Regency, A Villa Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a functioning call light for one (R15) of one resident reviewed for environment resulting in unmet safety needs.Findings include:On 1/16/26 at 11:58 a.m. upon entering R15's bedroom, an unidentified resident was observed standing at the bedside, standing behind the wheelchair. R15 was then observed attempting to scoot to the edge of the bed and get into the wheelchair. The resident was asked what was occurring and the other resident stated, She wants to get up. The wheelchair wheels were not locked as the other resident stood behind the chair. The other resident was asked to put on the call light so staff can assist. The call light was observed activated while in the room. After several minutes of no staff response to the room, LPN H was observed at the end of the hall and asked to come to the room. The call light indicator that was located above the door of the bedroom was not illuminated. LPN H came to the room and redirected the…

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

This citation pertains to intake 1316302.Based on interview and record review the facility failed to prevent the misappropriation of resident's property for one (R702) of seven residents reviewed for abuse resulting in R702 missing 28 doses of hydrocodone (narcotic pain medication).Findings include:The State Agency received a Facility Reported Incident (FRI) on 5/20/25 that identified the misappropriation of a resident's (R702) pain medication by Licensed Practical Nurse (LPN) I. The medication was a schedule II drug; a substance that is classified as having a high potential for abuse and severe psychological or physical dependence.On 7/28/25 at 1:00 PM R702 was interviewed and said that they had received all their pain medications and had no complaints regarding medication administration.On 7/29/25 at approximately 9:30 AM the Director of Nursing (DON) reviewed the FRI investigation report and confirmed that R702's pain medication had been taken by LPN I. The DON stated, On May 6th a nurse went to give the pain med to the resident and saw the cartridge for that medication 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 2565437.Based on interview and record review the facility failed to report a potential incident of neglect for one (R707) of seven resident reviewed for abuse/neglect. Findings include:The State Agency (SA) received an anonymous complaint that a resident had eloped from the facility unbeknownst to facility staff on 7/15/25.On 7/28/25 at 11:30 AM the Nursing Home Administrator (NHA) was asked if any resident had eloped from the facility. The NHA said, Yes, we had a resident that was new to us. The first time he went out to the patio enclosure during an activity he climbed over the fence. We notified the family and the police. At that time the resident's son told us that the resident had eloped from the hospital two times in the past. The resident was found shopping at Kohl's without any injury and is currently with living with his son. The NHA provided an investigation report that confirmed the police, and family had been notified of the missing resident but there was no incident…

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 2574104. Based on interview and record review, the facility failed to ensure adequate supervision to prevent a resident to resident altercation for one resident (R712) of seven residents reviewed for abuse, resulting in R712 being struck on the head by R711 and the potential for continued physical abuse to occur.Findings include:A review of the facility's investigation summary of a resident-to-resident incident between R711 and R712 documented in part the following: On 7/5/25, at approximately 6:30 PM, there was a verbal exchange between R712 and R711 resulting in R711 ambulating across the room and initiating physical contact with R712. Residents were immediately separated with licensed nurses performing skin, pain, and psychosocial assessments. No injuries noted. Witness statement from Certified Nurse Assistant (CNA) O, dated 7/5/25, I (CNA O) was assisting (unnamed resident) and while walking past the dining room I witnessed (R711) standing over (R712) punching him. I immediately…

