Optalis Health and Rehabilitation of Three Rivers

Based on interview and record review, the facility failed to address and resolve grievances reported in Resident Council Meetings as stated during a confidential Resident Council meeting resulting in unresolved concerns, unmet resident needs and frustration. Findings include:During a confidential Resident Council meeting on 12/02/2025 at 10:34 AM, 6 of 12 residents stated that management didn't follow up on concerns that they brought up in Resident Council meetings and individual concerns that came from the meetings.One resident stated that she didn't hear anything back about her grievances, so she doesn't fill them out anymore.Three residents stated that management did not resolve all of the grievances, only parts of it so they don't get a resolution on everything. One resident stated Nothing becomes of what you write in the concern form. They don't care. It's like talking to the wind.10 of 12 residents stated that food tickets were not read correctly and as a result aren't being followed. The residents said this had been a concern for several months. Review of the Resident Council…

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 a safe, clean, homelike environment in 3 of 4 residents (Resident #19, #39, & #69) reviewed for environmental concerns, and maintain cleanliness of storage closets containing resident supplies, resulting in the potential for resident dissatisfaction, injury, and respiratory complications due to dust buildup. Findings include:Resident #19 Review of an admission Record revealed Resident #19 was a male, with pertinent diagnoses which included obstructive lung disease, heart failure, a seizure disorder, gastroparesis (a chronic condition where the stomach empties too slowly due to damaged nerves or muscles), gastrostomy status (an opening in the stomach where a feeding tube is inserted), history of traumatic brain injury, and presence of a tracheostomy (an opening in the neck to the trachea through which a tube is inserted to provide an airway). Review of a Minimum Data Set (MDS) assessment for Resident #19, with a reference date of 9/20/25, revealed he had severe cognitive impairment. Review of 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 promote dignity in 2 of 4 residents (Resident #48, #69) reviewed for dignity/respect, resulting in long wait times for assistance, feelings of frustration, and dissatisfaction with care. Findings include:Resident #48 Review of an admission Record revealed Resident #48 was a female, with pertinent diagnoses which included peripheral vascular disease, high blood pressure, atrial fibrillation (an irregular heart rhythm that results in poor blood flow), heart failure, irritable bowel syndrome (a chronic disorder causing symptoms such as abdominal cramping, gas, and changes in bowel habits), and neuromuscular dysfunction of the bladder (occurs when nerve damage interferes with the bladder's ability to store and release urine properly). Review of a Minimum Data Set (MDS) assessment for Resident #48, with a reference date of 11/17/25, revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total score of 15, which indicated moderate cognitive impairment. In an interview on 12/1/25 at 10:22 AM,…

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

Based on observation, interview and record review the facility failed to ensure residents medication was not left at bedside in 1 of 4 residents (Resident #69) reviewed for medication administration, when licensed nursing staff failed to ensure that Resident #69's medications were administered as ordered and per facility policy. Findings include:Resident #69: Review of an admission Record revealed Resident #69 was a male with pertinent diagnoses which included major depressive disorder, anxiety, high cholesterol, drug induced dyskinesia (involuntary movement disorder caused by antipsychotics use), diabetes, malnutrition, and paranoid schizophrenia (persistent delusions and hallucinations due to a chronic brain disorder that affects how a person thinks, feels, and behaves, leading to distorted perceptions of reality). During an observation on 12/02/2025 at 2:08 PM, This writer observed a medication cup on the resident's tray table with an unidentified pill in the cup which was a reddish-brown color and had a stamp on the pill. Noted: The medication cup and pill were not on the tray…

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 appropriate bariatric bed and assistive devices were available for use to promote independence for 1 resident (Resident #7) of 1 resident reviewed for accommodation of needs, resulting in the development of a stage 3 pressure ulcer. Findings include: Resident #7: Review of an admission Record revealed Resident #7 was a male with pertinent diagnoses which included contracture of muscle, left ankle and foot, contracture of muscle, right ankle and foot, anxiety disorder, muscle loss, stroke, severe obesity with low oxygen levels due to failure to breath deep enough, pressure ulcer stage 3, and Parkinson's disease. Review of Care Plan for Resident #7 initiated on 5/14/24, revealed the focus, .The resident has potential impairment to skin integrity r/t (related to) impaired mobility, obesity, and diabetes . with the intervention .The resident needs pressure relieving/reducing mattress to protect the skin while in bed .Turn/Reposition resident regularly to relieve pressure points .Use a draw sheet or lifting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a person-centered care plan related to contact precautions for 1 resident (Resident #53) of 18 reviewed for person centered care plans resulting in the potential for unmet care needs of the resident.Findings include:Resident #53 (R53)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R53 admitted to the facility on [DATE] with pertinent diagnoses including depression, anxiety and Clostridium Difficile (C-diff, a bacterium that causes diarrhea and potentially life-threatening inflammation of the colon). Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R53 was cognitively intact (13 to 15 cognitively intact).During an observation on 12/01/2025 at 9:53 AM, there was a contact precautions sign posted outside R53's door. During an interview on 12/01/2025 at 9:56 AM, R53 stated that he had C-diff 4 separate times and had it before he was admitted to the facility. R53…

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 residents received care by qualified persons in 1 of 5 residents (Resident #13) reviewed for psychotropic medications, when nursing staff completed Resident #13's Psychotropic Medication Review for GDR (Gradual Dose Reduction) assessment without involvement from the physician or nurse practitioner, resulting in an incomplete GDR assessment for Resident #13.Findings include: According to the facility's policy Psychotropic Medication Use dated 1/10/24 revealed, .Residents who use psychotropic medications will receive gradual dose reductions, unless clinically contraindicated, in efforts to discontinue the medication when appropriate.For any resident who is receiving a psychotropic medication to treat a disorder other that expressions of indications of distress related to dementia (examples include, schizophrenia, bipolar mania, depression with psychotic features, or another medical condition other than dementia, which may cause…

