Regency at Troy

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This complaint pertains to Intake #2702800. Based on observation, interview and record review the facility failed to ensure a resident with a history of Urinary Tract Infections (UTI) received timely urine samples causing a delay in treatment and extended pain for one (R702) out of three residents reviewed for UTI's. Findings include: A complaint was filed with the State Agency (SA) that alleged it took over four days to obtain a urine specimen to determine treatment for a UTI. The complainant further alleged that staff blamed the delay on the resident not drinking enough water and noted that R702 could only drink water with staff assistance, and they felt there was either a lack of staff or staff did not respond timely to residents call light. On 3/17/26 at approximately 10:20 AM, R702 was observed lying in bed. Both the right and left hand were contracted. There was food items located near the window and several cups of water that were out of reach of the resident. The resident was alert and able to answer…

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: 2795651 & 2796703.Based on interview and record reviews the facility failed to ensure oxygen therapy and maintenance was administered as ordered by the Clinician for one (R704) of one resident reviewed for respiratory care. Findings include:A complaint submitted to the State Agency (SA) noted the following in part: On 2/22/26 the family member of (R704) received a call that R704's oxygen had dropped under 90%. The family member raced to the nursing home to find R704 hallucinating with the oxygen tank empty and nasal cannula on the floor. They informed R704's nurse of the 02 (oxygen) tank being empty and the oxygen tubing to be observed on the floor and the nurse instructed the family member to put the oxygen tubing back into R704's nose. The family member noted the nurse did not come in to assess the resident, so the family member called 911. EMS (Emergency Medical Services) arrived and assessed the resident 02 at 86% and transferred the resident to the hospital.A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: 2709710.Based on interviews and record reviews the facility failed to ensure non-pharmacological interventions were consistently utilized before the administration of pharmacological interventions, failed to ensure appropriate indication for psychotropic medications, failed to revise and individualized the behavioral health care plan, and ensure behavioral health service monitoring for one (R201) of one resident reviewed for falls. Findings include:A review of the hospital referral provided to the facility upon R201's admission documented the following in part, . Hospital Problem List - Open fracture of nasal one, initial encounter. Nasal septum fracture. Nasal laceration. Fracture of fingers, left. Fall. Syncope and collapse.A review of the medical record revealed R201 admitted to the facility on [DATE], with diagnosis that included: dementia, alzheimer's disease, falls, major depressive disorder, glaucoma, and fracture of the nasal bones. A Minimum Data Set (MDS) 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: 2605657. Based on interview and record reviews the facility failed to ensure an appropriate admission, staff competency and ensure coordinated care was implemented prior to the admission of one (R708) of four residents reviewed for quality of care. Findings include:A review of a complaint submitted to the State Agency (SA) documented in part . Admitting a resident with a fresh laryngectomy that the facility did not have the competence to care for, resulting in the facility having to rush the resident into a transfer the next morning.Review of the medical record revealed R708 was admitted on [DATE] and transferred out of the facility on 4/10/25. A review of the preadmission transferring hospital documents provided to the facility before and upon R708's admission identified the following:An otolaryngology progress note dated 4/3/25, documented in part . s/p (status post) total laryngectomy (surgical removal of larynx), bilateral neck dissection, left oropharyngectomy (surgical…

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: 2605657. Based on observation, interview and record reviews the facility failed to ensure bladder incontinence care was completed timely for one (R702) of three residents reviewed for a urinary tract infection. Findings include:On 9/24/25 at 9:59 AM, R702 was observed sitting up in bed. When asked, R702 explained how they have been in and out of the hospital due to infections. R702 explained how they are .always wet and sitting in wet diapers for hours. This is why I always get infections. R702 stated they had not seen or met their Certified Nursing Assistant (CNA) for the day and the last time their brief was changed was by the night shift CNA at 6 AM. R702 stated they were wet and had been laying in their wet brief for some time. At 10:24 AM, an interview was conducted with CNA A. When asked CNA A confirmed they were assigned to R702 for their shift. CNA A was asked what time they began their shift and CNA A replied at 7 AM. CNA A was asked how many residents they were…

