Optalis Health and Rehabilitation of Troy

This citation relates to Intake 2655900. Based on interview and record review, the facility failed to report a physical and sexual abuse incident for three residents (R103, R104, and R108) of six residents reviewed for abuse. Findings include:Review of a Complaint reported to the State Agency, received on 10/29/25, alleged R108 (a male resident) went into R103's room naked, got into bed with them, and touched her on her breast, and then R103 hit them with her shoe. The complaint further alleged R108 attempted to get into R103's roommates' bed, R104 (a second female resident), and did not touch them. Review of a FRI (Facility reported incident), received by the State Agency on 11/06/25, revealed on 10/28/25, R104 reported R108 came into their room, attempted to get into their bed, and then exposed and fondled themselves next to her in her room. On 11/05/25 at 11:15 a.m., R104 reported a resident-to-resident incident during an interview, which revealed R108 attempted to climb into her bed about a week prior, when R104 was in her bed. R104 said she yelled at R108 to stop, and then R108…

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 is based on complaint: 2655900. Based on observation, interview and record reviews the facility failed to provide adequate supervision for a resident with medical issues and physical limitations which makes client unsafe to leave the facility alone and cognitive function and awareness concerns, for one (R105) of four residents reviewed for supervision/accidents. This resulted in the facility's failure to ensure the necessary supervision for R105 was provided. Findings include:A review of a complaint submitted to the State Agency (SA) documented concerns of R105 to have eloped from the facility. A review of the medical record revealed R105 was admitted to the facility on [DATE] with diagnoses that included: unsteadiness on feet, dysphagia, anxiety disorder, chronic obstructive pulmonary disease, hypertension and alcoholic cirrhosis of liver. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired…

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 Complaint #2596436Based on interview and record review the facility failed to ensure timely medical appointments and debridement treatments were implemented to prevent the worsening of a wound for one (R302) out of two residents reviewed for pressure ulcers/wounds resulting in R302 being hospitalized for additional care. Findings include:A complaint was filed with the State Agency (SA) that reported that R302 was scheduled to see their wound surgeon for treatment and the facility sent them to the wrong office. R302 then had to wait another week to see the wound surgeon. On 8/7/25 the wound surgeon examined them at their office, and they immediately sent them to the hospital.Hospital Records were reviewed and documented in part, .(name redacted) Emergency Department 8/7/25.History.R302.presents with evaluation of right foot wound. Patient underwent amputation with Dr. Z 7 weeks ago due to gangrene of his right fifth toe.Patient was seen by Dr. Z today (8/7/25) for wound care. There 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 2597366Based on interview and record review, the facility failed to ensure appropriate supervision was provided to a resident for one (R303) of two residents reviewed for transportation resulting in R303 being sent multiple times to medical appointments with no staff supervision. Findings include:A complaint was filed with the State Agency (SA) that alleged in part, .On 8/14/2025. (R303) was sent to the appointment and left in the lobby of the doctor's office without any caretaker from the facility.Review of the clinical record revealed R303 was admitted into the facility on 4/11/25 and readmitted [DATE] with diagnoses that included: dementia, convulsions and blindness right eye. According to the Minimum Data Set (MDS) assessment dated [DATE], R303 had moderately impaired cognition. The clinical record also indicated R303 had a Durable Power of Attorney (DPOA) that was the Responsible Party for financial and medical care.Review of a Physician Statement of Capacity for Medical…

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 #MI00151683 Based on observation, interview and record review, the facility failed to ensure consistent implementation and documentation of a DNR (Do Not Resuscitate) order for one resident (R408) of four residents reviewed for resident rights. Findings include: On [DATE] at approximately 9:50 a.m., R408 was observed in their room, laying in their bed. R408 was observed with a wander guard on their right ankle. R408 was observed to be thin and have some confusion when participating in the interview. On [DATE] the medical record for R408 was reviewed and revealed the following: R408 was initially admitted to the facility on [DATE] and had diagnoses including Dementia and Malignant Neoplasm of Prostate. A review of R408's MDS (minimum data set) with an ARD (assessment reference date) of [DATE] revealed R408 needed some assistance from facility staff with most of their activities of daily living. R408's BIMS score (brief interview for mental status) was 12 indicating moderately…