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 indwelling catheter care was completed, monitored urinary output, ensured securement device positioning, and the urinary drainage bag was not resting on the floor for 1 (Resident #70) of 1 resident reviewed for indwelling catheter care, resulting in the potential of a urinary tract infection. Findings include: Review of [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 68514-68515). Elsevier Health Sciences. Kindle Edition, revealed .Securing indwelling catheters reduces risk of urethral trauma, urethral erosion, CAUTI (Catheter-Associated Urinary Tract Infection), or accidental removal .A CAUTI (Catheter associated urinary tract infection), or a UTI (urinary tract infection) associated with a catheter, is common if you have an indwelling catheter inside your urethra.Symptoms are similar to a general UTI and include bloody or cloudy urine, gritty particles…

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 administer oxygen therapy and provide respiratory care per physician order and professional standards of practice in 1 of 1 resident (Resident #19) reviewed for respiratory care, resulting in the potential for decreased oxygen levels and respiratory complications.Findings include:Resident #19 Review of an admission Record revealed Resident #19 was a male, with pertinent diagnoses which included obstructive lung disease, heart failure, a seizure disorder, history of traumatic brain injury, and presence of a tracheostomy (an opening in the neck to the trachea through which a tube is inserted to provide an airway). Review of a Minimum Data Set (MDS) assessment for Resident #19, with a reference date of 9/20/25, revealed he had severe cognitive impairment, utilized oxygen therapy, and required tracheostomy care. Review of a current Care Plan for Resident #19 revealed the focus .The resident has altered respiratory status/difficulty breathing (related to) tracheostomy, COPD (obstructive lung disease) . initiated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement Enhanced Barrier Precautions (EBP) (an infection control measure designed to reduce the transmission of multidrug-resistant organisms (MDROs) in nursing homes) for 2 residents (Resident #94 & #19) of 6 residents reviewed for infection control and prevention, resulting in the potential for the spread of MDROs among a vulnerable population of residents.Findings include:Resident #94 Review of an admission Record revealed Resident #94 was admitted to the facility on [DATE]. Review of Resident #94's Physician Orders revealed, Enhanced Barrier Precautions: Indwelling medical device. Active on 12/2/25. During an observation on 12/03/2025 at 9:51 AM, a small sign in the hallway outside of Resident #94's room indicated EBP was in place. Certified Nursing Assistant (CNA) M was observed walking into the room to provide morning cares and get the resident up for therapy. CNA M donned gloves but did not put on a gown, then proceeded to change the resident's…

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 track and offer the pneumococcal vaccine for 1 (Resident #7) of 5 residents reviewed for immunizations, resulting in a delay of Resident #7, to be given the opportunity to receive or decline the pneumococcal vaccination.Findings include: In an interview and record review on 12/4/25 at 12:08 PM, Infection Preventionist (IFP) D reviewed Resident #7's age was [AGE] years old, review of the Immunization Record and it revealed, Resident #7 had received the not received the Prevnar 13 on 01/29/2017 and PPSV 23 (Pneumococcal) Dose on 08/14/2010. CV 20 or PCV 21. IFP D reviewed the medical record and was unable to locate a consent or declination for the immunization. According to the Centers for Disease Control and Prevention (CDC) PCV20 Vaccination for Adults 50 Years and Older dated 12/05/25, revealed, .Routine vaccination: Adults 50 years or older who have- Previously received both PCV13 and PPSV23, AND NO PPSV23 was received at age [AGE] years or older: 1…

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 1) provide the resident representative a written notice for a bed hold upon a transfer to the hospital and 2) follow up with the resident/responsible party and document the follow up in the resident's medical chart for 1 resident (Resident #1) of 1 resident reviewed for hospital transfers resulting in the potential for a resident and/or resident's representative being uninformed of the bed hold policy.Findings include: Resident #1 (R1)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R1's initial admission date to the facility was on 10/16/2024 with pertinent diagnoses including dementia (decline in mental abilities such as memory, thinking and reasoning that is severe enough to interfere with daily life) and depression. Brief Interview for Mental Status (BIMS) reflected a score of 4 out of 15 which indicated R1 was severely cognitively impaired (00 to 07 is severe cognitive impairment). R1 was transferred to the hospital…

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 #2616813Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from resident-to-resident verbal abuse for 2 (Resident #101 and Resident #100) of 3 residents reviewed for abuse, resulting in Resident #101 experiencing verbal threats, insults and mocking by Resident #100. Findings include:Resident #100 Review of an admission Record revealed Resident #100 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: Borderline intellectual functioning (indicating cognitive abilities below average, but not low enough to be classified as an intellectual disability), bipolar disease (a mental health condition that causes extreme mood swings), and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 9/19/25 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #100 was cognitively intact.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of abuse to the State Agency for 2 (Resident #100 and Resident #101) of 2 residents reviewed for abuse. Findings include:Resident #100Review of an admission Record revealed Resident #100 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: Borderline intellectual functioning (indicating cognitive abilities below average, but not low enough to be classified as an intellectual disability), bipolar disease (a mental health condition that causes extreme mood swings), and anxiety disorder.Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 9/19/25 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #100 was cognitively intact.In an interview on 10/6/25 at 11:18 AM, Resident #100 reported she was involved in an incident with Resident #101, and he continued to make her angry. Resident #100 stated I told…

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 investigate an allegation of abuse for 2 (Resident #100 and Resident #101) of 2 residents reviewed for abuse resulting in the potential for allegation to not be thoroughly investigated and further abuse to occur. Findings include:Resident #100Review of an admission Record revealed Resident #100 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: Borderline intellectual functioning (indicating cognitive abilities below average, but not low enough to be classified as an intellectual disability), bipolar disease (a mental health condition that causes extreme mood swings), and anxiety disorder.Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 9/19/25 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #100 was cognitively intact.In an interview on 10/6/25 at 11:18 AM, Resident #100 stated I told him (Resident #101) if…