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 MI00153114. Based upon interview and record review, the facility failed to ensure transfer documentation was in place for one resident (R101) reviewed for transfer, resulting in the lack of information regarding resident's health status, safety, and transfer arrangement and destination upon transfer from the facility. Findings include: A review of the clinical record documented R101 was originally admitted to the facility on [DATE] and readmitted on [DATE]. R101's medical diagnoses included anxiety disorder, mood disorder, unspecified psychosis, and unspecified dementia with other behavioral disturbance. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment, impairment on one side of the lower extremity, and the use of a wheelchair for mobility. Census documentation in the EHR (electronic health record) revealed a stop billing date of 5/15/25 which indicated R101 no longer resided in the facility. Beginning on 7/7/25 at 2:58 PM, the Director of Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to MI00153114. Based on interview and record review, the facility failed to provide documentation in the EHR (electronic health record) for a psychiatric petition to the hospital for one resident (R101), resulting in missing clinical information regarding the resident's psychiatric status at the time of the transfer. Findings include: It was reported to the State Agency that a resident kicked open locked doors to the fifth and third floor and attacked staff and other residents. A review of the clinical record documented R101 was originally admitted to the facility on [DATE] and readmitted on [DATE]. R101's medical diagnoses included anxiety disorder, mood disorder, unspecified psychosis, and unspecified dementia with other behavioral disturbance. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment. Census documentation in the EHR revealed a stop billing date of 5/15/25 which indicated R101 no longer resided in the facility. Beginning on 7/7/25 at 2:58 PM,…

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 physician orders for one (R603) of four residents reviewed for falls, resulting in R603 not receiving a topical pain medication or having a urinalysis (laboratory test used to detect urinary tract infections) completed. Findings include: On 3/18/25 at 10:36 AM, R603 was observed in the dining room seated in a wheelchair with a purple discoloration surrounding the left eye and upper left cheek bone area. R603 was interviewed and could not recall how they obtained the black eye. R603 denied having any pain. Certified Nursing Assistant (CNA) I was present and said the resident had a fall, about a week ago. According to R603's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with multiple diagnoses that included Parkinson's disease and Alzheimer's disease. The Minimum Data Set (MDS) dated [DATE] indicated R603 had severely impaired cognition status with a Brief Interview for Mental Status (BIMS) score…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain dignity while assisting during mealtime for one resident (R163) of three residents reviewed for dignity, resulting in the potential for feelings of embarrassment and low self-esteem. Findings include: On 10/29/2024 during a lunch meal observation on the fifth-floor dining room, certified nurse aide K (CNA) was observed feeding R163. During the observation R163 was observed positioned in a Broda Chair (a chair like a geriatric chair but with more versatile features for comfort staff flexibility). Occasionally, R163 was observed with a forward jerking movement. CNA K was observed standing on the resident's left side and shifting to the right trying to prompt R163 to eat the food displayed in front of the resident, as CNA K stood over R163 portions of the resident's pureed food dropped onto the resident's clothing. On 10/30/24 at approximately 12:40 P.M. R163 was observed being fed by CNA K, while attempting to sit in a dining room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain and respect the personal privacy by opening packages of one resident (R142) of two residents reviewed for privacy, resulting in a breach of personal privacy and the feeling of anger and disrespect. Findings include: On 10/31/2024 at 10:30 am, R142 discussed during Resident Council that their packages were being opened by staff. On 10/31/24 at 11:55 PM, R142 was observed in bed watching television. R142 was asked about concerns related to personal privacy and mail being opened. R142 said, Sometimes when a package is delivered to me, it's already opened .that's not right to open my mail .what if they take something .that makes me mad. 10/31/24 11:38 AM, Receptionist P was interviewed and queried about when the residents receive mail/packages. Receptionist P stated, All packages are inventoried prior to delivery to the residents. On 10/31/24 at 12:16 PM, Facility Concierge Q was interviewed and queried about the process of delivering…

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 change soiled linens for one resident (R131) of 27 reviewed for homelike environment resulting in R131 sleeping on soiled and damp linens and dissatisfaction with living conditions. Findings include: On 10/29/24 at 8:20 AM, R131 was observed lying on a soiled sheet that had a urine ring that was wet in the center and dried around edges and measured approximately two feet long and two feet wide. R131, reported that they (staff) should change the sheets after my shower. On 10/30/24 at 8:30 AM, R131's bed was observed to be soiled with a urine ring that was wet in the center and had dried edges. Soiled area measured approximately three feet long by two feet wide. R131 reported that staff had not changed the bed linens after shower yesterday and slept on the same linens last night. R131 further reported that sheets should be changed when they are dirty. Review of R131's electronic medical record (EMR) revealed admission into the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to record, track, and respond to resident concerns/grievances for one (R15) of one resident reviewed for grievances resulting in R15's grievance not being addressed. Findings include: On 10/31/24 at 11:00 AM, R15 reported a missing item concern at the resident council meeting. On 10/31/24 at 11:30 AM, R15 was interviewed and said I gave Concierge (C) some clothing items in a bag that I no longer wanted. I left the room and when I came back there were some pants and shirts missing from my closet. I told Concierge (C) that the clothing was missing from my closet. This was within the last two weeks. Record review of the Electronic Health Record (EHR) revealed R15 was admitted to the facility on [DATE] with diagnosis that included chronic kidney disease, type two diabetes. Review of a Minimum Data Set (MDS) assessment for R15, with a reference date of 8/7/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated intact cognition.…

