens once per day. A review of the medical record revealed that R801 admitted into the facility on [DATE] with the following diagnoses, Fistula of Intestine and Dysphagia. A review of the Minimum Data Assessment set revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R801 also required assistance with bed mobility and transfers. A review of the physician's orders revealed the following orders, Order: Change Colostomy every 3 days. Directions: Every day shift every Monday and Thursday for monitoring. Order: Cleanse Abdominal Wound with Normal Saline, pat dry, and apply…

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 MI00142280. Based on interview and record review the facility failed to ensure a resident was weighed and documented weekly for one resident (R901) of three whose weights were reviewed resulting in dietitian recommendations and physician orders not followed. Findings include: A review of the facility record for R901 revealed, R901 was admitted into the facility on [DATE] and discharged to the hospital on [DATE]. Diagnoses included Protein Calorie Malnutrition, Muscle Wasting and Atrophy and Colon Cancer. The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition with 14/15 Brief Interview for Mental Status score, impairment of an upper extremity on one side and was dependent (helper does all the effort) for toileting hygiene, bathing, lower body dressing, rolling left to right, sitting to lying, lying to sitting, sitting to standing and transfer. Substantial to maximal assistance was required for upper body dressing. Eating required supervision and or set up. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00142280. Based on interview and record review the facility failed to ensure physical rehabilitation services were provided as ordered and scheduled for one resident (R901) of three whose rehab services were reviewed. Findings include: A review of the facility record for R901 revealed, R901 was admitted into the facility on [DATE] and discharged to the hospital on [DATE]. Diagnoses included Muscle Wasting and Atrophy, Sarcopenia (age related loss of muscle mass) and Colon Cancer. A review of the care plan dated 12/23/23 documented a ADL (activities of daily living) self care deficit as evidenced by impaired strength realted to weakness. The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition with 14/15 Brief Interview for Mental Status score, impairment of an upper extremity on one side and was dependent (helper does all the effort) for toileting hygiene, bathing, lower body dressing, rolling left to right, sitting to lying, lying to sitting, sitting 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 Intakes MI00140458 and MI00141009. Based on observation, interview, and record review, the facility failed to assist with care in a timely manner for two residents (R702 and R704) out of four reviewed for call light response, resulting in feelings of frustration and delay in care. Findings include: R702 On 11/27/2023 at 10:08 AM, R702 was observed in their room sitting up in their wheelchair. R702 was asked how their day was going and they stated, I want to get back in the bed. R702 was instructed to activate their call light. R702 stated that they hit their light and people will come in and just turn it off. R702 stated that they had also been asking for a piece of paper and pen and people keep saying that they would bring it back, but they never do. At 10:10 AM, R702 call light was answered and turned off. R702 was observed still sitting in their wheelchair. R702 stated that the nurse turned their light off and stated that someone would be back with them. At 10:16 AM, R702 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 follow recommendations of no straws, for two residents (R702 and R703) out of two reviewed for person-centered care. Findings Include: R702 On 11/27/2023 at 10:08 AM, R702 was observed in their room sitting up in their wheelchair. Observed on a white board in R702's room there was, No Straws written on it. R702 was observed with a white Styrofoam cup with a straw in it. R702 stated that there was water in the cup. A review of the medical record revealed that R702 admitted into the facility on [DATE] with the following diagnoses, Fracture of Left Femur and Fall. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 12/15 indicating a moderately impaired cognition. R702 also required two-person extensive assist with bed mobility and transfers. Further review of the physician orders revealed the following, Order Date: 11/17/2023. Status: Active. Diet Type: Mechanical Soft Texture, Thin consistency,…

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: MI00140118. Based on interview and record review, the facility failed to notify the resident's representative of a change in condition for one resident (R901) of one reviewed for notification of changes, resulting in the resident's representative being unaware of significant medical changes, and inability to participate in medical decisions regarding care and treatment. Findings include: A review of R901's medical record revealed that they were admitted into the facility on 3/17/20 with diagnoses that included End Stage Renal Disease, Respiratory Failure, Diabetes and Depression. A review of the Minimum Data Set assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status score of 15/15 indicating an intact cognition, and required extensive assistance with transfers, bed mobility, and toileting. Further review of R901's medical record indicated that they were receiving dialysis treatment on Tuesdays, Thursdays and Saturdays, however treatment was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake: MI00139787 Based on interview and record review the facility failed to administer medications as ordered by the physician for one resident (R909) reviewed for medication administration resulting in medication not given as prescribed, with the potential for adverse side effects. Findings include: A review of the Intake revealed the following, My [spouse] was admitted to [facility] in August .the first few days they had given [R909] the wrong dose of [their]seizure medications which I believe caused a lot of his falls, and decline . A review of R909's closed medical record revealed that they were admitted into the facility on 8/24/23 with diagnoses that included Dementia, Depression, Dysphagia, and Repeated Falls. Further review of R909's medical record revealed that the resident was severely cognitively impaired, and required extensive assistance with bed mobility, transfers, and toilet use. Further review of R909's medical record revealed a medication list indicating 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.