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 proper discharge notification was completed for 1 resident (Resident #101) of 2 residents reviewed for the discharge process, resulting in Resident #101's Durable Power of Attorney (DPOA) GG not receiving written notification of the reason for discharge and the right to appeal.Findings include:Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: dementia (general term used for loss of memory, language, thinking skills that interfere with daily life) with behavioral disturbance.Review of a Minimum Data Set (MDS) assessment for Resident #101 with a reference date of 9/11/25, revealed a Brief Interview for Mental Status (BIMS) assessment score of 3/15, which indicated the resident was severely cognitively impaired. Section E of the MDS revealed Resident #101 did not display the presence of wandering during the 7-day assessment period.Review of a Care Plan 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 Based on interview and record review the facility failed to develop and implement person centered individualized care plan interventions for 2 (Resident #100 and Resident #101) of 5 residents reviewed for person centered individualized care plans resulting in the potential for residents to not attain or maintain their highest practicable physical, mental, and psychosocial well-being.Findings include:Resident #100Review of an admission Record revealed Resident #100 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: Borderline intellectual functioning (indicating cognitive abilities below average, but not low enough to be classified as an intellectual disability), bipolar disease (a mental health condition that causes extreme mood swings), and anxiety disorder.Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 9/19/25 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #100 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 #2616813Based on interview and record review, the facility failed to provide medically related social services to support the mental and psychosocial health of 2 (Resident #101 and Resident # 100) of 3 residents reviewed for social services resulting in a lack of advocacy for Resident #101's rights, and a lack of individualized behavior management interventions and discharge planning for Resident #100 and Resident #101.Findings include:Resident #101Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: dementia (general term used for loss of memory, language, thinking skills that interfere with daily life) with behavioral disturbance.Review of a Minimum Data Set (MDS) assessment for Resident #101 with a reference date of 9/11/25, revealed a Brief Interview for Mental Status (BIMS) assessment score of 3/15, which indicated the resident was severely cognitively impaired. Section E of the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain clear and accurate medical records for 2 (Resident #100 and Resident #101) of 5 residents reviewed for clear and accurate medical records resulting in an incomplete reflection of resident's behaviors, ongoing care needs, and the need for Resident #101 to discharge from the facility. Findings include:Resident #100 Review of an admission Record revealed Resident #100 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: Borderline intellectual functioning (indicating cognitive abilities below average, but not low enough to be classified as an intellectual disability), bipolar disease (a mental health condition that causes extreme mood swings), and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 9/19/25 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #100 was cognitively intact. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 1213927.Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff for 1 resident (Resident #101) of 4 residents reviewed for abuse, resulting in Licensed Practical Nurse (LPN) K intimidating and threatening to take away the resident's phone and the potential for psychosocial harm.Findings include:Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: legal blindness, cerebral palsy (neurological disorder that affects movement, posture and muscle coordination), post-traumatic stress disorder, anxiety, bipolar disorder (mental health condition characterized by extreme mood swings), blood cancer and seizure disorder. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 5/22/25 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which…

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 1213992,1213991, and 2570298.Based on observation, interview and record review the facility failed to ensure a resident received care in accordance with physician orders and professional standards of care in 1 resident (Resident #101) of 12 residents reviewed for quality of care, resulting in failure to adequately monitor Resident #101 with a history of recurrent Urinary Tract Infection (UTI), failure to accurately identify symptoms of UTI and provide necessary treatment, and failure to ensure hospital discharge physician orders for treatment of UTI were followed, resulting in Resident #101 requiring hospital intervention multiple times to receive treatment for UTI and the potential for negative resident outcomes.Findings include:Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: legal blindness and cerebral palsy (neurological disorder that affects movement, posture and muscle…

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 1213992.Based on interview and record review, the facility failed to provide medically related social services to attain and maintain the highest practicable physical, mental and psychosocial well-being for 1 resident (Resident #112) of 3 residents reviewed for social services, resulting in Resident #112 not receiving assistance with identifying community placement options and completion of the application process based upon the resident's expressed desire to discharge to the community, and not receiving timely quarterly care conference. Findings include:Resident #112Review of an admission Record revealed Resident #112 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #112, with a reference date of 7/2/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #112 was cognitively intact. In Section Q - Participation in Assessment and Goal Setting…

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 MI00150000. Based on interview and record review the facility failed to prevent the misappropriation of scheduled narcotic medication for 2 (R111 and R103) of 3 residents reviewed for misappropriation of property, resulting in the potential for ongoing misappropriation of narcotic medications. Findings include: R110 & R111 Review of R111's medical record Census revealed STOP BILLING on 12/31/24. Review of R111's Controlled Drug Receipt/Record/Disposition Form dated 1/12/25 revealed at 9:00 AM, RN T had removed 1 Morphine Sulfate 30 mg ER tablet from the card and indicated Medication Error. It was noted R111 had been discharged from the facility on 12/31/24, 13-days prior to the misappropriation. Review of the Medication Error Report dated 1/12/2025 at 10:00 AM revealed, In resident's (R#110) room .Resident due for Morphine 15 mg. Nurse pulled 30 mg dose from wrong card (#R111's) and gave to resident. Residents unable to follow conversation with nurse explaining what error…

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 adhere to nursing professional standards related to documentation of medication administration for 2 of 3 (Resident #206 and Resident #110) residents reviewed for medication administration documentation, resulting in a potential for missing controlled substances and inaccurate medication administration. Findings include: Resident #206 Review of an admission Record revealed Resident #206 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: anxiety disorder (mental health condition characterized by excessive and persistent worry, feat and unease that can significantly interfere with daily life. Review of a Minimum Data Set (MDS) assessment for Resident #206 with a reference date of 3/26/25, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #206 was cognitively intact. Section D of the MDS revealed Resident #206 had thoughts of harming himself during 2-6 days of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake # MI00149896 Based on interview, and record review, the facility failed to comprehensively assess and prescribe appropriate treatment for 1 (Resident #103) of 3 residents reviewed for change of condition, resulting in Resident #103 being hospitalized with aspiration pneumonia. Findings include: Review of an admission Record revealed Resident #103 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: major depressive disorder, recurrent, severe with psychotic symptoms (serious mental health condition characterized by persistent low mood and other symptoms that significantly interfere with daily life). Review of a Minimum Data Set (MDS) assessment for Resident #103 with a reference date of 11/8/24, revealed a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated Resident #103 was moderately cognitively impaired. Review of a Behavior Health Progress Note for Resident #103, with a reference date of 1/21/25 revealed He (Resident…