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 properly position a resident for proper medication administration and failed to ensure that medication was administered according to physician orders for one (R5) out of twenty-seven residents reviewed for medication administration, resulting in the potential for less than therapeutic effects of the prescribed medication and placing the resident at risk for choking. Findings include: On 10/30/2024 at 8:30 a.m. during a morning medication administration, Licensed Practical Nurse (LPN) N was observed with five pills in a cup. R5 was observed lying flat in bed. LPN N did not assist the resident into a sitting position. LPN N proceeded to give R5 the medication cup with instructions to take the medication. R5 attempted to ingest the medication when the pills fell on and behind the bed leaving one pill in the cup. LPN N recovered three of the pills from the resident's bed and disposed of the three unidentified pills in a sharp container (a container to dispose unused medication). LPN N was observed pulling two of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide ADL assistance for three (R107, R5, and R110) of 27 residents reviewed for ADL care resulting in unkempt hair, jagged nails, unshaven facial hair, and lack of showers/bedbaths. Findings include: R107 On 10/29/24 at 12:31 P.M. R107 was observed in his room with portions of his hair pulled back into a rubber band. The resident's facial beard had grown 2-3 inches with particles of food stuck in between the facial hair. In the front of the resident's clothing drops of food were attached to the resident's clothes. During the observation CNA J was observed informing residents and staff I will try and shave this resident today, I am not on that set today. CNA J indicated each nurse aide was assigned their designated residents to shower and on that day residents were given a shave, nails cleaned if possible. On 10/30/24 at 8:51 A.M. R107 was observed in the dining room, the resident's hair was knotted and matted around the edges 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 Based on observation, interview, and record review the facility failed to follow standards of practice for respiratory care for one resident (R162) out of two residents reviewed for respiratory care, resulting in the improper storage of a nebulizer mask and the potential for cross-contamination. Findings include: On 10/29/24 at 10:59 AM R162's nebulizer mask was observed hanging on the dresser drawer next to the bed. R162 was asked if there was a storage bag for the nebulizer mask when not in use. R162 replied I don't know if there is a bag I hang it on the dresser when I'm done with the treatment. There was no storage bag observed. On 10/30/24 at 9:00 AM R162's nebulizer mask was observed hanging from the dresser drawer next to bed. On 10/30/24 at 1:30 PM R162's nebulizer mask was observed hanging from the dresser drawer next to bed. Record review of Electronic Health Record (EHR) revealed R162 was admitted into facility on 5/18/23 with a pertinent diagnosis of chronic obstructive respiratory disease (COPD).…

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 a safe and functional environment for two residents (R54) and (R147), resulting in dissatisfaction with the resident's home an a increased risk for harm. Findings include: R54 On 10/31/24 at 2:02 P.M. during an interview with R54, the resident complained that her bathroom did not get warm or hot water. The resident gestured and explained the faucets only ran cold water. The temperature in the hand sink registered 54 Degrees Fahrenheit. During an observation of the bathroom the hand sink faucets were checked. There was no hot or warm water. The cold-water faucet was loose, and the water continuously ran even when placed in the off position. Above the bathtub the ceiling walls were cracked, had broken plaster and peeling paint. Holes and pieces of plaster were suspended from the ceiling over the tub. Around the base of the bathtub a loose cove base was noted. On 11/1/24 at 10:30 A.M. in an observation of the resident's room Maintenance Director M indicated the entire unit was going to be remodeled and…