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 #MI00150318 Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a staff member for one resident (R404) of four residents reviewed for abuse/neglect/mistreatment. Findings include: On 4/9/25 a concern submitted to the State Agency was reviewed which alleged R404 was physically abused by a staff member. On 4/9/25 the medical record for R404 was reviewed and revealed the following: R404 was initially admitted to the facility on [DATE] and had diagnoses including Parkinsonism, Dysphagia and Cognitive communication deficit. A review of R404's MDS (minimum data set) with an ARD (assessment reference date) of 2/3/25 revealed R404 needed assistance from facility staff with most of their activities of daily living. R404's BIMS score (brief interview for mental status) was 14 indicating intact cognition. On 4/9/25 a statement from the facility pertaining to the alleged incident on 2/3/25 that was received during 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 # MI00150676. Based on interview, and record review, the facility failed to report an allegation of abuse to the State Agency and Administrator (Abuse Coordinator) within the required time frame for one (R406) of four residents reviewed for abuse. Findings include: A review of a Facility Reported Incident (FRI) submitted to the State Agency on 2/19/24 documented R406 sustained an injury of unknown origin which was a fracture of the tibia and fibula while receiving care from an agency CNA (Certified Nursing Assistant) on 2/14/25. On 4/9/25 at 10:40 AM, R406 was observed lying in bed with a trapeze bar positioned above the head of the bed and there was a pillow placed along the resident's right lower extremity. R406 was alert and remembered this surveyor from a previous survey. The resident reported since their initial back injury that brought them to the facility in August 2024, their right leg tended to wander to the right and when it did, they didn't have any control over the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake # MI00150676 and MI00150318. Based on interview and record review, the facility failed to complete a thorough investigation into an initial injury of unknown origin and allegation of mistreatment for one resident (R406) and ensure protection/prevention of further access with an employee (alleged perpetrator) with confirmed abuse findings from having continued access to one resident (R404) out of four residents reviewed for abuse. Findings include: According to the facility's policy titled, Abuse dated 4/13/2022: .Prevention consists of facility systems designed to detect, identify, correct, and prevent the occurrence of abuse .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation .If a staff member is the alleged perpetrator, that staff member should be immediately removed from the facility and the schedule pending the outcome of the investigation .Once reported, the center conducts a timely,…

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 promptly respond, provide timely assistance and proper positioning in bed for one (R410) of four residents reviewed for quality of care. Findings include: On 4/9/25 at 9:37 AM, upon walking off the elevator onto the second floor, a resident was heard yelling out continuously, very loudly. There were three employees observed seated at the nursing desk which included an CNA (Certified Nurse Assistant), NM (Nurse Manager) 'A', and Unit Clerk 'F'. There was a female resident and male visitor seated just outside the nursing desk (across from the staff) making remarks about the resident yelling. At this time, no staff were observed to respond to the resident's yelling. Continued observations down the hallway around the corner from the yelling resident revealed several other residents in their rooms making remarks about how bad they felt about the resident yelling and hoped they were ok. On 4/9/25 at 9:40 AM, upon entry into R410's room, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00151683. Based on interview and record reviews the facility staff failed to follow the facility policy on capacity decision making for one (R402) of four residents reviewed for the accuracy of medical records. Findings include: Review of a complaint submitted to the State Agency (SA) documented concerns of the facility's failure to timely assess R402's capacity for decision making, a concern regarding the accuracy of the capacity document once it was completed and the ethics of the Physician that signed off on the capacity report. A review of the medical record revealed R402 was admitted to the facility on [DATE] with diagnoses that included: Fracture of right pubis, repeated falls, severe protein-calorie malnutrition, dysphagia-oropharyngeal phase, and abnormal weight loss. Review of a call log submitted to the SA documented a conversation on 1/3/25 at 10:50 AM, between the Daughter of R402 and the facility's Social Work Director (SWD) J. The conversation noted discussions…

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 intake pertains to MI00149760. Based on observation, interview, and record review, the facility failed to provide safe, operational mechanical lifts for three Residents (R502, R503, R504) of four residents reviewed for safe transfers and equipment. Findings include: Review of a complaint received by the State Agency, dated [DATE], revealed an allegation of the mechanical lifts in the building not working on [DATE], and on [DATE]. The complainant (a resident) alleged they were told they would not be fixed for nearly a week by facility staff. The complainant reported the full body mechanical lifts were in disrepair, with the batteries frequently not holding a charge. The complainant said this kept them stuck in their room and they were unable to exercise or leave their room for activities, which upset them. R502: On [DATE] at 9:22 a.m., Certified Nurse Aide (CNA) E was asked about the use and availability of the full body mechanical lifts in the facility. CNA E stated, Yes, there was a time when the lifts…