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 remove and safely dispose of discharged resident controlled substance medication in 1 of 3 residents (R111) reviewed for medication storage and disposal, resulting in diversion and/or misappropriation. Findings include: Review of facility policy, Medication Disposal, Destruction, and Sending Home with Resident, date approved 4/1/2022, revealed, Policy: The medications of residents who are .discharged , or medication that has been discontinued will be removed from the facility in accordance with local, State, and Federal regulations .the medication should be removed from the medication storage area(s) .This includes .medication carts .When a resident is discharged .The controlled medications being destroyed by the facility will be destroyed by two or more licensed personnel as designated by the Director of Nursing (DON) .When a resident is transferred out to the hospital. All medications prescribed for the resident will be placed in a medication room up to 14 days after transfer . R110 Review of R110's…

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 identification and timely reporting of an injury of unknown origin in one Resident (#100) of three residents reviewed for reporting, resulting in the potential for unidentified abuse or neglect and further exposure to abusive situations. Findings include: Resident #100 Review of an admission Record revealed Resident #100 was a female, with pertinent diagnoses which included: age-related osteoporosis with current pathological fracture, left femur, initial encounter for fracture (Onset Date 10/15/24) and vascular dementia. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 9/10/24 revealed a Brief Interview for Mental Status (BIMS) score of 4, out of a total possible score of 15, which indicated Resident #100 was severely cognitively impaired. Review of a Facility Reported Incident (FRI) document for Resident #100 revealed, Type of Alleged Incident: Injury of Unknown Source .Date/Time Incident Discovered: 10/15/2024 07:30 PM Date/Time Incident Occurred: 10/15/2024 07:30 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 observations, interviews, and record reviews, the facility failed to: (1) effectively clean and maintain food service equipment, and (2) date mark all potentially hazardous ready-to-eat food products effecting 82 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness. Findings include: On 09/26/24 at 09:00 A.M., A comprehensive tour of the food service was conducted with Corporate Director of Food and Nutrition Services GGG. The following items were noted: Six color coded (beige, yellow, purple, blue, white, red) cutting boards were observed severely (etched, scored, worn) resting upon the storage rack, adjacent to the hand sink. The oven backsplash panel was observed severely soiled with accumulated and encrusted food residue. The griddle surface corners and side panel plates were also observed severely soiled with accumulated and encrusted food residue. The Vulcan convection oven interiors were observed severely soiled with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and/or implement comprehensive care plans in 6 of 22 residents (Resident #46, #29, #19, #42, #41, & #51) reviewed for comprehensive care plans, resulting in the potential for unmet medical, physical, mental, and psychosocial needs. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.18.11, Chapter 4: Care Area Assessment (CAA) Process and Care Planning, dated October 2023, revealed .the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care . According to [NAME], [NAME] A.; [NAME], [NAME] Griffin;…

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 Resident #5 Review of an admission Record revealed Resident #5 was a female, with pertinent diagnoses which included chronic respiratory failure, muscle weakness, anemia, morbid obesity, peripheral vascular disease (PVD), high blood pressure, diabetes, seizure disorder, neuropathy (weakness, numbness, and pain from nerve damage), and major depression. Review of a Minimum Data Set (MDS) assessment for Resident #5, with a reference date of 8/21/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated she was cognitively intact. Review of a current Care Plan for Resident #5 revealed the focus .(Resident #5) has an ADL (Activities of Daily Living) Self care deficit as evidenced by weakness r/t (related to) morbid obesity, Chronic respiratory failure, PVD, Idiopathic neuropathy . initiated 4/2/24, with interventions which included .Assist to bathe/shower as needed . initiated 6/7/24, and .assist x 1 with bathing, dressing and grooming needs . initiated…

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.

In an interview on 09/25/24 at 10:29 AM, Licensed Practical Nurse (LPN) I reported the agency had been brought in the last few weeks, the Director of Nursing and the Administrator left, and a bunch of nurses left after they did. During an observation on 09/27/24 09:41 AM, review of the resident listing revealed C Hallway had 18 residents with one CNA to provide care for them. The schedule indicated it was a split assignment but this writer did not observed the split CNA on the hallway throughout the observations the whole day. In an interivew on 09/27/24 at 09:45 AM, Anonymous LLL when queried reported the C Hallway always had one CNA. The CNAs never got breaks because there was not enough staff to cover. In an interview on 09/27/24 06:26PM, Anonymous LLL reported the administration staff would never come to the hallway to assist the nursing staff unless the surveyors were in the building. The situation in the facility was so bad many of the CNAs had quit or went as needed, and the facility couldn't get anyone to work. The residents were not taken care of and not getting the showers…

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 competency evaluations were completed for 3 certified nursing assistants (CNAs) of 5 reviewed for annual competency evaluations resulting in the potential for unmet resident care needs. Findings include: On 10/1/24 at 10:15 AM., employee education files provided by Nursing Home Administrator (NHA) A for 5 CNAs were reviewed for annual competency evaluations; no annual competency evaluations were noted in the files. In an interview on 10/1/24 at 10:55 AM., Human Resources/Payroll (HR/P) MM reported that annual competency evaluations for CNAs was done electronically. HR/P MM reported that the director of nursing (DON) was responsible for the CNA evaluations. HR/P 'MM reported the DON was notified electronically when a CNAs evaluation was due, and it should be completed electronically. HR/P MM reported when the manager had completed the evaluation the CNA was notified electronically that it was ready for review. On 10/1/24 at 11:00 AM., HR/P MM provided an annual competency evaluation for a CNA with a date of…

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

Based on observation, interview, and record review, the facility failed to ensure medications remained safely stored in 2 of 4 medication carts, resulting in the potential missing medications. Findings include: Review of the policy/procedure Medication Administration, dated 8/7/23, revealed .POLICY OVERVIEW: Lock medication cart when not in direct view of nurse administering medications . In an observation on 9/26/24 at 9:34 AM, noted the C Hall medication cart was unlocked, with no staff present nearby (not in direct view of nurse administering medications). In an observation on 9/26/24 at 9:37 AM, Agency Registered Nurse (RN) XX returned to and locked the C Hall medication cart. Agency RN XX reported today was her first day at the facility. In an observation on 10/1/24 at 12:30 PM, noted the C Hall medication cart was unlocked, with no staff present nearby (not in direct view of nurse administering medications). In an observation on 10/1/24 at 12:34 PM, Director of Nursing (DON) B approached and locked the C Hall medication cart. DON B reported the nurse on C Hall today was an…