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 #2605657Based on observation, interview and record review, the facility failed to ensure medications were stored appropriately in one medication cart of one medication carts reviewed for medication storage and labeling. Findings include:On 9/25/25 a concern submitted to the State Agency was reviewed which alleged facility staff were not storing medications properly. On 9/25/25 at approximately 11:22 a.m., a medication cart that was located on the second floor next to room [ROOM NUMBER] was observed unlocked and unattended by any Nursing staff. The medication cart top drawer was observed to contain multiple unidentified pills stored in an uncovered and unlabeled plastic cup as well as a second uncovered plastic cup full of a white powdery substance. No resident name was attached to the pills or powder that identified what the pills/powder were or what resident they belonged to. On 9/25/25 at approximately 11:25 a.m., Nurse Manager B (NM B) was observed coming out of a 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 This citation pertains to intake #'s 2605657 and 2623220. Based on observation, interview and record review, the facility failed to ensure a substantial evening meal was provided for one resident (R709) of three residents reviewed for meals/food. Findings include:On 9/25/25 a concern submitted to the State Agency was reviewed which alleged residents were not receiving meals. On 9/25/25 at approximately 9:47 a.m., R709 was observed in their room, laying in their bed. R709 was observed to have contracted hands, turned into their palms. R709 was queried if they had any concerns regarding their care and they reported they were not provided with a dinner meal the previous day (9/24) and that the only food they got after lunch was a yogurt and chocolate pudding that the night Nurse gave them due to the kitchen being closed. R709 reported the facility never provided them with a supper meal tray at dinner and they did not get the yogurt until around 8:30 or 9:00 PM. R709 reported that their night Nurse (Nurse C) 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 # 2605657. Based on observation, interview and record review, the facility failed to ensure infection control procedures were followed for one resident (R709) of three residents reviewed for infection control. Findings include:On 9/25/25 a concern submitted to the State Agency was reviewed which alleged the facility was not following infection control policies/procedures. On 9/25/25 at approximately 9:47 a.m., R709 was observed in their room, laying in their bed. R709 was observed to have contracted hands, turned into their palms. R709 was queried if they had any concerns regarding their care and they reported they were concerned about the facility having a COVID-19 outbreak. R709 was queried if staff had been observed wearing masks and gowns in their room and they reported that some do and some do not. On 9/25/25 at approximately 11:13 a.m., and 12:05 p.m., R709's door was observed to not contain any signage indicating staff were to use enhanced barrier precautions (EBP) when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This complaint pertains to complaint 2587774Based on interview and record review facility failed to ensure timely admission orders were implemented for one (R901) of two residents reviewed for admission orders resulting in the potential for residents to not receive timely care/services with potential for decline in their health condition and avoidable hospitalization. Findings include:R901A complaint received by the State Agency revealed that R901 was admitted to the facility for recovery after hospitalization and did not receive care/services as ordered by the hospital for hours after admission to the facility. R901's family had to transport the resident back to the hospital late at night (around midnight) as they were upset with the care/services that were not provided timely after admission to the facility. The report further revealed that the complainant had filed a police report after they were informed (over the phone) by a facility staff member that they were unable to find the nurse assigned to care for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This complaint pertains to complaint 2587774 and 1361575.Based on observation, interview, and record review facility failed to ensure nursing professional standards were consistently followed for two (R907 and R910) of two residents reviewed for nursing standards, when staff failed to reconcile the medication orders for R907 for an extended period; and failed to administer timely as ordered and document medication administration for R910. This deficient practice has the potential for adverse effect/interaction from improper dose/time and overall decline in health condition with/without avoidable hospitalization. Findings include:R910 Record review revealed R910 was originally admitted to the facility on [DATE]. R901’s admitting diagnoses included left radius (forearm) fracture and right humerus (upper arm bone) fracture from a fall and recent (outpatient) surgery on the left forearm on 8/15/25, anxiety disorder, high blood pressure, heart failure, and aortic stenosis (narrowed or stiff heart valve making it hard…