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

Based on interview and record review, the facility failed to ensure that grievances were promptly documented, investigated, tracked and resolved for four residents (R24, R30, R37, R40) of five residents that participate in the resident council (RC) meetings. Findings include: On 12/10/24 at approximately 10:41 a.m., during the group meeting, the residents were asked if their concerns that were brought up in the monthly resident council meetings were addressed and resolved and four residents (R24, R30, R37 and R40) all indicated that their concerns were not addressed and resolved in a timely manner. R40 reported that concerns are brought up, but no resolution is provided. On 12/10/24 the resident council meeting minutes were reviewed for September, October and November 2024. Further review of September's meeting minutes revealed the RC had concerns with Nursing services. On 12/11/24 at 8:32 a.m., the Administrator was asked for grievance/concern forms that showed resident council concerns were addressed and resolved for the previous four months. On 12/11/24 at 9:43 a.m., the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure services provided met professional standards of practice for four (R2, R45, R13, and R308) of four residents reviewed for professional standards. Findings include: R2 On 12/9/24 upon entrance into the facility, a Daily Census report dated 12/9/24 at 8:35 AM was provided. R2 was listed as Active. On 12/9/24 at approximately 9:35 AM, the door to R2's room was closed, upon knocking and entering, the room was observed fully cleaned, and no belongings were observed. Registered Nurse (RN) Y was asked about R2. RN Y explained R2 had been discharged to the hospital. Review of the clinical record revealed R2 was admitted into the facility on [DATE] with diagnoses that included: diabetes, depression and dementia. According to the Minimum Data Set (MDS) assessment dated [DATE], R2 was cognitively intact. The record also indicated R2 was still a resident at the facility. Review of R2's progress notes revealed: A nursing note dated 12/6/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure accurate documentation of controlled substances for one (R258) of one resident reviewed for controlled medications. Findings include: Review of the closed record revealed R258 was admitted into the facility on [DATE] with diagnoses that included: intraspinal abscess, meningitis and rheumatoid arthritis. According to a Brief Interview for Mental Status (BIMS) assessment dated [DATE], R258 scored 15/15 indicating cognitively intact. Review of medications revealed a physician order for Hydromorphone 2 milligrams (mg), give 2 tablets every 4 hours as needed for pain. Comparing the Controlled Drug Receipt/Record/Disposition Form for Hydromorphone 2 mg with R258's November 2024 Medication Administration Record (MAR) revealed the following discrepancies: On 11/16/24 at 6:00 PM two tablets were documented as being removed from R258's supply. There was no documentation on the MAR that R258 was given the two tables of Hydromorphone. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were appropriately stored and in a safe/sanitary manner in three of four medication carts and one treatment cart reviewed. Findings include: Review of a facility policy titled, Storing Drugs and Biologicals-Storage and Maintenance of Medication dated 3/1/18 read in part, .Only drugs (and supplies necessary for their administration) are to be kept in medicine cabinets and carts . Medication must be checked regularly for expiration dates and deterioration On 12/10/24 at 9:41 AM, observation of the 1st floor Cart 2 medication cart was made with Licensed Practical Nurse (LPN) T. In the third drawer from the top on the left, a large, clear plastic coffle cup with a coffee colored liquid and straw was on the left side of the drawer. When asked what it was, LPN T explained it was her coffee, and she needed to move it. Also in the same drawer was a vial of Lispro Insulin that had no open date written on it. A bottle of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure appropriate infection control practices related to transmission-based precautions (TBP) for two (R159 and R6) of three residents reviewed for infection control, resulting in the potential for the spread of infection. Findings include: According to the facility's policy titled, Infection Control - Standard and Transmission-Based Precautions dated 3/4/2024: .Transmission-based precautions are used for residents who are known or suspected to be infected with infectious agents that require additional control measures above standard precautions to effectively prevent transmission which included: Contact Precautions .Each route of transmission will dictate the necessary personal protective equipment (PPE) and precaution may be used. When used singly or in combination, they are always used in addition to standard precautions .Residents on transmission-based precautions should have a sign outside of the resident's room with Stop See Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide an environment that promoted and enhanced resident's dignity for multiple residents, including two (R50 and R259) of two residents reviewed for dignity and anonymous residents attending resident council. Findings include: Review of a facility policy titled Dignity dated 9/21/23 read in part, .It is the policy of this facility that each resident will be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth, and self-esteem .Demeaning practices and standards of care that compromise dignity are prohibited . R259 On 12/9/24 at 9:20 AM, R259 was observed lying in bed with a sling on their right arm. R259 was asked about the care at the facility. R259 explained one night they pushed their call light because they had to go to the bathroom, but when a staff member came in they told them just to go in their brief, and they would change them later. R259 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure resident's right to personal privacy during treatment (lab draw) for one (R6) of one resident reviewed for privacy. Findings include: On 12/11/24 at 9:18 AM, from the hallway outside R6's room, the resident was observed laying in bed and another person was observed at their bedside performing a blood draw. The privacy curtain and/or door was not closed and the entire procedure was observed from the hallway. On 12/11/24 at 9:20 AM, Unit Manager 'FF' was observed just outside R6's room and confirmed the lack of privacy. On 12/11/24 at 9:22 AM, upon exiting the resident's room, Phlebotomist (Lab Staff 'K') was asked about why they didn't close the door, or pull the curtain to provide privacy during a lab draw and they offered no response. Review of the clinical record revealed R6 was admitted into the facility on [DATE] with diagnoses that included: MSSA (Methicillin-susceptible Staphylococcus aureus - a type of bacterial infection). On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure necessary documentation was completed, provide evidence of communication to the receiving facility, and completing the discharge process for one (R2) of one resident reviewed for hospitalization. Findings include: On 12/9/24 upon entrance into the facility, a Daily Census report dated 12/9/24 at 8:35 AM was provided. R2 was listed as Active. On 12/9/24 at approximately 9:35 AM, the door to R2's room was closed, upon knocking and entering, the room was observed fully cleaned, and no belongings were observed. Registered Nurse (RN) Y was asked about R2. RN Y explained R2 had been discharged to the hospital. Review of the clinical record revealed R2 was admitted into the facility on [DATE] with diagnoses that included: diabetes, depression and dementia. According to the Minimum Data Set (MDS) assessment dated [DATE], R2 was cognitively intact. The record also indicated R2 was still a resident at the facility. Review of R2's assessments revealed no…