Based on interview and record review, the facility failed accurately document 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 107 residents currently residing in the facility. Findings include: On 3/8/23 at 8:10 AM, the Nursing Home Administrator (NHA) provided daily staff postings and explained that due to a staffing change, they were still looking for additional postings. A review of the postings that were available revealed the following: October 2022: No RN coverage noted. November 2022: No RN coverage noted. December 2022: 12/8, 7 hours of RN coverage. January 2023: No RN coverage. On 3/8/23 at 11:00 AM, the Nursing Home Administrtor (NHA) and DON (Director of Nursing) were queried regarding multiple months of staff postings with no RN coverage noted, and they stated that this was incorrect, which they became aware of when they obtained a 1 star staffing rating (star rating system which rates 1 star and low…

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 display current nurse staffing information daily, and failed to maintain 18 months of daily staff postings, affecting all 107 facility residents, resulting in the likelihood of necessary staffing information not being available to residents and visitors. Findings include: On 3/6/23 on 12/10 PM, a daily staff positing was observed posted, and dated for 1/31/23. On 3/8/23 at 8:10 AM, the Nursing Home Administrator (NHA) provided daily staff postings and explained that due to a staffing change, they were still looking for additional postings. A review of the postings revealed the following: February 2022: Daily Staff postings were provided for 2/8, 2/9, 2/10 and 2/11. March 2022, missing the following dates: 3/1, 3/2, 3/3, 3/4, 3/5, 3/6, 3/7, 3/8, 3/9, 3/10, 3/12, 3/13, 3/18, 3/19, 3/20, 3/25 3/26 and 3/27. April 2022, missing the following dates: 4/2, 4/3, 4/9, 4/10, 4/12, 4/14, 4/15, 4/16, 4/17, 4/23, 4/24, 4/25, 4/26, 4/27, 4/28, 4/29, and 4/30. May 2022: No postings provided. June 2022: No postings provided.…

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 food items were dated, failed to ensure staff with facial hair donned beard restraints, and failed to maintain kitchen equipment in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 3/6/23 between 9:00 AM-9:45 AM, during an initial tour of the kitchen with Chef Y, the following items were observed: In the walk-in cooler, there was an undated container of sliced tomatoes, an undated container of soup, and an undated container of chopped lettuce. In addition, there were 2 one pound containers of opened, undated sour cream, with a manufacturer's best by date of 3/5. In the Hoshizaki reach-in cooler, there were 2 undated bowls of soup. According to 2017 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when…

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

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen to eliminate the harborage of gnats. This deficient practice had the potential to affect all residents in the facility. Findings include: On 3/6/23 at approximately 9:30 AM, the kitchen was observed with Chef Y. It was observed that there was an accumulation of dried on food debris, crumbs and grease on kitchen equipment, carts and floors. In addition, there were numerous gnats observed throughout the kitchen. When queried, Chef Y stated that they have been short staffed in the kitchen, and that he is new to the kitchen and trying to get things in order. Review of the pest control service reports for the facility revealed the following: 2/28/23 Poor floor sweeping- the gnats issue is a sanitation problem. The floors in kitchen have grease, food, and other substances gunk causing problem, regular mopping and cleaning of floors will eliminate the problem .Dirty equipment- tables and sinks dirty with old food. 1/24/23 Poor floor sweeping- the gnats issue is a…

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

Based on observation, interview, and record review, the facility failed to ensure resident personal belongings were accounted for, affecting one sampled Resident (R121), resulting in missing personal items, the potential for further missing/unaccounted for items, and resident/family dissatisfaction. Findings include: On 3/6/23 at 2:33 PM, an interview was completed with R121 and Family Member A. They explained that upon admission into the facility, they brought in a suitcase and a duffle bag full of clothing, including a winter coat, and designer slippers however, none of those items can be located. They further explained that it has been approximately six weeks since their concerns have been brought to the facility, and they have yet to hear anything about their concerns. At this time, Family member A provided a copy of the inventory sheet R121 completed upon admission. A review of the Inventory of Personal Effects listed the following items: 1 coat 1 dress 2 house coat/robe 2 overnight case/luggage 1 shoes (pair) 5 slacks 1 slippers (pair) 9 socks (pair) 5 sweaters 4…