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 intake pertains to intake # 2587857.Based on observation, interview, and record reviews, the facility failed to properly label, and date opened insulin pens for two of two residents (R911 and R912) reviewed for medication storage, resulting in insulin pens being mixed up and the potential to administer the incorrect insulin to a resident and adverse reactions. Findings include:Complaint 2587857On 8/20/25 at approximately 9:19 AM, an observation of the Maple East cart was made and a review of insulin was made with the Unit Manager B and Nurse L. It was noted that R911 had a Lantus insulin pen with their name on it but the insulin pen was in a bag with R912's name on it. The medication cart also had a total of 6 insulin pens with no date of when they were opened. An interview was conducted at the same time the medication cart was observed with Unit Manger B and Nurse L, they were asked about the residents' insulin that was in the incorrect resident's bag and should insulin pens be dated upon opening. Nurse L reported that the medication should have been labeled for 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(s) #: MI00151883 and MI00153034. Based on observation, interview and record review the facility failed to maintain complete and accurate electronic medical records for two (R904 and R906) out of six residents reviewed for medical records. Complaints were filed with the State Agency (SA) that alleged residents were not receiving Activities of Daily Living (ADL)/Shower Care on a regular basis and not receiving medication timely. R904 On 5/13/25 at approximately 12:08 PM, R904 was observed sitting in a wheelchair. Their hair appeared greasy, and they had long nails. The resident was alert and able to answer most questions asked. When asked if they received ADL care including nail and shower/bath care, R904 reported that they have not received a shower since being admitted to the facility at the end of April 2025. R904 reported that they do not like showers but needed to have their hair washed and agreed that their nails were long. A review of R904's clinical record revealed 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 prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: On 3/25/22 at 9:10 AM, during an initial observation of the kitchen, 4 whole, foil-wrapped frozen turkey breasts were observed in the sink basin. The faucet was running with a thin stream of running water flowing over 1 of the frozen turkey breasts. On 3/25/25 at 12:00 PM, all 4 turkey breasts were still in the sink basin, this time with no running water. When queried at that time, Dietary Staff CC stated he was getting ready to cook the turkey, which would be served on the following day. According to the 2017 FDA Food Code section 3-501.13 Thawing, Except as specified in (D) of this section, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be thawed: 1.(A) Under refrigeration that maintains the FOOD temperature at 5ºC (41ºF) or less; or 2. (B) Completely…

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 # MI00150969 Based on observation, interview and record review, the facility failed to treat residents with dignity and respect for three (R60, R52 and R318) of four resident reviewed for dignity. Findings include: Review of a facility policy titled, Resident Rights revised 5/14/24 read in part, .The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . Facility staff will assist residents in exercising their rights . R60 On 3/25/25 at 5:16 PM, R60 was observed sitting in a wheelchair, their Family Member (FM) V was sitting on R60's bed. R60 was asked about care at the facility. R60 explained the day before they needed to be changed, no one was answering the call light so they yelled out because the nurse station was near their room . a staff member came into their room and told them that they did not have enough patience and that she was just coming on to her shift. R60…

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/concerns were promptly documented, investigated, tracked and resolved for two residents (R7 and R60) of six residents that participate in the resident council (RC) meetings. Findings include: On 3/26/25 at approximately 11:03 a.m., during the group meeting, the group of residents was queried if the facility had provided resolution to the concerns they were bringing to the regular resident council meetings. R60 reported they were unaware of the plans were to fix any of the issues they bring up in resident council because nobody tells them what they are doing. R7 reported the facility staff just tell them they will fix it and do not follow-up with the council on how, which is why call lights response is an issue every month. On 3/26/25 a review of the previous six months of resident council minutes was conducted and revealed the following concerns noted by the residents: 1. Date of meeting-10-24-24 .New Business: .Hskpg (housekeeping)./Laundry - Occasional long wait for returns of personal .*Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake #MI00151101, MI00150969 Based on observation, interview, and record review, the facility failed to ensure staff provided prompt response to answering call light requests for four (R7, R60, R17, R37) of four reviewed for Activities of Daily Living resulting in R7 left in a soiled brief for an extended period on 3/25/25 leading to concern of developing an infection. Findings Include: Clinical record review revealed R7 was admitted to the facility on [DATE] with a history of stroke resulting in impaired mobility with right sided weakness, COPD (Chronic Obstructive Pulmonary Disease) and diabetes. R7 was identified as incontinent of bladder and bowel and had a history of Urinary Tract Infections (UTI's). Brief Interview of Mental Status (BIMS) dated 1/18/25 revealed R7 scored 14/15 indicating no cognitive impairment. On 3/25/25 at 10:09 AM, during initial introduction, R7 voiced concern that they had been lying in bed with a soiled brief for hours and that the staffing is so bad,…