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 record review and interview, the facility failed to ensure an admission medication order was followed for one (R38) of one resident reviewed for admission orders. Findings include: Record review revealed R38 was admitted to the facility on [DATE] requiring nursing care and rehabilitation after a fall resulting in spinal and elbow fractures. Medical history included hypertension, anxiety, asthma, and muscle weakness. R38's BIMS (Brief Interview Mental Status) documented on admission was 14/15 indicating R38 was cognitively intact. On 12/10/24, A record review revealed on 10/25/24 pharmacy recommendations to nursing documented .Resident has orders .Per hospital records, the resident should not continue on Trelegy Ellipta (an inhaled medication to control and prevent wheezing and shortness of breath) .Please clarify with the provider and update the medical record accordingly . On 12/10/24 at 11:38 AM, the Director of Nursing (DON) was interviewed and confirmed the signature on the document was theirs and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess and implement treatment orders, and identify skin changes and/or the worsening of pressure ulcers for two (R38 and R39) of three residents reviewed for pressure ulcers. Findings include: This citation pertains to intake: MI00148681. Resident #38 Review of a complaint submitted to the State Agency on 11/29/24 documented an allegation the facility failed to provide adequate and appropriate interventions to prevent and care for pressure ulcers. Record review revealed R38 was admitted to the facility on [DATE] requiring nursing care and rehabilitation after a fall resulting in spinal and elbow fractures. Medical history included hypertension, anxiety, asthma, and muscle weakness. R38's BIMS (Brief Interview Mental Status) documented on admission was 14/15 indicating R38 was cognitively intact. Record review revealed on 10/25/24 an order to consult wound care was placed for R38. On 11/25/24 a skin assessment was performed for R38 and…

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

Based on interview and record review, the facility failed to ensure two (Certified Nurse Aides - CNA 'L' and CNA 'P') of five CNAs reviewed for competency was evaluated for skills and techniques necessary to care for the needs of the residents. Findings include: On 12/10/24 at 2:11 PM, the Administrator was requested to provide documentation for review which included skills/competency evaluations for five CNAs. Review of the documentation provided revealed concerns with the lack of annual skills/competency evaluations not completed timely with two of the five CNAs reviewed. These concerns included: 1) For CNA 'L', their date of hire was 4/22/11, and the most recent skills/competency evaluation was completed on 7/6/23. 2) For CNA 'P', their date of hire was 5/14/12 and the most recent skills/competency evaluation was completed on 7/6/23. On 12/11/24 at 11:24 AM, an interview was conducted with the In-Service Director (Staff 'I'). They reported they took over the role for in-service education in October 2024 and had been working to try to complete many things that had not been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a Physician ordered laboratory (lab) diagnostic was completed for two residents (R47 and R52) of two residents reviewed for diagnostics. Findings include: R47 On 12/9/24 the medical record for R47 was reviewed and revealed the following: R47 was initially admitted to the facility on [DATE] and had diagnoses including Tracheostomy, End stage renal disease and Cerebral infarction. A review of R47's MDS (minimum data set) with an ARD (assessment reference date) of 11/20/24 revealed R47 needed assistance from facility staff with all their activities of daily living. A Physician's order dated 11/18/24 revealed the following: Weekly cbc (complete blood count), cmp (comprehensive metabolic panel) A review of R47's weekly lab results only revealed one set of the cbc/cmp results with a collection date of 12/2/24. R52 On 12/9/24 the medical record for R52 was reviewed and revealed the following: R52 was initially admitted to the facility on [DATE] and had…

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 collaboration with hospice representatives with one (R32) of one resident reviewed for hospice services, resulting in hospice not informed of clinical and intervention changes. Findings include: Clinical record review revealed R32 was admitted to the facility on [DATE] under the care of hospice services for medical diagnoses of cerebral infarct, hypertension, atrial fibrillation (abnormal heart rhythm) right sided hemiplegia, contractures, sepsis, and urinary retention. The BIMS (Brief Interview Mental Status) recorded on admission was 14/15 indicating R32 was cognitively intact. Review of a Nursing progress note dated 12/7/24 documented .Resident observed moaning in discomfort, stated (It burns/hurts when I pee), discharge noted from penile area . Nursing obtained orders to collect a urine sample and remove the catheter. Review of the Physician progress note dated 12/10/24 detailed R32 was seen for a urinary tract infection, had an abnormal…