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

Based on interview and record review the facility failed to ensure annual Dementia Management and Abuse training were performed for one Certified Nurse Assistant (CNA) G out of five CNAs reviewed for in-service training resulting in the potential for unmet resident care needs. Findings include: On 10/31/24 at 2:24 PM, review of five CNAs in-service training education content revealed the following: CNA G Date of hire (DOH)- 6/2/2009. Review of a facility provided transcript dated 6/2/23 through 6/2/24 for CNA G, failed to identify abuse and dementia management training. On 10/31/24 at 3:05PM the Assistant Director of Nursing (ADON) E was interviewed and said there was no record of abuse and dementia training for CNA G and said the training was due on 6/2/24. When queried about the significance of CNA trainings, ADON E stated, It is important to have trainings for the CNAs to meet their requirements and to provide education for what they do daily to meet resident needs. On 11/01/24 at 10:01 AM the Director of Nursing (DON) was interviewed and agreed that CNAs are expected to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #'s MI00146301 and MI00146393. Based on observation, interview, and record review, the facility failed to ensure accurate assessments and implementation of indwelling urinary catheter care for two residents, (R901 and R902) of three residents reviewed for urinary catheters, resulting in the potential for the development of urinary tract infections and complications from indwelling urinary catheters. Findings include: R901 On 8/27/24 at 10:50 AM, R901 was observed in their bed asleep. A urinary catheter drainage bag was observed clipped to the left side of the bed. The urine in the catheter tubing and drainage bag was clear and dark yellow in color. A review of R901's clinical record revealed they admitted to the facility on [DATE], discharged to the emergency room on 8/12/24, and re-admitted on [DATE]. R901's diagnoses included: Parkinson's Disease, urinary tract infection (UTI), obstructive reflux uropathy, urinary retention, intestinal hemorrhage, heart failure, and seizures.…

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 MI00139649. Based on interview and record review, the facility failed to ensure appropriate transfer documentation was in place for one resident (R607) out of one resident reviewed for hospital transfer, resulting in the lack of information regarding resident's health status, safety, and transfer arrangements upon transfer from the facility. Findings include: A review of the admission Record for Resident #607 (R607) documented an admission date of 2/18/23. R607 was discharged from the facility on 11/9/23. R607's diagnoses included congestive heart failure, opioid dependence, atrial fibrillation, and depressive disorder. A Minimum Data Set assessment dated [DATE] documented intact cognition. An interview and record review were conducted with the Director of Nursing (DON) on 4/4/24 at 11:19 AM. The DON said R607 went to the hospital for hip surgery and did not return. An eMAR (Electronic Medication Administration Record) note of 11/9/23 at 1:05 PM documented R607 went out for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00141041. Based on interview and record review, the facility failed to demonstrate professional standards of practice by not consistently obtaining resident's blood pressure readings prior to the administration of anti-hypertensive medications as ordered for one resident (R608) out of three residents reviewed for physician's orders, resulting in the potential for hypotension. Findings include: It was reported to the State Agency that a resident was receiving medication without proper monitoring. A review of the admission Record for Resident #608 (R608) documented an admission date of 7/23/21. R608 was discharged from the facility on 10/31/23. R608's diagnoses included chronic obstructive pulmonary disease, hypertension, hypertensive heart disease without heart failure, and atherosclerotic heart disease of native coronary artery without angina pectoris. A Minimum Data Set assessment dated [DATE] documented intact cognition. A review of physician's orders documented that R608 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 MI00141603. Based on interview and record review, the facility failed to adequately complete discharge instructions and recapitulation of stay in a timely manner for one resident (R611) of three residents reviewed for a comprehensive discharge summary, resulting in the potential for lack of communication to care providers assuming the resident's care. Findings include: It was reported to the State Agency that the facility did not adequately help resident with a discharge from the facility. A review of the admission Record for Resident #611 (R611) revealed an admission date of 11/21/23. R611 was discharged home from the facility on 12/22/23. R611's diagnoses included hypertensive urgency and cervical disc disorder with myelopathy. A Minimum Data Set assessment dated [DATE] documented intact cognition. During an interview and review of R611's clinical record with the Director of Nursing (DON) on 4/4/24 at 12:02 PM, a document titled, Recapitulation of Stay [Discharge Summary],…