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 #MI00151325 Based on observation, interview, and record review, the facility failed to implement appropriate interventions timely and consistently as recommended/indicated for two (R48 and R38) of four residents reviewed for accidents resulting in the potential for further falls, elopements, and avoidable accidents. Findings include: R48 Record review revealed R48 was a long-term resident admitted to the facility on [DATE]. R48 was recently transferred to hospital on 3/19/25 for further evaluation due to altered mental status after a fall and they were readmitted back to the facility on 3/21/25. R48's admitting diagnoses included dementia, anxiety disorder, heart and renal failure with history of falls. Based on the Brief Interview for Status (BIMS) assessment dated [DATE], R48 had a score of 0/15, indicative of severe cognitive impairment. Based on the Minimum Data Set (MDS) assessment dated [DATE], R48 needed moderate (staff assistance less than 50%) from bed to wheelchair;…

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 facility failed perform appropriate hand hygiene during medication administration (R80, R35, R59), and wear appropriate Personal Protective Equipment (PPE) while providing service/care to resident(s) (R45, and R365) who were on contact precautions and enhanced barrier precautions respectively, for five of five residents reviewed for infection prevention/control practices resulting in the potential for cross-contamination with likelihood for spread of infection. Findings include: R365 R365 was admitted to the facility for skilled nursing and rehabilitation on 3/18/25. R365's admitting diagnoses included hemiplegia (stroke), urinary tract infection, pneumonia and Clostridioides difficile (C. Diff) infection of the colon (Bacterial infection in the longest part of the large intestine. Symptoms can range from diarrhea to life-threatening damage to the colon) and dementia. During an initial observation completed on 3/26/25 at approximately 8:15 AM. R365's door had 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 Based on observation, interview, and record review, the facility failed to accommodate a resident with the appropriate bed for one Resident (R92) of two residents reviewed for accommodation of needs. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 3/10/25, revealed R92 was admitted to the facility on [DATE], with diagnoses including asthma, atrial fibrillation (heart rhythm disorder), anxiety, and depression. R92 required maximal assistance with bed mobility and was dependent for toileting. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, which showed R92 was cognitively intact. R92 was 67 tall (5', 7) and weighed 281 pounds. On 3/25/25 at 12:57 p.m., R92 was observed in a bariatric hospital bed, wearing a gown. R92 was wearing oxygen via a nasal cannula, with their head of bed elevated. Their feet were observed resting on the wooden footboard of their bed. On 3/25/25 at 1:00 p.m., R92 stated, My bed is too short. R92 reported they slid down in their bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Nursing standards of practice were followed for medication administration for one resident (R7) of one residents reviewed for pain management. Findings include: On 3/26/25 at approximately 11:01 a.m., during the resident council meeting, R7 indicated that they had an issue with the facility failing to ensure they received their pain medications. R7 indicated the facility had run out of their medication on multiple occasions. On 3/26/25 the medical record for R7 was reviewed and revealed the following: R7 was initially admitted to the facility on [DATE] and had diagnoses including Congestive heart failure and Chronic kidney disease. A review of R7's MDS (minimum data set) with an ARD (assessment reference date) of 1/18/25 revealed R7 needed assistance from facility staff with most of their activities of daily living. A review of R7's comprehensive plan of care revealed the following: [R7] is at risk for pain r/t (related to): Anemia,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 Based on observation, interview, and record review, the facility failed to transcribe and implement treatment orders as prescribed by the Physician for one resident (R18) reviewed of one resident reviewed for edema. Findings include: Clinical record review revealed R18 was admitted to the facility on [DATE] and required physical therapy for a decline in function from left shoulder surgery. R18 had a functional ability deficit related to stroke with left sided weakness which required assistance with self-care and mobility. R18 required diuretic therapy related to their history of hypertension and edema. The Brief Interview of Mental Status (BIMS) scored on 3/10/25 was 15/15 indicating R18 had no cognitive impairment. On 3/25/25 at 10:01 AM, R18 was observed in their room, sitting in a wheelchair watching television. Both lower extremities were observed swollen, shiny, and reddened with scattered dry scabs. Both legs were exposed (open to air) and observed with areas on the front and back of the calves 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 provide adequate standards of care including lack of proper positioning and adequate documentation for two Residents (R81 and R312) of two residents reviewed for pressure ulcers. Findings include: R81: Review of R81's Minimum Data Set (MDS) assessment, dated 3/15/25, revealed R81 was admitted to the facility on [DATE], with diagnoses including stroke, dementia, quadriplegia, malnutrition, adult failure to thrive and seizure disorder. The assessment revealed R81 was dependent for all care, bed mobility, and transfers, and had seven pressure ulcers, with two not present on admission. It was noted R81 had a urinary catheter and an ostomy. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 3/15, which showed R81 had severe cognitive impairment. On 3/25/25 at 1:49 p.m., the wound care nurse, Licensed Practical Nurse (LPN) C, was asked about R81's wounds. LPN C confirmed two of their pressure ulcers were…