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 MI00147673 Based on observation, interview and record review facility failed to follow-up and resolve grievances for one (R503) of three residents reviewed for grievances. Findings include: On 11/4/24 at 10:25 AM, R503 was observed lying in their bed. R503 was asked about care at the facility. R503 explained they had a hard time getting help to go to the bathroom timely. R503 was asked if they had ever told their concern to anyone at the facility. R503 explained they had, but nothing really had changed, just that morning, they had pushed their call light and the CNA (Certified Nursing Assistant) had come in and turned off the light and said he would be back, then after awhile he was bringing in their breakfast tray, when they reminded the CNA he was supposed to take them to the bathroom, he said he had forgotten. Review of the clinical record revealed R503 was admitted into the facility on [DATE] with diagnoses that included: compression fracture of lumbar (spine), stroke and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00147673. Based on interview and record review, the facility failed to ensure an allegation of abuse/neglect/mistreatment was reported to the State Agency (SA) for one resident (R501) of three residents reviewed for abuse/neglect/mistreatment. Findings include: On 11/4/24 a complaint submitted to the State Agency was reviewed which alleged R501 was pushed by a facility staff member and that a police report was filed. On 11/4/24 the medical record for R501 was reviewed and revealed the following: R501 was initially admitted to the facility on [DATE] and had diagnoses including Morbid Obesity and Pressure ulcer of right heel. A review of R501's MDS (minimum data set) with an ARD (assessment reference date) of 10/8/24 revealed R501 was dependent on staff assistance with most of their activities of daily living including toileting. R501's BIMS score (brief interview for mental status) was 12 indicating moderately impaired cognition. On 11/4/24 at approximately 9:56 a.m., a request…

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 #MI00147673. Based on interview and record review, the facility failed to ensure bed mobility was completed according to the plan of care for one resident (R501) of three residents reviewed for abuse/neglect/mistreatment. Findings include: On 11/4/24 a complaint submitted to the State Agency was reviewed which alleged R501 was pushed by a facility staff member and that a police report was filed. On 11/4/24 the medical record for R501 was reviewed and revealed the following: R501 was initially admitted to the facility on [DATE] and had diagnoses including Morbid Obesity and Pressure ulcer of right heel. A review of R501's MDS (minimum data set) with an ARD (assessment reference date) of 10/8/24 revealed R501 was dependent on staff assistance with most of their activities of daily living including toileting. R501's BIMS score (brief interview for mental status) was 12 indicating moderately impaired cognition. A review of R501's [NAME] (directions of care for direct care staff)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00147673. Based on interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) was provided required training on abuse policies/procedures prior to working with residents in the facility for one resident (R501) of three residents reviewed for abuse/neglect/mistreatment. Findings include: On 11/4/24 a complaint submitted to the State Agency was reviewed which alleged R501 was pushed by a facility staff member and that a police report was filed. On 11/4/24 the medical record for R501 was reviewed and revealed the following: R501 was initially admitted to the facility on [DATE] and had diagnoses including Morbid Obesity and Pressure ulcer of right heel. A review of R501's MDS (minimum data set) with an ARD (assessment reference date) of 10/8/24 revealed R501 was dependent on staff assistance with most of their activities of daily living including toileting. R501's BIMS score (brief interview for mental status) was 12 indicating moderately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #'s MI00146745, MI00147112, MI00147118. Based on observation, interview and record review, the facility failed to document follow-up and resolve grievances/concerns for one resident (R901) of two residents reviewed for dignity/respect. Findings include: On 9/25/24 a concern submitted to the State Agency was reviewed and alleged R901 was not treated with dignity and respect and their concerns were not being followed up on. On 9/25/24 at approximately 10:14 a.m., R901 was observed in their room, laying in their bed. R901 indicated that they had issues with a medication not being given in a timely manner during the morning on 9/3/24 and that when they had emailed the Director of Nursing (DON), nobody had followed up with them regarding the resolution of the concern. The medical record for R901 was reviewed and revealed the following: R901 was initially admitted to the facility on [DATE] and had a diagnosis of Pain. A review of R901's MDS (minimum data set) with an ARD (assessment…

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: MI00146135. Based on interview and record reviews the facility failed to develop and implement a comprehensive person-centered care plan to address the urinary diagnoses for one (R303) of four residents reviewed for quality of care. Findings include: Review of the preadmission documents provided to the facility by the transferring hospital at R303's admission documented the following: A History and Physical dated 7/14/24, documented in part . Chief Complaint- Dysuria (painful urination) . past medical history of recurrent UTI's (Urinary Tract Infections) with resistant bacteria . right ureteric stent (a thin tube inserted into the ureter to prevent or treat obstruction of the urine flow from the kidneys) for hydronephrosis (a condition characterized by excess fluid in a kidney due to a backup of urine) exchanged every 3 months . Patient has been admitted multiple times for recurrent complicated UTIs with multidrug-resistant (MDR) bacteria as Pseudomonas (bacteria), ESBL…