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: MI00147064 Based on interview, observation, and record review, the facility failed to:1.) implement effective infection control to prevent the spread of COVID-19 and, 2.) maintain effective Enhanced Barrier Precautions (EBP) for 3 of 21 residents (Resident #23, #17, and #51) reviewed for infection control, resulting in the potential for the continued spread of COVID-19 with negative resident outcomes and the increased risk for the transmission/transfer of pathogenic organisms and cross contamination between residents. Findings include: Review of the COVID Positive list of residents received on 9/27/24, revealed, there were 50 COVID positive residents out of a census of 82 at entry. During an observation on 09/25/24 at 09:21 AM, There were yellow Stop Signs posted on the wall for Rooms D-106 and D-109 with no other signage which indicated the appropriate PPE (personal protective equipment) to wear or to see a nurse prior to entering a room. There were no PPE carts/bins outside of…

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

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 82 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased air quality, and cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies. Findings include: On 09/26/24 at 01:30 P.M., The facility grounds oxygen storage building interior was observed soiled with dead leaves, paper products, plastic products, etc. The storage building interior flooring surface was also observed soiled with accumulated dust and dirt deposits. On 09/26/24 at 03:35 P.M., A common area environmental tour was conducted with Environmental Services Director EE. The following items were noted: A-B Shower Room: 1 of 4 return-air-exhaust ventilation grills were observed heavily soiled with dust and dirt deposits. 1 of 2 shower stall wand assemblies were observed missing an atmospheric vacuum breaker. C-D Shower Room: The hand sink basin waste drain and faucet assembly were observed leaking…

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 promote dignity and respect in 2 of 7 residents (Resident #44 and Resident #58) reviewed for dignity, resulting in the potential for feelings of diminished self-worth, sadness, and anxiety. Findings include: Review of Fundamentals of Nursing ([NAME] and [NAME]) 8th edition revealed, Promote Dignity and Self-Esteem. A sense of dignity includes a person's positive self-regard .attending to the patient's physical appearance promotes dignity and self-esteem. Cleanliness, absence of body odors, and attractive clothing give patients a sense of worth . [NAME], P. A., [NAME], A. G., Stockert, P. A., & Hall, A. (2014). Fundamentals of Nursing (8th ed.). St. Louis: Mosby. p. 721. Resident #44 Review of an admission Record revealed Resident #44 was a male, with pertinent diagnoses which included cerebral infarction (stroke), depression, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #44, with a reference date of 9/5/24,…

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

Based on observation, interview, and record review, the facility failed to determine the safety of self-administration of medication in 1 of 6 residents (Resident #5) reviewed for medication administration, resulting in the potential for complications for Resident #5's medical condition. Findings include: Review of the policy/procedure Medication Administration, dated 8/7/23, revealed .POLICY OVERVIEW: To safely and accurately prepare and administer medication according to physician order, professional standards of practice, and resident needs .Remain with resident until administration of medication is complete . Review of an admission Record revealed Resident #5 was a female, with pertinent diagnoses which included chronic respiratory failure, muscle weakness, anemia, morbid obesity, peripheral vascular disease (PVD), high blood pressure, diabetes, seizure disorder, neuropathy (weakness, numbness, and pain from nerve damage), and major depression. Review of a Minimum Data Set (MDS) assessment for Resident #5, with a reference date of 8/21/24, revealed a Brief Interview for Mental…

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

Based on observation and interview the facility failed to honor resident choices in 2 (Resident #14 and Resident #42) of 7 residents reviewed for self-determination resulting in feelings of anger and frustration. Findings include: Resident #14 Review of an admission Record revealed Resident #14 had pertinent diagnoses which included: Type 2 diabetes (a condition that occurs when the body is unable to use insulin resulting in persistently high blood sugar levels). Review of a Minimum Data Set (MDS) assessment for Resident #14, with a reference date of 9/22/24 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #14 was cognitively intact. On 9/26/24 at 9:26 AM., Resident #14 reported she was no longer able to access the vending machines and that made her angry. Resident #14 reported the vending machines were moved to the employee break room and residents no longer had access to them. Review of Order Summary for Resident #14 revealed .cardiac/diabetic diet, regular texture, thin consistent .ordered 9/23/2024 . Resident #42 Review of an admission…

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 MI00146657 Based on interview and record review the facility failed to ensure mail was delivered to 1 (Resident #42) of 1 resident reviewed for mail delivery resulting in feeling of anger and frustration. Findings include: Resident #42 Review of an admission Record revealed Resident #42 had pertinent diagnoses which included: acquired absence of the right and left legs above the knee. Review of a Minimum Data Set (MDS) assessment for Resident #42, with a reference date of 8/17/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #14 was cognitively intact. In an interview on 9/26/24 at 8:30 AM., Resident #42 reported she did not have her mail delivered for 4 days in August, 2024. In an interview on 9/27/24 at 1:11 PM., Receptionist (R) KK reported the mail was delivered to her, she sorted it and then provided resident mail to the activities department. R KK reported in August of 2024 the mail was given to the nursing home administrator to be logged before the administrator gave the mail to the activities…

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 update/revise a comprehensive care plan after a change in resident condition in 2 of 22 residents (Resident #44 & #14) reviewed for comprehensive care plans, resulting in an inaccurate reflection of the resident's status, and the potential for unmet medical, physical, mental, and psychosocial needs. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.18.11, Chapter 4: Care Area Assessment (CAA) Process and Care Planning, revealed .the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care . According 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.