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: MI00150969 Based on interview and record review facility failed to implement appropriate and consistent weight monitoring for one (R360) of six residents reviewed for nutrition resulting in the potential for unidentified weight loss and malnutrition with overall decline. Findings include: A complaint received by the State Agency revealed that R360 was admitted to the facility and did not have any appetite and was not eating well. Family had requested to transfer to the hospital because of their concern related to intake and weight loss. Additional information received via e-mail revealed that R360 was readmitted to hospital after family request and their weight was 231 pounds (lbs.) when they were readmitted to hospital; there was a 28 lbs. weight loss based on previous hospital weight (259 lbs.) prior to initial admission to the facility. The complaint also revealed that the facility failed to obtain an accurate admission weight and failed to monitor R360's weight throughout…

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 comprehensive behavioral care management for one Resident (R12) of one resident reviewed for behavior health services. Findings include: Review of R12's Minimum Data Set (MDS) assessment, dated 2/10/25, revealed R12 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, dementia, and adjustment disorder. The assessment showed R12 was independent with toileting, transfers, and walking. The sensory assessment revealed R12 was sometimes able to understand, and sometimes able to be understood, and had no vision or hearing impairment. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 3/15, which showed R12 had severe cognitive impairment. Review of the Electronic Medical Record (EMR) revealed R12 had aggressive and wandering behaviors towards residents and staff in the past month, including two resident-to-resident incidents. On 3/25/25 at 11:35 a.m., R12 was observed in their…

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, including medications used for treatments, were appropriately stored and in a safe manner for four residents (R45, R46, R81 and R7) of four residents reviewed for safe storage. Findings include: Review of a facility policy titled, Medication/Treatment Cart Use revised 8/15/23 read in part, .The nursing staff uses the medication/treatment cart to systematically distribute physician ordered medications to residents . The medication/treatment cart and its storage bins are kept locked until the specified time of medication/treatment administration . R46 On 3/27/25 at 11:23 PM, upon entering R46's room with Licensed Practical Nurse (LPN) C, who served as the Wound Care Nurse, a bottle of Half Strength Dakin Solution (a dilute sodium hypocholorite solution commonly known as bleach) was observed on the three drawer cabinet next to R46's bed. The bottle was labeled with an open date of 3/14/25. LPN C was asked about the bottle…