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 #MI00145683 and MI00145247 Based on interview and record review, the facility failed to ensure timely showers were provided for one (R302) of two residents reviewed for Activities of Daily Living (ADL). Findings include: Complaints were filed with the State Agency (SA) that alleged residents were not adequately groomed and told by staff that they did not have time to provide showers. R302 A review of R302's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: sciatica right side, dementia, leukemia of B-cell and hearing loss. A review of the resident's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (cognitively intact cognition) and required assistance with all transfers. The resident's care plan documented, in part: Focus: ADL Self care deficit as related to back pain with sciatica Interventions: Assist to bathe/shower as needed .Bed mobility x1 .Toilet x2 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00146135. Based on interview and record reviews the facility failed to obtain an adequate assessment, notify the physician of the change in condition and ensure the timely transfer to a higher level of care, for one (R303) of four residents reviewed for quality of care. Findings include: Review of a complaint submitted to the State Agency (SA) documented concerns of R303's care and the delay in transferring the resident to a higher level of care. A review of the medical record revealed R303 was readmitted to the facility on [DATE], with diagnoses that included acute respiratory failure with hypoxia, urinary tract infection, hydronephrosis with ureteral stricture, sepsis, obstructive and reflux uropathy, and chronic kidney disease stage 3. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status score of 14 (which indicated intact cognition). R303 required staff assistance for all Activities of Daily Living (ADLs). Review of a change 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: MI00146135. Based on interview and record reviews, the facility failed to ensure an order for oxygen was continuously administered as prescribed by the physician, for one (R303) of two residents reviewed for oxygen administration. Findings include: Review of a complaint submitted to the State Agency (SA) documented the facility failed to ensure the resident was receiving their supplemental oxygen continuously as ordered. A review of the medical record revealed R303 was readmitted to the facility on [DATE], with diagnoses that included acute respiratory failure with hypoxia. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status score of 14 (which indicated intact cognition). R303 required staff assistance for all Activities of Daily Living (ADLs). A review of the physician orders documented the following: Oxygen delivery via NC (nasal cannula) 3 L (liters) continuous every shift for breathing. Start date 7/19/24 & reordered on 7/30/24.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake: MI00145107. Based on interview and record reviews the facility failed to implement an effective baseline care plan to ensure the necessary care was provided to one R402 of three residents (including R405) reviewed for a change of condition. Findings include: R402 was admitted to the facility on [DATE], with diagnoses that included: chronic respiratory failure with hypoxia, gastrostomy status, paralysis of vocal cords and larynx and tracheostomy status. R402 required staff assistance for all Activities of Daily Living (ADLs). Review of the physician orders revealed R402 was receiving enteral feeding 24 hours continuously. Review of the progress notes revealed the following: On [DATE] at 10:11 PM, a Nursing note documented . upon arriving on shift at 1900 writer walked into (R402's name) room to do rounds and pt (patient) appeared to be lying in bed in <sic> feed tube running. At 2120 Writer later went into pts room to get vitals and given medications to pts and pt appeared…

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: MI00144714. Based on interview and record review the facility failed to ensure a change of condition was timely addressed and accurately reported for one (R403) of three residents reviewed for a change of condition. Findings include: Review of a complaint submitted to the State Agency (SA) documented concerns of the facility staff failure to address a change of condition for R403 timely. Review of the medical record revealed R403 was admitted to the facility on [DATE] with diagnoses that included syncope and collapse. Review of the Nursing progress notes documented the following: On 5/25/24 at 8:26 PM, . Resident has excessive menorrhagia (abnormally heavy menstrual bleeding), family insisted on sending pt (patient) to ER (emergency room). Family contact <sic> (local police department name) and pt was sent by request of pt and family to (hospital name). On 5/25/24 at 9:59 PM, . Pt passing blood clots. Writer informed MD (Medical Doctor). BP (blood pressure) 107/57, P (pulse) 75,…