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 MI00141883 and MI00141437. Based on interview and record review the facility failed to consistently conduct weekly skin observations for two residents (R606 and R610) and a Braden skin assessment for one resident (R610) of three residents reviewed for maintenance of skin integrity, resulting in the potential for skin care needs to go undetected. Findings include: R606 A review of R606's EMR (Electronic Medical Record) revealed R606 was admitted to the facility on [DATE] and discharged from the facility on 12/20/23. According to R606's EMR, R606 had the following medical diagnoses: Cutaneous Abscess of the Buttock, Generalized Muscle Weakness, need for assistance with personal care, and moderate protein-calorie malnutrition. A review of R606's MDS (Minimum Data Set), dated 11/25/23, revealed R606 had a BIMS (Brief Interview of Mental Status) score of 9/15 (moderate cognitive impairment). According to the MDS, R606 required maximal assistance with bed mobility, transfers, and…

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

Based on observation, interview, and record review, the facility failed to perform proper sterile hygiene practices, hand hygiene, and glove usage for one resident (R624) of two residents reviewed for tracheostomy care, resulting in the potential for tracheostomy infection and airway impairment. Findings include: On 4/4/24 at 9:35 AM an observation was made of LPN (Licensed Practical Nurse) G providing tracheostomy care on R624. LPN G sanitized his hands when entering the room. LPN G put a PPE (Personal Protective Equipment) gown on. LPN G put on gloves and a face shield. Then LPN G closed R624's curtain for privacy. LPN G gathered tracheostomy supplies and placed them on the bedside table. LPN G opened the tracheostomy kit. LPN G took out the basin that was inside the kit. LPN G removed and discarded both gloves. LPN G then donned a sterile left-hand glove. The right-hand sterile glove fell on the bedside table prior to LPN G donning it. Then LPN G placed the sterile field on to the bedside table. LPN G opened the normal saline solution with his left hand and poured the solution…