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 pass medications in a timely manner and per physician's orders and standards of practice affecting two residents (R41 and R40), resulting in resident dissatisfaction, and the potential for adverse effects. Findings include: On [DATE] at 8:51 AM, Licensed Practical Nurse (LPN) K (agency nurse) was seen on the east wing at Cart #1 passing medications. LPN K was observed to have a wireless headphone bud in her right ear. LPN K indicated that R41 would be the next resident for medication pass. On [DATE] at 9:00 AM, LPN K returned to the medication cart and no longer had the headphone bud in her ear. LPN K removed a cup of pills from one of the middle drawers on the cart and indicated she had already pulled R41's medications, but that the resident had left his room to go get some sugar so she stored them in the cart. The medication cup was not labeled with any identifying information as to whose pills were in it. R41's scheduled morning…

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: MI00134600 and MI00134043. Based on observation, interview, and record review, the facility failed to provide showers as scheduled for two residents (R40, and R75) and a bed pan for one resident (R24) out of ten reviewed for Activities of Daily Living (ADL's), resulting in dissatisfaction with care and fustration. Findings include: Resident 24 (R24) On 3/6/2023 at 10:30, R24 call light appeared to be activated. R24 stated that they were waiting to be put on the bed pan and that it usually takes a while for someone to come answer their light. R24 stated that their light had already been on 15 minutes prior to surveyor entering room. At 10:40 AM, a certified nursing assistant (CNA) was observed walking past the light. At 10:45 AM, multiple staff were observed sitting at the nurse's station on the unit. At 11:05, the nurse from the other hallway came and answered R24's call light and getting a CNA to enter the room and answer the light. A review of the medical record revealed 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 observation, interview, and record review, the facility failed to apply a splint to one resident (R75) out of one reviewed for limited range of motion, resulting in the potential for the worsening of a contracture. Findings include: On 3/7/2023 at 1:06 PM, an interview was conducted with R75 regarding their stay in the facility. R75 stated that they can roll on their right side. R75 right hand appeared to be contracted. R75 was asked if they had a splint for their right hand. R75 stated that they had a splint but haven't had one in over a year. A review of the medical record revealed R75 admitted into the facility on 3/5/2021 with the following diagnoses, Idiopathic Peripheral Autonomic Neuropathy and Atrial Fibrillation. A review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14/15 indicating an intact cognition. R75also required extensive one person assist with bed mobility and transfers. A review of the physician orders revealed the following,…

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 store medications per professional standards during medication administration, and failed to label/date insulin pens in two of four medication carts, resulting in the potential for medication error. Findings include: On [DATE] at 8:51 AM, Licensed Practical Nurse (LPN) K (agency nurse) was seen on the east wing at Cart #1 passing medications. LPN K was observed to have a wireless headphone bud in her right ear. LPN K indicated that R41 would be the next resident for medication pass. On [DATE] at 9:00 AM, LPN K returned to the medication cart and no longer had the headphone bud in her ear. LPN K removed a cup of pills from one of the middle drawers on the cart and indicated she had already pulled R41's medications, but that the resident had left his room to go get some sugar so she stored them in the cart. The medication cup was not labeled with any identifying information as to whose pills were in it. R41's scheduled morning medications…

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 completely and accurately document current COVID-19 vaccination status and offer the vaccine/booster if eligible for four residents (R28, R38, R51, R114) of nine reviewed for immunizations, resulting in the potential for miscommunication and misunderstanding of resident immunization preferences, and the potential for the development of severe disease if infected with COVID-19 (highly contagious respiratory virus). Findings include: On 3/7/23 at 2:22 PM, a review of the infection control task was initiated with Infection Preventionist (IP). At this time, record review was conducted with the IP for R28 and their immunizations. R28 was noted to have been admitted into the facility on 2/14/23 but complete information regarding the resident's COVID vaccination status was not found in the medical record. The IP looked up the resident in [State of Michigan online immunization database] and indicated there was no COVID immunization information present. The IP then reviewed R28's medical record for a COVID vaccination screening…

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.