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: MI00144428. Based on interviews and record reviews the facility failed to accurately document and address the concerns verbalized for one (R402) of two residents reviewed for quality of care. Findings include: Review of a complaint submitted to the State Agency (SA) documented in part, . On more than one occasion (R402's) bed was wet, and she was left sitting in her own urine. (R402 name) told staff that it is burning her when she went to pee. A strong urine smell was in her room . Staff advised they would take a urine sample . Staff never took her sample to see if she had a UTI (urinary tract infection) . On 5/6/24 she was sitting on soaked bedsheets . (complainants name) pulled (R402 name) out of (facility name) on 5/7/24 due to them not providing her with proper care . Review of the medical record revealed R402 was admitted to the facility on [DATE], with diagnoses that included: Rhabdomyolysis (condition where your muscles break down and release toxins into your blood and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00144428. Based on interviews and record reviews the facility failed to ensure consistent physician monitoring and follow-up of vaginal/urinary concerns for one R402 of two residents reviewed for quality of care. Findings include: Review of a complaint submitted to the State Agency (SA) documented urinary concerns to have not been address and followed up on by the facility nurses and physician, which resulted in R402 to have been admitted to the hospital with a diagnosis of a Urinary Tract Infection (UTI). Review of the medical record revealed R402 was admitted to the facility on [DATE], with diagnoses that included: Rhabdomyolysis (condition where your muscles break down and release toxins into your blood and kidneys) and a urinary tract infection. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition and required staff assistance for all Activities of Daily Living (ADLs). 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: MI00144428. Based on interviews and record reviews the facility failed to ensure laboratory services for a urinalysis and culture/sensitivity test were completed as ordered and ensured the timeliness of a urinalysis results were processed, obtained, and reported to the physician for follow-up for one (R402) of two residents reviewed for quality of care. Findings include: Review of a complaint submitted to the State Agency (SA) documented concerns of the facility staff failing to have obtained a urine sample, ensure it was processed and the results were reported to the physician, which resulted in R402 to have been admitted to the hospital with a diagnosis of a Urinary Tract Infection (UTI). Review of the medical record revealed R402 was admitted to the facility on [DATE], with diagnoses that included: Rhabdomyolysis (condition where your muscles break down and release toxins into your blood and kidneys) and a urinary tract infection. A Minimum Data Set (MDS) assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly store/label food items, and maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 10/24/23 between 9:20 AM to 9:50 AM, during an initial tour of the kitchen with Dietary Manager (DM 'A'), the following items were observed: In the dry storage room, there was a container of rainbow sprinkles had a lid that was not closed and the contents were exposed. There was a box which had a bag of graham cracker crumbs that was not sealed, nor was there an opened date identified. DM 'A' reported their process was the box should've been dated when opened and properly sealed. The floors of the dry storage room were observed to have debris underneath most of the metal racks, as well as a build-up of larger black unidentifiable debris in the corner of the room, behind the metal shelving unit. DM 'A' was asked about the frequency 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 complete a resident self-administration of medication assessment for four (R's 5, 17, 35 & 52) of four residents reviewed for medications observed at the bed side. Findings include: R35 On 10/24/23 at 9:35 AM, an observation of an albuterol 90 mcg (micrograms) inhaler was observed on R35's bedside table. Review of R35's medical record revealed no assessment completed for the self-administration of the inhaler. R52 On 10/24/23 at 9:39 AM, an observation was made of two nasal spray bottles (afrin) on the bedside table of R52. Review of R52's medical record revealed no assessment completed for the self-administration of the nasal decongestion spray. On 10/24/23 at 9:43 AM, Licensed Practical Nurse (LPN) L was asked to come into the rooms of R's 35 and 52 and asked if the resident's medications should be stored at the bedside. LPN L replied the resident's can have the medications stored at their bedside if they can administer it themselves. LPN L was then asked if R35 & 52 had a self-administration assessment…

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 contains two Deficient Practice Statements (DPS). DPS# 1 Based on interview and record review the facility failed to ensure a dementia medication was continued for one (R69) of one resident reviewed for a death closed record review. Findings include: Review of the medical record revealed R69 was admitted to the facility on [DATE], with diagnoses that included: dementia, depression, encephalopathy, acute kidney failure, hypertension, legal blindness, aphasia, weakness, and the need for assistance with personal care. Review of the hospital documents provided to the facility on R69's admission documented the following: A Physician General Medicine consult dated 9/6/23 at 1:31 PM, documented in part . presented with c/o (complaints of) AMS (altered mental status-more confused than baseline not taking medications appropriately) . she did require IV (Intravenous) Ativan for acute agitation . Spoke to dtr (daughter) and son. Son has been giving her medications since last week and pt (patient) suspicious…

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 coordination of behavioral health services for three (R2, R43, and R58) of five residents reviewed for behavioral care, resulting in delayed and/or unmet mental and psychosocial care needs, staff to be unaware of individualized approaches or targeted behaviors, and the inability to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence. Findings include: According to the facility's policy titled, Behavioral Health Services dated 8/7/2023: .The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care .Behavioral health care and services shall be provided .Ongoing monitoring of mood and behavior .Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological interventions .The Social Services Director shall serve as the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that medically-related social services were adequately provided to four (R2, R37, R43, and R58) of five residents reviewed for social services, resulting in insufficient/ineffective mood and behavior monitoring, inaccurate social service assessments to effectively monitor and/or address changes in mental and psychosocial health needs, patient advocacy, and coordination with behavioral care. Findings include: R2 Observations conducted for R2 on 10/24/23 at 11:00 AM and 10/25/23 at 11:10 AM revealed the resident was calm, with some confusion but responded to simple questions asked. On 10/24/23 at 11:30 AM, a phone interview was conducted with R2's daughter who was R2's designated patient advocate and emergency contact. During this interview, the daughter reported concerns with R2's use of Seroquel medication (an antipsychotic medication) and reported they and their brother initially approved the medication, but they were not sure why…