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 laboratory diagnostic (lab) was completed in a timely manner per the Physician's order for one resident (R13) of one residents reviewed for laboratory diagnostics. Findings include: On 03/25/25 the medical record for R13 was reviewed and revealed the following: R13 was initially admitted to the facility on [DATE] and had diagnoses including Heart failure and Chronic kidney disease. A review of R13's MDS (minimum data set) with an ARD (assessment reference date) of 2/23/25 revealed R13 needed assistance from facility staff with most of their activities of daily living. A Physicians order dated 2/25/25 revealed the following: STAT (immediate) CBC (complete blood count) W DIFF (with differential) CMP (comprehensive metabolic panel) Further review of the medical record did not reveal any CBC results from the lab order dated 2/25/25. On 3/27/25 at approximately 9:20 a.m., Nurse manager AA (NM AA) was queried regarding the lab order for the CBC 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 provide alternate menus and alternate meal choices for one Resident (R312) of one resident reviewed for menus. Findings include: Review of the R312's Minimum Data Set (MDS) assessment, dated 3/16/25, revealed R312 was admitted to the facility on [DATE], with diagnoses including heart failure, kidney failure, femur fracture, and malnutrition. R312 was independent with eating, was 68 inches tall, and weighed 176 pounds. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 14/15, which showed R312 was cognitively intact. On 3/25/25 at 12:03 p.m., R312 was observed lying in their hospital bed, with their Family Member, FM II , seated in their room. FM II reported R312 did not like the lunch entree so they went to a local restaurant and brought them a meal. FM II stated they had asked facility staff for an alternative menu several times, and none was provided, which R312 confirmed. R312 stated, None of the food tastes…

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 attractive palatable pureed meal to one resident (R45) of one resident reviewed for meal service, resulting in verbalized complaints and dissatisfaction with meal service and potential for weight loss. Findings include: Clinical record review revealed R45 was admitted to the facility on [DATE] with a history of recurrent cerebral vascular accidents (stroke), resulting in left sided weakness, and dysphagia (difficulty swallowing) and required a Percutaneous Endoscopic Gastrostomy (PEG) tube (a surgically placed tube into the stomach to provide nutrition). R45 had vascular dementia, and the Brief Interview of Mental Status (BIMS) assessed on 1/25/25 scored 11/15 indicating moderate cognitive impairment. Review of the dietary progress note dated 11/5/24 revealed R45 had received pureed pleasure trays (pleasure feeding offers comfort through the enjoyment of food) in addition to their ordered nutrition via PEG. R45 was identified…

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 #MI00150135. Based on interview and record review the facility failed to provide scheduled showers for one resident (R702) of three residents reviewed for activities of daily living, resulting in verbalized complaints and frustration with the provision of care. Findings include: On 2/12/25, a clinical record reviewed revealed R702 was admitted to the facility for rehabilitation and continued medical care on 1/17/25 after being hospitalized for a recurrent stroke which resulted in R702 having a new onset of ride sided weakness, aphasia (difficulty speaking), and bowel and bladder incontinence. Their medical history included: diabetes, uterine cancer, and left nephrectomy (removal of kidney). R702's Brief Interview for Mental Status (BIMS) scored totaled 15/15 indicating intact cognition. On 2/12/25 at 11:41 AM, an interview with Registered Nurse (RN) A confirmed residents are provided showers/bathing twice a week. RN A provided a white binder stored at the Nurses station 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 This citation pertains to intake #MI00149847 Based on observation, interview, and record review, the facility failed to ensure physician ordered dressing changes for pressure ulcers were performed for one resident (R701) of three residents reviewed for pressure ulcers, resulting in the potential for worsening of wounds and development of infections. Findings include: On 2/12/25 at 8:51 AM, R701 was observed in their bed with their eyes closed. R701 had kerlix (dressing wrap) on their bilateral lower extremities. On 2/12/25 at 9:32 AM, a review of R701's clinical record revealed they re-admitted to the facility on [DATE]. Their diagnoses included: osteomyelitis (bone infection), sepsis, protein calorie malnutrition, failure to thrive, neuromuscular dysfunction of the bladder, quadriplegia, presence of a feeding tube, urinary catheter, and colostomy. Continued review of the record included a wound care note dated 2/11/24 that indicated they had multiple pressure ulcers including a sacrum, right hip, and right calf…

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 #MI00149847. Based on observation, interview, and record review, the facility failed to ensure appropriate transmission based precautions were implemented for one resident, (R701) of three residents revealed for infections, resulting in the potential for the development of infection. Findings include: On 2/12/25 at 8:50 AM, R701's room was observed. The door of the room did not contain any signage to indicate they were on any TBP (transmission based precautions), nor were there any PPE (personal protective equipment) supplies (gowns, gloves, masks, etc.) outside or in the vicinity of the room. On 2/12/25 at 8:51 AM, R701 was observed in their bed with their eyes closed. A tube feeding pump delivering tube feeding formula, a urinary catheter drainage bag hung on the left side of the bed, and an intravenous infusion of antibiotics being delivered via PICC (peripherally inserted central catheter) line were observed. On 2/12/25 at 9:32 AM, a review of R701's clinical record revealed…