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 establish a system of records of receipt and disposition of controlled drugs (drugs that are subject to high levels of regulation, such as narcotics) in sufficient detail to enable an accurate reconciliation resulting in the potential for medication missappropration and drug diversion. Findings include: On 9/12/23 at 11:15 AM an observation of the 2nd floor medication room and narcotic/controlled drug back-up box with nurse manager, Licensed Practical Nurse (LPN) B was conducted. LPN B said the 2nd floor medication room contained the facility's only narcotic 'back-up box' (emergency box of medications containing controlled drugs). The narcotic back-up box was observed to be in a locked cabinet inside the locked medication room. There was a red numbered plastic lock on the box. LPN B said that when a narcotic/controlled drug is retrieved from the back-up box the red plastic lock is broke off. Then the nurse completes a 'medication form' to indicate which medication was removed and places the form inside 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 observation, interview, and record review the facility failed to prevent 11 significant medication errors for one resident (R226) when the resident was simultaneously prescribed and administered Phenytoin suspension, (an anti-seizure medication) with enteral nutrition through a PEG tube (flexible tube surgically inserted through the abdomen into the stomach to deliver medication and nutrition) resulting in the potential for decreased efficacy and less than therapeutic effect of the medication (Phenytoin). Findings include: On 9/12/23 at approximately 2:00 PM during medication administration Licensed Practical Nurse (LPN) F prepared to administer Phenytoin 4 ml (milliliters) 100 mg (milligrams) via PEG tube simultaneously with enteral nutrition (feeding bolus). LPN F was asked if Phenytoin should be administered with enteral nutrition. LPN F reviewed the Medication Administration Record (MAR) and said, That's the way it's ordered. LPN F administered the Phenytoin along with 1 can of Jevity 1.5 (enteral nutrition). Observation of the Phenytoin bottle did not include any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure updated and accurate Advanced Directive information was in place for one (R4) of five residents reviewed for Advanced Directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility or other healthcare providers. Findings Include: Review of an Electronic Health Record (EHR) revealed, Resident #4 (R4) had a code status of Full Resuscitate in the banner. R4's Code Status Elective Form revealed Do No Resuscitate (DNR) signed on 7/17/23. Review of an admission Record revealed, R4 admitted to the facility on [DATE] with pertinent diagnosis which included Heart Failure. Review of a Minimum Data Set (MDS) assessment, with a reference date of 7/10/23 revealed R4 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15, out of a total possible score of 15.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure an annual update for a preadmission screening (PAS)/ Annual Resident Review (ARR) (3877) for a Level II evaluation was completed for one resident (R87) of seven residents reviewed for PASARR, resulting in the potential for the resident to not receive appropriate mental health treatment and services. Findings include: Review of the Electronic Health Record (EHR) revealed, Resident #87's (R87) determination letter with a date 4/28/22 revealed, . If the above-named individual remains in the nursing facility, a Level II Evaluation is needed by April 27, 2023 . Review of an admission Record revealed, R87 admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included bipolar disorder and adjustment disorder with anxiety. Review of a Minimum Data Set (MDS) assessment, with a reference date of 7/12/23 revealed R87 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15, out of a total…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two deficient practice statements. Deficient Practice Statement #1. Based on observation, interview, and record review the facility failed to follow professional standards of practice for medication administration through a PEG tube (flexible tube surgically inserted through the abdomen into the stomach for nutrition/medication administration) for two of two residents (R137 and R226) when PEG tube placement was not verified prior to medication administration resulting in the potential for medications not being administered into the stomach and aspirated into the lungs. Findings include: R137: On 9/12/23 at 8:02 AM during medication administration observation, Licensed Practical Nurse (LPN) E was observed to flush R137's PEG tube with water and attempt to administer a medication when she was stopped and asked if she checked for appropriate PEG tube placement. LPN E said, No, I usually push air through the PEG tube with a syringe and listen for a 'swoosh' sound over the abdomen with my…

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 MI00137524 and MI00135643 Based on observations, interview, and record review the facility failed to provide adequate nail care for two residents (R7 and R20) reviewed for nail care resulting in the potential of low self-esteem, skin irritation, and spread of infection. Findings include: R20 On 09/11/23 at 2:57 PM, R20 was observed that bilateral hands had long fingernails with brown debris under each nail. On 09/12/23 09:45 AM, R20 was observed that bilateral hands had long fingernails with brown debris under each nail. On 09/13/23 1:45 PM, R20 was observed that bilateral hands had long fingernails with brown debris under each nail. Record review revealed R20 was admitted into the facility on 6/26/23 with a diagnosis of acute and chronic respiratory failure. According to the Minimum Data Set (MDS) dated [DATE], R20 had intact cognition and required extensive assist with Activities of Daily Living (ADLS). Record review of ADL care plan documented the following: The resident has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Deficient Practice #2. Based on observation, interview and record review, the facility failed to ensure proper anchoring/securing of an indwelling urinary catheter for one (R182) of five residents reviewed for urinary catheters, resulting in the potential for skin trauma. Findings include: In an observation and interview on 9/11/23 at 10:05 a.m., R182 stated he had a supra pubic catheter that hasn't been changed in over a month and didn't have a leg strap or attachment device. R182 pulled catheter bag out from under pant leg and revealed there was no catheter anchor or leg strap. The tube is hanging directly out of my gut; I asked the nurse for a leg strap but never got one. Review of an admission record revealed, R182 admitted to the facility 8/2/23 with pertinent diagnosis acute prostatitis, urinary tract infection, and retention of urine. Review of a Minimum Data Set (MDS) assessment, with a reference date of 8/14/23 revealed R182 had intact cognition a Brief interview for Mental Status (BIMS) of 15/15 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.