Based on observation, interview, and record review, the facility failed to implement care planned intervention and updated interventions after a fall to maintain safety in 1 of 4 residents (Resident #80) reviewed for falls, resulting in the potential for injury and continued falls. Findings include: Resident #80: Review of an admission Record revealed Resident #80 was a female with pertinent diagnoses which included diabetes, stroke with left sided weakness, and high blood pressure. Review of current Care Plan for Resident #80, revised on 10/1/24, revealed the focus, .At risk for falls due to history of falls, poor safety awareness, unsteady gait, hx (history) of CVA (cerebral vascular accident) . with the intervention .Bed in low position when resident is in bed . Review of Kardex for Resident #80 dated 10/1/24, revealed, .Safety: Bed in low position when resident is in bed .hipsters on at all times .signage at bedside to encourage resident to call for assistance prior to transferring .toilet frequently with cares . Review of Incident Reports dated 8/3/24 at 1:45 PM, 8/5/24 at 3:50…

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 that pneumococcal vaccines were offered to one resident (Resident #51) of five residents reviewed for pneumococcal vaccinations, resulting in the resident potentially acquiring and experiencing complications related to pneumonia. Findings include: Resident #51 (R51) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R51 admitted to the facility on [DATE] with diagnoses of type 1 diabetes, anxiety and depression. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R51 was cognitively intact (13 to 15 cognitively intact). Review of R51's immunization records revealed that she did not have a pneumonia vaccine listed. R51's chart also revealed there weren't any signed consents or declination of the vaccine. During an interview on 9/27/2024 at 9:07 AM, Infection Preventionist (IP) C stated that R51 was due for a pneumonia vaccine and was not offered one upon admission. IP 'C verified that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure COVID-19 immunizations were offered to three residents (Residents #51, #343, #23) of five residents reviewed for COVID-19 immunizations, resulting in the increased likelihood of severe infection and complications/death related to COVID-19. Findings include: Resident #51 (R51) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R51 admitted to the facility on [DATE] with diagnoses of type 1 diabetes, anxiety and depression. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R51 was cognitively intact (13 to 15 cognitively intact). Review of the COVID positive list provided by the facility revealed R51 tested positive for COVID on 9/19/2024. Review of R51's immunization records revealed historical data that her last COVID-19 booster dose 2 was given on 11/22/2022. R51's chart also revealed that a COVID 19 SARS-CoV2 Antigen Test Assessment was not found and there weren't any signed…

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 by 1 Certified Nursing Assistant (CNA) of 5 reviewed for the completion of 12-hours of annual in-service training, resulting in the potential of unmet resident care needs. Findings include: In an interview on 10/1/24 at 10:55 AM., Human Resource/Payroll (HR/P) MM reported 12-hour annual in-services are assigned at hire, and then annually by the corporate office. HR/P MM reported she can access the online system used for in-services to print reports, but she had no other responsibilities regarding in-service trainings for CNAs. HR/P MM reported managers presented educations to new hire CNAs at orientation, but she was unsure about long term staff. HR/P MM reported that 4 modules were assigned to staff a month. HR/P MM reported department managers were responsible for tracking employee completion of assigned education modules. In an interview on 10/1/24 at 12:18 PM., Clinical Coordinator (CC) UU reported CNA in-services were provided by both online education…

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 #MI00142953, and MI00144298. Based on observation and interview, the facility failed to maintain a safe, and sanitary environment resulting in the increased likelihood for resident to sustain injuries, bacterial harborage, increased dust particulate in the air, and the potential for decrease in the satisfaction of environment for residents of the facility. Findings include: During a tour of the facility on 5/23/24 at 3:16pm the following observations were made: During on observation on 5/23/24 at 3:16pm the corridor floor outside room D103 contained a broken tile with missing piece approximately 2 in diameter, the same area had a build up of an unknown white material on the floor. During an observation on 5/23/24 at 3:17pm the ventilation screen outside room D105 was heavily soiled with dust and debris. During an observation on 5/23/24 at 3:19pm several strips of laminate flooring in the dining room were noted to be peeling up from the subfloor with the ends of the strips elevated. During the same observation the ventilation screen in the 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 ensure 1 (Resident #104) of 3 residents reviewed for management of personal funds, had ready and reasonable access to those funds upon request, resulting in Resident #104 experiencing anxiety and frustration related to a delay in access to her money that could result in a loss of property and life insurance coverage. Findings include: Review of an admission Record revealed Resident #104, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: myocardial infarction (heart attack), hypertension (high blood pressure), and chronic obstructive pulmonary disease (chronic inflammation of lung tissue that causes obstruction of air flow). Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 1/10/24 revealed a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated Resident #104 was moderately cognitively impaired. Review of a Care Plan for Resident # 104, with 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 #MI00143174 Based on interview, and record review, the facility failed to prevent misappropriation of resident money for 1 of 3 residents (Resident #104) reviewed for misappropriation, resulting in the loss of Resident #104's lock box(that contained $152), and feelings of frustration, and helplessness. Findings include: Review of an admission Record revealed Resident #104, was originally admitted to the facility on [DATE]. Review of a Care Plan for Resident #104, with a reference date of 10/23/23, revealed 2 relevant focus/goal/interventions: 1. Focus: Indicators of depression/sadness present, Goal: Maintain involvement with ADL performance and social activities, Interventions: . Involve in making own schedule/ sequencing of activities to enhance a sense of control . Offer choices to enhance sense of control . 2. Focus: Prefers to have cash on hand .Goal: none noted, Interventions: lock box provided for resident to keep personal money safe in room. Review of a facility policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes #MI00139525, MI00139682, MI00139556, and MI00139691. Based on observation, interview and record review, the facility failed to protect resident's right to be free from abuse for 5 (Resident #101, #102, #116, #117, and #118) of 9 residents reviewed for abuse, when Resident #102 physically abused Resident #101, Resident #116, Resident #117, and Resident #118, causing physical pain and emotional distress. Findings include: Resident #102 Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 11/6/23 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #102 was severely cognitively impaired. Review of Resident #102's Behavioral Care Plan revealed, Focus: At risk for behavior symptoms r/t (related to) dementia aeb (as evidence by) yelling at staff, attempting to bite staff, cursing, throwing trash, attempting to enter other residents' rooms and becoming hostile when not allowed…