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 #MI00149338. Based on observation, interview and record review facility failed to document and promptly resolve grievances/concerns reported to facility staff for one resident (R901) of three residents reviewed for grievances. Findings include: On 1/29/25, a complaint received by the State Agency was reviewed that alleged the facility failed to follow-up on care and abuse concerns that R901 had allegedly experienced and that the facility administration was aware of of the concerns. On 1/29/25 at approximately 9:46 a.m., during a conversation with a person who preferred to remain anonymous, the person reported that R901 had experienced a few incidents of improper care that the administration staff should have been aware of on 1/3/25 and 1/4/25 that needed to be investigated including R901 being told by a Nurse that their breasts were exposed in the hallway and that a CNA (Certified Nursing Assistant) had refused to assist R901 in wiping up during their use of the restroom. 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.

This citation pertains to intake: MI00148683. Based on observation, interview and record reviews the facility failed to ensure the kitchen staff followed proper procedures for sanitation and food storage, this had the ability to affect all 78 of 78 residents that resided in the facility at the time of the survey. Findings include: On 12/9/24 at 8:30 AM, a kitchen tour was conducted with Certified Dietary Manager (CDM) A. Upon observation in the refrigerated food storage was a large white tub of ricotta cheese with the top ajar with no open date noted. When asked about the tub, CDM A stated it was not dated because it was not opened yet. CDM A was asked to lift the top of the ricotta which revealed a plastic film fully ripped off the tub of ricotta. This indicated the ricotta tub had previously been opened. On the top shelf of the refrigerated storage area stored with food was an insulin pen with CDM A's name noted on the pen. CDM A was asked if the insulin pen belonged to them and they confirmed that it did. CDM A was asked why they stored their insulin pen on the shelves with 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: MI00148683. Based on interview and record reviews the facility failed to timely identify, intervene, and notify the physician of a change in respiratory condition for one (R901) of three residents reviewed for a change of condition, resulting in the delayed care, delayed notification to the physician/practitioner and ultimately requiring a transfer to the hospital for a higher level of care. Findings include: A review of a complaint submitted to the State Agency (SA) documented concerns regarding negligence of the facility staff to have not identified R901's respiratory distress timely and concern of the facility staff to have ignored the abnormal respiratory respirations tracked by the facility's wall devices that monitor the residents vitals. The complainant noted in part . found her (R901) having immense difficulty breathing, using muscles in her chest, neck and abdomen to breathe. I went to get staff. They responded slowly to this emergent situation and took her oxygen level…

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: MI00148683. Based on interview and record reviews the facility failed to consistently implement and apply wound treatments as ordered by the practitioner timely, failed to consistently identify and report worsening of the wound to the Wound Practitioner (WP) and failed to document clinical reasons and/or justification for the change of an antibiotic treatment, and the delayed/missed IV (Intravenous) and oral antibiotics for a wound infection, for one (R901) of three residents reviewed for wounds, resulting in delayed and omitted treatments and transfers to the hospital for higher level of care. Findings include: A review of a complaint submitted to the State Agency (SA) documented concerns of the facility's failure to provide adequate and appropriate care to prevent and care for an infected pressure wound. Review of the medical record revealed R901 was readmitted to the facility on [DATE] with a diagnosis that included a fracture to the neck of the right femur and required 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: MI00148683. Based on interview and record review the facility staff failed to ensure all required documentation for a transfer to the hospital was documented in the medical record for one (R901) of three residents reviewed for a change of condition. Findings include: A review of a complaint submitted to the State Agency (SA) documented multiple concerns of negligent care provided by the facility that resulted in multiple hospitalizations. Review of the medical record revealed R901 was readmitted to the facility on [DATE], with diagnoses that included a fracture to the neck of the right femur. R901 was admitted for rehabilitation. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. Review of the progress notes revealed the following: A Nursing note dated 11/3/24 at 10:15 AM, documented hospitalized . A Nursing note dated 11/8/24 at 4:42 PM, documented in part . arrived…

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.