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 R41 On 10/24/23 at 10:32 AM, R41 was observed in their room walking from bathroom to the side of bedroom and sat in chair. R41 sat down and crossed legs and asked what did I need. R41 was interviewed and asked about the care, R41 shrugged their shoulders and stated ok. Record review revealed that R41 was admitted to the facility on [DATE] with Brief Interview for Mental Status(BIMs) of 5 with the medical diagnosis of Parkinson's Diseases, Sarcopenia and Major depressive disorder, recurrent sever with psychotic symptoms. Upon a record review of R41's medication, R41 was prescribed Olanzapine 10milgram(mg) one time a day at bedtime for bipolar initiated for 8/1/23. On 10/25/23 a interview with the Director of Nursing (DON) was conducted to see where did the facility get the diagnosis for bipolar for R41, what was the appropriate diagnosis for the medication Olanzapine 10mg prescribed and was R41 supposed to be receiving the medication? The DON replied that she would have to see where that diagnosis came from.…

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 implement comprehensive person-centered care plans for two (R2 and R37) of five residents reviewed for mood/behavioral care plans, resulting in the potential for unmet care needs. Findings include: According to the facility's policy titled, Care Plan - Comprehensive and Revision dated 8/25/2023: .The interdisciplinary team (IDT) develops and implements a comprehensive, person-centered care plan for each resident .The comprehensive, person-centered care plan: Includes measurable objectives and timeframes .Reflects currently recognized standards of practice for problem areas and conditions . R2 Observations conducted for R2 on 10/24/23 at 11:00 AM and 10/25/23 at 11:10 AM revealed the resident was calm, with some confusion but responded to simple questions asked. On 10/24/23 at 11:30 AM, a phone interview was conducted with R2's daughter who was R2's designated patient advocate and emergency contact. During this interview, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to address recommendations from Physical Therapy (PT) to ensure restorative care was provided to maintain functional mobility status for one resident (R53) of two residents reviewed for Range of Motion (ROM)/Physical Therapy. Findings include: The facility policy titled, Restorative Nursing Programs (1/11/23) was reviewed and documented, in part: .Policy: It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level .Nursing personnel are trained on basic or maintenance nursing care that does not require the use of a qualified therapist or licensed nurse oversite. The training may include .Assisting residents with range of motion exercises .All residents will receive maintenance nursing services .by certified nursing assistants. The Restorative Nurse and restorative aides receive additional training on restorative nursing program…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to implement adequate and resident specific interventions to prevent further falls for a resident with a history of falls, one (R62) of one resident reviewed for falls. Findings include: On 10/24/23 at 10:30 AM, an observation was conducted of R62 lying on their back in bed. Oxygen was observed being administered via nasal cannula at 2 Liters. A urinary catheter bag was observed on the right side of the bed. The left arm and hand was observed swollen. Review of the medical record revealed R62 was admitted to the facility on [DATE], with medical diagnoses that included: pneumonia, fracture of superior rim of left pubis, dislocation of left shoulder joint, congestive heart failure, acute and chronic respiratory failure, mild cognitive impairment, and the need for assistance with personal care. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderately impaired…

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 proper management of tube feeding including labeling on the formula to ensure appropriate administration in accordance with physician orders for one(R39) for tube feeding, resulting in the potential for inaccurate tube feeding administration. Findings include: On 10/24/23 at 10:23 AM R39 was observed in room lying in bed with eyes open. Head of bed was elevated, and Enteral Feeding was infusing. Record review revealed that R39 admitted to facility on 11/17/2021 with a readmission date of 9/7/2023 with the diagnosis of Cerebral Infraction due to thrombosis of left middle cerebral artery, Gastrostomy status and type two diabetes without complications. Record review revealed that R39 Brief Interview for Mental Status was not conducted due to section C0100 being filled out as No resident is rarely/never understood. On 10/24 at 10:23 AM an observation of R39 eternal feeding was infusing with a water bag dated for 10/22/23 and Enteral feed was not labeled or dated with R39 rate, time and date. Record review…

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 #MI00139048 Based on observation, interview and record review, the facility failed to ensure medications were available for administration and the Physician was notified of missed doses of medication for one resident (R908) of one resident reviewed for Nursing standards of practice. Findings include: On 9/27/23 a concern submitted to the State Agency was reviewed which alleged R908 was not being administered their medications as ordered by the Physician. On 9/27/23 at approximately 11:28 a.m., R908 was observed in their room, laying in their bed. R908 was queried regarding their medication administration and they reported the facility had ran out of their medications on multiple occasions. R908 reported that they remembered a time in August around the 13th/14th where they were unable to get their oxycodone administered because the facility ran out of it and Nurse J was on duty was unable to get it from the backup supply because he was a newer Nurse. On 9/27/23 the medical record…

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