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

This citation pertains to intakes #MI00139682, MI00139556, and MI00139691. Based on interview and record review, the facility failed to immediately report incident's of resident to resident abuse to the State Agency for 5 of 5 Residents (Resident #101, #102, #116, #117 and #118) reviewed for abuse, resulting in the potential for continued unidentified, unreported abuse to occur. Findings include: Resident #101 Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 12/15/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #101 was cognitively intact. Resident #102 Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 11/6/23 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #102 was severely cognitively impaired. Resident #116 Review of a Minimum Data Set (MDS) assessment for Resident #116, with a reference date of 10/20/23 revealed a Brief Interview for Mental…

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 #MI00139682, MI00139556, and MI00139691. Based on interview and record review, the facility failed to thoroughly investigate alleged violations and prevent further resident to resident abuse from occurring in 5 of 5 residents (Resident #101, #102, #116, #117, and #118) reviewed for abuse, resulting in the lack of thorough investigations and continued resident to resident abuse. Findings include: In an interview on 1/3/24 at 9:22 AM, Nursing Home Administrator (NHA) reported that Resident #102 was not capable of intent to commit abuse due to her cognitive impairment, and therefore the facility did not consider the physical incidents abuse. NHA could not accurately define Willful and reported that Resident #102's actions were not accidental. Resident #101 Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 12/15/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident…

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: 1. Clean food and non-food contact surfaces to sight and touch; 2. Datemark and discard potentially hazardous foods; and 3. Repair a water-damaged wall in the kitchen area. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness for all residents who consume food from the kitchen. Findings include: During an observation/interview with Dietary Manager (DM) H during the initial kitchen tour on 7/31/23 at 9:54 AM in the dry storage area, noted an opened bag of cornbread mix that was not securely sealed closed and did not have an opened date or discard date. DM H reported the cornbread mix should have been labeled and dated and securely sealed to prevent contamination. There was a can of butterscotch pudding with a large dent at the seal that was located on the can storage rack. DM H reported that no dented can was okay, and that a dented can should not have been put on the can storage rack for use. During an observation/interview with DM H during 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 securely store resident medications in 2 out of 4 medication carts reviewed for medication storage, resulting in the potential for the compromise of medications and/or the misappropriation of medication. Findings include: During an observation on 7/31/23 at 12:09 PM., the medication cart on A hall left was noted to be unlocked. During an observation on 7/31/23 at 12:19 PM., the medication cart on A A hall continues to be unlocked, no nursing staff present on the hall. Noted residents and visitors walking by the medication cart. During an observation on 7/31/23 at 12:29 PM., Licensed Practical Nurse (LPN) II returned to the medication cart, placed a piece of paper on the top of the cart and walked away. LPN II did not lock the medication cart. During an observation on 7/31/23 at 12:43 PM., LPN II came back to the medication cart on A hall opened the computer, grabbed medications for a resident and then walked away leaving the computer open with personal identifying information in plain sight, and LPN II did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to: 1.) ensure proper infection control measures were implemented for hand hygiene during a dressing change for 1 of 1 resident (Resident #62) reviewed for dressing changes and 2.) ensure hand hygiene practices before and after entering/exiting resident rooms, resulting in the increased potential for the development and transmission of communicable diseases and infection in a vulnerable population. Findings include: Review of an admission Record revealed Resident #62, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: fracture of lower of left leg. In an observation on 08/01/23 at 1:51 PM., Licensed Practical Nurse (LPN) II completed a feeding tube dressing change for Resident #62. LPN II removed the old, saturated dressing with her surgical gloves on. LPN II then took her right-hand with the glove on it to reach into her scrub shirt pocket, grabbing a pen to write the date on the new foam bordered…

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

Based on observation and interview the facility failed to provide activities of daily living (ADL) care to promote dignity in 1 of 18 residents (Resident #5) reviewed for dignity resulting in the potential for a reasonable person to experience feelings of embarrassment and/or shame. Findings include: Resident #5 Review of an admission Record revealed Resident #5, had pertinent diagnoses which included vascular dementia. Review of a Minimum Data Set (MDS) assessment for Resident #5, with a reference date of 6/25/23 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #5 had severe cognitive impairment. During an observation and interview on 7/31/23 at 11:55 AM, Resident #5 sitting in wheelchair in the doorway of her room with food debris on her face and the back of her left hand. Certified Nursing Assistant (CNA) CC reported that resident's hand should be washed before and after meals and when needed. During an observation on 7/31/23 at 3:05 PM, Resident #5 sitting in wheelchair in her room food debris on her face and the back of her 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 interview and record review the facility failed to allow and accommodate resident choice related to showers in 1 of 18 residents (Resident #70) reviewed for resident choice, resulting in feelings of frustration and embarrassment. Findings include: Resident #70 Review of a Minimum Data Set (MDS) assessment for Resident #70, with a reference date of 6/7/23 revealed a Brief Interview for Mental Status (BIMS) score of 10/15 which indicated Resident #70 was moderate cognitive impairment. During an interview on 7/31/23 at 11:51 AM, Resident #70 reported it had been over a week since she had a shower, and she was frustrated with staff and worried she smelled bad. Resident #70 reported she would like to have showers when she wants them. Review of Task: Shower/Bath Monday Evenings for the month of July 2023, revealed Resident #70 received a shower on 7/3/23, 7/10/23, and 7/31/23. Review of Visit Note Report from (Name Omitted) Hospice provider, Resident #70 received a shower on 7/3/23, 7/5/23, and 7/12/23. During a interviews and a review of records on 8/1/23 at 12:10 Registered…

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 notify the resident and/or the resident's representative in writing of the reason for a transfer to the hospital in 1 of 3 residents (Resident #68) reviewed for transfer and discharge requirements, resulting in the potential for residents and/or their representatives to not be fully informed of the reason for a hospital transfer and their rights in regard to an appeal hearing. Findings include: Resident #68 Review of an admission Record revealed Resident #68 was a male, with pertinent diagnoses which included traumatic brain injury. Review of a Minimum Data Set (MDS) assessment, with a reference date of 7/19/23, revealed Resident #68 had severe cognitive impairment. Review of a Progress Note for Resident #68, dated 7/22/23 at 5:23 p.m., revealed .I was bolusing residents g-tube (gastrostomy tube) feeding and the top of the tube broke off. I called (Physician Name) and the type of g-tube the resident has is not one we can replace here. I called (Local Emergency Room) and informed them of our situation and they stated they…

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

Based on interview, and record review, the facility failed to provide written notification of the bed hold policy upon transfer to the hospital in 1 of 3 residents (Resident #68) reviewed for transfer and discharge requirements, resulting in the potential for residents and/or their representatives to be unaware of their rights in regard to facility bed holds. Findings include: Resident #68 Review of a Minimum Data Set (MDS) assessment, with a reference date of 7/19/23, revealed Resident #68 had severe cognitive impairment. Review of a Progress Note for Resident #68, dated 7/22/23 at 5:23 p.m., revealed .I was bolusing residents g-tube (gastrostomy tube) feeding and the top of the tube broke off. I called (Physician Name) and the type of g-tube the resident has is not one we can replace here. I called (Local Emergency Room) and informed them of our situation and they stated they would not be able to replace either and we would have to transport him to (City Name). I Called EMT (Emergency Medical Technician) and explained our situation and they came to transfer the resident 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 Based on interview and record review, the facility failed to ensure Preadmission Screening (PAS) / Annual Resident (ARR) Mental Illness / Intellectual Disability / Related Conditions Identification forms DCH-3877 and/or DCH-3878) documents were completed annually for 1 (Resident #26) of 18 sampled residents, resulting in the potential for unmet mental health care needs. Findings include: Resident #26 Review of an admission Record revealed Resident #26 was a female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: anxiety disorder, bipolar disorder, and major depressive disorder. Review of Resident #26's clinical record on 7/31/23 at 3:46 PM revealed a DCH-3877 form had been completed and dated on 12/17/21. No subsequent (annual) screening documentation was found in Resident #26's clinical record. In interview on 8/1/23 at 2:42 PM, Social Worker (SW) U reported residents should have the ARR Form DCH-3877 completed annually. SW U was requested to provide evidence that an ARR…

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

Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans in 2 of 18 residents (Resident #21 & #6) reviewed for comprehensive care plans, resulting in the potential for falls/injury for Resident #21 and a lack of resident-centered interventions for dementia care for Resident #6. Findings include: Resident #21 Review of an admission Record revealed Resident #21 was a male, with pertinent diagnoses which included a seizure disorder, obstructive lung disease, heart failure, and a traumatic brain injury. Review of a Minimum Data Set (MDS) assessment, with a reference date of 7/1/23, revealed Resident #21 had severe cognitive impairment. Review of a current Care Plan for Resident #21 revealed the focus .ADL (Activities of Daily Living) Self care deficit related to physical limitations, secondary to TBI (Traumatic Brain Injury) with right sided weakness and left sided mobility impairment . initiated 12/22/22, with interventions which included .Transfer with full mechanical lift x2 assist . revised 4/6/23. Review of a Kardex…

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 revise a care plan to include relevant interventions for 1 of 18 residents (Resident #23) reviewed for care plans, resulting in the potential for weight loss, malnourishment, and resident dissatisfaction of the dining experience. Findings include: Review of an admission Record revealed Resident #23, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: dementia. Review of a Minimum Data Set (MDS) assessment for Resident #23, with a reference date of 7/18/23 revealed a Brief Interview for Mental Status (BIMS) score of 02/15 which indicated Resident #23 was cognitively impaired. Further review of Resident #23's MDS assessment revealed Section G. Functional Status 1. ADL Self-Performance . Resident #23 was coded as 1/2 .1. Supervision - oversight, encouragement or cueing. 2. One-person physical assist Which indicated Resident #23 needed 1 staff to physically assist and or cue and supervise with meals.…

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 assistance with eating was provided for 1 of 3 residents (Resident #23) reviewed for activities of daily living, resulting in Resident #23 missing breakfast, and the potential for weight loss, feelings of hunger and an overall decline in health. Findings include: Review of an admission Record revealed Resident #23, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: dementia. Review of a Minimum Data Set (MDS) assessment for Resident #23, with a reference date of 7/18/23 revealed a Brief Interview for Mental Status (BIMS) score of 02/15 which indicated Resident #23 was cognitively impaired. Further review of Resident #23's MDS assessment revealed Section G. Functional Status 1. ADL Self-Performance . Resident #23 was coded as 1/2 .1. Supervision - oversight, encouragement or cueing. 2. One-person physical assist Which indicated Resident #23 needed 1 staff to physically assist and or cue 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 observations, interview, and record review the facility failed to ensure portable supplemental oxygen was administered to 1 of 1 resident (Resident #52) reviewed for oxygen use resulting in shortness of breath, feelings of anxiety, and fatigue. Findings include: Review of an admission Record revealed Resident #52, had pertinent diagnoses which included chronic obstructive pulmonary disease (COPD, restriction of the airway making breathing difficult) and acute respiratory failure (difficult breathing) with hypoxia (low oxygen level in the body). Review of a Minimum Data Set (MDS) assessment for Resident #52, with a reference date of 6/25/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #52 was cognitively intact. During an observation and interview on 7/31/23 at 1:15 PM, Resident #52 was sitting in her wheelchair in her room with nasal cannula (oxygen tubing) in her nose and connected to a portable oxygen tank (medical device that delivers oxygen) on the back of her wheelchair that the gauge on the oxygen tank displayed empty.…

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 # MI00138015. Based on interview and record review, the facility failed to ensure a resident with documented food allergies was not served those foods in 1 (Resident #43) of 18 sampled residents, resulting in the resident consuming a portion of the allergenic food item, having a mild allergic reaction, and feelings of frustration and meal dissatisfaction. Findings include: Review of a Face Sheet revealed Resident #43 was a female, with documented food allergies that included lemon, lime (citrus), and raspberries. Review of a Minimum Data Set (MDS) assessment for Resident #43, with a reference date of 5/18/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #43 was cognitively intact. In an interview on 7/31/23 at 1:52 PM, Resident #43 reported she had recently been served a food she was allergic to (lemon) on her meal tray. Resident #43 reported she was highly allergic to lemon, as well as other foods, and the facility was aware of her food allergies. Resident #43 reported…

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